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PATIENT PROTECTION PASSES IN HOUSE

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WASHINGTON-Congress is one step closer-with several crucial steps to go-to passing patient protection legislation.

After hours of highly emotional and often highly partisan debate, the House of Representatives Friday passed legislation-developed by a Republican task force-to give patients, especially those in managed care plans, new rights. The bill passed 216-to-210.

The Senate could vote on somewhat different bills as soon as this week, though it is possible Senate consideration could be delayed until after the August congressional recess.

Among other things, the House bill would give patients in traditional health maintenance organizations the right to obtain coverage through point-of-service options, as well as direct access to obstetricians/gynecologists and greater likelihood of receiving coverage for emergency room treatment.

The bill, H.R. 4250, also would set up a new system of internal and external review of health care plan coverage decisions, as well as making it easier for small employers to band together to self-insure their health care risks.

Passage of the bill sets the stage for the Senate to consider somewhat different measures developed by members in that body.

Judging, though, by the tone of the debate on the House floor, reaching a final agreement on a bipartisan bill in the remaining few weeks of the session could be extraordinarily difficult.

Democrats opposed to the House Republican bill described it as a sham.

"It is a fake. It is a charade. It is cosmetic. This is a bill with rhetoric and without a remedy," said House Minority Leader Richard Gephardt, D-Mo.

"It does nothing fundamental to fix the problem," said Rep. Vic Fazio, D-Calif.

Other congressional Democrats condemned the unusual process in which the House directly voted on the bill, bypassing committee consideration.

"I am outraged by the process in which we are considering this legislation," said Rep. Ben Cardin, D-Md.

House Republicans, though, highlighted the key difference between the Democratic bill, which would allow patients to sue health care plans and employers for damages under state law for coverage decisions, and their own measure, which does not.

The Democrats' bill "is for trial lawyers seeking to enrich themselves at the expense of everyone else," said Speaker of the House Newt Gingrich, R-Ga.

"Patients should be treated in hospital rooms, not courtrooms," added Rep. Dennis Hastert, R-Ill., who led the House Republican health care task force.

But the closeness of the vote and the partisan nature of the debate means that coming up with a compromise measure both sides can agree on and that can be signed by President Clinton could be difficult, observers say.

"While there is a consensus that something must be done to prevent HMO abuses, there is not yet a consensus on how to do this," said Henry Saveth, an attorney with William M. Mercer Inc. in Washington"

Still, some members say they will work together to get a bill passed. "The need for reform is more important than Democratic and Republican posturing. I will support whatever survives," said Rep. James Traficant, D-Ohio.

Under the House Republican bill passed last week, closed-panel HMOs would be required to offer employers a POS option. Employers, though, could reject the POS option for their plans at the time they purchase coverage. If an employer declined the POS option, the HMO would be required to offer a POS as a supplemental coverage that could be purchased by employees.

The Republican bill also would set up a new system of internal and external review of health care plan coverage decisions. For example, a patient could appeal a coverage denial decision involving medical necessity to a "named fiduciary," who must be a physician and who must not have been involved in the initial coverage decision.

If dissatisfied with the internal review decision, the patient could appeal that decision to an external panel comprised of independent medical experts. The legislation sets various procedures for selecting independent reviewers. If a health care plan failed to abide by an external reviewer's decision, a patient could go to court to seek damages. Those damages-awarded at a court's discretion-could be as much as $500 a day until the failure to provide the benefits is corrected. The maximum penalty would be $250,000.

Other provisions in the House Republican bill would exempt trade association health care plans from state regulation; allow employers of any size to offer tax-favored medical savings accounts; and cap non-economic damages in malpractice suits at $250,000.