In his State of the Union address, President Clinton voiced his support for a health care bill of rights. Phil Ponce and guests examine the options consumers face under managed care and discuss the possibility of federal action.
PHIL PONCE: Roughly 80 percent of American workers are enrolled in some form of managed care today compared to just 5 percent in 1980. But as it has grown, so too has criticism about what choices and options consumers have or don't have under managed care. In his State of the Union speech the President said it's an issue Congress should tackle.
PRESIDENT CLINTON: A hundred and sixty million of our fellow citizens are in managed care plans. These plans save money, and they can improve care. But medical decisions ought to be made by medical doctors, not insurance company accountants. (Applause) I urge this Congress to reach across the aisle and write into law a consumer bill of rights that says this: You have the right to know all your medical options, not just the cheapest; you have the right to choose the doctor you want for the care you need. (Applause) You have the right to emergency room care wherever and whenever you need it. (Applause) You have the right to keep your medical records confidential. (Applause)
Patient Access to Responsible Care Act
PHIL PONCE: On Capitol Hill more than 50 bills on managed care have been proposed. One of them know as the "Patient Access to Responsible Care Act" has gained strong support in the House and has several provisions which meet the President's goals on patients' rights. It's sponsored by Georgia Republican Charles Norwood, a former dentist, who joins us tonight. Also with us is Bill Gradison, president of the Health Insurance Association of America whose member companies provide care to 65 million people. Mr. Gradison is a former Republican Congressman from Ohio. And, gentlemen, welcome.
Congressman Norwood, what is wrong with managed care that makes you conclude that the federal government has to step in with legislation to create these kinds of rights that the President is talking about?
REP. CHARLES NORWOOD, (R) Georgia: Well, there's 160 million people in managed care, just as the President referred to. And they have nowhere to go--in a closed plan that they're in where they're losing choices, they can't choose their doctor, they can't choose their hospital. If the care is denied, there is nowhere to go, they don't have any options there but to call their congressman. Now, prior to 1974, we handled all this very well at the state level. We had public policy in regards to health care. But today there is none at the state level because the federal government has preempted all of that law, and the federal government has remained silent. And clearly, the American people know that there is a problem that we're speaking about, the bright problem in managed care, and they want it addressed. And I don't know where else to go but the federal government since the federal government won't let the states do it.
PHIL PONCE: Mr. Gradison, federal legislation the answer, in your view?
BILL GRADISON, Health Insurance Association of America: Well, frankly, today in health care the consumers are king. The consumers said health care inflation is too great; we want it slowed down; and the industry responded. It did so by negotiating discounted arrangements with hospitals and physicians, moving a lot of care into outpatient from inpatient, and shortening hospital stays. Consumers said we want greater choice; the growth has not been in restricted HMO plans; the great growth has been in plans like preferred provider plans, and point of service plans, which give greater choice. And the consumers have said loud and clear, we want quality. And what we see today in health plans all over this country is that they have a higher proportion of board certified physicians than the plans which they have replaced. They're doing a better job with mammography testing for women, with vaccination for children, with annual eye exams for diabetics. And study after study shows that the quality measured by medical outcomes is superior or equal in these plans to the form of care delivery that it replaced. Now our position is very simple; that the market is responding far more quickly and effectively than if Congress passes a lot of laws, the administration writes thousands of pages of regulation, the courts consider many, many cases trying to figure out what the law really means, and large numbers of bureaucrats go about making a judgment of their own, rather than letting the market, the consumer dictate what should be done in health plans.
PHIL PONCE: So are you saying that the market is already providing some of these choices, has--
BILL GRADISON: Absolutely.
PHIL PONCE: --the right to pick a--
BILL GRADISON: Absolutely.
PHIL PONCE: --doctor, the right to go to the emergency room?
BILL GRADISON: Absolutely.
PHIL PONCE: Congressman, is the market doing that?
Rep. Norwood: "There is no such thing as a free market in health care today."
REP. CHARLES NORWOOD: There is no such thing as a free market in health care today. It only requires two things to have a market in health care: that's a sick patient and a willing doctor. They are the very people that have been shut out of the health care system. Patients can't choose; doctors are being gagged; they are always having to be told what they can and can't do, frequently by people that are simply not trained to tell them that. They want to operate on the reduction of cost based on pure science. They want a computer screen. They want somebody up in front of there that can read that screen, and they make decisions based on math. You can't do that in medicine; you kill people. The practice of medicine is at least 60 percent art. They are not doing that, and you know the stories. I think Mr. Gradison knows the stories. There is an outcry around the nation. Everybody either has had a problem in managed care of it being denied to them at some point, or certainly they cannot always choose their doctors; they may choose from a group of doctors. But what he is talking about is yes, we're better today in managed care than we were in managed care 10 years ago. That isn't necessarily the case that we're better today than we were in the 70's for fee-for-service. Now, I'm not suggesting we go back because I appreciate the fact that managed care has, indeed, helped reduce the cost of medicine. I am for that. But we've gone too far. We've let the system go so far that the bottom line--the thing that we're most interested in--is how many dollars can we save.
