President's
Advisory Commission On
Quality in the Health Care Industry
Executive Summary Consumer Bill of Rights and
Responsibilities
The Advisory Commission on Consumer Protection
and Quality in the Health Care Industry was appointed by President
Clinton on March 26, 1997, to "advise the President on changes
occurring in the health care system and recommend measures as may be
necessary to promote and assure health care quality and value, and
protect consumers and workers in the health care system." As
part of its work, the President asked the Commission to draft a
"consumer bill of rights."
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Health plans: Covered benefits, cost-sharing, and procedures for resolving complaints; licensure, certification, and accreditation status; comparable measures of quality and consumer satisfaction; provider network composition; the procedures that govern access to specialists and emergency services; and care management information.
Health professionals: Education and board certification and recertification; years of practice; experience performing certain procedures; and comparable measures of quality and consumer satisfaction.
Health care facilities: Experience in performing certain procedures and services; accreditation status; comparable measures of quality and worker and consumer satisfaction; procedures for resolving complaints; and community benefits provided.
Consumer assistance programs must be carefully structured to promote consumer confidence and to work cooperatively with health plans, providers, payers, and regulators. Sponsorship that assures accountability to the interests of consumers and stable, adequate funding are desirable characteristics of such programs.
Value-based purchasing allows consumers to obtain greater value for their health care dollar by seeking higher quality care at the best price. To do this, consumers need accurate, reliable information that will allow them to assess differences in the quality and cost of health benefits plans, the health care providers who treat them, and the facilities and institutions that house them. Active and informed decisionmaking by consumers will improve the performance of the health care system, as providers seek to enhance their quality and reduce their costs in order to be more attractive to value-seeking consumers.
A more basic reason for providing consumers with information is an ethical one. Health plans, facilities, and professionals have an ethical obligation to inform consumers about how their actions can affect the consumer's life and health. Medical ethicists ground this obligation in the principle of respect for individual autonomy and individuals' right to make choices about how they receive medical care (Beauchamp and Childress, 1994).
This chapter provides a description of the types of information on health plans, health professionals, and health care facilities that should be made available to consumers either routinely or upon request. The Commission recognizes that much work remains to be done if all this information is to be readily available and understandable to consumers, specifically:
Detailed explanation is needed for certain types of information. Some types of information are straightforward and require no further definition (e.g., the names, board certification status, and geographic location of primary care providers in a plan's network). Other types of information would benefit from the development of more detailed explanation, such as the care management information on clinical protocols, practice guidelines, and preauthorization and utilization review standards and procedures.
Standardized measures are needed for comparative purposes. For the information intended to support consumer decisions regarding the choice of a health benefits plan, or choice of an individual provider or facility, standardized definitions will be needed to allow for "apples to apples" comparisons.
Ongoing development and promulgation of standardized measurement sets and instruments are needed for assessing satisfaction and quality. The Commission believes that some of the most important types of information a consumer has a right to receive fall into the categories of consumer satisfaction ratings and clinical quality performance measures for health plans, health care professionals, and facilities. For all consumers to exercise this right, processes must be put in place to create standardized performance measures. In its final report, the Commission intends to address how such a process might be established so as to build on existing efforts, encourage ongoing innovation in quality measurement, and provide the best possible information to consumers at any given time to encourage quality improvement through market-based decisions.
Useful and appropriate reporting formats and processes are needed for consumers. Although the Commission believes that consumers should have access to pertinent information, it recognizes that caution must be taken to provide information to consumers in useful formats (e.g., summary and detailed reports, printed copy, and Internet), at appropriate times (i.e., decision points), with assistance for vulnerable groups (i.e., those who are hearing impaired or non-English speaking). These issues also will be addressed in the Commission's final report.
Consumers
should be able to obtain other information upon request as outlined below.
Plans, providers, and facilities should inform consumers that such
information is available and describe how it can be obtained.
Many consumers face a choice of health plans such as an indemnity plan, an HMO, a point-of-service plan, or a preferred provider organization. Consumers' choice of a health plan has a significant impact on consumers' ability to make other choices about facilities, health professionals, and treatment options. Even in cases where consumers do not have a choice of plans, they require information on the plan in which they are enrolled to use the available services effectively.
To the extent that a right to information creates disclosure requirements for health plans, these requirements should apply equally to all types of plans (including indemnity, HMO, PPO, and POS) regardless of sponsor (e.g., such government programs as CHAMPUS, VA, FEHBP, Medicare, and Medicaid and private plans including fully funded, partially self-funded, or fully self-funded plans). If the specific information required for disclosure does not exist, or is unavailable, the consumer should be informed.
The primary responsibility of providing consumers with health plan information falls upon the plans themselves. In the case of self-insured plans, this responsibility will rest with the plan sponsor unless it is delegated or contracted to a third-party administrator.
Within the category of health plan information, one can discern four principal subcategories of information: (1) benefits, cost-sharing, and dispute resolution; (2) health plan characteristics and performance information; (3) network characteristics; and (4) care management information.
Benefits, Cost-Sharing, and Dispute Resolution. Consumers should receive the following information about a health benefits plan:
A general summary of all covered benefits, including:
General limits on coverage, including any annual or lifetime limits, as well as limits for specific conditions.
Whether preventative services are covered.
Whether a drug formulary is used and, if so, how decisions are made pertaining to inclusion of drugs, particularly new drugs (including a process to consider exceptions).
How drugs, devices, and procedures are deemed experimental.
Enrollee cost-sharing, including employee or beneficiary premium contributions, deductibles, copayments, and coinsurance.
