August 27, 2010 

Mr. Jim Mayhew 

Office of Consumer Information and Insurance Oversight 

Department of Health and Human Services 

Attention: OCIIO-9994-IFC, RIN 0991-AB69 

P.O. Box 8016 

Baltimore, Maryland 21244-1850 

Re: Comments on Interim Final Rules for Patient Protections 

(File Codes OCIIO-9994-IFC, RIN 0991-AB69/ RIN 1210–

AB43/REG–120399-10)

Dear Mr. Mayhew: 

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) 

appreciates the opportunity to comment on interim final rules that implement 

provisions of the Patient Protection and Affordable Care Act (P.L. 111-148, 

“Affordable Care Act” or “ACA”) regarding patient protections, preexisting 

condition exclusions, and lifetime and annual limits. We applaud the issuance 

of these interim final rules by the Departments of Health & Human Services, 

Labor, and Treasury (collectively, the “Departments”) because their 

promulgation is an important step forward in protecting patients and 

consumers against certain practices within the private health insurance market. 

AAPM&R has endorsed a broader set of comments submitted by the 

Consortium for Citizens with Disabilities (CCD) and we align ourselves with 

the specific recommendations and concerns contained in those comments. 

However, the Academy would like to take this opportunity to amplify our 

comments on one of the most important patient protections encompassed by 

the Rule, access to specialty care. 

AAPM&R is a national specialty society of more than 7,500 physical 

medicine and rehabilitation physicians, also known as physiatrists. Physical 

medicine and rehabilitation has been a recognized board-certified specialty 

since 1947 and our members have a primary focus on restoring function to 

patients with health conditions ranging from physical mobility impairments 

and pain to those with complex physical and cognitive deficits. Typical 

patients treated by physiatrists include those with spinal cord injuries, brain 

injuries, amputations, and a variety of musculoskeletal and neuromuscular 

conditions and chronic illnesses. 
 

Mr. Jim Mayhew 

Page 2 

August 27, 2010 

Patient Protections: Access to Specialty Care 

AAPM&R strongly supports the interim final rules regarding patient protections, which allow 

consumers greater choice in selecting their primary care provider in health plans that utilize a 

network of providers.1 This consumer access provision is one of several similar protections that 

were previously contained in more comprehensive patients’ rights legislation proposed in 2001, 

which AAPM&R supported but was not enacted at the time.2 The promulgation of a limited set 

of patients’ rights in this Rule is a positive development, but we urge the Departments to use 

their own authority to strengthen these consumer protections in the following ways: 

 Broad Conception of Primary Care Provider: The Secretaries of the Departments should 

strengthen the definition of a “primary care provider,” as used in the consumer protection 

rules. AAPM&R believes that a “primary care provider” should be defined in functional

terms, and not solely on the basis of who is providing care. In particular, we urge the 

Departments to adopt a multidimensional definition of primary care, as suggested by the 

Institute of Medicine (IOM):

“Primary care is the provision of integrated, accessible health care services by 

clinicians who are accountable for addressing a large majority of personal health 

care needs, developing a sustained partnership with patients, and practicing in the 

context of family and community.”3

We believe this definition would remove unnecessarily sharp distinctions between 

generalists and specialists, at least when it comes to the provision of care to people with 

chronic conditions and disabilities. Consequently, adoption of this concept of primary 

care may allow patients, particularly those with disabilities and chronic conditions, to 

have better access to specialty care without prior authorization from a primary care 

“gatekeeper” who is a generalist. This would be a critical protection in health plans that 

use a network of providers that are only accessible through a primary care coordinator or 

case manager. Many people with disabilities and chronic conditions know their condition 

well and are active participants in managing their health care. In this instance, direct 

access to a specialist, such as a physiatrist, is often more efficient, less costly to the plan, 

and may lead to better, more timely care. In fact, in many instances, physiatrists and other 

specialists already serve as de facto care coordinators for persons with disabilities. 

 

1

 The interim final rules are set forth at 26 CFR 54.9815-2719AT, 29 CFR 2590.715-2719A, 45 CFR 147.138. The 

interim final rules implement the statutory provisions of Sec. 2719A of the PHS Act, which was added by Sec. 1001 

of the ACA. 

2

 See the Bipartisan Patient Protection Act, S. 1052 and H.R. 2563 (as introduced) from the 107th Congress. 

Sections 112, 115, 116 contain provisions for access to primary care, obstetrical and gynecological care, and 

pediatric care, respectively. 

3

 Institute of Medicine, Committee on the Future of Primary Care, Primary Care: America’s Health in a New Era 

(Washington: National Academy Press, 1996), p. 31. 
Mr. Jim Mayhew 

Page 3 

August 27, 2010 

 

 Physiatrists as Care Coordinators for People with Disabilities and Chronic Conditions: 

AAPM&R therefore believes the Departments should permit enrollees, particularly those 

with disabilities and chronic conditions, to select a willing specialist—such as a 

physiatrist—to serve as a care coordinator in plans that employ a network delivery model 

that utilizes the care coordinator concept. Physicians such as physiatrists who treat 

patients with chronic illnesses and disabilities and who are willing to serve in the care 

coordinator role should have that same designation under the Rule. 

AAPM&R believes that the interim final rule provides significant new protections for the 

patients we serve but we believe that the rules can still be strengthened in the manner described 

above and through the recommendations offered by the Consortium for Citizens with 

Disabilities. 

Please feel free to contact Suzanne Butler at 847-737-6022 or AAPM&R counsel, Peter W. 

Thomas, at 202-466-6550 if you have any questions. Thank you for your time and consideration. 

Sincerely, 

M. Elizabeth Sandel, MD 

President 

Cc: 

Office of Health Plan Standards and Compliance Assistance 

Employee Benefits Security Administration, Room N-5653 

U.S. Department of Labor 

200 Constitution Avenue, NW 

Washington, DC 20210 

Attention: RIN1210-AB43 

Internal Revenue Service 

CC: PA: LPD: PR, Room 5025 

P.O. Box 7604, Ben Franklin Station 

Washington, DC 20044 

Attention: REG-120399-10