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The Spokesman-Review Newspaper
Spokane, Washington  Est. May 19, 1883

Precedence/Priorities Don’t Be Surprised If You, Too, Discover, ‘I Don’t Count’ Reform: Providers Must Not Have All The Say

Adrienne Mitchem Knight-Ridder

Americans are experiencing a true crisis of confidence in today’s managed care industry. Recent failures in the marketplace putting industry giants Oxford Health Plan and Columbia/HCA under intense scrutiny have only increased skepticism. Consumers’ faith has been shaken because of signs that managed care may be sacrificing quality health care to boost profits.

The fear voiced by Kim Little, a leukemia survivor from Texas, is all too common. Although Little credits her current treatment regimen with saving her life, she has been caught in a nasty showdown with her future insurance carrier about whether they will pay for her to continue those treatments when she is forced into a managed care plan later this year.

“The message that I was getting is that I don’t count, that profit is the bottom line. That’s what society values and everybody knows that. ‘How dare you make us pay for a treatment that’s going to save your life?”’ said Little, recalling the exhausting battles she had with the managed care industry.

“It was just dehumanizing to be told that over and over and over,” she said. “It is kind of an impersonal bureaucracy. Your life is at stake, and it’s just spiraling out of control.”

As managed care replaced the old fee-for-service system, the financial incentives driving this industry have turned upside down. This revolution, replacing incentives to over-treat patients with incentives to under-treat, has provoked a strong backlash. Nearly three in five Americans in a recent poll believe managed care plans make it harder for people who are sick to see a specialist. Consumers increasingly sense profits are being valued over quality of patient care.

But this revolution also creates an opportunity to reintroduce a simple and old-fashioned idea: consumer protection. Responding to grassroots uprisings, states have passed laws giving consumers tools to help them be smart shoppers, ensure accountability when costly mistakes are made, provide more access to specialist and emergency care, and guarantee a fair system to review patient disputes.

A presidential advisory commission recently developed another good idea: a “Consumer Bill of Rights.” This initiative has spurred a flurry of bill introductions on Capitol Hill and the promise of a healthy debate about nationwide reforms.

On one side is a multi-million dollar scare campaign, funded by industry, designed to preserve the status quo. On the other, a coalition of consumer groups and individual Americans who have been burned by the current system and want change.

A scorecard of principles for reform from Consumers Union will help measure who wins:

The linchpin for consumers is an appeals system that gives patients access to an independent entity to settle disputes over medically necessary care when benefits are denied, terminated or delayed. The current system, where the managed care company serves as both judge and jury for every appeal, is stacked against patients.

Another vital component is full disclosure. Plans should be required to provide consumers with information to help them understand all their alternatives for treatment, not just the cheapest.

Consumers also want assurance that they will not be holding the bag for medical mistakes. Families shouldn’t shoulder the financial burdens of medical negligence because industry is unaccountable for its actions.

Finally, a consumer bill of rights should set minimum standards for all managed care plans. Voluntary provisions won?t suffice. When you get sick, doctors - not accountants - should call the shots.

Too many of the 160 million consumers in managed care plans today find they cannot choose the doctors they want for the care they need, and confidence in the managed care system has been eroded as a result. Congress can restore consumer confidence in the managed care system by passing enforceable and loophole-free legislation which includes a fair review process, full disclosure and accountability. Anything less falls short of true reform.

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