Overview
Our health insurance system has changed dramatically over the past several years, and so has the way patients interact with providers and payers. Today, most consumers are insured through health plans that seek to manage the cost of, access to, and quality of care. AHA recognizes the need to better manage the quality and cost of care, and supports this movement. But sometimes these insurance arrangements make it difficult for consumers to access the care they need.
In response to these legitimate public policy concerns, state and federal legislators have introduced a plethora of proposals aimed at addressing these issues. Following is a list of current issues at the heart of this debate and a statement of AHA's view.
Summary of Issues
The AHA Supports Legislative Provisions that Would:
- Ensure Access To Emergency Care. Health plans should be required
to cover and pay for emergency services - both screening services to
determine if an emergency medical condition exists, and stabilization
if necessary - using the "prudent layperson." This standard suggests
that when someone is concerned about a potential emergency they should
be able to count on coverage of services to determine if they have an
emergency with no prior authorization.
Rationale:
Individuals should not hesitate to seek emergency care because they fear the care will not be covered. Assuring coverage without prior authorization in situations where the individual believes an emergency exists will help remove this doubt.
- Ensure Direct and Timely Access to Needed Services. Prior authorization requirements should not be an obstacle for obtaining necessary care in the following areas:
- Women should have direct access to obstetricians and gynecologists and other providers of women's services for routine women's health services.
- Children should have direct access to pediatricians as primary care providers
- Those with long-term chronic conditions, under certain circumstances,
should have standing referrals to the specialists they need for their
condition
Rationale:
Requirements that persons seek prior authorization from a primary care provider when it is clear what type of specialist is needed are unnecessary. They delay necessary treatment and waste the patients' and practitioners' time. In addition, they could result in lower quality or inappropriate care because the primary care provider may not be very knowledgeable about the specific condition. In fact, individuals with long-term chronic conditions are often more familiar with their own special needs than primary care doctors.
- Ensure Provider Participation in Developing Utilization Review
Standards and Appeals. The utilization review process should require
providers to participate in developing protocols for utilization review,
several levels of review, and at least one opportunity for a practitioner
to present their case to a provider who is in the same or a similar
specialty. If disputes arise in the appeals process regarding the application
or appropriateness of medical necessity definitions, the patient or
their provider should be referred to an external appeal process.
Rationale:
To ensure appropriate, clinically based management of care, the process for managing utilization of services and coverage should ensure that providers of care help develop the criteria for determining coverage decisions and standards for determining how the criteria will be applied.
- Ensure Continuity of Care. Plans should be required to continue
to cover patients who are in the middle of active treatment, as well
as pregnant women in their second or third trimester until the treatment
is no longer necessary up to a set period of time. In the event a provider
leaves or is terminated from the health plan, all current coverage and
plan management requirements should still apply to the provider and
enrollee.
Rationale:
One of the primary criticisms of managed care is that providers included in approved networks often change. Patients should not bear the burden of these management decisions. Forcing a person to see a provider who is not familiar with their condition in the middle of treatment or pregnancy could result in diminished quality and increased cost. This assurance addresses the problem without restricting the health plan or provider's ability to sever the contract.
- Expand Agency for Health Care Policy and Research's Role in Quality
Measurement to Encourage Partnership with Private Sector. Legislative
provisions aimed at improving quality measurement should focus on research
on appropriate measures and emphasize partnerships with those delivering
care. Legislation should not leave the specifics of quality measurement
to the sole discretion of a single regulatory agency.
Rationale:
Measuring quality, particularly outcomes, is in its infancy. AHA believes that the public sector should play a major role in supporting research on quality measurement. This research should be done in partnership with those delivering services. We believe the Agency for Health Care Policy and Research (AHCPR) is best suited for this role. Therefore, we support measures that would expand the role of AHCPR and provide the necessary resources.
We do not support open-ended discretion given to the Secretary of Health and Human Services to develop specific measures. Previous legislative proposals relied too heavily on secretarial discretion to determine which performance measures were appropriate and how they should be implemented. Legislation should create the opportunity for federal regulators to work with the private sector, not dictate requirements.
- Create the Opportunity to Appeal to an External Panel. Require
health plans to allow patients to access review panels outside that
health plan if they have exhausted their internal appeal rights. The
appeals board should be certified using standards that require clinical
knowledge and objectivity. The external panel should be required to
base their judgement, to the extent possible, on scientific evidence
regarding safety, effectiveness, and appropriateness of treatment. They
should also consider the specific condition of the patient and the experience
of the practitioner.
Rationale:
Giving patients the option of appealing to a review panel outside their health plan creates the ability for both the plan and the individual to present their case in front of a neutral third party. It may also act as a timelier alternative to court action for settling a dispute. If legislators seek to establish medical necessity criteria, the external appeals process is the appropriate setting to outline the types of evidence to consider.
The AHA Is Concerned About Legislative Provisions that Would:
- Create Special Protections for So-Called "Whistleblowers."
Provisions that mandate special protections from retaliation for hospital
and health plan employees and contractors erroneously assume: employees
do not currently have the ability to report quality problems, and employees
should be encouraged to "go public" with what may turn out to be patently
false claims.
Rationale:
Many mechanisms are already in place for such quality-problem reporting to occur through internal quality departments, state licensing boards, state health departments, and the JCAHO. Disgruntled employees could use any protections made available to make accusations and cause harm, even if it is subsequently determined that these accusations are not true.
- Establish Legislative Definitions of Medical Necessity. Determinations
regarding medical necessity of care should be left to those who are
closest to the delivery, management, and coverage of care. They should
not be defined in legislation, nor left solely to the discretion of
an individual practitioner. It may be appropriate for legislation to
outline the criteria external appeals boards would use to determine
medical necessity.
Rationale:
The desire for such a definition is understandable. Some managed care plans have denied coverage for services that many would recognize as "medically necessary." But managed care has the potential to encourage more uniformity and excellence in the practice of medicine by encouraging physicians to keep up with the latest medical research and best practices. We recognize this often results in a struggle between plans and providers, but believe it can be a positive struggle - often resulting in improved delivery of care.
- Expand ERISA Remedies Through State Laws by Creating New Liability
for Employers and Plans (Right to Sue). Remedies under ERISA should
be enforced through the federal ERISA law, not through state law. In
addition, any expansion of liability should be carefully crafted to
ensure adequate due process and to discourage frivolous lawsuits.
Rationale:
It is reasonable to discuss expansion of the remedies under ERISA. They are very limited. However, jurisdiction over ERISA plans should remain at the federal level. Proposals that give states the ability to regulate ERISA plans could create tremendous new liability for ERISA plans which could extend to the hospitals and health systems with which they contract. They will also create a new patchwork of regulations for the many companies that operate across state lines.
Any legislative proposal must weigh the cost of expanded liability with the benefit of broader consumer and health care provider redress.
- Mandate Point-of-Service Offering. Legislation should not include
requirements that health plans offer a point-of-service plan.
Rationale:
These requirements put provider-based "closed" networks at a disadvantage in the market. Requiring a point-of-service option limits a health plan or provider plan's ability to select only the best caregivers for its network. Consumers should have as many choices as possible, and the closed "option" should be one of them.
