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HEALTH CARE
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| A PUSH FOR PATIENTS' RIGHTS By Denyse Tannenbaum See sidebar "Legislature |
Over the
course of a year of discomfort and pain, Patricia
Sutphin of James City County visited her
primary-care physician five times and had three
pelvic exams. Although she asked repeatedly
for a referral to a gynecologist, her doctor
refused. Sutphin's condition worsened. In
September 1997, she was in such bad shape her
primary-care physician gave her permission to go
to the hospital. It was there that an emergency
room doctor finally discovered a mass "the
size of seven videotapes" in her abdomen,
the former geometry teacher testified at the
Virginia General Assembly this past winter. |
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| Patricia Sutphin wants the General Assembly to give patients more power. |  photo by Mark Rhodes |
In her first
surgery, doctors removed the tumor, and Sutphin
remained at the hospital 11 days. But she became
incontinent after surgery. Although Sutphin
complained repeatedly, no tests were taken, and
it took months before she won permission from her
new primary-care doctor to see a urologist. The
specialist ran tests and discovered that a
bladder fistula -- an abnormal connection -- was
causing her problems. She returned to the
hospital and had a second surgery in March 1998.
Now 42, Sutphin, who lives with her husband and
teen-age son, has a bladder about 60 percent the
normal size, which she says makes it improbable
she will ever return to classroom teaching. |
Legislators listened to dozens of stories like Sutphin's during the 1999 General Assembly. The testimonies fueled hot partisan debates that raged for weeks. Prime among the controversial health care measures was a patients' bill of rights aimed at protecting people enrolled in managed-care plans. Congress also is debating health care regulations, so it's at the forefront of Virginia legislators' concerns.
"This became the session of HMO reform," says Republican Delegate Morgan Griffith of Salem.
The contentious session sparked one of the most aggressive efforts yet by the health insurance industry, with more than 170 registered lobbyists appealing to Virginia legislators. After many modifications, the General Assembly in March approved a patients' rights bill. Among its provisions is a prohibition on health plans offering financial incentives to physicians for denying care to patients. It also sets up an external appeals process for patients with grievances against their health plans.
But one particularly controversial and sensitive provision remains unresolved: "Assignment of benefits" would require health plans to pay physicians or hospitals outside their networks the same negotiated rates they pay doctors within their networks. This would apply whenever patients choose to use out-of-network doctors or hospitals, as long as those providers agree to accept the same payment the network doctors receive. Neither doctors nor hospitals are allowed to bill the patient more than the plan pays.
The "assignment of benefits" provision was passed with a re-enactment clause: The Bureau of Insurance and the Joint Commission on Health Care have one year to study the provision's potential impact on managed care businesses and patients. Legislators will vote on it again in the next session. If re-enacted, the bill will take effect in July 2000.
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Stories like Sutphin's grabbed legislators' attention. Lawmakers also had stories of their own. Griffith, one of the bill's authors, says he saw the need for such legislation in mid-1997, when Trigon was negotiating with Columbia HCA hospitals in western Virginia. Columbia HCA hospitals in that region were members of Trigon's network at the time. Talks between the two organizations faltered, however, and Trigon dropped Columbia.
Virginia Tech employees, Salem city employees and others were outraged. Many were told during benefit discussions with Trigon that they would continue to have coverage at Lewis Gale, a Columbia Hospital that is popular in Salem. Farther south, Virginia Tech employees would have had to drive past Columbia's Montgomery Regional Hospital to get to the network hospital in Radford.
"There were a lot of groups upset," Griffith says. He and other authorities worked out an administrative solution with Trigon to allow state employees to go to either hospital. But the deal didn't help city employees or Griffith's other constituents. So the legislator introduced "any willing provider" legislation. The legislation meant that any doctor willing to accept the same reimbursement and terms offered to doctors within an HMO or other managed-care network can become part of that network.
"We felt we ought to look at it primarily as a sword to hang over the heads of the HMOs," Griffith says. "We wanted to send a message that says, 'You all need to try to deal with people in less of a high-handed fashion.'"
In its current form, the legislation makes it a little harder for patients to go outside of their networks. But it still gives the patient control.
* * *
The business and insurance communities have a different take on the legislation. They warn of potentially damaging repercussions to small health-insurance companies and, for Virginians, an inevitable rise in the cost of coverage.
