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Introduction
The patients usually make complaints in respect of various issues connected with provision of health care by the HMOs. In the area of specialist care, the patients complain on the time it takes to see the specialist, the refusal of authorization to consult a specialist, less number of choices in the specialists available, the time it takes to get appointments with the specialists and limited options to have consultation with the specialists.
In the matter of treatment, the complaints of the patients include the refusal to provide treatment, time taken to authorize treatment, time taken to provide treatment, time delays in authorizing the treatments including the conducting of the tests complain about general denial of treatment, delay in providing treatment, delaying the and length of waiting time in the offices. The other complaints in the formulary are; refusal to provide effective drugs, too restrictive nature of formulary, patients getting the offer of poor quality and ineffective medicines, offering of only generic drugs, lesser quantum of medicines and frequent changes in formulary with more than 60 notations.
The patients do complain in the area of doctor-patient relationship. The complaints are poor relationships between doctor and patient, doctors spending inadequate time with patients, lengthy waiting time for appointments, indifferent nature of physicians, less effective communications with the physicians and lesser personal contacts with the physicians. The patients also make complaints on the selection of physicians. The complaints in this respect cover the refusal to see the doctor as per the choice of the patients, on each appointment the patient getting to consult different doctors and discontinuity of care (Friedenberg, 1999).
Consolidated Omnibus Budget Reconciliation Act (COBRA)
COBRA provides the opportunity to the workers and their families the right to get a continuation of the health benefits lost by them. The right to choose the continuation is available for a limited time only. There are different circumstances prescribed by the Act under which this continuation benefit can be availed by the employees and their families. These include where the employee loses the job voluntarily or involuntarily, if there is a reduction in the number of hours worked by the employee due to any reason, where there is a time gap when the employee changes the jobs, or where there is a calamity or divorce or other life events which caused the loss of benefits.
Under the Act, the individuals qualified are required to make payment of the entire premium coverage up to 102 percent of the cost of the entire plan. The Act generally extends to the group health plans sponsored by employers having 20 or more employees in the respective prior year. The employers have to offer the employees and their families the chance of temporary extension of health coverage up to a period of one year (US DOL).
Employee Retirement Income Security Act (ERISA)
ERISA passed as a federal legislation sets the minimum standards in respect of most of the voluntarily established pension and health plans in private industry. The objective of the Act is to provide protection for individual employees in respect of these plans.
The Act has placed the requirement on the plans to provide the participants with the plan information. This requirement includes the provision of important information about plan features and funding. The Act prescribes fiduciary responsibilities to the people who are vested with the job of controlling plan assets. There is the requirement to establish a grievance and appeals process for the participants to get benefits from their plans. The Act also provides the participants the right to sue for benefits and breaches of fiduciary duty (United States Department of Labor).
Any Willing Provider Law
“A typical any willing provider law requires all health insurers to be ready and willing at all times to enter into service contracts with all health care providers who are qualified under state law, who practice within the general geographic area served by the insurance company, and who are willing to meet the terms and the conditions set forth by the insurer” (NCSL).
The arguments in favor of this legislation hold that with the selective nature of contracting there is the eventuality of excluding some providers, which threatens the providers’ freedom of choice. The opponents to the concept argue that the legislation undermines the cost control mechanisms employed by health plans allowing them to offer lower premiums to enrollees.
References
Friedenberg, R. M. (1999). The Primary Care Physician’s View of Managed Care in 1998. Radiology , 210, 297-300.
NCSL. (n.d.). Any Willing Provider. Web.
United States Department of Labor. (n.d.). Employee Retirement Income Security Act. Web.
USDOL. (n.d.). Continuation of Health Coverage – COBRA. Web.
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