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Frequently, a complex and comprehensive array of medical and other services is required to manage the multidimensional sequelae of populations with serious or complex medical conditions. Interventions are required not only to respond to the most immediate and acute threats to physical well-being, but also to prevent further complications and to initiate and sustain improvements in overall quality of life. Efforts to accomplish the latter require systems and services to address the long-term physical, social, and mental dimensions included in currently accepted definitions of health.
The nation's health care delivery system has been challenged to accommodate the unique and complicated needs of the growing numbers of Americans with serious or complex medical conditions. Of particular concern are strategies to finance the long-term provision of complicated arrays of health and other services required by these patients. Issues have also arisen about ensuring access to care and quality of care for the growing numbers of individuals with persistent, disabling, or progressively life-threatening medical conditions. Federal health care programs (Medicare and Medicaid) share concerns about these issues with health care plans—including health maintenance organizations, other types of managed care plans, and fee-for-service plans—and a broad constituency of consumers including persons with disabilities.
A leading initiative to address quality of care and access to care issues has been the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. One aspect of the commission's work has been development of a Consumers' Bill of Rights and Responsibilities (President's Advisory Commission, 1998a). Of particular relevance to consumers with serious, complex, persistent, disabling, or progressively life-threatening medical conditions is the right to select providers and health care plans that will ensure access to appropriate high-quality health care. Specifically, the Consumers' Bill of Rights and Responsibilities states that "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. Authorization, when required, should be for an adequate number of direct access visits under an approved treatment plan" (President's Advisory Commission, 1998b).
Coincident with the activities of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, the Balanced Budget Act of 1997, Title IV, was passed with implications for Medicare, Medicaid, and Children's Health Provisions (Public Law 105–33, August 5, 1997). A major implication of the Balanced Budget Act of 1997 was the development of a new health care plan for Medicare beneficiaries called Medicare+Choice. According to the interim final regulations for the establishment of the Medicare+Choice program, Section 422.112 addressed issues concerning patient access to services. Specifically, it states that plans must have procedures approved by HCFA for:
identification of individuals with serious or complex medical conditions;