Congress takes a pass on managed care reform measures

Both Democratic and Republican efforts at managed care reform failed to gain Congressional approval this year, a mixed blessing to emergency medicine providers.

The American College of Emergency Physicians (ACEP) had lobbied against the GOP-sponsored bill (HR 4250), known as the Patient Protection Act, because it did not include the "prudent layperson" standard for coverage of emergency services that was mandated in last year’s Balanced Budget Act.

This standard of coverage holds that managed care plans must pay for emergency services, regardless of the outcome or final diagnosis, if the patient sought the care while experiencing symptoms that the average person would believe to be an emergency.

The BBA provisions included the "prudent layperson" standard, but only applied to patients covered by Medicare and Medicaid, not to patients covered by private or ERISA-protected health plans. Seventeen states have so far enacted their own "prudent layperson" legislation, but a federal law would have covered everyone.

The GOP bill would have required coverage only if the emergency physician certified in writing that a patient needed emergency medical care; the health plan would have been required to cover the care only if a "prudent" emergency medical professional would agree with the treating physician’s assessment, according to a July statement released by ACEP opposing adoption of the GOP measure.

The Patient Protection Act passed the House, but was tabled in the Senate and never made it up for a vote.

A substitute bill, proposed by Demoratic leaders in the Senate, would have included the "prudent layperson" standard, but that measure also failed to pass.

This leaves Medicaid and Medicare patients with guaranteed coverage of emergency services, while patients with private insurance, in most states, are not covered by such legislation.