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The Orlando Sentinel

Rossello: Patients' Bill Of Rights Caps Puerto Rico’s Sweeping Health-Care Reform

by Iván Román

September 17, 2000
Copyright © 2000 The Orlando Sentinel. All Rights Reserved.

SAN JUAN, Puerto Rico -- Joining a handful of states, Puerto Rico now has a patients` bill of rights. And it`s one of the strongest ones on the books.

Intense debates over patients` rights have raged in Florida and other states -- and are continuing at the national level. But the process in Puerto Rico was so quiet that even the head of the island`s largest health-insurance company was unaware of the bill until the day after it was signed into law.

Gov. Pedro Rossello touts the patients` bill of rights as the piece that completes the island`s sweeping health-care reform. As of June, the reform package had brought health insurance to virtually every Puerto Rican who didn`t have coverage.

"With this law, we make all patients equal because they have a way to defend their rights," Rossello said when he signed the bill into law recently. "This is a bill of rights that is more complete than many in the United States. And it doesn`t take away the right people have to sue in court."

Varying legal interpretations led local Health Department lawyers to decide they didn`t need to spell out the patient`s right to sue in the bill of rights, as some states have done. Managed health care and doctors and patients` advocates are slugging it out in Congress and the courts over whether federal laws shielding HMOs from lawsuits should apply to decisions about and denial of a patient`s medical treatment.

But Puerto Rico`s intent on this issue is firm. "Whatever is not written in there, there is room to broaden it or add it if we end up needing to," said Rossello`s health-affairs adviser, Roberto Rosso Quevedo.

As restrictive as the 1997 Texas law, the precursor and model for the bill of rights now before Congress, the Puerto Rico law sets up an independent mechanism to promptly handle complaints and fine insurance companies, doctors or hospitals up to $5,000 for unjustifiably denying medical treatment.

It also obligates insurance companies to pay for unrestricted access to emergency room care anywhere on the island and prohibits gag clauses that would keep doctors from discussing all possible treatments. Patients also have easier access to specialists and are free to change primary-care physicians at will. Health plans are liable for "routine medical costs" if a doctor refers a patient to be part of experimental clinical studies.

Puerto Rico`s law establishes a mandatory independent grievance procedure, going further than Texas` voluntary case review. But when it comes to dealing with HMOs, many in Puerto Rico have some catching up to do, because this is a relatively new health system for the island.

Health plans are now required to give all patients a government-approved copy summary of the patient`s rights.

Insurance Commissioner Juan Garcia expects disputes over coverage and malpractice suits to remain at current levels, but as people become more familiar with HMOs, he says, complaints about denial of treatment may go up.

Some insurance-company heads in Puerto Rico question the need for the patients` bill of rights.

"It`s already the law so we have to live with it," said Miguel Vazquez Deynes, president and chief executive officer of Triple-S Management Inc., the island`s largest health insurance carrier with 620,000 clients.

Doctors applaud the new patients` bill of rights, particularly the prohibition on gag clauses that prevent them from discussing all treatment options.

"This takes away the cloak of secrecy that exists now between the insurance company and the patient," said Freddie Roman Aviles, president of the Doctors and Surgeons Professional Association of Puerto Rico.

Before 1993, about half of Puerto Rico`s 3.8 million people didn`t have private health insurance and were relegated to crowded government hospitals and clinics, sometimes waiting months for diagnostic tests or treatment.

When he came into office in 1993, Rossello vowed to change all that.

To make his controversial health-care reform happen, he began selling all but five of the island`s 84 government hospitals and clinics. During a five-year period, his plan gave Puerto Rico`s 1.8 million uninsured people -- 47 percent of the island`s population -- a broad network-based HMO. Another 40 percent, 1.5 million people, have private insurance; 450,000 have Medicare, along with a prescription drug benefit funded through the health reform, and the uninsured dropped to a low of 50,000 people.

The annual price tag for premiums: $1.3 billion.

"Now the Health Department turns into what it should be, getting out of the business of providing most health care and being the defender of health services for everyone, from the richest multimillionaire to the poorest of the poor," said Health Secretary Carmen Feliciano de Melecio.

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