Type and extent of dispute resolution procedures available in the event of a dispute.
Health Plan Characteristics and Performance Information. Consumers joining or considering whether or not to join a health plan should receive information about:
State licensure status, Federal certification, and private accreditation status (including publicly available reports).
Consumer satisfaction measures.
Clinical quality performance measures.
Service performance measures (e.g., waiting time to obtain an appointment with primary care providers and specialists).
Disenrollment rates (adjusted for involuntary disenrollment and other relevant factors).
Additional information that should be made available upon request includes:
Number of years in existence.
Corporate form of the plan (i.e., public or private; gateway.html or for-profit ownership and management).
Whether the plan meets requirements (State and Federal) for fiscal solvency.
Whether the plan meets standards (State, Federal, and private accreditation) that assure confidentiality of medical records and orderly transfer to caregivers.
Network Characteristics. It is important to provide consumers with information about the characteristics of the network and the procedures that govern its use. Consumers should receive:
Aggregate information on the numbers, types, board certification status, and geographic distribution of primary care providers and specialists.
Detailed list of names, board certification status, and geographic location of all contracting primary care providers; whether they are accepting new patients; language(s) spoken and availability of interpreter services; and whether facilities are accessible to people with disabilities.
Provider compensation methods, including base payment (e.g., capitation, salary, fee schedule) and additional financial incentives (e.g., bonus, withholds, etc.).
Rules regarding coverage of out-of-network services, and applicable rates of cost-sharing.
Information about circumstances under which primary care referral is required to access specialty care.
Information about what options exist for 24-hour coverage and whether enrollees have access to urgent care centers.
Additional information that should be made available upon request includes:
Detailed list of names, board certification status, and geographic location of all contracting specialists and specialty care centers; whether they are accepting new patients; language(s) spoken and availability of interpreter services; and whether facilities are accessible to people with disabilities.
Detailed list of names, accreditation status, and geographic location of hospitals, home health agencies, rehabilitation and long-term care facilities; whether they are accepting new patients; language(s) spoken and availability of interpreter services; and whether they are accessible to people with disabilities.
Care Management Information. Information in this category that should be available upon request includes:
Preauthorization and utilization review procedures followed.
Use of clinical protocols, practice guidelines, and utilization review standards pertinent to a patient's clinical circumstances.
Whether the plan has special disease management programs or programs for persons with disabilities. (This information should indicate whether these programs are voluntary or mandatory or if a significant benefit differential results.)
Whether a specific prescription drug is included in a formulary and procedures for considering requests for patient-specific waivers.
Qualifications of reviewers at the primary and appeals levels.
All consumers should receive information on:
Whether the health professional's ownership or affiliation arrangement with a provider group or institution would make it more likely that a consumer would be referred to particular specialists or facility or receive a particular service.
How the provider is compensated, including base payment method (e.g., capitation, salary, fee schedule) and types of additional financial incentives (e.g., bonus, withholds).
Consumers should receive upon request the following information on health professionals:
Education, board certification, and recertification status.
Names of hospitals where physicians have admitting privileges.
Years of practice as a physician and as a specialist if so identified.
Experience with performing certain medical or surgical procedures (e.g., volume of care/services delivered), adjusted for case mix and severity.
Consumer satisfaction measures.
Clinical quality performance measures.
Service performance measures.
Accreditation status (if applicable).
Corporate form of the practice (i.e., public or private, gateway.html or for-profit, ownership and management, sole proprietorship or group practice).
The availability of translation or interpretation services for non-English speakers and people with communication disabilities.
Any cancellation, suspension, or exclusion from participation in Federal programs or sanctions from Federal agencies; any suspension or revocation of medical licensure, Federal controlled substance license, or hospital privileges.
Consumers should receive the following information from a health care facility:
Corporate form of the facility (i.e., public or private; gateway.html or for-profit; ownership and management; affiliation with other corporate entities).
Accreditation status.
Whether specialty programs meet guidelines established by specialty societies or other appropriate bodies (e.g., whether a cancer treatment center has been approved by the American College of Surgeons, the Association of Community Cancer Centers, or the National Cancer Institute).
The volume of certain procedures performed at each facility.
Consumer satisfaction measures.
Clinical quality performance measures.
Service performance measures.
Procedures for registering a complaint and achieving resolution of that complaint.
The availability of translation or interpretation services for non-English speakers and people with communication disabilities.
Numbers and credentials of providers of direct patient care (e.g., registered nurses, other licensed providers, and other caregivers).
Whether the facility's affiliation with a provider network would make it more likely that a consumer would be referred to health professionals or other organizations in that network.
Initial results indicate that consumer assistance programs support consumer needs for information on health plans, providers, and facilities. A loose patchwork of consumer assistance services currently exists in the public and private sectors. In the public sector, 14 State or locally based Medicaid programs now have established ombudsmen programs to assist beneficiaries with information needs. Some Medicare beneficiaries and people with chronic health problems have access to consumer assistance services through Information, Counseling, and Assistance (ICA) programs, long-term care ombudsmen programs, and protection and advocacy programs.
In the private sector, health plans often provide consumers with assistance services through customer and member service departments (Oxford Health Plans, 1997; Harvard Pilgrim Health Plan, 1997). Large group purchasers and labor unions often provide their employees with consumer assistance by organizing information on plans, educating employees about their rights, and intervening when employees have complaints about their plans (Darling, 1997).
