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Fixing HMO Healthcare

Dr. Bill Wattenburg has been greatly concerned over some of the practices of some of the nations Health Maintenance Organizations. He and many of his listeners are especially concerned over delayed and denied services, particularly in those HMOs where the administrative costs are as high as 30% of the total dollars spent and where denials of health services are made by boards of people who are not trained medical doctors and thus who are incapable of making sound medical decisions. This area will be devoted to collecting information presented on Bill’s show for as long as he covers the issue.

Bill feels that enacting the following five items into legislation is imperative, and must be done to ensure quality health care:

  1. You may see any doctor of your choice, without having to go through a cumbersome referral process, and must have the right to appeal any denial of service to other medical doctors.
  2. Doctors must be paid fees for services at a rate at least equal to the standard Medicare schedule, and insurance companies shall be prevented from paying doctors a flat rate per patient per month (called capitation) in lieu of paying for individual services.
  3. Hospitals must likewise be paid according to the standard Medicare fee schedule.
  4. You must have the right to visit an emergency room without getting prior approval from your primary care physician, and must be given prompt service without the hospital being required to obtain permission from your doctor.
  5. Insurance companies that use approval or procedure payment review boards may have only medical doctors on those boards.

The PARCA bill described below addresses some, but not all of these five points. Demand that your representatives pass this legislation, and add the missing pieces to it.

capitation
The term used for HMO health insurance companies’ fixed payment per patient per month to a primary care physician, instead of paying a specified amount for specific procedures. According to Dr. Wattenburg, a typical capitation payment is $11/month, with which the doctor must pay for all of his time, tests, and procedures performed. Webster’s defines capitation as “a tax or fee upon head of each person”.
Patient Access to Responsible Care (PARCA) Act of 1997 (105th Congress: H. R. 1415; S. 644)
According to Bill, this bill is dead for the year, but he feels that its goals need to be passed into law. It currently has over 211 co-sponsors, has had several hearings in the House and one hearing in the Senate.
H.R. 1415 was sponsored by Congressman Charlie Norwood (R-GA) and S. 644 was sponsored by then Senator Alfonse M. D’Amato (R-NY) (both are Republicans). It is supported by about 90 republicans and 110 democrats. President Clinton has not yet addressed this specific legislation, although he has publicly endorsed the concept of a patient bill of rights.
HMO Task Force Spells Out Suggested Managed-Care Reforms
This article appeared in the January 6th, 1998 issue of the San Francisco Chronicle. Its subtitle reads “Consumers, legislators blast them as ‘wimpy’ ”.
Other similar bills
There is also H.R. 820 (Health Insurance Bill of Rights Act of 1997), H.R.586, H.R. 815, H.R. 1515, and H.R. 66.

To contact your representatives please call the House of Representatives switchboard at 1 (202) 225-3121 and the Senate switchboard at 1 (202) 224-3121. When your representatives’ offices, please ask them to support both of these bills.