Richmond-based Trigon Health Services Inc., the Virginia Association of Health Plans, the Virginia Chamber of Commerce and scores more registered lobbyists fought hard against such legislation. Their work helped dress down the "any willing provider" legislation into its current "assignment of benefits" bill, and they hope that in the coming year they will persuade the Joint Commission on Health Care and the Bureau of Insurance that the current bill also should be defeated. "It is not as threatening," says Brooke Taylor, Trigon vice president of media relations, "but believe me, this is not something we think is a good idea."
HMOs are able to contain the otherwise accelerating cost of health care because they offer physicians incentives to join their health plans. This is in exchange for the doctors' acceptance of often lower fees for services. The doctors who join are assured a steady stream of patients and timely payments. If a physician outside an HMO gets all these benefits without other obligations or restrictions, the HMO loses its leverage to develop networks and negotiate costs -- and will ultimately go out of business, the HMO proponents argue.
"We are vigorously opposed to the broad assignment of benefits provision," Taylor says. "It's bad policy. Why would you give someone the benefits of being a contracted provider if they don't actually contract for you?"
Health insurance premium rates rose between 18 percent and 20 percent annually before the advent of managed care, Taylor recounts. "Building networks is what helped to bring the costs down, and now to start chipping away at the networks around the edges by saying providers get the same benefits outside as inside -- it will serve to weaken the networks."
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Proponents of the bill are betting it will be re-enacted.
Moreover, the negative implications of the bill are highly exaggerated, says Bill Cimino, spokesman for the Medical Society of Virginia, which represents 6,800 doctors statewide. "I don't think this will be the death knell of HMOs, as some of the HMOs might be predicting," Cimino says.
Few other states have experience with the assignment of benefits system, but those that have implemented similar regulations have not seen any substantial consequences either to health care costs or the ability of HMOs to do business. In fact, in practice, very few patients likely will take advantage of the new law, Cimino predicts.
"Is this really going to have a tremendous impact?" he asks. "The process has been the same, except in extreme cases. While this applies to everyone, the percentage of people who actually are affected will be very few indeed."
LEGISLATURE SAYS
'NO' TO Business groups and insurance lobbyists are cheering the defeat of a bill that would have allowed patients to sue their health insurance plans for denying services. "It was like a phoenix kept showing up and then disappearing and coming back again," says a relieved Sandy Bowen, executive vice president of the Virginia Chamber of Commerce. The chamber was concerned that plan liability would add litigation to an already overburdened court system -- without providing better health care. "We need more tort like we need to be shot," she says. Trigon Health Services Inc., the largest health insurer in Virginia, warned that the liability provision would increase litigation and raise insurance costs. "Everyone knows that physicians have practiced defensive medicine because of malpractice, which adds to the cost," says spokeswoman Brooke Taylor. "You would probably see that happen with health plans, too." Despite the bill's defeat, many remain convinced that patients need the right to sue their health plan. At the heart of the issue is the belief that a managed-care medical director's judgment against a surgery or treatment could cause health complications -- and worse. Some suggest denying coverage is tantamount to denying care. Those who argue for plan liability, such as the Newport News-based National Patient Advocate Foundation, say some cases cannot be resolved without at least the threat of a lawsuit. For example, foundation representatives used attorneys in 25 percent of the roughly 2,000 cases they handled nationwide last year. "We've never had to go to court and sue, but we have had to threaten legal action to ultimately get the care," says President Nancy Davenport-Ennis. "Our contention is that you can go into a good external appeal, but what about the patient whose disease is so aggressive that without immediate answers they are going to be dead?" Trigon instituted an external review process for patients with grievances. The company had 231 requests for external review in the first nine months of 1998, Taylor says. A decision was overturned in 22 percent of those reviews. "It's a very small percentage of cases," Taylor says. "To immediately jump to liability is a rather radical solution to a small problem." Morgan Griffith, a Republican delegate from Salem who voted against plan liability, hopes the external independent review process favored by the General Assembly will help patients get satisfaction when health-plan directors make bad decisions. But he and like-minded colleagues will vote to allow lawsuits next year if the review process fails to fairly address patients' grievances. "What I'm hoping will occur with this compromise is that we will be able to get people the treatment they need without having to worry about lawsuits," he says. "If this doesn't work, we'll be facing that liability issue again." -- Denyse Tannenbaum |
© May 1999, Media General Business Communications, Inc.
publisher of Virginia Business Magazine