MANAGED CARE UPDATE

Fall Preview on Health-Care Legislation

by Randolph Brooks, O.D. 

This fall should be an interesting season in Washington, D.C. That's not because the leaves will change color earlier due to the drought on the East Coast. Something else appears to be changing in our nation's capital: Congress' desire to regulate health insurers. It's getting stronger, and could result in legislation before all the leaves fall from the trees.

Of course, as optometrists we serve multiple roles: health-care providers, health-care consumers and small employers. So, we want to make sure that Congress enacts reasonable legislation that protects our patients and our role in providing health care.

The bill receiving most of the attention is the Republican-sponsored Senate bill passed last month. One of the largest debates concerning this bill was the Republican contention that it just covers so called ERISA (Employee Retirement Income Security Act) plans. ERISA plans are self-funded, large corporations that provide health-care coverage across state boundaries and are not subject to state laws and regulations that govern insurance companies and managed-care organizations. Nearly 50 million Americans are covered by such plans.

ERISA plans have been troublesome for optometry for several reasons. Our main concern is that there has been provider discrimination. For example, the plan might cover a service when provided by an ophthalmologist, but not when provided by an optometrist. This has happened throughout the country, and efforts to resolve coverage issues have often resulted in both patients and providers hitting the proverbial brick wall.

Another problem: We often can't identify these plans until they've denied a claim. We can always bill the patient, but this isn't pleasant. Neither of us knew the plan would not cover the service.

The Republicans believe there already is sufficient regulation on a state level for commercial insurance carriers and that additional protections for patients and doctors are necessary for ERISA-type plans. The current Senate bill does include an amendment prohibiting provider discrimination. The Senate Democrats unsuccessfully sought a broader bill that would have included patient protection and provider non-discrimination language that applied to all plans.

The Senate bill is now in the House of Representatives, where another bill seems to be gathering steam. Rep. Charles Norwood, D.D.S., (R-Ga.) who tried to pass the Patient Access to Responsible Care Act (PARCA) last year, has teamed up with Rep. John Dingle (D-Mich.). The Norwood/Dingle bill (HR 2723) is broader than the Senate bill, and appears to have some bipartisan support. The American Medical Association recently endorsed the bill.

Reps. Tom Colburn, M.D., (R-Okla.) and John Shadegge (R-Ariz.) also are looking to develop meaningful patient-protection legislation. A blending of several of these bills appears possible. From all indications, the House is more likely to want to extend patient protection and freedom of choice as well as provider non-discrimination not only to self-funded ERISA plans, but to commercial managed-care organizations as well.

Another major issue: extending liability to insurers and MCOs for decisions about coverage of care. While the Republicans want to narrowly define liability, the Democratic bills would give patients broader rights to sue managed-care plans that deny coverage of certain procedures and thus, cause the patient harm.

We'll watch with interest as the political dynamic plays out these next few months. Expect to see newspaper ads from coalitions of physician groups and insurance companies. Optometry, meanwhile, hopes to achieve meaningful provider non-discrimination language that would apply to both ERISA and commercial managed-care plans.

Look for action on the House floor this fall. And, you can be sure that President Clinton wants to leave office with a legacy that includes meaningful health-care legislation. In the meantime, we must let our legislators know of our concerns for both our profession and patients before the trees in Washington lose their leaves.

Send questions to Dr. Brooks c/o Review of Optometry, 201 King of Prussia Road, Radnor, PA 19089; or e-mail them to reviewofoptometry@jobson.com.