While there are a number of sources that provide assistance to consumers, most programs target specific subpopulations and have limited funds, and hence provide a limited range of services. There are reasons to believe that consumers and other stakeholders would benefit from greater availability of consumer assistance programs that:
Provide a safety valve. Even in the best of systems, there will be individuals who fall through the cracks. Assistance programs provide a resource that can help such individuals resolve problems quickly and efficiently, often bridging communication failures between the consumer and the provider or health plan.
Foster collaboration. Assistance programs should work with the array of available resources to best meet the needs of consumers.
The challenge to crafting assistance programs for health care consumers is to ensure that such programs are not duplicative, but rather that they supplement and complement existing resources.
With regard to consumer assistance, the Commission has not addressed issues of implementation. Specifically, this is not an endorsement or a requirement for any particular form of consumer assistance programs, but lays out desirable characteristics of such programs.
Obtaining the information listed above and making it available to consumers will not, by itself, equip consumers with the knowledge and abilities required to act on this information. Discussed below are some basic considerations in making this information useful to consumers and the implications of this for key segments of the health care industry.
Information Should Be Useful to Consumers and Cost Effective to Obtain. Edgman-Levitan and Cleary (1996) have documented that consumers are able to evalute critical information about quality. However, research on how consumers use information to make decisions suggests that too much information can be overwhelming. In its 1988 assessment of methods for commmunicating the quality of medical care to consumers, the Office of Technology Assessment's Expert Advisory Panel concluded that "limiting information to only a few indicators of quality will probably be necessary [because] people can consider only a few items at any one time. Information is processed as a unit or chunk -- a person's processing capacity has been estimated as being anywhere from four to seven chunks" (OTA, 1988). Ongoing research must be conducted to determine what is the most effective subset of information that consumers can use. Finally, while consumers clearly have a right to information, it must be understood that there are costs associated with collecting and distributing it. While providing information to consumers generates significant benefits for both the consumers and the health system as a whole, it is not necessarily inexpensive. Recognizing these costs, however, is not an argument for a "bare bones" approach to information disclosure. The failure to provide information also has costs. Well-informed consumers are the bedrock of an efficiently operating market. Without meaningful information, consumers are more likely to make choices that can result in less than optimal outcomes for themselves and there is less incentive for participants to strive for excellence. The challenge is to develop coordinated approaches to information collection and dissemination that will provide consumers the information they need to make decisions without imposing severe burdens on plans and providers.
Investments in Clinical Information Systems and Workforce Education and Training Will Be Needed. Greater investment in automated information systems will be necessary for health plans and providers to satisfy these information disclosure requirements, especially ones pertaining to product, facility, and provider performance and quality. The Commission is currently assessing barriers or impediments to investment in clinical information systems (e.g., inadequate data collection standards; confidentiality concerns; magnitude of capital investments required) and plans to speak to this issue in its final report. Responding to these increased information demands also has implications for the training and education of the health care workforce. There will be greater demand by health care organizations for individuals with particular technical and analytic skills (e.g., computer programming, engineering, data auditing, and statistics). Ongoing training and continuing education programs for practitioners and other workers whose work involves recording, compiling, or manipulating clinical and administrative data will also be needed to assure the completeness and accuracy of data and adherence to confidentiality safeguards.
Beauchamp TL, Childress JF. Principles of Biomedical Ethics (New York): Oxford University Press; 1994.
Darling H. Xerox Corporation. testimony before the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, May, 1997.
Edgman-Levitan S, Cleary S and P. "What Information Do Consumers Want and Need: What Do We Know About How They Judge Quality and Accountability?" in: Jones SB, Lewin ME, editors, Improving the Medicare Market: Adding Choice and Protections, Washington, DC: National Academy Press; 1996.
Harvard Pilgrim Health Care. telephone conversation with Janice Boyce, Public Affairs Department, August 25, 1997.
Office of Technology Assessment. The Quality of Medical Care: Information for Consumers, No. OTA-H-386. Washington, DC; 1988.
Oxford Health Plans. telephone conversation with Scott Schwartz, Assistant General Counsel, August 25, 1997.
Sofaer S. "How Will We Know If We Got It Right? Aims, Benefits and Risks of Consumer Information Initiatives," The Joint Commission Journal on Quality Improvement, May 1997; 23(5):258-264.
Statement of
the Right:
Consumers have the right to a choice of health care providers that
is sufficient to ensure access to appropriate high-quality health care.
To ensure such choice,
health plans should provide the following: Access to
Qualified Specialists for Women's Health Services: Women should be able to
choose a qualified provider offered by a plan -- such as gynecologists,
certified nurse midwives, and other qualified health care providers -- for
the provision of covered care necessary to provide routine and preventative
women's health care services.
Access to
Specialists: Consumers with complex or serious medical conditions who
require frequent specialty care should have direct access to a qualified
specialist of their choice within a plan's network of providers.
Authorizations, when required, should be for an adequate number of direct
access visits under an approved treatment plan.
Transitional
Care: Consumers who are undergoing a course of treatment for a chronic or
disabling condition (or who are in the second or third trimester of a
pregnancy) at the time they involuntarily change health plans or at a time
when a provider is terminated by a plan for other than cause should be able
to continue seeing their current specialty providers for up to 90 days (or
through completion of postpartum care) to allow for transition of care.
Providers who continue to treat such patients must accept the plan's rates
as payment in full, provide all necessary information to the plan for
quality assurance purposes, and promptly transfer all medical records with
patient authorization during the transition period.
Public and
private group purchasers should, wherever feasible, offer consumers a choice
of high-quality health insurance products. Small employers should be
provided with greater assistance in offering their workers and their
families a choice of health plans and products.
