When APA's Practice Directorate first went to Capitol Hill in 1995 with language calling for managed-care companies to be accountable for their actions, there was little support, says Russ Newman, PhD, JD, executive director for practice. Initially, only Rep. Charlie Norwood (R-Ga.) saw the need to hold companies accountable.
Now, six years later, largely a result of public pressure and changes in the political landscape, the issue is highly visible. Both the U.S. Senate and the House passed patients' rights bills this summer. That's certainly progress, but progress with a hitch: The bills are different--particularly when it comes to their stance on damages for patients--and the two bodies will have to reach a compromise in a conference committee to create a final bill to bring to President George W. Bush.
"It will be interesting," says Newman. "There are new dynamics for a conference negotiation that we haven't seen in a while in Congress, if ever."
Over the years, APA and its members--in thousands of letters, phone calls, e-mails and visits to Capitol Hill--have asked Congress to reject any amendment to the patients' bill of rights legislation that would weaken patients' ability to hold insurers legally accountable for their decisions, particularly in denying payment for care.
Those pleas didn't fall on deaf ears. On June 30, the Senate approved a bill (59-36) that would give Americans in managed-care plans the right to sue managed-care companies over decisions that lead to injury or death, as well as direct access to specialists and coverage for visits to the closest emergency room.
"The public's frustration with managed care made itself felt in the Senate," says Newman.
Yet, although the Senate passed strong accountability language, the House version of the bill was weaker. In a last-minute deal with President Bush, Rep. Norwood included an amendment that imposes a cap on noneconomic damages--a provision APA advocated against and one that 27 states don't presently have. Under this type of cap, children, stay-at-home parents and people with disabilities who have no or very low economic damages, may not be afforded adequate relief for potentially devastating injuries. And according to APA officials, because the $1.5 million damages cap won't be adjusted for inflation, over the years it will erode any disincentives health plans have for creating shortcuts in the provision of care to increase profits.
"If you limit the potential judgement against negligent companies, you take away their incentive to stop cutting corners," says Newman. "The fact that it won't be adjusted further exacerbates the disincentive. Potential lawsuits must cost these companies more than simply the cost of doing business."
In effect, advocates hope that legislation will spur managed care to do the right thing from the beginning. Indeed, according to Connecticut psychologist Daniel Abrahamson, PhD, representing APA at a summer press conference sponsored by the Democratic Policy Committee, penny-pinching can hurt. He told of patients whose problems became worse because of barriers to getting authorization for or limits on treatment. He noted administrative obstacles, like "1-800 voice-mail hell" that indirectly reduce care and frustrate providers.
Despite some weakened areas of the bill, the House-passed legislation--which only passed the Bush-Norwood liability compromise by a slim margin of 218 to 213--does contain several favorable provisions that exist in the Senate version, such as patient choice of health plan, provider nondiscrimination, and internal and external review provisions for denial of treatment. APA officials intend to work to see that the conference committee's efforts will reveal a bill that looks more like the Senate version.
"This year we have seen action which clearly reflects the growing pressure for managed-care accountability," says Newman. "The pressure has continued to build, but the public needs to keep the pressure on."