Is the doctor in?
by Jane M.Orient, M.D.
he idea of a federal takeover of American medicine, as embodied in the 1,300-page Clinton Health Security Act of 1993, didnt actually die: it just went to seed.
Over the past few years, the seeds have been sprouting, about 100 pages at a time, in other, innocuous-sounding pieces of legislation: the Health Insurance Portability and Accountability Act (HIPAA or Kassenbaum-Kennedy), KidCare (in one incarnation, called Hatch-Kennedy), and now the so-called Patients Bill of Rights Act of 1998 (Clinton, Kennedy, et al.)
The Clinton Bill of Rights, like the Patient Access to Responsible Care Act (PARCA, or the Norwood Bill), appears to be a reaction to widespread public outrage about the abuses of managed care. It might seem strange that Clinton, who tried to impose managed care on everybody just a few years ago, has apparently become a persecutor of HMOs. But he has not seen the light on any Road to Damascus. He is just responding to focus groups, while moving quite consistently in the direction of his original destination.
That goal is the nationalization of American medicine. One of the roadblocks is the private insurance industry. The question to ask is: "How would the Clinton Bill of Rights affect that industry?" (Hint: look at the "protections" in HIPAA. Is the return of double-digit premium increases just a coincidence?)
Turn to Section 108, entitled "Adequacy of Provider Network," which bears a striking resemblance to provisions of the highly regulatory PARCA.
Section 108 assures that no insurance plan that has any "participating health care providers" can simply engage in the business of insurance (which means pricing risk and paying claims for covered services). No, each plan will have to see to it that all "covered health care services" are "available and accessible in a timely manner to all participants, beneficiaries and enrollees." In other words, each plan shall be in the business of delivering services, not just of helping to pay for them.
What if a beneficiary lives in a rural area that doesnt have a 24-hour emergency room close by, or hasnt managed to attract a brain surgeon? The insurer is apparently responsible for conjuring these things up, and the bill doesnt say how.
One decision for an insurer is simply to quit, leaving the market to those plans that are already in the health care delivery business and offer a rigid, restricted menu of covered services. It is quite possible for expensive mandates to drive almost all companies out of the field; the state of Kentucky is probably the best demonstration.
Alternately, the company could become an HMO itself. Or, it could abandon all forms of coverage (such as PPOs) that use "participating" providers and simply offer high deductible indemnities for accidents and sickness. The latter would be a good thing, in my view. Not many such policies are sold now, partly because of other mandates. And then theres Section 112 (see below), which applies to all health insurers.
The Clinton Bill of Rights acknowledges that patients want to be able to choose their doctor, just as Henry Ford recognized that customers want to choose the color of their car. Thus, consumers should be allowed to pick any available provider. All the available Fords were black. The Clinton-qualified provider would adhere to the treatment plan, would not charge more than the allowed fee, would not have been terminated from the plan for noncompliance with requirements, and would agree to jump through hoops (for example, see Section 105).
All this, and more, in the name of protecting access, affordability, and "quality"which for some obscure reason are under much greater threat than ever before.
The Clinton National Health Board is back, in the form of the Health Care Quality Advisory Board. The Secretaries of Health and Human Services and Labor and 20 other political appointees will supervise the development and maintenance of the "minimum data set" required in Section 112, the "Collection of Standardized Data."
Representatives of the information industry who participated in the Clinton Task Force on Health Care Reform can see that their work is not in vain. The Clinton Bill of Rights demands masses of data, from every encounter with every patient, including treatments prescribed and "outcomes" of illness.
atients get to see aggregate results to help them choose a plan. That sounds good, but just how useful will it be to know that the plan gets a gold star for checking the blood pressures on all diabetics? (Most doctors already check everybodys blood pressure on every visit.) Is access to such information worth sacrificing your own privacy? Under the Clinton Bill of Rights, thats not for patients to decide.
How reassured can a patient feel to know that the plans diabetics have good outcomes? The secret is to get lots of diabetics with mild disease to sign (and to forget to send the enrollment forms to the brittle ones). With all the mandated data collection, there will be manifold opportunities to "manage the case mix."
Of course, all patients want an outstanding surgeon with a low rate of complications. Today, the best guidance they can get is from a family doctor or an operating room nurse. Under the Clinton Bill of Rights, they could get a statistic. But what does it mean? That a surgeon decided to operate only on good risks, and recommended certifiably excellent end-of-life care for the others?
In a free market, the quality assurance mechanism is the ability of the unhappy customer to take his business elsewhere, to any one of an abundant number and variety of others desiring to serve him. Under the Clinton Bill of Rights, the customer gets a very detailed grievance and appeals process, and an Ombudsman to "provide counseling and assistance to enrollees dissatisfied with their treatment."
Who wants this bill? Who has rushed to endorse it? The American Medical Association, for one, the logical choice for supplying the "professionally recognized standards." This could be even better than the exclusive contract with the government to supply procedure (CPT codes), which is probably worth at least $50 million per year in sales of codebooks to doctors.Policy wonks are skilled at counting the number of seeds (for new bureaucrats, new regulations, and whole new agencies) in the apple of proposed legislation. As some farm children pointed out to me recently, it is even more important to consider how many apples are in a seed. The various incarnations of Clintonesque legislation are full of seeds, and they are not appleseeds. They are seeds for a jungle of bureaucratic thistles that would inevitably choke out what remains of private medicine in America.u
Jane Orient, a private physician in Tucson, Arizona, serves as executive director of the Association of American Physicians and Surgeons. She is the author of YOUR Doctor Is Not In: Healthy Skepticism on National Healthcare and a new medical thriller entitled Sutton's Law.