Provider Network Adequacy: All health plan networks should provide access to
sufficient numbers and types of providers to assure that all covered
services will be accessible without unreasonable delay -- including access
to emergency services 24 hours a day and seven days a week. If a health plan
has an insufficient number or type of providers to provide a covered benefit
with the appropriate degree of specialization, the plan should ensure that
the consumer obtains the benefit outside the network at no greater cost than
if the benefit were obtained from participating providers. Plans also should
establish and maintain adequate arrangements to ensure reasonable proximity
of providers to the business or personal residence of their members.
The ability of consumers to exercise choice in the health care marketplace is associated with several desirable characteristics of a health care system.
First, choice is associated with increased consumer satisfaction. In a survey of consumers receiving health care in both indemnity and managed care plans, individuals with a choice of health products report greater satisfaction with their plan and tend to rate both their health insurance product and their individual physicians of higher quality (Davis and Schoen, 1997).
Second, the ability of consumers to choose among competing products is a hallmark of a healthy marketplace. Individual consumers are responsible for 34 percent of all direct expenditures for health care in the United States (Cowan et al., 1996). As the science of measuring and generating accurate and valid information on the quality of health plans, providers and facilities advances, consumers can wield their purchasing power to create incentives in the marketplace for improvements in health care quality.
Third, consumers who have a role in the selection of their caregivers are likely to have greater confidence in those practitioners and are, therefore, more likely to seek appropriate care in a more timely fashion and follow agreed-upon care regimens.
Fourth, having a choice of providers allows consumers to take action to preserve continuity of care within the health care system by selecting products and providers that allow them to continue provider relationships when continuity of care is especially important (e.g., prenatal care, care of individuals with complex chronic or disabling conditions).
Thus, a health care marketplace that promotes satisfied consumers, continuity of care, and continuous improvements in quality requires that an array of choices be available to consumers. Without consumers' ability to have and exercise choice, greater activities may need to be undertaken by group purchasers and regulators to ensure that the health care marketplace responds appropriately to consumers' health care needs.
During the last decade, there has been a marked increase in the number and types of health insurance products available in most geographic markets. Prior to the widespread development of managed care plans, most Americans had limited choice of health insurance products. Indemnity products dominated the market with HMO and PPO products available primarily in certain metropolitan areas. The past 10 years have seen a significant increase of insurance products with the expansion of many health plans into new geographic markets and the development of multiple insurance product lines by indemnity insurers and managed care organizations. As a result, with the exception of sparsely populated areas, most communities now have available HMO, POS, PPO, and indemnity products offering consumers a variety of options in terms of benefits, premiums, copayments, and health care delivery systems.
At the same time, there has been a steady migration from traditional indemnity plans to various managed care products in both the public and private markets. Between 1991 and 1995, the percentage of American workers enrolled in indemnity plans decreased from 59 percent to 35 percent (EBRI, 1997). In 1997, more than 5 million Medicare beneficiaries were enrolled in 336 managed care plans, an increase of more than 100 percent since 1993. Under Medicaid, 13 million, or 35 percent, of all beneficiaries have been enrolled in managed care plans, an increase of more than 170 percent since 1993. The Balanced Budget Act of 1997 will increase those trends by expanding the types of products available to beneficiaries of those two public programs.
Although there is greater choice of health insurance products available in most markets, it is important to note that this choice often is exercised at the level of the group purchaser instead of by individual consumers. Between 1988 and 1997, health plan offerings by moderate- and large-sized employers declined (Gabel, 1997). Those offering three or more plans declined from 35 percent to 32 percent, while those offering only one plan climbed from 41 percent to 44 percent over that period. Notably, the percentage of employees in firms with 200 or more workers who were offered coverage of PPOs and POS plans increased from 12 percent in 1988 to 58 percent in 1997 (Gabel, 1997). There also is evidence of variation in consumer preferences for various product characteristics. In the Kaiser-AHCPR survey (1996), 70 percent of survey respondents would prefer a high-cost product with a wide range of benefits over a low-cost product with a more limited range of benefits (26 percent). Respondents were more divided over other health product decisions. Fifty-three percent said they would pay more for unrestricted choice of physicians, while 43 percent would opt for a lower-cost product that limited choice to a list of physicians. Forty-six percent would pay more to have direct access to any specialist, whereas more than half (51 percent) would choose a lower-cost plan that requires a visit to the family physician for a referral (Robinson and Brodie, 1997).
The Commission is troubled by the limited choice of insurance products made available to many consumers through their employer group purchasers. Some of the reduction in choice of plan and product has resulted from conscious decisions by employers to select high-quality products at the best price in the market. In other instances, employers may be seeking to minimize administrative costs associated with multiple offerings. Affording consumers greater choice of plans would allow consumers to select the product that best meets their individual preferences and would encourage health plans to be responsive to consumers' expressed needs. However, the Commission recognizes that, for many consumers, the availability of one plan is better than no plan at all.
The Commission was unable to achieve consensus on creating a "right" to a consumer choice of health plan or product but it is determined to find ways to encourage and assist employers and other group purchasers in providing consumers with a meaningful choice of health plans and products. Consumer choice of health plans is important and should be provided whenever possible and in a way that is affordable both to employers and consumers. In its final report, the Commission will address policy options to provide greater choice of health plans and products, including encouraging the development of purchasing coalitions and alliances to assist small employers who encounter the greatest difficulty in offering multiple options.
