[Congressional Record Volume 143, Number 57 (Tuesday, May 6, 1997)]
[Senate]
[Pages S4000-S4004]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRASSLEY (for himself, Mr. Conrad, Mr. Helms, Mr. D'Amato, 
        and Mr. Durbin):
  S. 701. A bill to amend title XVIII of the Social Security Act to 
provide protections for Medicare beneficiaries who enroll in Medicare 
managed care plans, and for other purposes; to the Committee on 
Finance.


           the medicare patient choice and access act of 1997

  Mr. GRASSLEY. Mr. President, I rise today to offer bipartisan 
legislation to provide Medicare beneficiaries with the necessary tools 
and protections they need to choose the right health plan under the 
Medicare program for their individual health care needs. The bill I am 
introducing today, with my Democratic colleague, Senator Conrad, whom I 
have had the pleasure to work with on many issues, is entitled the 
Medicare Patient Choice and Access Act of 1997. I am also joined by my 
Republican colleagues, Senator D'Amato and Senator Helms, and my 
Democratic colleague from Illinois, Senator Durbin. Similar legislation 
has been introduced in the House by Representatives Coburn and Brown. 
Representative Coburn's bill currently has 91 cosponsors and has strong 
bipartisan support.
  The bill I am sponsoring accomplishes a number of important 
objectives for Medicare beneficiaries and for the success of the 
Medicare program. We often talk about providing more choices of health 
plans for Medicare recipients, but we rarely discuss what they need to 
make the right choice. As Congress examines ways to encourage more 
options for Medicare beneficiaries through the growth of managed care, 
it is critical that there is a trusting relationship between Medicare 
enrollees and their health plans. Medicare is a Federal program. 
Therefore, it is our job to ensure that health plans participating in 
the Medicare program provide quality care to our Nation's elderly. 
Medicare recipients look to Congress to hold health plans accountable. 
The legislation I am introducing will encourage plans to compete based 
on the quality of care they provide and will give beneficiaries the 
necessary information they need make an informed choice.
  The bill includes the following provisions: Provides beneficiaries 
with standardized consumer-friendly charts to compare health plans in 
their area (information such as disenrollment rates and appeals denied 
and reversed by plans are included in these charts); ensures that 
beneficiaries will receive fair treatment when health plans deny care 
by establishing a uniform and timely appeals process for managed care 
plans participating in Medicare; creates an atmosphere of trust between 
beneficiaries and their providers by prohibiting the use of gag clauses 
which restrict communications between providers and their patients; 
provides beneficiaries with the assurance that their health care 
provider

[[Page S4001]]

will refer to specialists, when medically necessary, by expanding 
Medicare's restriction on the use of financial incentives in managed 
care to include not just physicians but all providers; given patients, 
especially those individuals who require specialized care, the 
assurance they will be able to see a specialist, as medically 
necessary, when they are enrolled in a managed care plan; and offers 
beneficiaries more choices by guaranteeing they will have the option, 
at the time of enrollment, to select a plan with coverage for out-of-
network services (point-of-service plans are the fastest growing health 
plans in the private sector).

  Many of the provisions in this bill are supported by research 
conducted by the General Accounting Office [GAO] and the Institute of 
Medicine [IOM]. In the Senate Special Committee on Aging, which I 
chair, we recently held a hearing on the importance of detailed health 
plan information in holding health plans accountable and improving the 
quality of care delivered. We heard from large health care purchasers 
such as the California Public Employees Retirement System [CalPERS] and 
Xerox Corp. on ways Congress could improve the Medicare program by 
providing comparative, standardized, information on participating 
health plans. We heard from the GAO and the IOM about ways the Health 
Care Financing Administration could be more cost-efficient by requiring 
that health plans standardize their information. These witnesses 
highlighted the costliness of high disenrollment rates among health 
plans and how rates are significantly reduced when beneficiaries are 
given accurate and detailed comparative information on available health 
plans.
  Most importantly, we heard from a recent Medicare beneficiary and a 
representative of a Medicare Insurance Counseling Assistance program on 
the lack of reliable, comparative information under the current 
Medicare program. The consistent theme from all these witnesses was the 
importance of trust between Medicare beneficiaries and their health 
plans. This trust in the program does not exist today, particularly in 
areas experiencing a rapid growth in managed care. However, by enacting 
the bill I am offering today which includes several incremental changes 
to the Medicare program, Congress can help to establish trust and 
rebuild confidence among our Nation's seniors in the Medicare program.
  Many of the provisions in this bill are strengthening current law or 
providing beneficiaries protection in statute in addition to 
regulation. I believe it is the responsibility of Congress and 
administration to ensure that our Nation's elderly are getting quality, 
cost-effective care under the Medicare program. I urge my colleagues on 
both sides of the aisle to join me and Senator Conrad in cosponsoring 
this very important bipartisan legislation.
  Mr. President, I ask that a summary and full text of the bill be 
printed in the Record.
  There being no objection, the items were ordered to be printed in the 
Record, as follows:

