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Advocacy for Accountability: Practice’s Integrated Agenda

Russ Newman, Executive Director
APA Practice Directorate

The central mission of the APA Practice Directorate is to advocate on behalf of practicing psychologists. The activities leading up to the U.S. House of Representatives adopting legislation giving patients the right to sue their managed care organization for negligent care provides a good example of how the Directorate’s integrated legislative, legal, marketplace, and consumer education strategy is working to shift the focus of our rapidly evolving health care toward a better balance – away from cost and toward quality.

As the House of Representatives prepared to debate patient protection bills in early October, the center of controversy was clear: whether to include the right to sue negligent managed health plans. When APA first proposed legislative language four years ago to establish plan accountability, no one on Capitol Hill was much interested in taking on this battle. Rep. Charlie Norwood (R-Ga.) later emerged as a strong advocate, and the provision garnered growing bipartisan congressional support over the past couple of years.

On the other side of the issue, having spent millions on advertising, the managed care and insurance industries captured substantial media attention for its key messages: plan liability will cause a wave of litigation, drive up health insurance costs and force many employers to drop employee health benefits. APA has been working to convey contrasting messages to employers and consumers – that accountability offers a sound way of encouraging greater attention to quality and less attention to profits, and can actually serve to prevent patient injury. In the weeks preceding House deliberations, the Practice Directorate took a series of strategic steps aimed at refocusing congressional debate on the critical role of plan liability in assuring quality patient care.

This past summer, the Directorate asked PriceWaterhouseCoopers (PWC) to analyze the income that insurance and managed care companies can generate by investing the money saved while denied claims are appealed. The financial assumptions were based on a scenario reflecting the Senate Patients’ Bill of Rights Plus Act (S.1344). The PWC study found that the insurance and managed care industries could gain interest income of up to $280 million each year if as few as one percent of a year’s claims were denied and later paid after the maximum amount of time allowed by the review process. The PWC study helps make the point that managed care companies stand to make considerable money by denying even a tiny percentage of claims and waiting for the review process to overturn the decision.

On the eve of House debate, APA, joined by the Center for Patient Advocacy, ran an ad in Roll Call, a Capitol Hill newspaper. The intent was to remind Congress that little incentive exists for MCOs to provide high quality care, while considerable financial incentive exists to restrict patient access. The ad, which asks, "Do HMOs care about the treatment your family gets?," caricatures an HMO executive whose decisions to deny care through the utilization review process result in considerable company profits. The ad, and a companion fact sheet, encourages Congress to counter this financial incentive by enacting health plan accountability through the Norwood-Dingell bill (H.R. 2723).

Not unexpectedly, insurance industry representatives attempted to counter organized psychology’s efforts. The Health Insurance Association of America (HIAA) publicly criticized the PWC study of potential interest earnings from denied claims and demanded that the association issue a "correction" to our conclusions of the study.

On October 7th, the House passed a bill giving patients the right to sue and thereby forcing managed care firms to be held accountable for their actions. While the Senate managed care reform bill did not contain a similar provision – and a compromise needs to be worked out before the bill can become law – combining legislative advocacy, lawsuits, consumer education and market analysis provides the Directorate with an integrated approach to reforming the health care system with that is beginning to have an impact.

This article first appeared in the Winter 2000 Edition of the APAGS Newsletter, Vol. 12(1)

 


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