Managed care suffered a setback recently when the House Ways and Means Committee passed two provisions the industry opposed.
The first amendment requires health plans to allow beneficiaries to seek care outside the plan, provided they pay an unspecified additional amount for the point-of-service option. The committee also passed an any-willing-provider requirement, which obligates managed-care plans to enroll any physician willing to accept the plan's reimbursement and live by its credentialing and quality criteria.
The move was surprising because it came after months of intense lobbying that, until the committee's recent action, had yielded a string of successes in Congress for advocates of managed care.
Managed-care groups, which call the actions the "managed-care massacre," say the two measures combined would increase insurance premiums and lower quality by taking away the ability of plans to manage patients' care. A study released last week by the Group Health Association of America said the any-willing-provider provision alone could add between 9.1% and 28.7% to the average cost of insurance premiums.
Some provider groups, including the American Hospital Association and the American Group Practice Association, also vigorously oppose the measure for much the same reason.
Supporters of the measures, including the American Medical Association, contend such protections are needed to ensure that patients can choose their own physicians.
The votes came in a late-night Ways and Means session on June 24. Before that action, opponents of the measures said they were convinced they had enough votes to kill the amendments.
"It really beats me how it happened," said a lobbyist for a group that opposed both measures. "We weren't even working that hard on the issue because we never thought they had the votes to pass it."
An AMA spokeswoman said the any-willing-provider measure "just sort of took on a life of its own."
According to several congressional aides, the any-willing-provider provision passed only after its sponsor, Rep. William Jefferson (D-La.) agreed to exempt all staff-model HMOs and certain other managed-care plans, such as Kaiser Permanente and Health Insurance Plan of Greater New York. The provision was further narrowed to apply only if a managed-care plan is understaffed, although it's still unclear how a plan's staffing needs would be determined.
The Ways and Means bill will likely be the only one to include an any-willing-provider measure. That may make it easier for opponents to defeat the provision as the bill advances.
"It's certainly better than if all the bills had the same language," said Michael Bromberg, executive director of the Federation of American Health Systems, which also opposed the measures. "The problem is, once something is in, it's tougher to get out. This is going to be a much tougher fight now."