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Managed Care Reform
Below are provisions that the American Academy of Family Physicians believes are essential to include when advocating for comprehensive managed care reform:
The Academy supports:
- A requirement that basic information about covered and excluded benefits, financial obligations, plan providers, experimental benefits and other important plan provisions be available to all plan enrollees in a uniform format that is easily readable;
- A requirement that plans have an internal and external appeals process enabling meaningful and prompt access for patients and their physicians;
- A requirement that plans have a prudent lay person standard enabling patients to secure emergency care out of plan without prior authorization (a requirement that is as strong as the standard established for Medicare beneficiaries in the Balanced Budget Act of 1997);
- A requirement that plans honor the right of each physician and other health care providers to communicate freely with all patients;
- A requirement that plans have a policy protecting physicians who advocate on behalf of their patients for needed medical benefits;
- An assurance that "medical necessity" decisions will be made by physicians who have knowledge of a patient's particular medical history and circumstances;
- A requirement that self-funded ERISA plans be held responsible for medical outcomes, as are other plans, within any given state;
- The modification of ERISA to allow injured patients to seek recovery in federal court for improper coverage denials; and meaningful liability caps in federal court which will ensure health plans recognize their responsibility to guarantee patients have timely access to needed medical care;
- A requirement that plans have a process to enable use of non-formulary drugs when they are medically indicated;
- The inclusion of family physicians in any definitions of women's and children's health care providers to ensure access to all qualified physicians;
- An accurate definition of primary care, consistent with the AAFP definitions of primary care and family medicine;
- A requirement that managed care entities must regularly update their list of participating providers every 30 days and make it available to physicians and patients;
- A requirement that managed care entities should furnish physicians with a fee schedule showing what they will be paid for services that will be provided by that physician under the plan when negotiating with the physician to become or continue as a healthcare provider under the managed care plan;
- Recognition of the importance of the Patient-Centered Medical Home (PCMH). Managed care plans should encourage patients to utilize a PCMH and provide a graduated payment for physicians who meet recognized criteria for providing such an entity.
- The use of a uniform provider contract template.
- First dollar coverage for preventive services by managed care plans.
The Academy has 105,900 members delivering medical and preventive care nationwide and in all U.S. territories. Patients make 200 million office visits to family physicians each year -- 79 million more than any other specialty. In fact, one out of every four office visits in America is to a family physician. Family physicians see one out of every five children to provide their health care, and one out of every four women for their health care. Family physicians focus on the whole person, as well as the entire family, and play a central role in helping patients navigate today's complex health care system.
The Academy is equally concerned that comprehensive managed care reform promote quality health care, instead of hindering it. Nearly 80 percent of Academy members accept patients from one or more managed care plans. It is essential that health care quality measures be based in science. The Academy is committed to evidence-based research and has created a $7.7 million research initiative over the next five years to fund office-based primary care research. The Academy has also established the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in Washington, D.C., to inform its policy initiatives. (March 2001) (2012 COD)