The shift from indemnity coverage to managed care arrangements can affect consumers' choice of physicians and other health care providers. In a 1995 study, 41 percent of managed care enrollees who changed health plans over the prior 3 years also changed physicians (Davis et al., 1995). However, nearly all covered workers can now choose a health plan that covers non-network providers. In some cases, however, the additional cost of these products or of the option to go out of network effectively puts such choice out of the reach of some consumers.
It also is clear that consumers value some degree of choice of physicians. The 1997 Kaiser/Commonwealth National Health Insurance Survey found that respondents with a choice of physicians registered the highest level of satisfaction with their plans (Davis and Schoen, 1997). A Kaiser-AHCPR survey of consumers identified four reasons why consumers prefer a greater choice of physicians and other health care professionals:
"So you can see whatever doctor you think is best qualified to treat a particular medical problem" (43 percent);
"So you can change doctors if you become dissatisfied with the one you're seeing" (24 percent);
"So you can continue seeing your regular doctor" (20 percent); and,
"So it's easier to see someone else if your doctor is not available for an appointment" (9 percent).
The most frequently cited reasons speak to consumers' desire to use choice of physicians as a way to obtain quality care. The third is directed toward maintaining relationships with physicians with whom consumers have an existing relationship. In other words, 63 percent of consumers surveyed wanted a choice of physicians so that they can develop and maintain a relationship with a physician they trust to provide them high-quality care.
Therefore, it is important for all health plans and products to maintain an adequate network of physicians and other health care providers, to provide for continuity of care when consumers change plans, and to allow consumers with special health care needs to have adequate choice of physicians and other health care providers. This can lead to higher consumer satisfaction with providers and their health plans without undermining the efforts of provider groups and health plans to develop organized delivery systems.
The Commission's recommendations seek to build on these trends toward providing greater choice by taking several steps to ensure (1) network adequacy; (2) greater access for women to qualified specialists for women's health services; (3) ease of access to specialists for consumers with complex and serious conditions; and (4) greater continuity of care for consumers who enroll in new health plans or see their provider dropped from a plan for other than cause.
When appropriately structured, a plan using a network of providers can improve the quality and coordination of care delivered to consumers through careful selection and credentialing of providers and through coordination of care by primary care physicians and those with specialty training. The National Association of Insurance Commissioners (NAIC, 1996) has developed standards for provider network adequacy that have been adopted by several States. The Commission believes universal adoption of these standards will improve both the quality of care and consumers' satisfaction with their health plans and their care. Because of its strong desire to maintain the integrity of health plan networks, the Commission has rejected approaches to mandate the inclusion of providers into networks (i.e., "any willing provider" laws) or to require plans to allow enrollees to go out of plan networks at will (i.e., "freedom of choice" laws).
Consumers with ongoing health needs often require regular access to physicians and other health care professionals who are specially trained to serve those needs (Bernstein, Dial, and Smith, 1995). This is especially true of those consumers who have disabling or terminal conditions. In such cases, the traditional "gatekeeper" approach used by some health plans can be an impediment to access to quality care and result in unnecessary inconvenience to consumers. The Commission's recommendations are designed to promote consumers' access to appropriately trained specialists while maintaining the integrity of network models of care. Consumers with complex and serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within a plan's network of providers. Authorizations, when required, should be for an adequate number of direct access visits under an approved treatment plan.
Morbidity and mortality associated with breast cancer, cervical cancer, ovarian cancer, and sexually transmitted diseases in women can be significantly reduced through the provision of preventive and routine gynecological services. The U.S. Preventive Services Task Force has issued recommendations pertaining to the provision of Pap smears, mammograms, and other preventive services for women. Women should be able to choose a qualified provider offered by a plan -- including gynecologists, certified nurse midwives, and other qualified health care providers offered by a plan -- for the provision of routine and preventive women's health care services.
Finally, consumers who are undergoing an extensive course of treatment (e.g., chemotherapy or prenatal care) at the time they join a new health plan should be able to continue to see their current providers for a period of up to 90 days (or through completion of postpartum care). Similarly, such consumers should be able to continue to see a provider who is terminated from a plan's network for reasons other than cause. Sudden interruption of care can compromise the quality of care and patient outcomes. Continuity of care has been shown to increase the likelihood that patients receive appropriate preventive services (O'Malley et al., 1997). Appropriately transitioning of care can protect the quality of that care and improve consumers' satisfaction with a new health plan or product. The Commission's recommendations are designed to ease the impact of these transitions from one health insurance product to another and changes in the composition of health plan networks while maintaining the integrity of network models of care. Consumers who are undergoing a course of treatment for a chronic or disabling condition (or who are in the second or third trimester of a pregnancy) at the time they involuntarily change health plans or at a time when a provider is terminated by a plan for other than cause should be able to continue seeing their current specialty providers for up to 90 days (or through completion of postpartum care) to allow for transition of care.
Health plans will need to comply with network adequacy standards. Because these changes are primarily to be carried out within existing networks, there should not be a significant increase in costs to health plans or enrollees. Many licensed plans already meet these requirements as laid down by the National Association of Insurance Commissioners (NAIC) in its Managed Care Plan Network Adequacy Model Act. Plans also will need to develop processes to comply with requirements regarding continuity of care and ease of access to specialists within their network of providers.
Consumers will need to exercise their right to choice by using good judgment and providing direct feedback to plans about their level of satisfaction with the network provided for them.
Quality Oversight Organizations will need to incorporate network adequacy standards into their review activities.
Bernstein AB, Dial TH, Smith MD. "Women's Reproductive Health Services in Health Maintenance Organizations." West J. Med 1995; 163[suppl]:15-18.
