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PUT PATIENTS BACK INTO PATIENTS' BILL OF RIGHTS

The physicians of America believe that adequate health coverage and access to health care services are vitally important to their patients and to the nation.

But despite economic prosperity and substantial job creation during the last decade, there remains a considerable and increasing portion of the American population that does not have health insurance coverage. As a result, they defer obtaining preventive and medical services, jeopardizing the health and well being of themselves and their families.

Medical and consumer groups are pinning their hopes for strong patient protection legislation on the House as they continue to face the same powerful force they squared off against in the Senate debate, namely the insurance and managed care lobbies.

What is fundamentally at stake is the autonomy of physician decision-making. It is important for all of us to put patients back into the patients' bill of rights. The present bill of rights fails to guarantee that physicians, rather than plans, determine medical necessity. It does not give patients enrolled in employment-based insurance the right to sue their plans.

Furthermore, it primarily covers only the 48 million people in employer-sponsored plans that are not subject to state insurance laws. It is imperative that the same protection should apply to all Americans, regardless of their health plan type.

The United States relies primarily on a private, employment-based system to provide health insurance. From 1987 to 1997, the percentage of people with job-based coverage dropped from 69 to 64 percent, and the number of uninsured Americans rose from 31.8 million to 43.1 million.

The erosion of job-based insurance coverage and the general decline in the number of people with private health insurance have generated a great deal of concern across the nation and, in particular, for physicians and other health care clinicians everywhere.

There currently exists an important "window of opportunity" to influence public policy with the upcoming 2000 election. We challenge the 106th Congress and urge 2000 presidential candidates to make the critical issues of health insurance coverage and health care access a top priority.

It is imperative to push the issue onto the national agenda, increase public awareness and begin a debate of the issues involved.

Any future agenda must include three important concepts: All Americans must have health care coverage; health care coverage will contain a benefit package that provides quality care, and medical necessity determinations made under the benefit package should reflect generally accepted standards of medical practice, supported by outcome-based evidence, where available.

In addition, there are four core values that should be incorporated into any future policy related to increasing health care coverage and access. They are:

-- We place the interest and well being of our patients as paramount.

-- We support universal coverage that is designed to improve the individual and collective health of the society.

-- We must have an infrastructure that maintains the highest quality of service, education, research and administration of care.

-- We believe that patients, individually and in partnership with their physicians, also have a responsibility for their own well being and health.

We recognize there may be more than one way to finance providing all Americans with coverage. A variety of financing options, including employer funding, individual funding, government funding or a combination of these options have been offered as possible "reforms."

Expanding the individual's ability to choose among several health insurance options is crucial. We support pluralism of health care delivery systems and financing mechanisms in achieving coverage for and access to health care services. Expanding health coverage to all Americans must become a priority on the federal, the state and the general public agendas.

The AMA believes that true patients' rights legislation must include the following provisions:

(1) Giving physicians the final say about what is medically necessary.

(2) Giving patients the right to appeal a health plan's medical decision with an independent, timely, fair external review.

(3) Holding health plans accountable when their actions cause a patient to be injured or die.

(4) Extending protection to all insured Americans.

(5) Providing point of service language, so that all insured employees have the opportunity to choose, at their own expense, an option that allows them to go outside the network of health care professionals chosen by the employers.

These are basic fundamental reforms that must be included in a real patients' rights bill.

Over the years, the U.S. has repeatedly opted for market mechanisms over government controls to determine both the price and availability of most forms of health care. HMOs, in particular, are an outgrowth of the market system -- a private response to the rising health costs imposed on employees, employers, governments and the uninsured.

At the least, consumers should have options within a given health plan to select among different levels of care, including different levels of discretion in choosing among doctors. Health care plans with more discretion and higher service levels would, of course, be expected to cost consumers more.

Another prerequisite for well functioning markets in health care is information. In this respect, many HMOs have been their own worst enemy, preferring secrecy over openness in dealing with both doctors and patients. Certainly, issues regarding availability, credibility, comprehensiveness and timeliness of information released by HMOs should be an integral part of a patients' bill of rights.

An adequate patients' bill of rights will improve the market for health care. But society will still have to come to grips with how best to protect life and enhance human dignity in a situation of limited health resources.

DATTA G. WAGLE, M.D., is president of the Erie County Medical Society and also president of the American Association of Clinical Urologists.

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