|A BILL OF HEALTH?|
July 16, 1999
Senate Republicans say their bill, which now moves to the House of Representatives, will significantly expand patient care. Following a Kwame Holman background report, four health care providers discuss the proposed legislation with Elizabeth Farnsworth.
ELIZABETH FARNSWORTH: And joining me now, Dr. Bohn Allen, a general and vascular surgeon at Arlington Memorial Hospital in Arlington, Texas. Dr. Beth Gallup, a family physician in Kansas City, Kansas -- she's with an independent practice association that works with Health Maintenance Organizations to deliver patient care; Judy Sheridan Gonzalez, a staff nurse in the emergency department at Montefiore Medical Center in the Bronx, in New York City; and Rex Lagestrom, a doctor of internal medicine with his own private practice -- he formerly worked for Humana Incorporated, a health maintenance organization in Louisville, Kentucky. Thanks to you all for being with us. And, Dr. Allen, from your experience, does managed care need to be reformed?
DR. BOHN ALLEN: Yes, it certainly does. In Texas, we have dealt with this problem since 1995 and have passed the Patient Protection Act of 1997, and the Physician Negotiation Bill this past legislature. And this was all done at the frustration of the physicians in dealing with the health plans and trying to be advocates for their patients and to represent their patients in their conflicts.
ELIZABETH FARNSWORTH: What was the key problem you saw and has it been dealt with by the state, changes?
DR. BOHN ALLEN: Well, the key thing that we dealt with was to set up accountability for the health plans through liability; that is, they were liable for medical necessity decisions that they made that wound up injuring or killing the patient. And we put in the protections of an independent review organization, which had the authority then to look at all complaints by patients, screen out the frivolous suits and only deal with those issues that were substantive. And as a result, we have only had two, maybe three suits come out of this whole process in two years. The independent review organization has to be independent. It has to have no financial ties or financial benefits from the decisions, and they must be able to look at all information, both from the health plan, from the patient's physician and from the patient.
|Opinions on managed care|
ELIZABETH FARNSWORTH: Okay. Dr. Gallup, in your practice is there a need for reforms in managed care?
DR. BETH GALLUP: Well, in Kansas City we're lucky to be able to work with some health plans that are partnering with physicians on a daily basis. In my experience these health plans are improving the health care of our patients by in fact partnering with our physicians and giving us data and helping us manage our patients' health care better from the whole patient standpoint.
ELIZABETH FARNSWORTH: Explain that specifically. What do you mean? What kind of data?
DR. BETH GALLUP: Well, the managed health care plans look at the rate of mammography in your practice, the rate of prostatic exams in your practice, how often you are checking up on your diabetic patients and gives you information and data so you can make sure that your patients are getting what they need. This doesn't usually happen in a fee-for-service environment.
ELIZABETH FARNSWORTH: So, it's working for you. You don't think big reforms are necessary?
DR. BETH GALLUP: I don't think big reforms are necessary. I think the reforms that are coming are because the managed care plans want to do a better job, want to work more closely with the patients. They are not into denial the care; they're into taking care of the patients and working with the physicians.
ELIZABETH FARNSWORTH: Judy Sheridan Gonzalez, as a nurse, what are you seeing in the emergency room in your hospital?
JUDY SHERIDAN GONZALEZ: Well, we're seeing a lot more patients than we used to see, and what's happened is the managed care corporations have put pressure on the medical centers to reduce costs and that's translating into less staff, so you have a lot less staff taking care of many more patients, with many more complicated illnesses, with fewer supports at home. For example, something for which you might stay in the hospital for five days ten years ago, you might not even stay overnight now. And the support at home in terms of home care, which was the promise that people would get quality care at home, is not happening. Home care nurses have to fight tooth-and-nail with managed care companies to provide just the minimum level of care that patients require.
ELIZABETH FARNSWORTH: So you think that reforms are definitely necessary?
JUDY SHERIDAN GONZALEZ: Absolutely, and I've seen a lot of people suffer as a direct result of managed care.
