[Congressional Record Volume 143, Number 38 (Friday, March 21, 1997)]
[Extensions of Remarks]
[Page E564]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




[[Page E564]]



  INTRODUCTION OF THE QUALITY HEALTH CARE AND CONSUMER PROTECTION ACT

                                 ______
                                 

                           HON. MARGE ROUKEMA

                             of new jersey

                    in the house of representatives

                         Friday, March 21, 1997

  Mrs. ROUKEMA. Mr. Speaker, I rise today to introduce the Quality 
Health Care and Consumer Protection Act of 1997.
  The past several years have seen an increasing and disturbing trend 
of the health insurance industry putting bottom-line medicine ahead of 
quality medical care. The evidence is everywhere.
  First were the documented reports that women were being discharged 
from hospitals 24 hours--even 12 hours--after giving birth. Then came 
reports of women being shown the door after having outpatient 
mastectomies. In addition, physicians are barred from telling a patient 
about a lifesaving or life-improving treatment option or specialized 
care if it is more expensive than the insurer is willing to pay. 
Doctors were literally being gagged, in violation of their professional 
oaths. Men and women are not allowed to call for an ambulance without 
receiving prior approval from their managed care plan. Enrollee records 
are not kept confidential.
  These practices, and others, spell an alarming trend in managed care. 
It would appear that managed care has allowed--or even forced--
insurance companies to place company profits ahead of patient care. To 
many of us, this smacked of third world medicine. Are we to abandon our 
historical position as the world's leader in medical care?
  As a result, many individual States have started to mandate the 
coverage that insurers must provide. While I understand the States' 
desire to protect the quality of care, I am not sure this commonsense 
regulation is best executed at the State level.
  Congress should go beyond taking these issues on a piecemeal basis 
and take broad comprehensive action. Consequently, I am introducing the 
Quality Health Care and Consumer Protection Act. Based on a series of 
proposals from Women in Government, a bipartisan group of State 
legislators from across the country, my bill represents a consensus on 
steps to ensure that managed-care networks provide high-quality, 
efficient care, not just low-cost care that boosts profits.
  I am aware that there are other health reform plans pending in 
Congress. My bill, however, goes further because it also includes the 
millions of American workers whose health plans are regulated under 
ERISA. ERISA is the Federal law that regulates large corporations that 
self-insure and these companies would be exempt from the other 
legislation pending before this House. We must provide the same high 
standard of quality of medical care for all Americans, not just some.
  This legislation would protect consumers without denying managed 
care's potential for legitimate innovation and cost control. This 
measure would return the power over medical decisions to those with the 
medical training and expertise--the doctors and the nurses.
  Better Access to Personnel and Facilities--Ensures that enrollees are 
given meaningful choice of available physicians and specialists, which 
includes reasonable access to acute care hospital services, primary 
care practitioners, registered nurses, specialists and specialty 
medical services such as physical therapy and rehabilitative services.
  Continuity of Care--Requires that enrollees are provided continued 
coverage with the established primary care practitioners for 60 days, 
when the health care professional's contract is terminated without 
cause.
  Emergency Service Coverage--Ensures that the health plan reimburse 
expenses for treatment of an emergency medical condition, when prior 
authorization was not obtained, if a prudent layperson would reasonably 
assume that the condition required immediate medical treatment.
  Adequate Choice of Health Care Professionals--Ensures that the health 
plan permit enrollees to choose their own primary care practitioner 
from a diverse list of qualified professionals who are accepting new 
enrollees. In addition, when the enrollee's medical conditions warrant 
it, the enrollee shall be permitted to use a medical specialist primary 
care practitioner.
  Point of Service Option--Ensures that the plan have an option for an 
enrollee to receive benefits by a nonnparticipating health care 
professional for an additional reasonable premium.
  Prohibition of Gag Rules--Ensures that there is open communication 
between health care professionals and enrollees.
  Coverage of Drugs and Devices--Requires that a health plan that 
provides benefits with respect to drugs and medical devices shall 
provide coverage for all drugs and medical devices approved by the Food 
and Drug Administration so long as the primary care practitioner or 
other medical specialist determines the drug or device is medically 
necessary and appropriate.
  Coverage of Experimental Treatment--If a health plan limits coverage 
for services, then the plan shall define the limitation and disclose 
the limits in any agreement of coverage. When a plan denies coverage 
for an experimental treatment, then the plan shall provide a letter 
explaining the denial, along with a description of alternative 
treatment covered by the plan.
  Quality Assurance Program--Requires that the health plan develop 
comprehensive quality assurance standards which are adequate to 
identify, evaluate and remedy problems relating to access, continuity 
and quality care.
  Data Systems and Confidentiality--Ensures that the health plan 
provide information on the plan's structure, decision making process, 
health care benefits and exclusions, cost and cost-sharing 
requirements, list of participating providers as well as grievance and 
appeal procedures to all enrollees, the Secretary of Labor, and the 
Secretary of Health and Human Services.
  Reporting of Data--Requires that the health plan report annually to 
the Secretary of Labor and the Secretary of Health and Human Services 
data including the number and types of enrollee grievances or 
complaints during the year, the status of decisions, and the average 
time required to reach a decision. In addition, the health plan must 
report the number, amount, and disposition of malpractice claims 
resolved during the year.
  Medical Records and Confidentiality--Requires that the health plans 
establish policies and procedures for keeping enrollee information 
confidential.
  Disclosure about Financial Arrangements--Requires that the health 
plan inform enrollees of the financial arrangements between the plan or 
issuer and participating providers and professionals.
  Grievance Procedures--Provides a grievance procedure that all health 
plans must follow, while also requiring that the plan provide written 
notification to enrollees regarding the right to file a grievance 
concerning denials or limitations of coverage under the plan. In 
addition, the plan shall report to the Secretary of Labor and the 
Secretary of Health and Human Services the number of grievances and 
appeals received by the plan.
  Mr. Speaker, managed care has a legitimate role to play in today's 
health care system. However, no health care system should be allowed to 
sacrifice patient care on the altar of corporate profits. The Quality 
Health Care and Consumer Protection Act makes significant steps toward 
returning medical decisions to doctors and other health care 
professionals and away from gatekeeper bureaucrats in HMO offices.
  Medical professionals for generations have worked long and hard to 
give the United States the highest standard of medical care in the 
entire world. Our physicians, nurses, and medical researchers have 
performed miracles in combating dreaded disease, repairing ghastly 
injuries, and correcting infirmities. We cannot allow green-eyeshadded 
bean counters in insurance company accounting departments to throw that 
progress away. With a health care system that is the envy of the world, 
we must not allow the United States of America to slip to third world 
standards of medicine.

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