                                 S. 701

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Medicare Patient Choice and 
     Access Act of 1997''.

     SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) There should be no unreasonable barriers or impediments 
     to the ability of individuals enrolled in health care plans 
     to obtain appropriate specialized medical services.
       (2) The patient's first point of contact in a health care 
     plan must be encouraged to make all appropriate medical 
     referrals and should not be constrained financially from 
     making such referrals.
       (3) Some health care plans may impede timely access to 
     specialty care.
       (4) Some contracts between health care plans and providers 
     may contain provisions which impede the provider in informing 
     the patient of the full range of treatment options.
       (5) Patients cannot make appropriate health care decisions 
     without access to all relevant information relating to those 
     decisions.
       (6) Restrictions on the ability of health care providers to 
     provide full disclosure of all relevant information to 
     patients making health care decisions violate the principles 
     of informed consent and the ethical standards of the health 
     care professions. Contractual clauses and other policies that 
     interfere with communications between health care providers 
     and patients can impact the quality of care received by those 
     patients.
       (7) Patients should have the opportunity to access out-of-
     network items, treatment, and services at an additional cost 
     to the patient which is not so prohibitive that they are 
     deterred from seeing the health care provider of their own 
     choice.
       (8) Specialty care must be available for the full duration 
     of the patient's medical needs when medically necessary and 
     not limited by time or number of visits.
       (9) Direct access to specialty care is essential for 
     patients in emergency and nonemergency situations and for 
     patients with chronic and temporary conditions.

     SEC. 3. PROTECTION FOR MEDICARE HMO ENROLLEES.

       (a) In General.--Section 1876 of the Social Security Act 
     (42 U.S.C. 1395mm) is amended--
       (1) in subsection (c)(1), by striking ``subsection (e)'' 
     and inserting ``subsections (e) and (k)''; and
       (2) by adding at the end the following:
       ``(k) Beneficiary Protection.--
       ``(1) Assuring adequate in-network access.--
       ``(A) Timely access.--An eligible organization that 
     restricts the providers from whom benefits may be obtained 
     must guarantee to enrollees under this section timely access 
     to primary and specialty health care providers who are 
     appropriate for the enrollee's condition.
       ``(B) Access to specialized care.--Enrollees must have 
     access to specialized treatment when medically necessary. 
     This access may be satisfied through contractual arrangements 
     with specialized health care providers outside of the 
     network.
       ``(C) Continuity of care.--An eligible organization's use 
     of case management may not create an undue burden for 
     enrollees under this section. An eligible organization must 
     ensure direct access to specialists for ongoing care as so 
     determined by the case manager in consultation with the 
     specialty health care provider. This continuity of care may 
     be satisfied for enrollees with chronic conditions through 
     the use of a specialist serving as case manager.
       ``(2) Out-of-network access.--If an eligible organization 
     offers to members enrolled under this section a plan which 
     provides for coverage of items and services covered under 
     parts A and B only if such items and services are furnished 
     through health care providers and other persons who are 
     members of a network of health care providers and other 
     persons who have entered into a contract with the 
     organization to provide such services, the contract with the 
     organization under this section shall provide that the 
     organization shall also offer to members enrolled under this 
     section (at the time of enrollment) a plan which provides for 
     coverage of such items and services which are not furnished 
     through health care providers and other persons who are 
     members of such a network.
       ``(3) Grievance process.--
       ``(A) In general.--An eligible organization must provide a 
     meaningful and expedited procedure, which includes notice and 
     hearing requirements, for resolving grievances between the 
     organization (including any entity or individual through 
     which the organization provides health care services) and 
     members enrolled with the organization under this section. 
     Under that procedure, any member enrolled with the eligible 
     organization may, at any time, file a complaint to resolve 
     grievances between the member and the organization before a 
     board of appeals established under subparagraph (C).
       ``(B) Notice requirements.--
       ``(i) In general.--The eligible organization must provide, 
     in a timely manner, to an enrollee a notice of any denial of 
     services in-network or denial of payment for out-of-network 
     care.
       ``(ii) Information required.--Such notice shall include the 
     following:

