Cost containment and coverage provisions got most of the attention given to the reform plan approved by the House Ways and Means health subcommittee late last month.
But other provisions in the plan, which was drafted by subcommittee Chairman Fortney "Pete" Stark (D-Calif.), would have an impact on providers. Those areas include physician self-referral, malpractice and physician work force reform.
"It would be negligent to ignore any part of this plan," said Robert Doherty, vice president of governmental affairs and public policy at the American Society of Internal Medicine. "These are the types of issues that Congress traditionally defers to Ways and Means on."
One provision expands the scope of the ban on physician self-referrals, which prohibits physicians from referring patients to facilities in which they have a financial interest. Currently, the ban applies only to certain services for Medicare and Medicaid patients. The health subcommittee bill would ban referrals of private-pay patients and would increase the number of services included.
More significantly, the bill would require that medical groups provide certain services in only one location within a metropolitan statistical area. If a group has more than one location within a metropolitan area, it couldn't refer patients from one to another for those services, making it difficult for groups to sustain branch offices or clinics.
The rule wouldn't apply to groups in rural areas or those paid under a capitated basis.
"We're very concerned," Mr. Doherty said. "This is the first time that the self-referral definition has been extended beyond its original concept, which was to regulate investment situations."
Opponents of the measure say they hope to overturn it when the plan reaches the full Ways and Means Committee.
"If this can't be fixed, it would undermine the coordination of patient care considerably," said Brent Miller, director of government relations for the American Group Practice Association. "A group practice that is a regional provider would have a real problem if this provision stood as is," he said.
Another controversial portion of the Stark bill is the $350,000 cap on non-economic damage awards. Advocates of malpractice reform say that, primarily because of the cap, the plan is a major victory. The bill also would limit lawyers' contingency fees to no more than one-third of a damage award.
The malpractice reforms are "the most significant item in Stark bill," said Fred Graefe, a lobbyist for a malpractice reform coalition. "This is the first testing ground, and it was a defeat for the trial lawyers."
In addition, the plan allows as many as 10 states to implement demonstration projects to test alternative dispute resolution concepts, which are designed to keep malpractice cases out of the courts. States also could begin allowing providers to use adherence to practice guidelines as a defense against malpractice.
The victory may be difficult for malpractice advocates to keep, however. In a telephone conference with the California Medical Association, President Clinton said he didn't believe a national cap would be enacted because there is "so much difference among the various congressional delegations."
Providers also are watching the physician work force provisions in the Stark plan. The bill would require 53% of medical school training slots to be reserved for primary care by 1998. In 1990, about one-third of all practicing physicians were in primary care.
Mr. Stark's quota is less onerous than the 55% threshold for primary care in the president's reform plan. However, the Clinton bill gave the system until the 2002-2003 academic year for the transition to occur.
The Stark provision is aimed a forcing a shift in the balance of primary care and speciality physicians in the healthcare market. Many healthcare experts are contending that the current overabundance of specialists fuels spiraling health costs.
But Republicans argued that residency programs would respond on their own to the changing marketplace under reform, making government quotas unnecessary.