The Right Medicine
The Right Medicine Last February Democratic senator Edward Kennedy introduced a "patients' bill of rights." His proposal instantly became his party's top priority on health care, attracted the...
...But since roughly half the 161 million Americans with private health insurance are in HMOs, the use of these diagnostic tests obviously wouldn't have soared if HMO patients were being denied them...
...In the past, HMOs would only pay for drugs, mostly generics, on their preferred list...
...They needn't be...
...The crisis is a lack of capacity...
...Which is exactly why HMOs were given immunity from most lawsuits in the first place...
...In 1996, 70 percent of women in the vulnerable 52 to 69 age bracket received mammograms as HMO patients...
...In a single sentence, Kennedy summed up the "abuses" health maintenance organizations and other managed care plans have inflicted on patients, creating the need for his Bipartisan Patient Protection Act...
...In 1999, 73 percent...
...The truth is quite different...
...There are too many patients, too little space, and not enough doctors...
...But there's no reason to believe HMO referrals to specialists have declined since then...
...But a state auditor studied the matter and found no violations...
...His proposal instantly became his party's top priority on health care, attracted the endorsement of Republican senator John McCain, and won the support of a majority of senators...
...More mandates would inject rigidities—and more paperwork—into an HMO system that is working...
...Emergency doctors in Maryland recently complained that claims were being denied...
...But the jackpot for trial lawyers is a provision permitting suits against both HMOs and employers in state courts—with no specific cap on damages against HMOs...
...Probably not...
...If Kennedy were correct, the public would have demanded a sweeping patients' bill of rights years ago and Congress would have swiftly approved one...
...It would permit lawsuits against HMOs only in federal court and cap pain-and-suffering damages at $500,000, but allow no punitive damages...
...Women are more likely to get them if they're in HMOs than in fee-for-service health plans...
...Fred Barnes, for the Editors...
...Kennedy-McCain would allow federal courts to award punitive damages up to $5 million...
...By "protection of doctors" who deliver their best advice, Sen...
...Forty states now require HMOs to allow disgruntled patients to appeal treatment decisions to outside physicians...
...For three election cycles, the issue was supposed to hurt Republican candidates...
...Kennedy introduced the legislation with a flurry of dema-goguery that rivaled his accusation in 1987 that Supreme Court nominee Robert Bork favored back-alley abortions and racially segregated lunch counters...
...But the health care marketplace, public opinion, and state regulation have forced drastic improvements...
...And lawsuits are bound to cause doctors to treat patients defensively by ordering unneeded treatments and tests just to ward off litigation...
...And at least one study found no evidence that HMOs are denying payments for emergency room visits...
...Under current law, doctors in HMOs can be sued in state court, though suits against HMOs themselves usually go to federal court...
...The General Accounting Office looked into this in 1997 and found no "explicit gag clauses" in HMO contracts...
...Meanwhile, the use of CT scans jumped 15 percent from 1998 to 2000 and MRIs rose 20 percent...
...What's needed are federal mandates to insure the needs of patients trump the quest for profits— mandates backed up by the threat of lawsuits against HMOs and employers...
...There, judges can order benefits be paid, but they cannot award punitive damages...
...The Kennedy-McCain bill is especially egregious in promoting lawsuits...
...There's simply not much empirical evidence, on any of these issues, to justify a patients' bill of rights...
...Indeed, the Congressional Budget Office found in a 1998 study that health care plans, including HMOs, paid 90 percent of the patients' costs in clinical trials...
...But of course he's not correct...
...Diagnostic tests...
...Would HMOs have done this on their own...
...One of the largest HMOs, UnitedHealth-care, which covers about 8.6 million people, announced recently that patients could go directly to specialists without a referral from a primary care physician...
...Advocates of a patients' bill of rights insist these reforms aren't sufficient...
...In fact, most states require HMOs to pay...
...Clinical trials of experimental medicines and treatments...
...What about emergency care...
...Sure, a decade or so ago there were plenty of examples of care denied as HMOs struggled to accommodate a tidal wave of new patients...
...But Frist-Breaux looks good only in comparison with Kennedy-McCain...
...Here's what he said: "Whether the issue is diagnostic tests, specialty care, emergency care, access to clinical trials, availability of needed drugs, protection of doctors who give patients their best possible advice, or women's ability to obtain gynecological services—too often, in all these cases, HMOs and managed care plans treat the company's bottom line as more important than the patient's vital signs...
...Heart attack survivors are far more likely to get beta blockers if they're in HMOs...
...But the point is that, for whatever reason, HMOs have corrected glitches, abandoned dubious practices, and upgraded their level of medical care...
...As often as not, HMOs have expanded coverage and instituted safeguards only under pressure, including pressure generated by the drive for a national patients' bill of rights...
...And a Johns Hopkins study found that patients who see a primary care physician at an HMO are 66 percent more likely to be sent to a specialist than are fee-for-service patients...
...Most Republicans, President Bush included, are running scared on a patients' bill of rights...
...All this doesn't mean HMOs have been transformed into lovable organizations whose sole concern is their patients...
...It didn't...
...The White House favors the alternative measure sponsored by GOP senator Bill Frist and Democratic senator John Breaux...
...Then trial lawyers could sue these deep-pocket defendants in the very courts where, currently, they often win outlandish damages...
...True, the Hopkins survey was based on slightly dated information from 1989 to 1994...
...Specialty care...
...Availability of needed drugs...
...Now, patients in many HMOs have access to generics as well as branded drugs, even ones that aren't on a preferred list...
...You're better off in an HMO if paying for prescription drugs is a problem...
...Other HMOs have what are known as "open access products," which offer quick access to specialists for a slightly higher co-payment...
...Now, the good news is that while Senate majority leader Tom Daschle has refused to bargain away any of Kennedy-McCain, the president has promised a veto if it passes...
...Most insurers handle these on a case-by-case basis, and routine costs are generally covered...
...The only difference is a higher co-payment for branded drugs...
...There are no contrasting figures on these tests for HMOs and other health plans...
...The idea was to keep costs down and encourage the growth of HMOs, and it worked...
...As for "women's ability to obtain gynecological services," it's greater in HMOs...
...The result: Today, most patients get more and better medical care in HMOs than they've ever had before...
...Take mammograms...
...The crisis in emergency rooms is not that HMOs are refusing to pay for treatment...
...The trouble here is the unintended consequence: higher costs and fewer patients covered as strapped employers drop health coverage...
...Let's examine Kennedy's list...
...Kennedy was presumably referring to alleged gag rules that bar doctors from recommending certain costly treatments...
...And women in Medicare HMOs have a better chance of having breast cancer detected at an earlier date, an American Medical Association study concluded in 1999...
...For America's health care system, stalemate on a patients' bill of rights is just the right medicine...
...Federal law already requires emergency rooms to treat all patients who show up...
...For starters, women are more likely to have OB/GYN physicians as their primary doctors in HMOs...
Vol. 6 • June 2001 • No. 39