       ``(I) A clear statement of the reason for the denial.
       ``(II) An explanation of the complaint process under 
     subparagraph (A) which is available to the enrollee upon 
     request.
       ``(III) An explanation of all other appeal rights available 
     to all enrollees.
       ``(IV) A description of how to obtain supporting evidence 
     for the hearing described in subparagraph (C), including the 
     patient's medical records from the organization, as well as 
     supporting affidavits from the attending health care 
     providers.

       ``(C) Hearing board.--
       ``(i) In general.--Each eligible organization shall 
     establish a board of appeals to hear and make determinations 
     on complaints by enrollees concerning denials of coverage or 
     payment for services (whether in-network or out-of-network) 
     and the medical necessity and appropriateness of covered 
     items and services.
       ``(ii) Composition.--A board of appeals of an eligible 
     organization shall consist of--

       ``(I) representatives of the organization, including 
     physicians, nonphysicians, administrators, and enrollees;
       ``(II) consumers who are not enrolled with an eligible 
     organization under this section; and
       ``(III) health care providers who are not under contract 
     with the eligible organization and who are experts in the 
     field of medicine which necessitates treatment.

     Members of the board of appeals described in subclauses (II) 
     and (III) shall have no interest in the eligible 
     organization.

[[Page S4002]]

       ``(iii) Deadline for decision.--

       ``(I) In general.--Except as provided in subclause (II), a 
     board of appeals shall hear and resolve complaints within 30 
     days after the date the complaint is filed with the board.
       ``(II) Expedited procedure.--A board of appeals shall have 
     an expedited procedure in order to hear and resolve 
     complaints regarding urgent care (as determined by the 
     Secretary in regulations).

       ``(D) Other remedies.--Nothing in this paragraph may be 
     construed to replace or supersede any appeals mechanism 
     otherwise provided for an individual entitled to benefits 
     under this title.
       ``(4) Notice of enrollee rights and comparative report.--
       ``(A) In general.--Each eligible organization shall provide 
     in any marketing materials distributed to individuals 
     eligible to enroll under this section and to each enrollee at 
     the time of enrollment and not less frequently than annually 
     thereafter, an explanation of the individual's rights under 
     this section and a copy of the most recent comparative report 
     (as established by the Secretary under subparagraph (C)) for 
     that organization.
       ``(B) Rights described.--The explanation of rights under 
     subparagraph (A) shall be in a standardized format (as 
     established by the Secretary in regulations) and shall 
     include an explanation of--
       ``(i) the enrollee's rights to benefits from the 
     organization;
       ``(ii) the restrictions (if any) on payments under this 
     title for services furnished other than by or through the 
     organization;
       ``(iii) out-of-area coverage provided by the organization;
       ``(iv) the organization's coverage of emergency services 
     and urgently needed care;
       ``(v) the organization's coverage of out-of-network 
     services, including services that are additional to the items 
     and services covered under parts A and B;
       ``(vi) appeal rights of and grievance procedures available 
     to enrollees; and
       ``(vii) any other rights that the Secretary determines 
     would be helpful to beneficiaries in understanding their 
     rights under the plan.
       ``(C) Comparative report.--
       ``(i) In general.--The Secretary shall develop an 
     understandable standardized comparative report on the plans 
     offered by eligible organizations, that will assist 
     beneficiaries under this title in their decisionmaking 
     regarding medical care and treatment by allowing the 
     beneficiaries to compare the organizations that the 
     beneficiaries are eligible to enroll with. In developing such 
     report the Secretary shall consult with outside 
     organizations, including groups representing the elderly and 
     health insurers, in order to assist the Secretary in 
     developing the report.
       ``(ii) Contents of report.--The report described in clause 
     (i) shall include a comparison for each plan of--

