McCarthy spoke recently with the local press as both a member of Congress and a nurse on her support for The Bipartisan Consensus Managed Care Improvement Act. In addition to supporting the bill she has offered an amendment to it, Whistleblower Protection.

She commented, "I offered this amendment in committee to protect my nurses and other healthcare workers from retaliation. Nurses, doctors, and other healthcare workers are on the front lines of our health care and when they see abuse of any kind they should have the ability to report it without fear of repercussions. I am confident with this one small change in this legislation our health care will be about the patients' rights and not the HMO's bottomline."

The legislation, which McCarthy calls the "New and Improved Patients' Bill of Rights," calls for assurances that patients will have access to emergency services without prior authorization. It also calls for access to specialists, even if they are out of the plan's network without penalty fees if no other specialist in the plan is appropriate. Individuals who have chronic conditions would also be able to obtain referrals and select a specialist to monitor their condition and refer them to other caretakers. Obstetrics and gynecological services would be guaranteed to patients, as would pediatric specialists and the ability to have a pediatrician serve as the primary care physician for a child.

Another provision of the bill is to protect, in a limited way, the continuity of care even when a patient's health care plan changes in midcare. There are specific provisions to protect the care provided in cases of pregnancy, terminal illness, and those on waiting lists for surgery. There is also consideration given to allowing patients to participate in clinical trials and access to drugs not listed in the plan's "formulary."

McCarthy argued that providing choice is one of the biggest ways patients can find greater satisfaction with their managed health care. The bill would allow health care consumers to "elect a point of service option when their health insurance plan did not offer access to non-network providers. Any additional costs of this option would be borne by the patient," according to McCarthy. The bill also calls for plans to provide more information to their members about policies, procedures, benefits, and other requirements.

McCarthy shared a story of one hospital that had treated a patient and run a series of tests to determine the patient's problem. Originally it was thought the patient had appendicitis, and so a series of tests was run to determine if this diagnosis was accurate. It turned out it was something else, and when the insurance company received the bill for the appendicitis tests it denied them. She said this kind of hindsight denial of covering testing costs will seriously hurt the quality of care patients will receive. With this and other HMO horror stories in mind, the bill allows patients the ability to appeal plan decisions to deny, delay, or otherwise overrule doctor-prescribed care.

Also, the bill calls for not only a more efficient internal appeal process, but it calls for an external, independent body to resolve disputes for cases involving medical judgment. The plan would pay for this process and be compelled to adhere to the decision rendered by this body. The option of going to federal court to enforce the external appeal body's decision is also provided by the bill. The court would have the ability to penalize the plan $1,000 a day until the plan complies and it could order the plan to cover attorney fees.

McCarthy also noted, "The Bipartisan Consensus Bill lays out basic criteria for a good utilization review program: physician participation in development of review criteria, administration by appropriately qualified professionals, timely decisions (within 14 days for ordinary care, up to 28 days if the plan requests additional information within the first 5 days, or 72 hours for urgent situations), and the ability to appeal these decisions."

The bill prohibits the health care plans from attempting to "gag" doctors from sharing all treatment options with patients or attempting to provide incentives to providers to limit services. Provider discrimination based on licensing, location, or patient base is also prohibited. Health plans will also be expected to pay providers in a timely manner and within Medicare guidelines for prompt payment.

McCarthy also explained, "Health plans are not currently held accountable for decisions about patient treatment that result in injury or death. Currently, the Employee Retirement Income Security Act pre-empts state laws and provides essentially no remedy for injured individuals whose health plans' decisisons to limit care ultimately cause harm. If the plan was at fault, the maximum remedy is the denied benefit itself."

"The Bipartisan Consensus Bill would remove ERISA's pre-emption and allow patients to hold health plans accoutnable according to state law. However, plans that comply with an external reviewer's decision may not be held liable for punitive damages. Additionally, any state law limits on damages or legal proceedings would apply," she said. McCarthy added, "The provision also protects employers from liability when they were not involved in the treatment decision. It explicitly states that discretionary authority does not include a decision about what benefits to include in the plan, a decision not to address a case while an external appeal is pending or a decision to provide an extra-contractural benefit."

McCarthy concluded, "Health care is a right and we need to make managed health care become a provider of that right in a responsible and efficient way."