Micromanaged Care?

Sure, everyone's for improving quality in health care, especially as horror stories about managed care keep making headlines. Nonetheless, Members of Congress up for reelection next year might not want to promise too much.

The problem is that there are as many definitions of "quality" as there are Members eager to jump on the issue, and that profusion of views could squelch any attempt to enact comprehensive legislation next year.

Does quality mean finding out why only two-thirds of kids in health plans get immunizations? Does it mean collecting data so that patients can compare health plans for how easy they make it to see a specialist? Does quality mean that patients should have a chance to appeal decisions denying them treatment?

It all depends on who's doing the defining. Many Members--and not only Democrats--want far-reaching legislation that would go so far as to allow patients who are denied treatments to sue their health plans. Others want health plans to be forced to cover specific procedures, such as reconstructive surgery after a mastectomy.

But even if there's agreement on what issues should be addressed, there's still a big split on who should do the addressing. There's a move just under way to establish an independent health care regulatory agency, modeled after the Securities and Exchange Commission (SEC). The managed care plans, naturally, would prefer that someone other than politicians fix whatever's amiss. "How do you balance what the market should do and what government should do?" said Karen Ignagni, president of the American Association of Health Plans (AAHP), which represents most health maintenance organizations and managed care plans. "This is going to be a very thoughtful debate about where the lines should be drawn, which is the essential underlying question here."

The line has been moving. In 1993-94, President Clinton favored a heavy hand from government to guarantee health coverage to every American. That attempt failed miserably with the public and played a large part in the Republican takeover of Congress in 1994.

Since then, the government has let the marketplace take the lead. The result: the moving of 56 per cent of Americans into managed care and a slowdown in the rise of health care costs, which had been soaring. But at a cost. The public has become angry at the limitations of managed care and at the news accounts of people being denied treatments or prevented by "gatekeepers" from seeing medical specialists.

Last month, in endorsing the recommendations of his blue-ribbon commission on health care quality, Clinton characteristically chose a middle way. He vowed to put the panel's suggestions--such as making insurers pay for an emergency-room visit for a patient who suspects a heart attack but has indigestion--into effect for government-run health programs such as Medicare and Medicaid. For private-sector health plans, however, he only requested voluntary compliance.

Republicans are all over the lot. GOP leaders and some of the most conservative Republicans are sticking with an ideological predisposition to keep government out of health care markets. Many of the Republican rank and file, though, are going their own way, on an issue that has frightened a multitude of voters.

On the surface, it's a politically tempting issue. But when the combatants get into the morass of details and the inevitable disputes over what quality means and who should do something about it, nothing may happen.

Micro-Danger

To the enduring criticisms about managed care, Congress so far has responded piecemeal, with laws that dictate how many days a new mother may stay in the hospital and how much coverage insurers must offer for mental-health problems. Still, some Members--especially Republicans--charge that the latest batch of bills to ensure medical quality are simply a pretty mask for micromanaging managed care.

Take the bill that has attracted more than 200 House co-sponsors--Republicans and Democrats alike--and may become the vehicle next year for comprehensive legislation on quality. The author, Rep. Charlie Norwood, R-Ga., a dentist, says that the legislation has moved the debate over quality along because it wouldn't force health plans to cover specific new services.

"These little stopgap measures that treat one body part will never be the way to go, because there are too many body parts," Norwood, a conservative Republican, said in an interview. "There are too many diseases. I'm trying to look at this a little broader than how long you have to stay in the hospital for a mastectomy."

Norwood's bill would let patients sue their health plans and let them go to an emergency room without getting approval first if they think their health is in danger; it would also ban health plans from paying bonuses to doctors, hospitals or claims adjusters for limiting patients' care and would require health plans to accept all qualified doctors.

But even that is too much--and too expensive--for businesses and managed-care plans. M. Anthony (Tony) Burns, who is the chief executive officer at Ryder System Inc. and the chairman of the Business Roundtable's task force on health and retirement, contends that government-imposed mandates aren't the answer. "The market is changing rapidly," he said, "and we have to be careful to let the market respond and [we have to ensure] that programs coming out of Washington be voluntary." The legislation enacted last year to require insurers to cover mental health as fully as physical health, he said, is an example of a mandate that will cost businesses and their employees too much. "Most programs have some type of accommodation for mental health care," he said, "yet the mandate requires more than is needed."

The National Center for Policy Analysis, a conservative think tank, predicted last month that Norwood's bill could raise individuals' premiums for health insurance by an average of 23 per cent.

And that's without the sort of mandates--body part by body part--that strike fear into managed care officials' hearts. Businesses and health plans alike worry that any new mandates will make health insurance too costly. Consider breast cancer. Congressional Democrats pushed hard for two bills this year--and will resume their fight next year. One sponsored by Rep. Rosa DeLauro of Connecticut, with 214 co-sponsors, specifies that a woman may stay in the hospital for 48 hours if she undergoes a mastectomy and for 24 hours if she has a lymph node removed. Rep. Anna G. Eshoo, D-Calif., has proposed requiring insurance companies, in the case of a mastectomy, to fully cover reconstructive surgery, which is often classified as a cosmetic procedure, she says, and isn't covered by insurance.