       ``(I) the premium for the plan;
       ``(II) the benefits offered by the plan, including any 
     benefits that are additional to the benefits offered under 
     parts A and B;
       ``(III) the amount of any deductibles, coinsurance, or any 
     monetary limits on benefits;
       ``(IV) the identity, location, qualifications, and 
     availability of health care providers in any health care 
     provider networks of the plan;
       ``(V) the number of individuals who disenrolled from the 
     plan within 3 months of enrollment and during the previous 
     fiscal year, stated as percentages of the total number of 
     individuals in the plan;
       ``(VI) the procedures used by the plan to control 
     utilization of services and expenditures, including any 
     financial incentives;
       ``(VII) the procedures used by the plan to ensure quality 
     of care;
       ``(VIII) the rights and responsibilities of enrollees;
       ``(IX) the number of applications during the previous 
     fiscal year requesting that the plan cover certain medical 
     services that were denied by the plan (and the number of such 
     denials that were subsequently reversed by the plan), stated 
     as a percentage of the total number of applications during 
     such period requesting that the plan cover such services;
       ``(X) the number of times during the previous fiscal year 
     (after an appeal was filed with the Secretary) that the 
     Secretary upheld or reversed a denial of a request that the 
     plan cover certain medical services;
       ``(XI) the restrictions (if any) on payment for services 
     provided outside the plan's health care provider network;
       ``(XII) the process by which services may be obtained 
     through the plan's health care provider network;
       ``(XIII) coverage for out-of-area services;
       ``(XIV) any exclusions in the types of health care 
     providers participating in the plan's health care provider 
     network; and
       ``(XV) any additional information that the Secretary 
     determines would be helpful for beneficiaries to compare the 
     organizations that the beneficiaries are eligible to enroll 
     with.

       ``(iii) Ongoing development of report.--The Secretary 
     shall, not less than annually, update each comparative 
     report.
       ``(D) Compliance.--Each eligible organization shall 
     disclose to the Secretary, as requested by the Secretary, the 
     information necessary to complete the comparative report.
       ``(5) Restrictions on health care provider incentive 
     plans.--
       ``(A) In general.--Each contract with an eligible 
     organization under this section shall provide that the 
     organization may not operate any health care provider 
     incentive plan (as defined in subparagraph (B)) unless the 
     following requirements are met:
       ``(i) No specific payment is made directly or indirectly 
     under the plan to a health care provider or health care 
     provider group as an inducement to reduce or limit medically 
     necessary services.
       ``(ii) If the plan places a health care provider or health 
     care provider group at substantial financial risk (as 
     determined by the Secretary) for services not provided by the 
     health care provider or health care provider group, the 
     organization--

       ``(I) provides stop-loss protection for the health care 
     provider or health care provider group that is adequate and 
     appropriate, based on standards developed by the Secretary 
     that take into account the number (and type) of health care 
     providers placed at such substantial financial risk in the 
     group or under the plan and the number of individuals 
     enrolled with the organization that receive services from the 
     health care provider or the health care provider group; and
       ``(II) conducts periodic surveys of both individuals 
     enrolled and individuals previously enrolled with the 
     organization to determine the degree of access of such 
     individuals to services provided by the organization and 
     satisfaction with the quality of such services.

       ``(iii) The organization provides the Secretary with 
     descriptive information regarding the plan, sufficient to 
     permit the Secretary to determine whether the plan is in 
     compliance with the requirements of this subparagraph.
       ``(B) Health care provider incentive plan defined.--In this 
     paragraph, the term `health care provider incentive plan' 
     means any compensation arrangement between an eligible 
     organization and a health care provider or health care 
     provider group that may directly or indirectly have the 
     effect of reducing or limiting medically necessary services 
     provided with respect to individuals enrolled with the 
     organization.
       ``(6) Prohibition of interference with certain medical 
     communications.--
       ``(A) In general.--
       ``(i) Prohibition of certain provisions.--Subject to 
     subparagraph (C), an eligible organization may not include 
     with respect to its plan under this section any provision 
     that prohibits or restricts any medical communication (as 
     defined in subparagraph (B)) as part of--

       ``(I) a written contract or agreement with a health care 
     provider;
       ``(II) a written statement to such a provider; or
       ``(III) an oral communication to such a provider.

