[Congressional Record Volume 144, Number 39 (Tuesday, March 31, 1998)]
[Extensions of Remarks]
[Page E527]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




  MANAGED CARE AND MENTAL HEALTH: WHY THE PATIENTS' BILL OF RIGHTS IS 
                               IMPORTANT

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                        Tuesday, March 31, 1998

  Mr. STARK. Mr. Speaker, I am proud to join today with my colleagues 
to urge support for passing the Patients' Bill of Rights Act of 1998, a 
bill that would give millions of Americans enrolled in managed care 
plans a measure of control over the quality of care they receive.
  For consumers of mental health and substance abuse benefits--which 
are often arbitrarily capped at a particular dollar level--this bill 
contains key quality provisions. It provides for continuity of care, 
access to specialists, choice of specialist, enables exceptions from 
overly restrictive drug formularies, and provides for an independent 
external appeals process.
  The bill will guarantee that consumers can continue seeing their 
providers for 90 days after they change plans if they are in the middle 
of a course of treatment. For those with psychiatric disabilities, this 
continuity of care provision is critically important, since studies 
show that a sudden change of doctors for patients with serious 
psychiatric disorders can result in devastating setbacks.
  The abrupt termination of psychiatric services to thousands of Los 
Angeles County Medi-Cal beneficiaries last year illustrates this point 
well.
  Last year, the California State Department of Health contracted with 
Foundation Health to provide comprehensive medical services to its 
Medi-Cal population in Los Angeles. In turn, Foundation subcontracted 
out the provision of psychiatric services to MCC Behavioral Health 
Care. When MCC's contract ended, it notified 5,000 enrollees that their 
mental health services would be terminated in two weeks.
  All were undergoing a course of psychiatric treatment, and many 
suffered from severe psychiatric disorders, such as schizophrenia, 
bipolar disorder, or major depression. Most were not fully fluent in 
English. A full-blown crisis was averted when the Los Angeles County 
Department of Mental Health offered to care for the notified patients--
but the Department was not fully equipped to do the job. As a result, 
some of the most severely disabled fell through the cracks and were 
lost to treatment.
  Beyond continuity of care, the Patients' Bill of Rights would boost 
consumer confidence in HMOs with a simple requirement that health plans 
provide a list of contracted providers and their qualifications on 
request and that enrollees be able to choose among the providers who 
serve the plan members. This requirement would apply to mental health 
providers if the plan offers mental health and substance abuse 
services.
  Today, consumers in managed care plans are not commonly given a list 
of the mental health providers in their own plans. When enrollees call 
to seek psychiatric care, they are often required to reveal 
confidential information about themselves over the phone to a 
``triage'' staffer whom they don't know--and who may have no formal 
mental health training. The staffer then generally gives the caller 
names of one or two mental health professionals who are selected on the 
basis of zip code--not based on an assessment of the individual's need 
for a particular type of care.
  In an article published on May 6, 1997, The Washington Post questions 
whether zip code referrals produce good patient care results. The 
article discusses the experience of Mark Hudson, who worked for a Blue 
Cross/Blue Shield plan as a telephone referral assistant in 
Massachusetts from 1992 to 1995. ``I did the diagnosis and approval'' 
for 80-100 calls a day for plan subscribers, Hudson is quoted as 
saying. He routinely made referrals to two therapists located in the 
town where the callers lived, regardless of the medical needs they 
described. Hudson has no mental health training, and says Blue Cross 
officials specifically instructed him not to provide enrollees with the 
names of other approved therapists.
  Mr. Speaker, this makes no sense at all. Consumers who need mental 
health services should have the same freedom to select from a full 
panel of providers just as those seeking physical care typically can. 
The Patient Bill of Rights would help equalize this unfair practice.
  Access to appropriate prescription drugs for psychiatric disorders is 
another paramount issue. In a 1997 survey, the National Alliance for 
the Mentally Ill found that five of the nation's largest behavioral 
health care companies failed to provide access to breakthrough 
antipsychotic medications. Yet for serious disorders such as 
schizophrenia, older medications may give only partial relief, and have 
far more serious side effects.
  There is a requirement in many managed care plans that psychiatrists 
must first document two failures of older medications before a new one 
can be approved. Such policies are penny wise and pound foolish, since 
patients suffering severe side effects from these sometimes-outdated 
drugs can easily wind up needing hospitalization. Obviously, this can 
also result in suboptimal psychiatric care.
  By requiring an exception process to the drug formularies often used 
by plans and by allowing access to the external appeals process, the 
bill will allow mental health patients to have stronger protection than 
they do today. The external appeals process required by this bill 
offers an additional important level of protection for consumers of 
mental health and substance abuse services. Without it, consumers are 
forced to receive final medical decisions from health plans that hold a 
financial interest in denying care.
  In an article published on March 3, 1998, U.S. News explores this 
risk in some details. The article discusses the experience of Dr. Linda 
Peeno, who worked as an HMO's medical director--the person who must 
ultimately approve or reject requests for care. ``The decision [to 
approve a voice machine for a plan beneficiary--a young woman who 
suffered a usually-fatal brain stem stroke] is now mine, and I feel the 
pressure to find a way to say no'', Dr. Peeno is quoted as saying. She 
went on to add, ``If I cannot pronounce it medically unnecessary, then 
I have to find a different way to interpret our medical guidelines or 
the contract language in order to deny the request.'' Unhappy with her 
role as a medical care denier, Dr. Peeno left the industry in 1991.
  Mr. Speaker, mental health and substance abuse is probably the area 
where managed care has the most serious problems. We need an entire 
bill devoted to addressing these special problems--but the bill I am 
cosponsoring today is a good beginning on these problems. In the coming 
weeks, I will be introducing separate legislation to deal with the 
unaddressed mental health and substance abuse consumer issues. In the 
meantime, we should not delay in passing the important protections 
contained in the Dingell-Gephardt-Kennedy bill.

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