A Middle Way

Clinton took pains to tread the middle of the road when his quality commission released its recommendations last month. The 32-member panel, co-chaired by Health and Human Services (HHS) Secretary Donna E. Shalala and Labor Secretary Alexis M. Herman, suggested many consumer-protection measures, which have drawn little opposition. The commission stressed the need for health plans to give consumers accurate, understandable information about their facilities and medical professionals. It also called on health plans to disclose any financial incentives medical practitioners might get that result in their denying care to patients, and to make sure that patients with dangerous or complex conditions get to see specialists.

Clinton didn't call for legislation--though he didn't rule it out--but merely urged businesses to follow the commission's recommendations. Still, business groups warned against using the recommendations as the basis for more government mandates--"at a time when the private health care market is providing innovative improvements for our employees," Ryder's Burns said. During the past couple of years, managed care officials at the AAHP have proposed adopting voluntary constraints as a tactic to avoid government-imposed ones. AAHP members took the position, for example, that new mothers may stay in the hospital longer than 24 hours if the doctor and the patient agree it's necessary.

Three of the group's large health maintenance organizations went even further--far enough to prompt criticism from within AAHP for exposing an internal split. Supporting legally enforceable national standards were Kaiser Foundation Health Plans Inc. of Oakland, Calif.; Kaiser/Group Health Inc. of Seattle; and HIP Health Insurance Plans of New York. They jointly announced their position with the American Association of Retired Persons and Families USA, a consumer group.

"We're getting hammered so constantly," said David Abernathy, a senior vice president in Washington for HIP, "that it comes down to one's political judgment about whether . . . there's such a hunger out there to do something legislatively that if you don't do something like this, you're going to get screwed." Otherwise, he added, "we'll keep getting disease-of-the-month legislation."

Another option for fending off micromanagement by Congress is to create an independent, nonpolitical regulatory body that would oversee health care quality, much the way the SEC regulates the securities industry. Its independence would allow it to supply comparative information for consumers and tough-minded enforcement of ethical standards, without excessive political interference, according to Lynn Etheredge, a health care policy consultant who has recommended the SEC as a model. Granting regulatory power over private-sector health plans to HHS, which already oversees Medicare and Medicaid, would be a mistake, Etheredge argued in the latest issue of Health Affairs, a bimonthly journal. The department "is run by political appointees," he noted, so that "its key regulatory decisions likely would be influenced by the White House."

Etheredge has in mind an agency that requires health plans to register with the government and makes sure that they meet national standards for disclosing information and for dealing fairly with consumers. It would have the authority to investigate questionable practices, impose penalties and seek civil injunctions. The standards would apply not only to managed-care plans but also to all types of health insurance, including "self-insured" plans. Most big corporations insure their own employees and thus operate under rules that critics say let them do whatever they want.

Etheredge also envisions setting up an equivalent of the Financial Accounting Standards Board (FASB), a private group of experts that develops standards the SEC enforces. A board on health care standards would "reflect the private sector's expertise and meet the real-world needs of market participants," he wrote. "There are a lot of things in quality assurance that relate specifically to medical questions that are moving fast, where the government is not nimble enough to be the entity that specifically defines the criteria."

If an FASB-like board had been around during the furor over how long new mothers may stay in the hospital, Ignagni of the managed care group said, "we would be at a very different place than where we are today, because we would have brought forth research, looked at the pros and cons and had a much more reasoned debate--as opposed to making these political footballs into political campaigns."

Saith the GOP Leader: Resist

Even with almost half the House as co-sponsors (and Alfonse M. D'Amato, R-N.Y., as its sponsor in the Senate), Norwood's bill--or any bill, for that matter--is far from enactment. A serious obstacle is opposition from GOP leaders and the most conservative among congressional Republicans to anything that involves Washington in regulating managed care.

"The marketplace adjusts to changes more quickly than the government can," a Senate Republican aide said, pointing to a growing number of health plans that let patients go to doctors outside the network if they're willing to pay more. "By the time government gets around to responding, they're responding to the wrong problem."

A memorandum last month from House Majority Leader Richard K. Armey, R-Texas, to House staff members spelled out the leadership's position: Resist. The memo aimed at Clinton's endorsement of his commission's recommendations but was clearly meant as a warning to any lawmaker who's thinking of writing a bill on the subject. "This new offensive--on `health plan quality'--follows a common Clinton pattern," Armey wrote. "First he identifies a `crisis,' usually in the fall before an election year. Then he highlights it in his January State of the Union. And then he calls on Congress to send him, by Election Day, some Kennedy-Blank bill to `solve' this crisis." The conservative Texan likened Clinton's latest thrust to his earlier health care plan. "It will address a different 'crisis,' " Armey ventured--"quality, instead of access--but the practical result will be the same: Washington bureaucrats defining people's health care choices."