       ``(ii) Nullification.--Any provision described in clause 
     (i) is null and void.
       ``(B) Medical communication defined.--In this paragraph, 
     the term `medical communication' means a communication made 
     by a health care provider with a patient of the provider (or 
     the guardian or legal representative of such patient) with 
     respect to any of the following:
       ``(i) How participating physicians and health care 
     providers are paid.
       ``(ii) Utilization review procedures.
       ``(iii) The basis for specific utilization review 
     decisions.
       ``(iv) Whether a specific prescription drug or biological 
     is included in the formulary.
       ``(v) How the eligible organization decides whether a 
     treatment or procedure is experimental.
       ``(vi) The patient's physical or mental condition or 
     treatment options.
       ``(C) Construction.--Nothing in this paragraph shall be 
     construed as preventing an entity from--
       ``(i) acting on information relating to the provision of 
     (or failure to provide) treatment to a patient; or
       ``(ii) restricting a medical communication that recommends 
     1 health plan over another if the sole purpose of the 
     communication is to secure financial gain for the health care 
     provider.
       ``(7) Additional definitions.--In this subsection:
       ``(A) Health care provider.--The term `health care 
     provider' means anyone licensed under State law to provide 
     health care services under part A or B.
       ``(B) In-network.--The term `in-network' means services 
     provided by health care providers who have entered into a 
     contract or agreement with the organization under which such 
     providers are obligated to provide items, treatment, and 
     services under this section to individuals enrolled with the 
     organization under this section.
       ``(C) Network.--The term `network' means, with respect to 
     an eligible organization, the health care providers who have 
     entered into a contract or agreement with the organization 
     under which such providers are obligated to provide items, 
     treatment, and services under this section to individuals 
     enrolled with the organization under this section.
       ``(D) Out-of-network.--The term `out-of-network' means 
     services provided by health care providers who have not 
     entered into a contract agreement with the organization under 
     which such providers are obligated to provide items, 
     treatment, and services under this section to individuals 
     enrolled with the organization under this section.
       ``(8) Nonpreemption of state law.--A State may establish or 
     enforce requirements with respect to the subject matter of 
     this

[[Page S4003]]

     subsection, but only if such requirements are more stringent 
     than the requirements established under this subsection.''.
       (b) Conforming Amendments.--Section 1876 of such Act is 
     amended--
       (1) in subsection (a)(1)(E)(ii)(II), by striking 
     ``subsection (c)(3)(E)'' and inserting ``subsection (k)(4)'';
       (2) in subsection (c)--
       (A) in paragraph (3)--
       (i) by striking subparagraph (E); and
       (ii) in subparagraph (G)(ii)(II), by striking 
     ``subparagraph (E)'' and inserting ``subsection (k)(4)'';
       (B) by striking paragraph (4); and
       (C) by striking ``(5)(A) The organization'' and all that 
     follows through ``(B) A member'' and inserting ``(5) A 
     member''; and
       (3) in subsection (i)--
       (A) in paragraph (6)(A)(vi), by striking ``paragraph (8)'' 
     and inserting ``subsection (k)(5)''; and
       (B) by striking paragraph (8).
       (c) Effective Date.--The amendments made by this section 
     shall apply to contracts entered into or renewed under 
     section 1876 of the Social Security Act (42 U.S.C. 1395mm) 
     after the expiration of the 1-year period that begins on the 
     date of enactment of this Act.

     SEC. 4. APPLICATION OF PROTECTIONS TO MEDICARE SELECT 
                   POLICIES.

       (a) In General.--Section 1882(t) of the Social Security Act 
     (42 U.S.C. 1395ss(t)) is amended--
       (1) in paragraph (1)--
       (A) by striking ``and'' at the end of subparagraph (E);
       (B) by striking the period at the end of subparagraph (F) 
     and inserting a semicolon; and
       (C) by adding at the end the following:
       ``(G) notwithstanding any other provision of this section 
     to the contrary, the issuer of the policy meets the 
     requirements of section 1876(k) (except for subparagraphs (C) 
     and (D) of paragraph (4) of that section) with respect to 
     individuals enrolled under the policy, in the same manner 
     such requirements apply with respect to an eligible 
     organization under such section with respect to individuals 
     enrolled with the organization under such section; and
       ``(H) the issuer of the policy discloses to the Secretary, 
     as requested by the Secretary, the information necessary to 
     complete the report described in paragraph (4).''; and
       (2) by adding at the end the following:
       ``(4) The Secretary shall develop an understandable 
     standardized comparative report on the policies offered by 
     entities pursuant to this subsection. Such report shall 
     contain information similar to the information contained in 
     the report developed by the Secretary pursuant to section 
     1876(k)(4)(C).''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to policies issued or renewed on or after the 
     expiration of the 1-year period that begins on the date of 
     enactment of this Act.