PHIL PONCE: Let's try and go through the list that the President laid out. Mr. Gradison.
BILL GRADISON: Where do you want to start?
PHIL PONCE: Choice of doctors.
BILL GRADISON: Choice of doctors--
PHIL PONCE: What's your position on that?
BILL GRADISON: --is--it is growing because the consumers are demanding it. And what we're seeing is that health plans are broadening the choice of physicians and specialists, which they offer, and they're also making it easier to get directly to the specialists than was true just a few years ago. For example, in procedures which are very important to women, for example, pap smears, and other procedures of that--tests of that kind, we're seeing almost identical proportions of women being treated as they should by obstetricians and gynecologists, rather than the family doctor or the generalist. And the percentage going to the specialist is almost identical today in managed care as it is in today's fee-for-service world.
PHIL PONCE: Do you buy that?
REP. CHARLES NORWOOD: I buy that point of service which is what Mr. Gradison is talking about, where people do have the ability to choose, is on the rise. About 60 percent of the plans in this country offer that today. There is a proposal in Congress that everybody offer that as a choice to people so they can choose their own doctor at their own expense if they want it. I see hardly any reason for that. What we're talking about here is having no public policy regarding health care. We're simply saying the states can't do it; the federal government's going to be quiet; and if the rest of us will just be quiet, they'll handle it. This is the only industry in the country that is immune from liability and because of that, that is the root problem of decisions that are being made that are negative for patients.
PHIL PONCE: And, Congressman, how about the issue of knowing--a patient knowing what his or her options are, as far as treatment? I want to get your response.
Rep. Norwood: "You can't read health care plans today and know what you've got. "
REP. CHARLES NORWOOD: Well, I don't know if you've read a health care plan lately but try it sometimes. It's pretty hard to find out what's in your plan. And there are options in Congress now that are saying, you know, we ought to simplify this, we ought to make it uniform, where patients can actually choose apples to apples. You can't read health care plans today and know what you've got. And if you do, you don't know that it's not going to still be denied. I'm not suggesting we add any benefits to anybody's plans. That's up to you. I don't want any part of that. I am suggesting that if you offer a plan, then you cannot deny what you offer a patient.
PHIL PONCE: Mr. Gradison, the options business?
BILL GRADISON: Absolutely. There have been accusations that there were gag clauses, restrictions within the health plans that stopped a physician from discussing the full range of treatment options with the patient, even including for possible treatments that weren't covered by the plan. The General Accounting Office--at the request of the Congress--took a look at this issue. They examined the actual contracts for over 500 health plans. And this is how many they found. Were there gag clauses once? Yes, I think there probably were. But the efforts of Mr. Norwood and others to call attention to these issues are bringing about change without the necessity of passing laws to do so. I applaud your efforts, and I think the bright light of public opinion in this society is going to bring about improvements in quality far more than passing regulations, hiring bureaucrats, and issuing regulations.
PHIL PONCE: Mr. Gradison, how does your industry respond to the issue about emergency rooms, the fact that maybe people don't have quite the access to them that maybe the President thinks they should?
BILL GRADISON: Well, I'm still looking for a case where somebody had an emergency and didn't get it reimbursed to buy a plan. The main question is: how do you deal with non-emergency situations where people go to the emergency rooms? And from a patient's point of view--I don't know if you've ever been in an emergency room with a sick kid--I have. And the fact of the matter is that the majority of people who present themselves in an emergency room do not have an emergency. And, as a result, the efforts of health plans and others to try to sort this out to get the people to go to the proper spot, which may be the emergency room, but it may be the next morning to go to a doctor's office or a clinic, or a health plan, is part of what is going on. Are the decisions always perfect? Of course not. They weren't in the old system. But I think that if you require a treatment in the emergency room and full reimbursement for it, in fact, becomes an entitlement, and the judgment of the patient then governs, which means there is no effective restraint on the use of emergency rooms, which are the most expensive site of care.
