Controversial company: The prudent layperson standard and the Patients' Bill of Rights

The prudent layperson standard (PLS) was passed by Congress for the Medicar e and Medicaid programs in 1997 and has been adopted by more than 30 stare legislatures. The standard defines an emergency medical condition based on the layperson's interpretation of symptoms, it requires payers to provide r eimbursement without prior authorization for patients who, on the basis of their symptoms could reasonably expect the absence of immediate medical car e to place their health in jeopardy. Reimbursement must cover services prov ided until the point of medical stabilization as defined by the Emergency M edical Treatment and Active Labor Act (EMTALA).(1) Although the PLS has bee n passed for Medicare and Medicaid, millions of privately insured Americans are not covered by the standard These individuals als are either insured b y plans in states that have not adopted the PLS, or are covered by federall y regulated private health plans. Therefore, lithe PLS is to apply uniforml y for all insured Americans, additional federal legislation is needed. Several managed care bills were debated in Congress during 1999 in response to widespread consumer backlash against managed care. Each of the managed care bills contained a provision for coverage of emergency care that was ba sed on the PIS. The bills also contained provisions that were much more con troversial (eg, liability for health plans), and these issues have complica ted the health care debate in Washington, DC. The Senate passed the "Patients' Bill of Rights Plus Act of 1999" (S 1344) in July after an extremely partisan debate.(2) Although the Senate bill inc ludes a version of the PLS, the language in the bill weakens coverage for p ost-stabilization services. This bill would make it more difficult to obtai n reimbursement for services after a patients condition is stabilized, even when a health plan is unavailable to make arrangements for necessary care. Another important weakness of the Senate bill is that it only applies the PLS to the 48 million people who are covered by federally regulated health plans. The House passed the "Bipartisan Consensus Managed Care Improvement Act of 1999"(HR2723) in October: The House bill, introduced by Charlie Norwood (R- GA) and John Dingell (D-MI), contains the original PLS language as adapted for the Medicare and Medicaid programs in 1997.(3) The House bill applies t he PLS to all Americans with private health insurance. As of this writing (January 2000), the task before Congress is to reconcile the managed care bills passed by the Senate and House in 1999. A conferenc e committee has been appointed, and its goal is to form a single bill that will be voted an by the House and the Senate. If the committee is unable to reach a compromise this year, the bills will die when Congress adjourns. It will be very difficult to reconcile the dramatic differences between the Senate and House bills. Thus, even though versions of the PLS were passed, it is still unclear whether any bill will become federal law that would co ver all privately insured Americans. This issue of the Annals Health Policy Report describes the controversy surrounding the managed care bills and ex plains the implications of last year's debates for the PLS. It illustrates how the more controversial provisions in the bills affected the success of the PLS. Because the author was working in the Senate during its managed ca re debate, the emphasis is placed on the Senate. Future challenges for the adoption and implementation of the PLS are discussed.