[Congressional Record (Bound Edition), Volume 147 (2001), Part 3]
[House]
[Pages 3599-3600]
[From the U.S. Government Publishing Office, www.gpo.gov]



                 MANAGED CARE REFORM--MEDICAL NECESSITY

  The SPEAKER pro tempore (Mr. Gilchrest). Under a previous order of 
the House, the gentleman from Texas (Mr. Green of Texas) is recognized 
for 5 minutes.
  Mr. GREEN of Texas. Mr. Speaker, I would like to congratulate my 
colleagues, the congressional women, for making this effort today for 
special orders for women's health care. I would like to associate 
myself with their remarks, because everything they have said on a 
bipartisan basis is so important.
  The reason I am here today, Mr. Speaker, is that the third time I 
have talked about the importance of managed care reform, real managed 
care reform, 3, 4 weeks ago I talked about the independent review 
process, and the accountability 2 weeks ago, and today I want to talk 
about medical necessity.
  Every patient in America deserves to have important medical decisions 
made by his or her doctor, not by an HMO bureaucrat. Unfortunately, 
managed care personnel, who often have no substantial medical training, 
are determining what is medically necessary.
  This practice endangers patients, threatens the sanctity of the 
doctor-patient relationship and undermines the foundation of our health 
care system.
  Most managed care companies base treatment decisions on professional 
standards of medical necessity. But we often hear cases where HMO plans 
write their own standards into their contracts, and these standards 
often conflict with the patients' needs.
  The case of Jones v. Kodak clearly demonstrates how a clever 
insurance health plan can keep patients from getting the needed medical 
care.
  Mrs. Jones' employer provided health insurance coverage for in-
patient substance abuse treatment. Unfortunately, the health plan 
determined that she did not qualify for this treatment. Even after an 
independent reviewer stated that the plan's criteria was too rigid and 
did not allow for tailoring of case management, Mrs. Jones was still 
denied treatment.
  To add insult to injury, the courts stated that the health plan did 
not have to disclose its protocols or its rationale for making that 
decision.
  A health plan's decision does not have to be based on sound medical 
science, standard practices or even basic logic. In fact, a health plan 
can

[[Page 3600]]

make medical necessity decisions using this child's toy called the 
Magic 8 Ball and not have to disclose the rationale, and when you turn 
this around and it says what do they suggest you are going to do, this 
is no way to practice medicine in our country.
  Mr. Speaker, unless Congress enacts meaningful patient protection 
legislation, the outlook will not be good for our patients.
  H.R. 526, the Bipartisan Patient Protection Act will ensure that 
treatment decisions are based on good medical practice and take 
individual patient circumstances into account.
  This legislation will protect patients from arbitrary and capricious 
decisions and will put health care decision-making back in the hands of 
the doctors and the patients. The patients should not have to be behind 
this eight ball when it comes to their health care, and we should not 
have to depend on the system that is patterned after this Magic 8 Ball 
when it says do not count on it for adequate health care treatment.
  Congress must act now to protect them.

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