PATIENTS' BILL OF RIGHTS BACKED; PRESIDENTIAL PANEL ENDORSES PROPOSALS.

Byline: Robert Pear The New York Times

A presidential advisory commission decided Wednesday to recommend a wide range of new rights for patients, including the right to appeal denials of care or coverage by insurance companies and health maintenance organizations.

The 34-member panel, which includes top executives of managed-care companies as well as doctors and consumer advocates, said patients should be able to obtain an ``external review'' of decisions that deny payment for services.

Many health plans now have their own procedures to deal with grievances and complaints. The commission said all patients also should have the option of appealing to an independent outside authority, as Medicare beneficiaries do.

The panel also said health plans, doctors and hospitals should be required to disclose substantial amounts of new information and data that could help patients assess the quality and experience of health care providers.

For example, it said, consumers should, on request, be able to find out how often a doctor has performed a particular procedure and how often the treatment was successful. In addition, it said, patients should be able to find out if their doctors have been sued for malpractice, how the doctors are paid and whether the doctors receive bonuses or other financial incentives.

Consumer advocates and some members of Congress say such financial rewards might encourage doctors to control costs by withholding care that patients need.

Kathleen Sebelius, the insurance commissioner of Kansas, a member of the commission, said, ``These proposals give consumers the tools with which to empower themselves.''

Another panel member, Stephen Wiggins, founder and chairman of Oxford Health Plans, said: ``Under these proposals, a urologist will have to disclose what percentage of his patients are incontinent or impotent after he does surgery. This type of information can produce a revolution in the health care system. Most patients have no idea if they are the first person or the 50th person to have surgery performed by a particular physician.''

These and other proposals were endorsed by the commission as part of a bill of rights for health care consumers. They come as Congress is considering numerous bills to regulate health plans and health insurance companies.

President Clinton is expected to endorse the panel's recommendations, adding momentum to the efforts on Capitol Hill. But the commission does not say how the new rights should be enforced. It lists several alternatives, including voluntary actions by health plans and new federal and state laws and regulations. Wherever possible, it said, the recommendations should be carried out within three years.

Several members of the panel supported its proposals with reservations, saying the changes could increase costs for consumers, employers and insurers. In recent weeks, several big managed-care companies have reported sagging profits, and experts on employee benefits have predicted that premiums will rise substantially next year.

The panel, the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, will submit its recommendations on a bill of rights to the president late next month, after a meeting here Nov. 18 and 19. It will continue work through March 1998.

The commission, headed by Donna Shalala, the secretary of health and human services, and Labor Secretary Alexis Herman, is working under rules that require virtual unanimity for major recommendations. It has been unable to reach agreement on several thorny issues, like patients' access to clinical trials of new treatments, lifetime limits on health insurance coverage and the appointment of ombudsmen to help consumers navigate the health care system.

Its recommendations would apply not only to people in Medicare, Medicaid and other government programs, but also to people with private health insurance. In particular, the proposals would apply to large employer-sponsored health plans that are not now subject to state regulation.

The commission also approved chapters of a draft report making these points:

Consumers have a right to a choice of doctors within a health plan. Consumers should be allowed to go outside the health plan, at no extra cost, if they need medical expertise not available in the plan.

``Consumers with complex or serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within a plan's network of providers.'' HMOs often have required patients to get permission or referrals from family doctors before they visit specialists.

Health plans should be required to pay for emergency care in any situation that ``a prudent lay person'' would regard as an emergency. HMOs sometimes refuse to pay if, for example, chest pains are found to be a result of indigestion rather than a heart attack.

Patients being treated for chronic illnesses or disabling conditions should be able to continue seeing their medical specialists for at least two months if, for some reason, the patients are forced to switch to another health plan. The purpose of this recommendation is to make sure that the treatment is not disrupted.

Doctors should tell patients about ``any factors'' that could influence the doctors' advice to patients. Such factors might include the doctors' investments in hospitals, clinics, home health care agencies and diagnostic imaging centers.