ELIZABETH FARNSWORTH: What would be the most important one?
|Informing the public about care|
JUDY SHERIDAN GONZALEZ: Well, one of the things that we are really concerned about is whistle blower protection -- just to let the public know what is going on. Our hands are tied without a health care bill giving us protection to talk about a lot of the abuses and the excesses and the cost savings that's not translating into better care -- that's just translating into money going into the pockets of stockholders and away from patient care.
ELIZABETH FARNSWORTH: Okay. Dr. Lagestrom, what kind reforms do you see -- what's needed from what you see in your practice?
DR. REX LAGESTROM: I think what's really needed is a comprehensive view of what HMO's really are. When we talk about HMO's, we talk as if it were a single entity that needed to be reformed. And there are many different HMO's throughout the country. My experience in Louisville, working with Humana's HMO, has been a really good one. In my former job with them, I was a regional director for Southern Indiana and Kentucky and found that on the corporate level, they were very, very interested in proving the management of care from a preventative stance and saving money in that issue. They asked me directly and worked with me directly what I thought was the best kind of care to give, and asked a number of other physicians. And so as I said, my experience has been very good. That's not to say that Humana and other HMO's like it couldn't improve their care significantly but I believe that they are a work in progress and they provide a type of care that is quite difficult to provide otherwise. And it was mentioned earlier about partnering with physicians, providing data to them, that they would otherwise not have access to. I think we tend to oversimplify problems and say these HMO's are a problem. I don't deny the problems that they're having in the Bronx or in Texas, but I don't believe that throwing the system into the courts is going to make it any less complex or any more salable to the public. I think we will ultimately complicate a problem that is already difficult to solve.
ELIZABETH FARNSWORTH: So, Dr. Lagestrom, when you say that some are working well and also that it's a work in progress, do you think there would be a kind of self-reform process that would continue, or do you think that government needs to act?
DR. REX LAGESTROM: Well, I tend not to rely on government very much. I think most of us have learned that the best type of reform begins on the ground level or the grass roots level. We can try and rely on the government to take care of the very large problems that come up. But really it comes down to people of goodwill working together and trying to identify real problems and deal with them. I think enlightened capitalism isn't a bad way to go. I think the market drives itself in a lot of different ways. But ultimately those things that serve the patients best, provide the best care, and are the most humanistic are the ones that will win the day. You have to understand, HMO's are a relatively new entity in this country and I believe that there's a wide spectrum of HMO's. Some, I'm sure are abysmal. Some are wonderful, but you have to really look at them.
ELIZABETH FARNSWORTH: Okay. Judy Sheridan Gonzalez, what is your response to that? Do you think that there can be reform through the marketplace, reform through sort of a self-reform process or does government really need to do something here as in Washington was debated all week?
JUDY SHERIDAN GONZALEZ: Yes. I think something really needs to happen. With the fee-for-service system, you had an incentive to overtreat. With this particular system, you have an incentive to undertreat. As long as you make a profit of delivering health care, you have an incentive to do something other than health care. Right now almost one third of the health care dollar goes into areas that have nothing to do with health care, whether it's marketing or overhead or profits for managed care corporations. That money should be put directly into patient care and to research. That's why people's premiums are so high because they are paying -- for example, I just read in the New York Times yesterday that managed care corporations are spending $20 million on the recent advertising campaign to the public. So, people are paying for advertisements that are telling them that they shouldn't get better protection. We have a big problem with it.
ELIZABETH FARNSWORTH: Sounds like you wanted reforms beyond what was debated in Washington this week.
JUDY SHERIDAN GONZALEZ: Yes.
ELIZABETH FARNSWORTH: Okay. Dr. Bohn Allen, what do you think? You've had some reforms in Texas. Does the government need to step in to make those national?
DR. BOHN ALLEN: Well, I think actually what we need is for, in some respects for the government to get out of the problem; that is, to do away with the go back ARISA preemption and go back to state action doctrine like we had.
ELIZABETH FARNSWORTH: Explain what is a preemption, briefly.
