Encouraging Step In Right Direction

When Americans pay for health insurance coverage they expect to get what they pay for: coverage. Americans and their physicians have become fed up with health plans that split hairs over coverage obligations, block patients from consulting specialists and interfere with a treating physician’s recommendations for care.

When insurance companies do these things they are practicing medicine. But their goal is healthier balance sheets, not healthy patients. Insurance carriers employ doctors who never see the patients; their only job is to cut costs, by second-guessing clinicians.

Tactics like these have prompted outcries from the public and reform proposals from the nation’s lawmakers.

In Washington, the state medical association has asked the Legislature to require that insurance company medical directors be licensed to practice medicine in the state, which would make them subject to professional discipline when their decisions hurt people. So far, insurance companies have blocked this proposal.

But state reforms can’t apply to those who get health coverage from big, self-insured, multistate corporations. If Congress changes federal law, however, it might apply to everyone.

Last week, Congress took a positive step.

After months of debate, a group of House Republicans and Democrats announced agreement on a bipartisan managed care reform bill, to be submitted for a floor vote next month. Key players in the deal were several Republican members who also have backgrounds as clinicians - such as Charlie Norwood, a dentist, and Tom Coburn, a physician.

The bill won applause from Democrats, including President Clinton, who has criticized a weaker bill passed in the Senate.

The bipartisan House proposal would entitle patients to appeal to an independent committee of physicians when an insurance company refuses to cover treatment that the patient’s doctor recommends. The independent committee’s conclusion would be binding.

Also, the bill would allow patients to sue insurance carriers in state courts if patients are hurt by a refusal to cover treatment to which they were entitled under their policy’s terms.

Permitting damage lawsuits against insurers is the bill’s most controversial provision. If the goal is to make insurers provide coverage of the care patients need, the independent medical review boards seem most constructive. The fear of lawsuits and costly verdicts also might prod insurers in the right direction. But lawsuits, by definition, come after patients have been hurt. Preventing harm is a better goal.

This battle isn’t over. But Congress has brightened the outlook for all who want insurance to provide coverage, not headaches.