Cowan, CA, Braden, BR, McDonnell, PA, et al. "Business, Households and Government: Health Spending, 1994." Health Care Finance Rev; Summer 1996; 17(4):157-178.
Davis K, Collins KS, Schoen C, et al. "Choice Matters: Enrollees' Views of Their Health Plans." Health Affairs; Summer 1995; 99-112.
Davis K, Schoen C. testimony before the Advisory Commission on Consumer Protection and Quality in the Health Care Industry; June 25, 1997.
Employee Benefits Research Institute. EBRI Databook on Employee Benefits, Washington DC, 1997.
Gabel JR (KPMG Peat Marwick LLP). testimony before the Advisory Commission on Consumer Protection and Quality in the Health Care Industry; June 23, 1997.
Kaiser Family Foundation and the Agency for Health Care Policy and Research (AHCPR). Americans as Health Care Consumers: The Role of Quality Information. Princeton Survey Research Associates; October 1996.
KPMG Peat Marwick, Health Insurance Association of America. Sourcebook of Health Insurance Data. Washington, DC; 1996.
O'Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. "Continuity of Care and the Use of Breast and Cervical Cancer Screening Services in a Multiethnic Community." Arch Intern Med 1997; 157(13):1462-70.
National Association of Insurance Commissioners. Managed Care Plan Network Adequacy Model Act. Model Regulation Service; October 1996.
Robinson S, Brodie M. "Understanding the Quality Challenge for Health Consumers: The Kaiser/AHCPR Survey." Journal on Quality Improvement, May 1997; 23(5):239-244.
Statement of the
Right:
Consumers have the right to access emergency health care services when
and where the need arises. Health plans should provide payment when a consumer
presents to an emergency department with acute symptoms of sufficient severity
-- including severe pain -- such that a "prudent layperson" could
reasonably expect the absence of medical attention to result in placing that
consumer's health in serious jeopardy, serious impairment to bodily functions,
or serious dysfunction of any bodily organ or part.
To ensure this
right:
Health plans
should educate their members about the availability, location, and appropriate
use of emergency and other medical services; cost-sharing provisions for
emergency services; and the availability of care outside an emergency
department.
Health plans
using a defined network of providers should cover emergency department
screening and stabilization services both in network and out of network
without prior authorization for use consistent with the prudent layperson
standard. Non-network providers and facilities should not bill patients for
any charges in excess of health plans' routine payment arrangements.
Emergency
department personnel should contact a patient's primary care provider or
health plan, as appropriate, as quickly as possible to discuss follow-up and
post-stabilization care and promote continuity of care. In 1995,
Americans paid an estimated 96.5 million visits to emergency departments,
nearly 37 visits per 100 persons (Stussman, 1997). By tradition, emergency
departments (EDs) have handled a spectrum of illness, but have had the primary
mission of treating those with acutely serious, even life-threatening, medical
conditions. Emergency services can be defined as services that are needed or
appear to be needed immediately because of injury or sudden illness that
threatens serious impairment of any bodily function, and/or serious
dysfunction of any bodily organ or part.
Patients go to
the emergency department with nonurgent problems for various reasons. Economic
and geographic barriers to other forms of care, the lack of a regular
provider, and other factors can and do prompt patients to turn to the
emergency department for primary and other nonurgent care. Apart from lack of
health insurance coverage, nonfinancial barriers to primary care encourage
patients to seek evaluation and treatment in the ED. These include problems
with work schedules, access to transportation, and concerns about personal
safety (Rask, Williams, Parker, et al., 1994). Physician offices and primary
care clinics often have limited hours of operation, while EDs are open 24
hours a day. Medicaid beneficiaries, who have a history of limited access to
regular providers, have particularly strong relationships with EDs as the
provider of first and last resort. Nonurgent visits to the ED can be costly,
contribute to overcrowded waiting rooms, divert resources away from other
hospital-based care, and compromise the coordination and continuity of care.
But drawing the
line between urgent and nonurgent use of the ED is not an easy decision for
providers, health plans, and consumers. Criteria -- both prospective and
retrospective -- for appropriate ED use are in many ways inadequate. By one
criterion, a patient's ED visit might be deemed appropriate, and by another,
not so (Lowe and Bindman, 1997). Health care professionals do not agree among
themselves about the need for urgent care among emergency department patients
(Gill, Reese, and Diamond, 1996). In a survey of 56 hospital EDs, 5.5 percent
of patients initially classified by triage nurses as nonurgent were later
admitted to the hospital from the ED (Young, Wagner, Kellerman, et al., 1996).
Studies estimate that those presenting with nonurgent problems to the ED range
from 6.3 percent (Cunningham, Clancy, and Cohen, et al., 1995) to 54.2 percent
(Stussman, 1997) of ED visits.
To better manage
care and costs in the ED setting, indemnity and managed care plans use a range
of tools that includes requirements for prior authorization and imposition of
higher cost-sharing for use of out-of-network emergency departments. A 1989
survey of HMO medical directors found coverage policies for ED use across the
HMO industry to be fairly uniform (Kerr, 1989). Unless the condition is
life-threatening, patients must obtain prior authorization before seeking
emergency care services in 80 percent of the responding HMOs, and 38 percent
limited their coverage to the EDs of selected network hospitals. A study
undertaken by the Center for Health Policy Studies shows that private
indemnity insurers have adopted many of these same practices in their
fee-for-service arrangements (PPRC, 1996).
