Today's News

Saturday, February 24, 1996

Patient Access to Specialty Care Coalition advocates patients' right to choice of specialists

In response to health care reform proposals and certain provisions in managed care contracts that many feel restrict patient access to specialty medical care, the American Academy of Orthopaedic Surgeons and more than 100 other medical and consumer organizations formed the Patient Access to Specialty Care Coalition.

"The Patient Access to Specialty Care Coalition is a group of about 119 organizations that has been advocating, for the last two and a half years, for the inclusion in any health care reform bill a provision that allows the patient to always be able to choose his or her doctor, even if the doctor is outside a managed care network," said Nicholas Cavarocchi, director of the Academy's Washington office and co-founder of the coalition.

The coalition's member organizations, which include physician-advocacy groups, patient-advocacy groups, and a senior citizen's group, believe that closed-panel HMOs are too restrictive in allowing patients access to specialty care. The coalition promotes point-of-service features in managed care contracts that permit patients to go outside a preselected network of physicians or hospitals to obtain specialty care at an affordable cost.

In addition, the coalition also is working to:

Eliminate financial incentives written into managed care contracts that reward physician gatekeepers for keeping the patient from seeing a specialist.

Include an appeals process in managed care contracts that patients can use to resolve any disputes between the plan and the patient. "It should be a fair mechanism and an expedited process," Cavarocchi said.

Enact legislation that specifies how much of a patient's premium must be spent on medical care. "In California, some HMOs spend only 60 or 65 cents of the premium dollar on medical care," Cavarocchi said. "The rest goes into profits and overhead. Our patient groups feel there should be a higher stated number, about 85 cents of every premium dollar as a minimum."

Getting the Message Across

The coalition has no permanent staff or budget. It gets its message across in face-to-face meetings between coalition volunteers and members of Congress and congressional staff members both in Washington and in home district offices.

"To answer accusations that our proposals would break the health care bank, the coalition supported a study by an actuarial firm which demonstrated that the costs to the HMO and enrollee would not be prohibitive but minimal," Cavarocchi said.

"We have a public relations firm that helps get the message out through editorials and articles in publications around the country. The coalition also has pamphlets and has raised money to buy radio ads." The pamphlets and ads contain an 800 number to call for information. Operators on the 800 line help callers get in touch with their congressmen or women to reinforce the coalition's message. "We have also gotten members of Congress to introduce individual pieces of legislation which address these points," he said.

How effective is the campaign? "When the Senate passed its version of the budget bill, Sen. Jesse Helms attached an amendment that would have required Medicare to offer patients a point-of-service contract option to closed-panel HMOs and it was overwhelmingly adopted," Cavarocchi said.

"We haven't won the battle yet, but there is an awareness now among members of Congress that there is a strong interest among their constituents in making sure patients are protected and have a right to choose their own doctor."

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Last modified 27/September/1996