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Dynamic Chiropractic – November 6, 1995, Vol. 13, Issue 23

ACA Proposal Would Guarantee Access to Chiropractors in Managed Care Plans

By Editorial Staff
In a startlingly short time, the U.S. health care delivery and financing system has been radically transformed. Managed care organizations, based on capitated or discounted payments to a limited network of health care providers, have all but replaced traditional fee-for-service health insurance. There are strong incentives in the system not to provide some of the needed health care services to patients. Health care professionals and providers face coercion to cooperate with health plan rules or find themselves out on the street.

At the same time, a rash of mergers among for-profit health plans, which are accountable to stockholders ahead of patients and providers, has concentrated enormous economic power over life and death clinical decisions under the umbrella of a few corporations.

An upsurge of discontent among consumers and providers has found little relief, as no existing laws adequately hold these new kinds of health plans accountable for providing safe, effective, or high quality care. Managed care plans promise better coordinated care at a lower cost, and hold themselves accountable on that basis. One obvious means of cutting expenses is the move towards more outpatient care/surgeries, and shortening hospital stays. Some have suggested, a bit facetiously, that the push to expedite care may soon bring "drive-by delivery" windows for expectant mothers, with fries to go.

After nearly a year of concentrated efforts by the ACA as part of the "Coalition for Health Care Choice and Accountability" (CHCCA), legislation to reign in the abusive power of managed care plans was introduced in the U.S. House of Representatives by Charlie Norwood (R-GA) and Bill Brewster (D-OK). The bill, H.R. 2400, is known as the "Family Health Care Fairness Act of 1995." The bill is designed to "put patients ahead of profits."

"It's time to take the gloves off," ACA Board Chairman Dr. Lowry Morton commented. "In the ACA's view, managed care companies are trying to consume the entire health care system, call all the shots and shove providers and patients around whenever and however they choose. We think that's wrong, and we think it's time Congress not only took a closer look at how they operate, but also put some simple and fair rules in place on the federal level to prevent them from acting improperly."

The bill sets a minimum set of uniform national standards that all health plans must meet, including self-insured ERISA plans. Many well-established MCOs claim they already implement some or all of these standards. In brief, they require health plans to:

_Ensure Access and Consumer Choice_: Under this provision, managed care plans must offer some coverage for services by qualified, out-of-network health care providers. This provision would guarantee enrollees the ability to access chiropractic care from a non-network DC;

_Enhance Consumer Protection_: Managed care plans would have to establish procedures for patients and providers to appeal coverage decisions;

_Provide Accountability_: MCOs would be held accountable to basic standards of quality, financial solvency and an appropriate number and mix of providers. Patients and providers would also have access to information about a plan's quality and performance, including patient satisfaction data. Patients and providers would be given adequate opportunities to participate in decisions regarding care;

_Ensure Provider Fairness_: Plans could not arbitrarily exclude or dismiss providers, including chiropractors, based on their type of license or certification, or because their patients have special needs.

_Preserve State Any-Willing-Provider Laws_: Following the collapse of national health reform efforts and the election of a Republican-controlled Congress, various provider groups and consumer organizations came together and outlined a strategy to advance a "basket" of legislative provisions in the new 104th Congress that would protect both providers and consumers from abusive managed-care practices. As a result, the CHCCA coalition was formed in late 1994 and immediately began the tedious process of drafting a "comprehensive" legislative package that would establish federal standards governing the conduct of private insurance plans.

Meetings of the CHCCA coalition, which has now grown to over 40 provider and consumer organizations, have continued regularly throughout 1995. ACA's vice president of government relations, Richard Miller, organized and "chaired" each of the coalition meetings, and the costs of supporting the coalition's extensive efforts have largely been borne by the ACA-PAC. According to Miller, other groups which have played a key role in the coalition: the American Dental Association (ADA), the National Association of Retail Druggists (NARD) and the American Psychological Association, among others. Observers have noted that the American Medical Association which advanced a somewhat similar "patient protection" proposal during the national health reform debate has failed, thus far, to introduce a similar package of reforms in the 104th Congress.

"Another strong motivation behind our push to form this coalition and to move this legislative package forward is the inherent and massive conflict-of-interest which exists when corporate profits clearly outweigh the desire to ensure the guaranteed delivery of quality care," explained Garrett Cuneo, ACA executive vice president.

"Controlling health care costs are important," Mr. Cuneo conceded, "but not at the expense of quality care, real competition among providers and basic consumer protections that ensure a patient can choose the care best for him or her."

Participating organizations of the Coalition for Health Care Choice and Accountability (CHCCA):

American College of Nurse-Midwives
American Dental Association
American Association of Nurse Anesthetists
American Academy of Nurse Practitioners
American Federation of Home Health Agencies
National Association of People with AIDS
American Chiropractic Association
National Association of Retail Druggists
American Optometric Association
American Psychological Association
American Podiatric Medical Association
American Pharmaceutical Association
American Occupational Therapy Association
International Society for Clinical Laboratory Technology
American Speech-Language-Hearing Association
American Association for Marriage and Family Therapy
National Association for Home Care
American Association of Bioanalysts
National Federation of Societies for Clinical Social Work
American Association of Hospital Dentists
Academy of Dentistry for Persons with Disabilities
National Association for the Advancement of Orthotics and Prosthetics
National Multiple Sclerosis Society
American College of Nurse Practitioners
National Association of Nurse Practitioners in Reproductive Health
National Association of Social Workers
National Head Injury Foundation
Association of Freestanding Radiation Oncology Centers
National Association of School Nurses
Outpatient Ophthalmic Surgery Society
American Physical Therapy Association
Federation of Special Care Organizations in Dentistry
American Society of Electroneurodiagnostic Technologists
National Association of Childbearing Centers
American Society of Outpatient Surgeons
Society of Gastroenterology Nurses, Inc.
National Association of Neonatal Nurses
Association of Medical School
Pediatric Department Chairmen
American Society of Radiologic Technologists
International Hearing Society

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