Protecting Consumers Rights in an Era of Managed Care

(© Michelle Sahl 1998)

 

“Insured Americans are protected by a patchwork of federal and state laws.  These [consumer / patient rights] protections depend on whether they are publicly or privately insured, the states in which they live, and whether their employers buy insurance or self-insure.” [i] Given that premise, how can consumers’ / patients’ rights be improved under the umbrella of managed health care?  A series of articles that attempt to address that issue have both similar and differing recommendations.  Daniels and Sabin call for more public involvement via reform at the public policy level.[ii]  Annas[iii]^,[iv] and Rodwin[v] espouse the merits of a strong patient voice at the health plan level, with Annas emphasizing a revamped appeals process and Rodwin applauding the benefits of consumer satisfaction surveys.  Both Daniels/Sabin and Rodwin describe the lack of consumer choice when it comes to switching health plans, largely due to the limited plan options offered to the insured who receive coverage through their employer.  Daniels/Sabin and Annas point out the advantage of engaging a neutral, (third party) independent consultant/arbitrator when disputes arise between managed care organizations and patients or physicians.  All of these recommendations (public policy, patient voice, and independent evaluators) appear laudable.  But are they workable?

 

 Daniels and Sabin believe that broad-sweeping reform is needed in managed care practice.  They present their loftier policy-level recommendations that speak to the issue of public accountability – both at the market level (i.e., adequately provide for informed choice) and in reasonableness (i.e., employ fair-minded rationale in plan decision-making).²   The timing of such proposed policy measures would, it appears in general, be at the early “before-the-fact” planning stages for a health plan in order to preclude expected problems, as opposed to the more immediate appeals procedure approach described by others which could be, in fact, contemporaneous with an individual health coverage problem.  Daniels and Sabin provide some insight into their process recommendations, by example, in their article on “Last Chance Therapies.”[vi] Here they discuss “up front” policy development measures employed by plans in consideration of experimental / investigational procedures for the treatment of breast cancer.....