When American Hospital Association and American Medical Association executives start talking publicly about how hard they're working together, discord often lurks behind the scenes.
That was the case again last week, as both healthcare groups began shopping around their own distinct versions of provider-sponsored organization legislation to congressional sponsors.
It was just about a month ago that the AHA, in a membership publication, hailed a "new era of collaboration" between the two top healthcare groups on the PSO issue. In fact, the associations were slated to hold their first joint PSO education program late last week in Atlanta as a prelude to the AMA's interim annual meeting there.
As it turns out, the two sides might as well meet in different cities.
Kirk Johnson, the AMA's general counsel, said his association is developing its own federal PSO legislation in conjunction with a number of medical specialty groups. He acknowledged that the AMA had not sought AHA support for its plan, but he added, "Hopefully, we will be able to get together."
That could be problematic, as the AHA has been promulgating its own PSO plan on Capitol Hill, seeking sponsors in both the House and Senate.
PSOs are networks of hospitals, physicians or both that would contract directly with Medicare for services without becoming formal insurance companies, which would make them subject to regulations governing insurance companies.
Richard Pollack, the AHA's executive vice president for federal relations, said the AHA had developed "our own version of what PSOs ought to look like." Like Johnson, Pollack admitted his group was not working with the AMA and, like Johnson, he added, "We would like to get them on board."
AMA officials would not disclose details of their plan. However, sources who have knowledge of both plans said the two groups agree on the basic structure of PSOs. Not too surprisingly, they differ on whether doctors or hospitals should be at the top of PSO organizational charts.
"(The AMA) would like to have PSO mean `physician-sponsored organizations,' not provider-sponsored organizations," said one hospital group source who asked not to be identified.
According to a physician group source, the AMA is seeking to allow specialists to cut separate subcontractor deals with Medicare within the PSO structure, a measure opposed by hospitals.
The AMA is also working on a measure to give further antitrust relief to physicians who want to collectively negotiate with Medicare and other payers. Earlier this year, federal officials unveiled new antitrust guidelines that gave physicians more lenient treatment under the law. At that time, the AMA said it was pleased with the new guidelines but would continue to seek a legislative solution that would further ease antitrust rules. The AHA has opposed such legislation.
Pollack would not detail the AHA's PSO plan but noted it would be similar to the proposal introduced last year by conservative Democrats known as the "Blue Dogs." That plan was endorsed by a coalition of provider groups, including the AHA.
The measure would have allowed PSOs to contract with Medicare under standards to be developed by HCFA within 120 days of enactment of the bill. It would also have barred states from imposing additional standards on PSOs.
The measure also would have allowed PSOs to count the value of hard assets in their calculations of any insurance-like solvency requirements, effectively lowering the amount of money they would have to hold in reserve to cover insurance losses.
Solvency requirements are a hot-button issue for physicians. Doctors are concerned that any AHA plan would include PSO solvency limits that will be too high for physicians to meet, giving de facto control of PSOs to hospitals.