DR. BOHN ALLEN: Well, the ARISA preemption means that those employees who have their insurance through their employer are exempt from state insurance laws. As a result, the insurance plans, the health plans, can make their own rules and regulations and they are exempt from state law. And what we need is to get rid of that ARISA preemption, put it back to state action doctrine and let each state deal with their own managed care problems -- much as we have done in Texas. And we work in collaboration with our health plans. We meet with them regularly. We try to iron these problems out. But you have to understand that the health plans operate from an economic incentive, not from moral authority. And as a result, we have to have some ground rules that allow patients to be protected.
ELIZABETH FARNSWORTH: And when you say we have to, how can that be best done, best assured?
|Medical necessity decisions|
DR. BOHN ALLEN: I think it can best be done if we get back to medical necessity decision making being made by the physician in consultation with their patient. There's no room in the examining room for a third chair for the health plan to be making medical necessity decisions. So we have to get back to a system that allows the physician who takes care of the patient to make the final decision as to what's in the best interest of that patient individually.
ELIZABETH FARNSWORTH: But you said you wanted government not to be forcing that decision; you want it to happen some other way.
DR. BOHN ALLEN: Well, what I want is for the government to give us the right to have state action doctrine and get rid of the ARISA preemption. Why should 124 million patients that are in employer-based insurance have their rights taken away from them simply because of the ARISA laws, which were never intended to be applied to health plans in the first place? It was for retirement plans. So it leaves those 48 million people who have insurance that's covered by state law, gives them the ability to recover when they are injured or death occurs. You have 124 million people that are exempt from that.
ELIZABETH FARNSWORTH: Okay. Dr. Lagestrom, what should happen next now? You told us that you think that some of this can be worked out in the marketplace and elsewhere. What should happen next? Do you hope that both of the bills or the various bills that may end up in Congress -- just nothing comes of them? Would that be the best possible solution, which it looks like could happen?
DR. REX LAGESTROM: Well, I think what I would really like to see happen would be an intelligent debate in Washington about health care and not a lot of posturing. I think we've had more posturing in the last year-and-a-half concerning health care than we can possibly live with. I think that both bills, both the Democratic bill and the Republican bill, are wrong. They are wrongheaded. They don't address the issues. They don't address the complexity of the system. If you talk to the lady in the Bronx, she has very good reasons to be angry about health care and angry about the way it's delivered to the patients and where the dollars go. But that may not be the same situation in Louisville or in Kansas City, and it's entirely different in Texas. And each environment operates differently. And I think the federal government needs to recognize that the state and local level has a much better idea of what's going on in their own backyard. I really believe that for every degree of separation you have a degree of obfuscation. People do not understand a problem the farther they get away from it. And I get very disheartened when I listen to the debates on Capitol Hill about health care when these people really don't live in the trenches and work with it every day like the people do in Texas or in the Bronx or in Kansas City -
ELIZABETH FARNSWORTH: I'm going to interrupt you in the interest of getting around to everybody. Dr. Gallup, I missed you on that last question. Where do you think should happen next? Weigh in any way you want here.
DR. BETH GALLUP: I think that there isn't a need for reform certainly at the Washington level. I do believe that states can take care of themselves. Moreover it's my belief that managed care organizations actually improve the quality of health care and improve the physician's ability to care for their patients. One gentleman talked about the managed care organization being in the room with the physician. Well, the managed care organization isn't in the room with the physician. It's in his office; it's giving him practice guidelines; it's giving him data on what medications to use; it's doing all the things that incur better patient care, higher efficiency, and hopefully control escalating costs.
ELIZABETH FARNSWORTH: And, Judy Sheridan Gonzalez, what would help you most that could be done next?
JUDY SHERIDAN GONZALEZ: Well, I think that we as a people in this country really need to talk about whether health care is a right or a privilege for a few million people. As far as I'm concerned, a lot of what is discussed in Washington is just window dressing because the vast population that we see in this country is really suffering, they are uninsured, and even those with insurance plans are really having a great deal of trouble. And I think we really have to take a hard look at how we view health care and what way we think it should be delivered.
ELIZABETH FARNSWORTH: Okay. Thank you all very much for being with us.