     SEC. 5. STUDY AND RECOMMENDATIONS TO CONGRESS.

       (a) Study.--The Secretary of Health and Human Services (in 
     this Act referred to as the ``Secretary'') shall conduct a 
     thorough study regarding the implementation of the amendments 
     made by sections 3 and 4 of this Act.
       (b) Report.--Not later than 2 years after the date of 
     enactment of this Act and annually thereafter, the Secretary 
     shall submit a report to Congress that shall contain a 
     detailed statement of the findings and conclusions of the 
     Secretary regarding the study conducted pursuant to 
     subsection (a), together with the Secretary's recommendations 
     for such legislation and administrative actions as the 
     Secretary considers appropriate.
       (c) Funding.--The Secretary shall carry out the provisions 
     of this section out of funds otherwise appropriated to the 
     Secretary.

     SEC. 6. NATIONAL INFORMATION CLEARINGHOUSE.

       Not later than 18 months after the date of enactment of 
     this Act, the Secretary shall establish and operate, out of 
     funds otherwise appropriated to the Secretary, a 
     clearinghouse and (if the Secretary determines it to be 
     appropriate) a 24-hour toll-free telephone hotline, to 
     provide for the dissemination of the comparative reports 
     created pursuant to section 1876(k)(4)(C) of the Social 
     Security Act (42 U.S.C. 1395mm(k)(4)(C)) (as added by section 
     3 of this Act) and section 1882(t)(4) of the Social Security 
     Act (42 U.S.C. 1395ss(t)(4)) (as added by section 4 of this 
     Act). In order to assist in the dissemination of the 
     comparative reports, the Secretary may also utilize medicare 
     offices open to the general public, the beneficiary 
     assistance program established under section 4359 of the 
     Omnibus Budget Reconciliation Act of 1990 (42 U.S.C. 1395b-
     3), and the health insurance information counseling and 
     assistance grants under section 4359 of that Act (42 U.S.C. 
     1395b-4).
                                                                    ____


        Summary--Medicare Patient Choice and Access Act of 1997

       The Medicare Patient Choice and Access Act of 1997 
     establishes certain standards and beneficiary protections for 
     Medicare recipients enrolled in Medicare managed care plans. 
     The legislation builds upon and strengthens existing law, 
     which already provides some protections to Medicare 
     beneficiaries. There is growing concern, however, that as 
     more and more beneficiaries (currently 4.9 million Medicare 
     beneficiaries with enrollment growth averaging 30% annually) 
     enroll in managed care greater protections must be in place 
     to ensure quality and access to care for seniors.
       The bill would require the following:
       Comparative Health Plan Information: Expands the consumer 
     information that health plans must provide to beneficiaries 
     under current law. Provides beneficiaries with standardized 
     consumer-friendly charts to compare health plans. Requires 
     the Health Care Financing Administration (HCFA) to include 
     disenrollment data, which will contribute to greater 
     competition among health plans. HCFA currently collects this 
     data, but does not distribute it to beneficiaries.
       Expedited Appeals Process: Provides an expedited appeals 
     procedure, consistent with new regulations, and a 30 day 
     resolution for grievances and appeals of health plan 
     enrollees. Preserves current law allowing beneficiaries to 
     appeal to the Secretary of the Department of Health and Human 
     Services.
       Prohibition of Gag Clauses: Prohibits gag rules, using the 
     managed care industry's definition of ``medical 
     communication.'' This is an expansion of HCFA's current 
     regulation banning the use of gag clauses regarding treatment 
     options.
       Expansion of Restrictions on Financial Incentives: Expands 
     the current Federal law which places certain restrictions on 
     the use of financial incentives to manage care from applying 
     to physicians only to covering all providers.
       Point-of-Service Option: Expands choice of health plans by 
     guaranteeing enrollees the option of choosing a point-of-
     service plan at the time they enroll in a Medicare managed 
     care plan.
       Timely and Appropriate Access to Specialists: Gives 
     enrollees the assurance they will be able to see a specialist 
     in-network, as medically necessary. Current law requires that 
     managed care health plans provide access to the full range of 
     Medicare health care services. The bill expands and 
     strengthens this provision.

