See also:
Health Plans
Managed Care Reform
The American Academy of Family Physicians supports managed care reform that ensures patients receive clear information and fair treatment from their health plans and protects the primary care physician's ability to act as the patient's advocate.
Below are provisions that the American Academy of Family Physicians believes are essential for Congress to include in comprehensive managed care legislation:
The Academy supports:
Below are provisions that the American Academy of Family Physicians believes are essential for Congress to include in comprehensive managed care legislation:
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 on clinically appropriate care will be made by physicians;
- A requirement that self-funded ERISA plans be held responsible for medical outcomes, as are other plans, within any given state;
- ERISA needs to be modified to allow injured patients to seek recovery in federal court for improper coverage denials; meaningful liability caps in federal court will ensure health plans recognize their responsibility to ensure 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, which is the care provided by family physicians, general internists and general pediatricians. They are specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern; not limited by problem origin, organ system, gender, or diagnosis.
- 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.
- 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.
- Plans should recognize the importance of the Patient-Centered Medical Home by encouraging patients to utilize such an entity and providing a graduated payment for physicians who meet recognized criteria for providing such an entity.
- All plans should use a uniform provider contract to allow easier comparison between available plans.
Background
The American Academy of Family Physicians supports managed care reform that ensures patients receive clear information and fair treatment from their health plans and protects the primary care physician's ability to act as the patient's advocate.
The Academy is deeply interested in seeing comprehensive managed care reform that ensures patients have appropriate information and fair treatment by health plans. The Academy has 94,000 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) (2007)
The Academy is deeply interested in seeing comprehensive managed care reform that ensures patients have appropriate information and fair treatment by health plans. The Academy has 94,000 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) (2007)