What Makes Better Care? The Series. Part 8: Consumer Protections

Principle 8: Patient Protection

As the House and Senate get close to releasing their versions of comprehensive payment and delivery reform legislation, the Campaign For Better Care, with the help of students from the Harvard School of Public Health, will be doing a series of blog posts this week highlighting our 10 Principles for Better Care.

8. Consumer Protections: Current protections provided by the Office of Patient Protection and other managed care regulations must be maintained and extended to encompass ACOs, patient-centered primary care homes, and other payment reform entities.

Over a decade ago, abuses in the managed care industry led to the enactment of a strong managed care patient bill of rights in Massachusetts. Under the law, individuals who receive health coverage from a Massachusetts insurer are entitled to new protections covering internal grievances, medical necessity guidelines, continuity of care and external appeals. The law established the Office of Patient Protection (OPP) within the Department of Public Health. They have successfully helped hundreds of patients get benefits they were entitled to, and made sure our insurers were acting in accordance with the rules. As payment systems evolve and shifting incentives apply to providers, and not just insurers, our consumer protection laws must be updated. Massachusetts must ensure that consumer protections are maintained as we enter this new era of payment reform.

Key Policy:

  • Patient rights to independent external review, similar to rights now provided to members of HMOs, should extend to members of ACOs and other provider risk arrangements. The OPP process, administered by the Department of Public Health, has been an important check on Massachusetts HMOs. Currently, OPP is suffering from drastic funding cuts, which have strained its ability to oversee independent reviews of denials of care. This is a very serious concern as ACOs are entering onto the health care scene and more resources will be needed for oversight. More funds must be provided to OPP in connection with their expanded duties under payment reform.

Although cost savings will be a major goal of payment reform in Massachusetts, cost reductions must come through better care, not by stinting on quality care to patients. If patients are denied access to care as a result of payment reform, we fail to keep the most basic promise of health care.

Better health care means protecting patients’ rights.
-Akash A. Desai

About HCFA

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