  Mr. HELMS. Mr. President, I certainly am not alone in having strong 
feelings that the senior citizens of America must not be deprived of 
their right to choose their own doctors.
  Senator Grassley's Medicare Patient Choice and Access Act of 1997, 
which I'm cosponsoring today, ensures choice, access, and quality care 
for senior citizens by guaranteeing enrollees the option of choosing a 
point-of-service plan at the time they enroll in a Medicare HMO.
  Five years ago, I had a close but fortunate encounter with some 
remarkable medical doctors in my home town of Raleigh. My heart surgery 
and the very effective subsequent rehabilitation made it clear that I 
had been cared for by some of the most capable people in the medical 
profession.
  I was free to choose the surgeon who performed the operation. Senior 
citizens enrolled in Medicare should have the same choice, and the bill 
I'm co-sponsoring today will enable senior citizens who join HMO's to 
preserve their right to choose their doctor.
  America's senior citizens depend on the health care coverage provided 
by the Medicare system, and those of us in Congress have a duty to make 
sure they will not be forced to give up their right to choose their 
doctors.
  Mr. President, the Health Care Financing Administration--which, of 
course, administers Medicare--is now the largest purchaser of managed 
care in the Nation, accounting for about 18 million Americans. As of 
February 1997, 5 million Medicare beneficiaries were enrolled in 
managed care plans. This represents a 108-percent increase in managed 
care enrollment since 1993. Increased migration of the elderly into 
health maintenance organizations, and other types of managed care 
plans, will surely lower the costs of operating the vast Medicare 
system. And citizens who belong to a Medicare-supported HMO may 
increase their benefits for prescription drugs, eyeglasses, and hearing 
aids coverage not available through fee-for-service plans.
  Without some moderating legislation, however, senior citizens could 
very well find themselves locked into coverage that limits them to 
services provided by HMO-affiliated doctors, other professionals and 
hospitals. No longer would senior citizens have the freedom to choose 
their own doctor.
  Mr. President, consider, if you will, the predicament of a patient 
who requires heart surgery, and whose HMO will not approve the 
cardiologist with whom the senior has built up a longstanding 
relationship. Should that patient be required to wait for a year's time 
to change to a plan that will cover the cardiologist whom the patient 
knows and trusts?
  We must provide a safety valve to protect seniors who find themselves 
in that position. A point-of-service option

[[Page S4004]]

would enable patients to see physicians and specialists inside and 
outside the managed care network. If senior citizens are satisfied with 
the care they receive within the network, they will feel no need to 
choose outside doctors and specialists. Without such options, however, 
these senior citizens will be locked into a rigid system which may, or 
may not, give them the health care they need from people they most 
trust to provide it.

  Mr. President, most Americans, whether their health is insured by 
private firms or by Medicare, enjoy their freedom to decide which 
medical professional will provide their care and treatment. According 
to polls I have seen, patients are willing to pay a little more for the 
ability to go out of network to be assured of seeing the doctors of 
their choice. As many as 70 percent of Americans over 50 years old 
declared in one poll that they would be unwilling to join a Medicare 
managed plan that denied them the freedom to choose their own 
physicians.
  Building a point-of-service option into all health plans under 
Medicare will not interfere with the plan's ability to contain cost, 
nor will it limit their efforts to encourage providers and patients to 
use their health care resources wisely. It simply will ensure that 
health plans put the patient first.
  The CBO indicated that a built-in point-of-service feature would not 
increase the cost of Medicare. In testimony before the Senate Budget 
Committee, CBO stated that:

       the point of service option would permit Medicare enrollees 
     to go to providers outside the HMO's panel when they wanted 
     to, and yet it need not increase the benefit cost to HMO's or 
     to Medicare * * *

  The Medicare Patient Choice and Access Act also includes patient 
protections and provisions ensuring Medicare participants' timely 
access to specialists and provides an expedited appeals process which 
requires patient grievances to be resolved within 30 days. Lastly, this 
bill expands the consumer information which must be provided to 
beneficiaries to help patients compare health plans. Unfortunately, 
although the Health Care Financing Administration collect vast amounts 
of data, virtually none of it is currently accessible to consumers.
  So, Mr. President, I urge Senators to support the Medicare Patient 
Choice and Access Act, which will provide senior citizens with real 
patient protections and real choice in health care.
                                 ______