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Clinton Reveals New Plans for Managed Care Patient Appeals

By Alissa J. Rubin
Los Angeles Times
WASHINGTON

With Republicans and Demo-crats still at odds over a comprehensive bill to protect patients, President Clinton announced a significant regulation that would dramatically speed up the appeal process for the 120 million Americans who have private, employer-sponsored health plans.

When a treatment is denied, patients would be entitled to an expedited appeal.

Health plans would have 72 hours to rule on an appeal in an emergency and 30 days if the contested procedure was not an emergency. Currently, plans have up to 90 days to respond in non-emergency cases and an appeal can often take as much as six months.

But the federal regulation is a far cry from the comprehensive patient protections that Clinton, congressional Democrats and a handful of Republicans are pushing. Those protections would provide easier access to specialists, appeals to an independent review board outside of the health plan and guaranteed coverage at the nearest hospital for emergencies.

"What we're doing today is trying to give quick and prompt appeals through an internal review process to the insurance companies and plans that are within our jurisdiction," Clinton said in his Saturday radio address. "But it is simply not enough. That's why I've worked so hard to pass a patient's bill of rights available to all Americans in all plans [a bill] that would say medical decisions should be made by doctors, not accountants."

In making health care the topic of Saturday's radio address, Clinton appeared to be reminding people that he intends to fight for his public policy agenda despite his personal troubles.

He criticized Republican leaders for blocking a full debate on managed care regulation. "The Republican leadership in both houses has not allowed full and open debate on the issue. The Senate hasn't even held a single vote," he said. "But, remember, this is not a partisan issue. Nobody asks your party affiliation when you visit your doctor."

Most private plans are governed by the 1974 Employee Retirement and Income Security Act and its health care rules have gone virtually unchanged for nearly 20 years. In that time the health insurance system has been transformed from one dominated by fee-for-service insurance to one dominated by managed care.

Today, 75 percent of all private insured Americans are in some kind of managed care plan, which attempts to hold down costs by limiting access to specialists, expensive treatments and tests.

Indeed, the old rules are so ill-suited to today's health system that private employers and health insurance plans have even urged the Department of Labor, which oversees the employer plans, to overhaul the old regulations.

In part, such urgings were self-interested since employers and insurers feared a wholesale backlash against managed care, which could end up raising the cost of health care.

"Much of what patients are concerned about could be taken care of by responsible regulating," said Paul Dennett, vice president for health policy at the Association of Private Pension and Welfare Plans, which represents large and midsized employer benefit plans. "There's absolutely no reason that the Labor Department's regulations and approach shouldn't be updated to reflect a new reality."

The American Association of Health Plans, which represents more than half of all managed care plans nationwide, also endorsed the principle of a quicker appeals.

"We've been very supportive of an expedited appeals process that would work as quickly as a patient's condition warranted it to work," said Susan Pisano, a spokeswoman for the group.

Over the past year, the White House has put in place guarantees for patients in government-run programs such as Medicare and Medicaid, including access to an independent appeal, payment for emergency treatment at any hospital and access to specialists.

But for Americans who get their health care through a plan offered by a private employer or who buy it on their own, the government's powers are far more limited. Clinton's announcement Saturday represented his first effort to make changes for them in the regulation of the private health insurance system.