A growing set of
State and Federal laws and regulations clarify and protect consumers' access
to appropriate emergency services. The Emergency Medical Treatment and Labor
Act (EMTALA) requires all Medicare participating hospitals to evaluate whether
a patient has an emergency medical condition and, if so, to stabilize the
patient. The Balanced Budget Act of 1997 requires health plans participating
in Medicare or Medicaid to reimburse for emergency services using a
"prudent layperson" standard. Numerous States also have adopted this
standard for access to emergency services. The Commission's recommendation
seeks to create uniformity in all States.
Health care
providers. Health care providers will need to work to educate consumers about
the appropriate use of emergency department services while working to increase
the hours and locations of primary care clinics and other facilities to ease
access to such services outside of emergency departments. Emergency department
personnel need to make strong efforts to ensure the continuity of care of
emergency patients by communicating with patients' primary care providers.
Efforts should be made to assist consumers with language, communication, or
other barriers.
Health plans.
Health plans need to expand consumer education efforts and, when it is within
their control, expand hours and location of primary care facilities to
facilitate access to such services outside of emergency departments. Plans
need to ensure that their coverage and payment policies are consistent with
the "prudent layperson" standard.
Consumers.
Consumers need to become more familiar with the location and hours of
nonemergency care settings and strive to make greater use of such facilities
when appropriate. Consumers should communicate with their providers and plans
to understand any restrictions on their access to emergency services. Cunningham PJ,
Clancy CM, Cohen WJ. "The Use of Hospital Emergency Departments for
Nonurgent Health Problems: A National Perspective." Med Care Res Rev
1995; 52(4):453-474.
Gill JM, Reese
CL, Diamond JJ. "Disagreement among Health Care Professionals about the
Urgent Care Needs of Emergency Department Patients." Ann Emerg Med 1996;
28(5):474-479.
Kerr HD.
"Access to Emergency Departments: A Survey of HMO Policies." Ann
Emerg Med 1989; 18(3):274-277.
Lowe RA, Bindman
AB. "Judging Who Needs Emergency Department Care: A Prerequisite for
Policy-Making." Am J Emerg Med 1997; 15(2):133-136.
Physician
Payment Review Commission. Managing Medicare's Fee-for-Service Program. 1996
Annual Report to Congress. Washington, DC: PPRC; 1996; 196-199.
Rask KJ,
Williams MV, Parker RM, et al. "Obstacles Predicting Lack of a Regular
Provider and Delays in Seeking Care for Patients at an Urban Public
Hospital." JAMA 1994; 271:1931-1933.
Stussman BJ.
National Hospital Ambulatory Medical Care Survey: 1995 Emergency Department
Survey. Advance Data from Vital and Health Statistics (no. 285). Hyattsville,
MD: National Center for Health Statistics; 1997.
Young GP, Wagner
MB, Kellermann AL, et al. "Ambulatory Visits to Hospital Emergency
Departments: Patterns and Reasons for Use." JAMA 1996; 276:460-465.
Statement of the
Right In order to
ensure consumers' right and ability to participate in treatment decisions,
health care professionals should:
Provide patients
with easily understood information and opportunity to decide among treatment
options consistent with the informed consent process. Specifically,
Discuss all
treatment options with a patient in a culturally competent manner, including
the option of no treatment at all.
Ensure that
persons with disabilities have effective communications with members of the
health system in making such decisions.
Discuss all
current treatments a consumer may be undergoing, including those alternative
treatments that are self-administered.
Discuss all
risks, benefits, and consequences to treatment or nontreatment.
Give patients
the opportunity to refuse treatment and to express preferences about future
treatment decisions.
Discuss the use
of advance directives -- both living wills and durable powers of attorney for
health care -- with patients and their designated family members.
Abide by the
decisions made by their patients and/or their designated representatives
consistent with the informed consent process.
To facilitate
greater communication between patients and providers, health care providers,
facilities, and plans should:
Disclose to
consumers factors -- such as methods of compensation, ownership of or interest
in health care facilities, or matters of conscience -- that could influence
advice or treatment decisions.
Ensure that
provider contracts do not contain any so-called "gag clauses" or
other contractual mechanisms that restrict health care providers' ability to
communicate with and advise patients about medically necessary treatment
options.
Be prohibited
from penalizing or seeking retribution against health care professionals or
other health workers for advocating on behalf of their patients.
Consumers depend
on health care professionals to provide them with expert consultation and
advice on how to stay healthy or how to cure or palliate their health and
medical problems. Unlike many other consumer transactions, the asymmetry of
information between consumer and health care provider often is great.
Decisionmaking also often occurs at a time of illness, which can undermine the
patient's ability to act most effectively in his or her own interest. Relationships
between consumers and health care professionals are most rewarding and likely
to result in positive outcomes when they are characterized by open
communication and active participation of patients in the treatment process.
Patient participation in treatment is an essential part of compliance, and
compliance improves the effectiveness of care and treatment.
The benefits of
patient participation go beyond just the anticipated therapeutic effect of the
intervention (Czajkowski and Chesney, 1990). For example, the Coronary Drug
Project Research Group (1980), which studied the efficacy and safety of
several lipid-lowering drugs, found that even among patients who only took
placebos, good adherers had a much lower 5-year mortality rate (15 percent)
than did poor adherers (24.6 percent).
Patient
participation in treatment decision making also leads to improved satisfaction
with care and better quality of life. For example, in a study of patients with
early breast cancer, it was found that those who believed they were more
responsible for treatment decisions and had more choice of treatment reported
higher quality of life than those who perceived themselves as less in control
of the treatment decisions (Street and Voigt, 1997).