REP. CHARLES NORWOOD: I totally agree that the emergency room is the most expensive place that you can go and receive care. The syndrome is sort of like the fox guarding the henhouse. That somebody on the other end of the phone, 300 miles away, that may or may not be trained to make a medical necessity decision has to be called today before the doctor can save you from your heart attack if you get to the right hospital. Frequently, you have to pass two or three hospitals to get to the one where the discount is. Now, we don't want to encourage people using emergency rooms that shouldn't use it, but we don't want to discourage people either, because people are scared to go today to the emergency room for fear that they won't get approval but will still have to be treated. You know, all they have to do is deny the authorization, and they don't pay, but the person still has to be treated. We're saying, let's don't let the fox make that decision; let's let any prudent layperson make that decision. It is reasonable to think that--
PHIL PONCE: Including consumer, you mean?
REP. CHARLES NORWOOD: Exactly. Exactly right. And we're not trying in our bill, for example, we're not trying to lay out for them exactly how that works. We are very open with suggestions. And I'm sure that the Labor Department will be too. But what we--
PHIL PONCE: The Labor Department would be implementing regulations--
REP. CHARLES NORWOOD: The Labor Department would oversee those part of health plans that fall under, again, the 1974 legislation that affected health care. So the--
BILL GRADISON: Today, if somebody who's covered by a plan within the jurisdiction of the Department of Labor feels that they are not getting the care which their plan has promised them, they have--they have recourse outside of the network. They go to the Department of Labor, and they have that option today right now.
REP. CHARLES NORWOOD: You ought to call the Department of Labor today and try to get ‘em to do something on this level. They have no option.
PHIL PONCE: Congressman, what is the enforcement mechanism? Say that these rights are created; somebody--say somebody is denied access to an emergency room. What does a person do to say, how does it work--does a person say my federal right to the emergency room was violated and, therefore, I'm going to do what?
REP. CHARLES NORWOOD: Which is what scares all of us to death, is that we'll have to let Secretary Hermann work out some of the regs as to how--
PHIL PONCE: The Labor Secretary.
REP. CHARLES NORWOOD: --it works. Labor Secretary. But if you are under--if you are shielded by federal law, meaning ERISA again, if you're shielded by that, then the--
PHIL PONCE: ERISA is--
REP. CHARLES NORWOOD: Employee Retirement Security Income Act that was passed in 1974 that threw federal government right in the middle of health care. It was about pension plans, and we wrote standard after standard about pension plans, and we through health care in it in the middle of the night, not one standard typically about--there are a few paragraphs about it, but it was done at the last minute; it was done with nobody's particular knowledge in town; it was done in the middle of the Watergate hearings; and we have gone downhill in quality of care in this country ever since then because people don't have to be responsible for the decisions they make about medical necessity.
Mr. Gradison: "...to say that the quality of health care has deteriorated in the United States since 1974, which you just said, is patent nonsense."
BILL GRADISON: Well, Congressman, you know I have great respect for you and the office you hold. I used to hold the same office. But to say that the quality of health care has deteriorated in the United States since 1974, which you just said, is patent nonsense.
REP. CHARLES NORWOOD: The health care in the country hasn't improved necessarily because people have been denied care. You will agree with that too. It doesn't mean that our medical profession isn't better. It doesn't mean our technology isn't better; but generally speaking--I'll give you--let me give you a perfect example of what this problem is about a little lady in my district. They have an HMO plan; they live in Covington, Georgia, 45 minutes from Atlanta. Their HMO has contracted with a hospital in Atlanta to do any services that they need. They have in their town a rural hospital, rural community hospital. That will soon be out of business as most rural hospitals will be out of business if we continue along the path we're going. If they have an emergency problem at their home, they have to drive 45 minutes to Atlanta so that their insurance company will reimburse them. That's not what I call good emergency care, and that is not improvement in health care.
PHIL PONCE: A very quick response, Mr. Gradison.
BILL GRADISON: Your plan, which I read very carefully, would have the Department of Labor make a determination, a bureaucrat, make the determination whether the facilities are conveniently, appropriately located in relationship to where people work and where people live. And I submit to you that that's a decision far better made by the people involved and by the institutions that are offering these plans. If there's a market closer to home, that market's going to be filled, and--
REP. CHARLES NORWOOD: The bureaucrat makes that decision today. It is a corporate bureaucrat.
BILL GRADISON: Responding to the market.
REP. CHARLES NORWOOD: You do not respond to a market because there is not a market between the patient and the doctor. The only market--
PHIL PONCE: Unfortunately, we have to respond to the clock, gentlemen. We are out of time. I thank you both very much.
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