Community-Based Strategies for Improving Quality
The methods discussed so far have focused on the quality of care provided to specific covered groups of employees. Groups with similar consumer protection interests have also worked together to improve the quality of care provided to entire communities. Following are examples of such efforts.
Presidential Advisory Commission
In March, 1997, President Clinton appointed the Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Thirty-two members sat on this commission; three from Labor, including AFSCME International President McEntee. Other members of the commission represented consumers, health care providers, health insurers, managed care health plans, state and local governments, and health quality experts. The commission was directed to advise the President “on changes occurring in the health care system and recommend such measures as may be necessary to promote and assure health care quality and value, and protect consumers and workers in the health care system.” As part of its work, President Clinton asked the commission to draft a “Consumer Bill of Rights.” Following is a summary of the Bill of Consumer Rights and Responsibilities adopted by the commission and supported by President Clinton:
- Information Disclosure - Consumers have the right to receive accurate, easily understood information and some require assistance in making informed health care decisions about their health plans, professionals, and facilities.
- Choice of Providers and Plans - Consumers have the right to a choice of health care providers that is sufficient to ensure access to appropriate high-quality care.
- Access to Emergency Services - Consumers have the right to access emergency health care services when and where the need arises. Health plans should provide payment when a consumer arrives at an emergency department with acute symptoms of sufficient severity — including severe pain — such that a “prudent layperson” could reasonably expect the absence of medical attention to result in placing that consumer’s health in serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
- Participation in Treatment Decisions - Consumers have the right and responsibility to fully participate in all decisions related to their health care. Consumers who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members or other conservators.
- Respect and Nondiscrimination - Consumers have the right to considerate, respectful care from all members of the health care system at all times and under all circumstances. An environment of mutual respect is essential to maintain a quality health care system. Consumers must not be discriminated against in the delivery of health care services consistent with the benefits covered in their policy or as required by law based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment. Consumers who are eligible for coverage under the terms and conditions of a health plan or program or as required by law must not be discriminated against in marketing and enrollment practices based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information or source of payment.
- Confidentiality of Health Information - Consumers have the right to communicate with health care providers in confidence and to have the confidentiality of their individually identifiable health care information protected. Consumers also have the right to review and copy their own medical records and request amendments to their records.
- Consumer Appeals - All consumers have the right to a fair and efficient process for resolving differences with their health plans, health care providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review.
- Consumer Responsibilities - In a health care system that protects consumers’ rights, it is reasonable to expect and encourage consumers to assume reasonable responsibilities. Greater individual involvement by consumers in their care increases the likelihood of achieving the best outcomes and helps support a quality improvement, cost-conscious environment.
In late 1997, President Clinton issued an Executive Order mandating that federal agencies operating health insurance programs bring those programs into compliance with the Bill of Rights. This executive order covers people on Medicare, Medicaid, all federal employees and members of the military.
While managed care plans are divided on the issue of regulation, some favor one federal law over a patchwork of state laws. In late 1997, three large HMOs (Kaiser Permanente, HIP Health Insurance Plans and Group Health Cooperative of Puget Sound) joined with two consumer groups (American Association of Retired Persons and Families USA) in crafting a set of quality health care standards. The group forwarded these standards to the Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry (see “Consumer Bill of Rights” above) and asked that they be incorporated into its recommendations, and that they be federally enforced. A number of standards similar to those developed by this group were included in the Presidential Advisory Commission’s recommendations. While the group’s quality health standards do not address all areas of concern, they do include many of the protections discussed throughout this manual.
Kaiser Permanente Partnership
Kaiser Permanente is the nation’s largest and oldest HMO, and is one of the most unionized health employers in the nation. The Kaiser Partnership was negotiated by a coalition of 14 unions, including AFSCME. Under the agreement, health care workers have a voice in management decisions that affect their jobs and their patients, thereby helping Kaiser base its competition with other HMOs on the quality of care provided, rather than strictly on cost. Kaiser has agreed to union neutrality, union organizing efforts, and card-check recognition and the AFL-CIO has agreed to make Kaiser a “provider of choice” for the AFL-CIO unions’ membership.