Principles of Patients’ Rights and Responsibilities
Principles of Patients Rights' and Responsibilities was developed and Approved by the National Health Council Board of Directors, January 1995 1 (Directors 1995)
- ALL PATIENTS HAVE THE RIGHT TO INFORMED CONSENT IN TREATMENT DECISIONS, TIMELY ACCESS TO SPECIALTY CARE, AND CONFIDENTIALITY PROTECTIONS.
- ALL PATIENTS HAVE THE RIGHT TO CONCISE AND EASILY UNDERSTOOD INFORMATION ABOUT THEIR COVERAGE.
- ALL PATIENTS HAVE THE RIGHT TO KNOW HOW COVERAGE PAYMENT DECISIONS ARE MADE AND HOW THEY CAN BE FAIRLY AND OPENLY APPEALED.
- ALL PATIENTS HAVE THE RIGHT TO COMPLETE AND EASILY UNDERSTOOD INFORMATION ABOUT THE COSTS OF THEIR COVERAGE AND CARE.
- ALL PATIENTS HAVE THE RIGHT TO A REASONABLE CHOICE OF PROVIDERS AND USEFUL INFORMATION ABOUT PROVIDER OPTIONS.
- ALL PATIENTS HAVE THE RIGHT TO KNOW WHAT PROVIDER INCENTIVES OR RESTRICTIONS MIGHT INFLUENCE PRACTICE PATTERNS.
Patients should be treated courteously with dignity and respect. Before consenting to specific care choices, they should receive complete and easily understood information about their condition and treatment options. Patients should be entitled to: coverage for qualified second opinions; timely referral and access to needed specialty care and other services; confidentiality of their medical records and communications with providers; and, respect for their legal advanced directives or living wills.
This information should include the range of covered benefits, required authorizations, and service restrictions or limitations (such as on the use of certain health care providers, prescription drugs, and "experimental" treatments). Plans should also be encouraged to provide information assistance through patient ombudsmen knowledgeable about coverage provisions and processes.
Patients are entitled to information about how coverage decisions are made, i.e., how "medically necessary" treatment is determined, and how quality assurance is conducted. Patients and their family caregivers should have access to an open, simple, and timely process to appeal negative coverage decisions on tests and treatments they believe to be necessary.
This information should include the premium costs for their benefits package, the amount of any patient out-of-pocket cost obligations (e.g., deductibles, copayments, and additional premiums), and any catastrophic cost limits. Upon request, patients should be informed of the costs of services they've been rendered and treatment options proposed.
Patients are entitled to a reasonable choice of health care providers and the ability to change providers if dissatisfied with their care. Information should be available on provider credentials and facility accreditation reports, provider expertise relative to specific diseases and disorders, and the criteria used by provider networks to select and retain providers. The latter should include information about whether and how a patient can remain with a provider who leaves or is not part of a plan network.
Patients also have the right to know the basis for provider payments, any potential conflicts of interest that may exist, and any financial incentives and clinical rules (e.g., quality assurance procedures, treatment protocols or practice guidelines, and utilization review requirements) which could affect provider practice patterns.
ALL PATIENTS, TO THE EXTENT CAPABLE, HAVE THE RESPONSIBILITY TO:
(It is recognized that patients may suffer significant physical and/or mental conditions which may limit their ability to fulfill these responsibilities.)
- PURSUE HEALTHY LIFESTYLES.
- BECOME KNOWLEDGEABLE ABOUT THEIR HEALTH PLANS.
- ACTIVELY PARTICIPATE IN DECISIONS ABOUT THEIR HEALTH CARE.
- COOPERATE ON MUTUALLY ACCEPTED COURSES OF TREATMENT.
Patients should pursue lifestyles known to promote positive health results, such as proper diet and nutrition, adequate rest, and regular exercise. Simultaneously, they should avoid behaviors known to be detrimental to one's health, such as smoking, excessive alcohol consumption, and drug abuse.
Patients should read and become familiar with the terms, coverage provisions, rules, and restrictions of their health plans. They should not be hesitant to inquire with appropriate sources when additional information or clarification is needed about these matters.
Patients should seek, when recommended for their age group, an annual medical examination and be present at all other scheduled health care appointments. They should provide accurate information to providers regarding their medical and personal histories, and current symptoms and conditions. They should ask questions of providers to determine the potential risks, benefits, and costs of treatment alternatives. Where appropriate, this should include information about the availability and accessibility of experimental treatments and clinical trials. Additionally, patients should also seek and read literature about their conditions and weigh all pertinent factors in making informed decisions about their care.
Patients should cooperate fully with providers in complying with mutually accepted treatment regimens and regularly reporting on treatment progress. If serious side effects, complications, or worsening of the condition occur, they should notify their providers promptly. They should also inform providers of other medications and treatments they are pursuing simultaneously.
1 National Health Council Board of Directors. “Principles of Patients Rights' and Responsibilities,” (National Health Council Principle, 1995) Washington D.C.