To participate
in decisionmaking about their care, consumers must have complete information
about treatment options -- including the alternative of no intervention -- as
well as the risks, benefits, and consequences of such options. Yet evidence
suggests that clinical practice often falls short of these expectations. A
1988 study of hospitalized patients found that physicians discussed test or
treatment rationale in only 43 percent of cases and alternatives in 12 percent
of cases (Wu and Pearlman, 1988). Physicians shared with patients information
about benefits in 34 percent of cases and risks in 14 percent of cases.
The continued
development of communications technologies to help consumers more fully
understand their treatment options and to evaluate the potential risks and
benefits of treatments should be encouraged, for example, the use of videos to
help men with prostate cancer evaluate the risks and benefits of surgery
versus a "watchful waiting" strategy (Wennberg, 1995) and to help
men with benign prostatic hypertrophy sort out options for treatment (Wagner
et al., 1995).
Increasingly,
effective communication between providers and patients demands some degree of
cultural competence. By the year 2000, nearly one-quarter of the U.S.
population will be members of racial or ethnic "minority" groups;
this will grow to 47.5 percent by the middle of the next century. Cultural
competence refers to the "demonstrated awareness and integration of three
population-specific issues: health-related beliefs and cultural values,
disease incidence and prevalence, and treatment efficacy" (Lavizzo-Mourey
and Mackenzie, 1996). Effective communication for people with communication
disabilities may require health care providers to provide auxiliary aids and
services and remove certain communication barriers.
It also is
imperative that providers be aware of and comply with their patients'
decisions with respect to advance directives. Once a patient makes a decision,
the health care team should respect this treatment choice. Yet there is clear
evidence that this is not happening in far too many instances. Teno et al.
(1995) studied 4,301 patients hospitalized in 6 hospitals and found that
physicians often were unaware of their patients' wishes. In 47 percent of
cases, physicians reported that they did not know of their patients' expressed
desire for a "do not resuscitate" order. In another study focusing
on nursing home residents transferred to hospitals, Davis, Southerland,
Garrett, et al. (1991) found that medical treatment was consistent with
advance directives in 75 percent of the 96 cases studied.
There are a
variety of organizational and contractual factors that also may influence
communication between patients and providers. These include financial
arrangements and contractual restrictions or sanctions that may inhibit the
free exchange of information.
Much attention
has focused in recent years on the potential effects of providers' financial
incentives on treatment. Methods of compensating physicians can be a powerful
mechanism to change provider practice, either to improve the quality of care
provided to consumers or to reduce the costs of that care. But poorly designed
compensation arrangements also can result in inappropriate use (including both
overuse and underuse) and barriers to care.
All methods of
compensating physicians and other health care providers create some form of
incentive for behavior. Various approaches are used to offset the potential
adverse effects of compensation arrangements. For example, fee-for-service
systems may use utilization review mechanisms to temper incentives toward
overutilization of health care services. Capitation systems may incorporate
measures of quality and consumer satisfaction to minimize incentives toward
overutilization. Similarly, salaried arrangements may use bonuses to encourage
higher provider productivity and exemplary performance.
In 1996, the
Health Care Financing Administration promulgated rules concerning the use of
certain types of financial arrangements on behalf of health plans serving
Medicare or Medicaid beneficiaries. These rules stipulate that compensation
arrangements "may not include any direct or indirect payments to
physicians or groups as an inducement to limit or reduce necessary services
furnished to an individual enrollee who is covered under the managed care
organization's contract." These regulations also require disclosure of
information about arrangements that transfer substantial financial risk to the
health care provider. If the compensation methods used places the physician or
physician group at substantial financial risk, then the health plan must
survey enrollees about access and satisfaction with the quality of services,
and institute adequate and appropriate stop-loss protections.
In addition to
financial incentives, contract rules that restrict providers' ability to
advise patients about medically necessary treatment options have been the
subject of much concern. Health care providers must be able to advocate for
their patients without constraint or fear of reprisal. A report by the General
Accounting Office (GAO, 1997) reported: "Of the 529 HMOs in our study,
none used contract clauses that specifically restricted physicians from
discussing all appropriate medical options with their patients. Two-thirds of
responding plans and 60 percent of the contracts submitted had a
nondisparagement, nonsolicitation, or confidentiality clause that some
physicians might interpret as limiting communication about all treatment
options. However, contracts with such business clauses often contained
anti-gag language stating that the physician should not misconstrue the
contract of a specific provision as restricting medical advice to patients or
that the physician should foster open communication." As of mid-1997, 25
States had prohibited the use of such clauses in managed care contracts with
physicians and legislation was pending in 23 other States (Health Policy
Tracking Service, 1997). In December 1996, HCFA banned the use of gag rules
under the Medicare program and in February 1997, HCFA took similar action
regarding health plans' participating in Medicaid.
Consumers must
take a more active part in the treatment decision process. Information can be
empowering, but navigating the health care system requires patient effort,
from completing advance directives to preparing questions for an office visit.
This requires that the consumer ask questions, understand and give informed
consent, and become a full partner in treatment decisions with his or her
health care provider.
Health care
providers also have the central role in ensuring the patient's participation
in treatment decisions, including compliance with informed consent. They will
need to improve their skills in providiRationale
Implications of the Right
References and Selected Reading
Consumer Bill of Rights and
Responsibilities
Chapter Four
Participation in Treatment DecisionsRationale
Patient and Provider Communication
Organizational and Contractual Issues
Implications of the Right
