Patients' Bill of Rights Moves Toward Approval
Managed care watchers say specialists have a lot to gain.
By Jerry Helzner, Associate Editor

Ask almost any ophthalmologist for an opinion on the Patients' Bill of Rights legislation that may soon become a reality and the answer invariably comes back: "Whatever will help my patients will help me."

The Senate and House of Representatives have each passed a version of the Patients' Bill of Rights, but the two bills contain different provisions regarding litigation that can be brought against health plans. This fall, House and Senate conferees will try to hammer out a compromise version of the legislation that President Bush will agree to sign.

It's no surprise that physicians are keeping their focus on how a new law will benefit their patients. The medical organizations and patient groups that have pushed hard for patients' rights legislation for the past 7 years know that any mention of potential benefits for physicians could weaken Congressional support for the law. But it's still fair to ask how a Patients' Bill of Rights will impact ophthalmologists and their practices.

"The impact of the legislation on doctors hasn't been our focus because all of our efforts have been aimed at putting patients first," says Nancey McCann, director of government relations for the American Society of Cataract and Refractive Surgery (ASCRS) and co-chair of the Patient Access Coalition, a patients' rights support group made up of more than 60 medical organizations and patient groups, including the American Academy of Ophthalmology and ASCRS. "But clearly, a strong law will go a long way toward restoring the doctor-patient relationship, which has been compromised with middlemen making medical decisions. With a Patients' Bill of Rights, we'll have medical professionals making medical decisions. And when a plan does deny a treatment recommended by a physician, there will be recourse through an independent and binding appeals process."

The implications are positive

Richard Gable, chief executive officer of Dynamic Health Connections , Inc., a California-based firm that provides consulting services to physician groups and medical organizations, thinks a Patients' Bill of Rights could have far-reaching, positive implications for ophthalmologists and other specialists.

"Giving patients the right to sue their HMO for an adverse outcome due to denied or delayed care will probably eventually result in the primary care 'gatekeeper' system being eliminated," says Gable. "With patients having more choice of physicians, those doctors who provide excellent patient care and who have superior people skills will flourish. This was the recipe for physician success before managed care came along."

Gable also believes new legislation will reduce or eliminate the practice of capitation contracting, as this method of physician payment has been seen by consumers as an incentive for doctors to limit patient care.

"In California, we're actually seeing some HMOs providing incentives to increase service utilization," says Gable. "And some HMOs are now offering incentives based on patient satisfaction ratings tied to convenient office access, service quality and clinical outcomes."

Gable sees patients having more direct access to ophthalmologists, without the administrative hassles of getting eyecare services preapproved.

"Ophthalmologists and other specialists will be able to reduce their managed care administrative costs, resulting in lower overhead and faster claims payments," says Gable. "Overall, ophthalmologists will no longer be 'political' hostages to primary care physicians who now have the power to determine which ophthalmologists will be included in their referral process and which will be excluded. I think we'll see an end to primary care physicians making unreasonable demands on specialists as a precondition for referrals."

If Gable's forecasts are accurate, ophthalmologists will be pleased with the changes brought about by Patients' Bill of Rights legislation. However, even a strong law will still leave some problem areas largely untouched. For example, highly specific issues (such as how many miles a patient might have to travel to reach an in-network specialist) have been left out of the proposed bills because supporters say including such provisions would make it much more difficult to pass the legislation.

"Our major priorities are point-of-service options for patients, timely access to specialty care, access to emergency room services, full and clear benefit information disclosure by healthcare plans, and an effective independent appeals process," says McCann.

Frank Weinstock, M.D., F.A.C.S., an ophthalmologist who practices in Canton, Ohio, says he welcomes a Patients' Bill of Rights but believes there will always be both good and bad healthcare plans.

"As an employer, I had to make the choice to cover my workers with a better plan or a cheaper plan," says Dr. Weinstock. "I could see the difference in benefits and how those differences could affect my employees, so I chose the better plan. A Patients' Bill of Rights will help, but in terms of healthcare plans, you'll still largely get what you pay for. That's why it's important to thoroughly read all the information that a plan provides before making a decision on a health insurer."