But if the quality commission's recommendations angered GOP leaders and upset business executives, the Norwood bill should terrify them. Letting patients sue their health plans, for instance, is anathema to many Republicans, who for ages have sought to limit medical malpractice awards. Armey's memo didn't specifically criticize Norwood's bill, but GOP leaders don't like that approach any better than Clinton's.

Still, Norwood's bill has drawn the most congressional support to date. Norwood said he's conducting "friendly negotiations" with Armey to work out some of the Majority Leader's concerns about too many mandates.

House Speaker Newt Gingrich, R-Ga., has stayed relatively quiet on a subject that has pitted Republican against Republican. But he has offered encouraging words, Norwood said. "Last year when I was talking to him about this, I told him what we were doing and he said, `When you get 200 co-sponsors, come back, and we'll take a look.' We've come back, and we're in the process right now of working with the [leadership] staff."

Another bill that's at least as broad as Norwood's--and of a surprisingly similar complexion--was introduced this year by Edward M. Kennedy of Massachusetts and John D. Dingell of Michigan, respectively the top Democrats on the Senate Labor and Human Resources and the House Commerce committees. That bill addresses many of the same issues as Norwood's, though in a more government-friendly way. For instance, it would create an Office of Health Insurance Ombudsman to assist patients. It would prohibit plans from denying access to "appropriate care," such as visits to specialists, and would give doctors more authority to decide what care the patient should get.

Senate Labor and Human Resources Committee chairman James M. Jeffords, R-Vt., has been working on a bill of his own, which he may wind up co-sponsoring with Kennedy. Jeffords, the only Senate Republican who backed Clinton's health care plan in 1993, has been warned by GOP leaders to proceed carefully.

An Iffy Public

What the public thinks about the quality of medical care will probably determine how the issue plays out next year, as Members worry about the midterm elections. But the thing is, the public doesn't seem to know what it thinks.

That's evident from an opinion poll that the Henry J. Kaiser Family Foundation released last month. "The public has anxieties about managed care and supports consumer protections," Drew Altman, the foundation's president, said in an interview."But they're also leery of the government and worried that government regulation will drive up costs. . . . The survey showed very clearly that the way in which this issue is framed and what spin the public buys will be critical to the outcome of the debate."

Fifty-two per cent of the respondents said the government should protect managed care consumers, but 40 per cent found intervention by the government wouldn't be worth the additional cost. The public also showed itself of mixed mind about who should regulate managed care plans--19 per cent named the federal government, 18 per cent preferred state government and 34 per cent favored an "independent organization." Sixteen per cent said that managed care plans shouldn't be regulated at all.

But in Altman's view, the survey's most powerful finding was that the public sees the horror stories about managed care as something commonplace, not as rare events. "As the marketplace has changed, more and more people have been brought into managed care, and people are anxious and a little worried about managed care and what it means for them," he said. "It's not that they're unhappy with their own plans, but that managed care might not be there for them if they're really sick." He suggested that consumer advocates for should frame the issue as offering solutions to problems that patients face on a day-to-day basis--" `Can I go to the emergency room?' for example"--while opponents will want to bash government regulation that drives up costs.

The sad fact, Altman added, is that the proposals are truly modest but will be viewed by ideology-driven Republicans as extreme, by the time the debate ends. He sees political motives. "Many of the most conservative Republicans have always viewed health care as a Democratic issue, one that they can never win on," Altman said. "It's always seen as an issue [for which], in the end, the Democrats get more political credit."

But one huge factor suggests something may happen, HIP's Abernathy said. In the end, "this stuff's easy to do. It sits well with voters," he explained. "We're facing a tremendous amount of public pressure out there." The managed care lobbyist sees a lot of reason to believe that Congress will do something about health care quality next year--"I don't think people are going to get over this frenzy."

Sens. John H. Chafee, R-R.I., and Joseph I. Lieberman, D-Conn.--a moderate Republican and a centrist Democrat--are trying to nudge the process along. They've formed a bipartisan, bicameral task force that will start meeting next year to study what to do about the quality of health care. Chafee has convened this group before, to provide a mainstream approach to ideologically divisive health-related issues. Faced with the President's bill during the health care reform debate of 1993-94, Chafee's coalition crafted a moderate alternative that nearly gained enough support to pass the Senate. "I don't think we've seen an end to body-part legislation," Chafee said. "Each is very appealing. But we've got to balance mandates versus costs. Too often, costs aren't considered."

Still, whether Congress will succeed in finding a middle ground is problematic. Democrats are sure to find legislation tempting--and Republicans may, too. There's more support among rank-and-file Republicans than among GOP leaders for a wide-ranging bill like Norwood's. Rank-and-file Republicans have been known to defy their leadership before, such as when they forced their Senate leaders last year to allow a vote on a bill--later enacted into law--to make it easier for workers to carry insurance from one job to the next. A few Republicans have introduced comprehensive bills to improve the quality of managed care.

But even with all these pressures to pass legislation, getting from here to there won't be easy. Too much is at stake, for too many people, for a political consensus to be obvious.