STATE REPRESENTATIVE
PAUL C. CASEY

Room 473-B
State House
Boston, MA 02133
Telephone: (617) 722-2230
District Office
585A Main St.
Winchester, MA 01890
Telephone: (617) 721-7285 or (617) 438-7185

A View from the Hill

FOR IMMEDIATE RELEASE: July 24, 2000
CONTACT: Michael Auerbach (617) 722-2240

A MEDICAL BILL WE ARE HAPPY TO RECEIVE

Above all else, the Hippocratic Oath- the affirmation recited by thousands of new doctors each year and upheld by millions of practicing doctors worldwide- reminds its adherents to "do no harm." When we, as patients, come to a doctor's office or a hospital, we want our medical caregiver to be unimpeded from providing us with the best care possible. We want to be assured that the only concern that the caregiver has when we are ill, injured, or simply getting our yearly checkup is our health.

Many of us are familiar with that folksy Norman Rockwell painting of the doctor holding his stethoscope to a little girl's doll. This painting portrays a profession in which the health and well-being of people was always the "bottom line."

I am certain that all of us long for our experiences with the medical profession to be that simple, that comforting. The Norman Rockwell illustration, however, was printed on the cover page of The Saturday Evening Post in the late 1920s- before Social Security, Medicare, Medicaid, and welfare. That illustration was even before the 1946 Hill-Burton Act, which prioritized the building and modernization of hospitals across the country, and helped to provide access to health care to anyone in need.

Health care has changed signnificantly since that idyllic scene painted 80 years ago. We have made several important improvements to our health care system and have enhanced the quality of life for many Americans. Of course, the system has not been without its problems. We still fall substantially behind other industrialized nations in terms of social health indicators such as infant mortality.

On the health insurance front, the United States has been struggling to find a way to provide all citizens with proper coverage. Since the 1960s, health maintenance organizations (HMOs) have been on the scene as a "market" solution to this dilemma. They are governed not by a motivation to do what is in the best interest of the patient, but by a core of managers whose main responsibility is to the bottom line. By the very nature of their structure, these organizations lack the sensitivity of Rockwell's doctor.

The lives of patients have been tangled up in the "red tape" of HMO bureaucracy, often with tragic results. Patients, for example, have been told they would not be covered for mammograms, MRIs or other tests that would have revealed life-threatening, but treatable conditions. In consequence, people have been diagnosed with terrible illnesses such as breast cancer beyond the point of effective treatment.

Some doctors are no longer simply practicing their art of administering to the sick. Instead, bureaucrats working for HMOS are dictating to members of this honorable profession the types of procedures and tests they must administer. In some cases, HMOs actually provide financial incentives for doctors not to recommend expensive tests and procedures for their patients, despite the fact that the patient might be in need of them. If the doctor in that Rockwell painting were alive today, he probably would have retired long ago.

In response to this distressing situation, we have begun implementing reforms to bring all players in the health care game back to basics. This week, this Legislature passed a set of measures that are designed to ensure that patients get the treatment they need, that doctors are not second-guessed in their diagnoses by HMOs and insurance companies, and that hospitals and health care providers are compensated for their services (and thus able to continue administering to patients).

Known as the "Patients Bill of Rights," H.5333 addresses a variety of issues concerning the care managed by HMOs and insurance companies. First, the bill establishes an "Office of Patient Protection," which would have oversight over certain quality of care issues, including internal and external reviews, consumer assistance, continuity of care and medical decision-making. It also establishes a "Bureau of Managed Care," which will have oversight over the accreditation of managed care organizations, compensation, and other insurance-related issues.

Second, the bill would require all managed care institutions to establish internal grievance procedures, including expedited resolution of grievances in certain urgent situations. Furthermore, the bill would require an external grievance procedure to be established, which is to be used in the event that the grievant has exhausted his or her plan's internal grievance procedure. If that individual has exhausted his or her resources with the internal grievance system, the bill would allow the Office of Patient Protection to seek the review of at least three outside, and therefore objective, review agencies.

Third, the bill establishes certain requirements for utilization review procedures. Under the bill, only a licensed physician or medical practitioner would be in a position to deny service to a patient. In addition, review practices would follow a written plan of conduct devised under the supervision of a physician and carried out by trained and qualified professionals. Doctors and medical personnel will be shielded from outside interference when they confer with patients about the most effective course of medical treatment.

HMOs and insurance companies will also be required to include certain criteria when setting medical necessity standards and guidelines. If a person reasonably feels that he or she is experiencing a medical emergency and goes to the nearest emergency room, then his or her insurance plan will pay for the emergency care he or she receives. Additionally, primary care physicians will be allowed to issue standing referrals for specialty care, and specialty care administered by obstetricians, gynecologists, family practitioners and certified nurse-midwives will be permitted.

Finally, the bill addresses delinquent payments to hospitals by insurers and HMOs. Medical plans would be required to pay completed claims within 45 days. Hospitals naturally have expenses to cover from the crucial services they provide, and without compensation they may have to shut their doors permanently.

Medical doctors are bound by their vow to "do no harm." We passed the Patient's Bill of Rights with this goal in mind, repairing flaws in the system and working to improve the medical environment. We are proud of this accomplishment. I think Hippocrates would be proud, too.

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