First came the backlash against managed care in the form of negative media coverage. Then followed the flood of legislative proposals seeking to impose mandates on HMOs. Now the country is witnessing a backlash against the backlash.
Although it's almost a certainty more HMO horror stories will be told, the media are now taking up the subject of legislative overkill-careless laws that could kill the goose that laid the golden egg of healthcare cost control.
Journalists also are questioning whether such "protective" legislation may be impeding implementation of medical advances that are good for patients.
California Commissioner of Corporations Keith Paul Bishop, addressing the California Association of Health Plans at its annual meeting last month, warned that "politics and healthcare may well be ingredients of a public health catastrophe." The group just changed its name from the California Association of HMOs.
In recent weeks, editorial writers on both coasts-including the staff at the Wall Street Journal-have weighed in with commentary arguing that the backlash against managed care is being taken to absurd lengths.
Last year, Congress and 20 states mandated a minimum 48-hour hospital stay following childbirth "despite scant empirical evidence that shorter hospital stays pose increased health risks or that longer stays guarantee health benefits," Michelle Malkin wrote in the Seattle Times.
This year-as she and other editorial writers point out-politicians, including President Clinton, are pushing for mandated hospital stays for mastectomy patients. This is happening even though there is little data to support the benefit of keeping all women in the hospital after the procedure.
In fact, the data show some women would benefit from going home the same day as the procedure. Johns Hopkins Breast Center in Baltimore reports that women who did not spend the night in the hospital after a mastectomy had lower infection rates and higher levels of satisfaction.
Several other studies show women undergoing outpatient mastectomies had faster recovery rates and were more satisfied with their treatment.
As for the familiar charge that managed-care plans are pushing for reduced hospital stays, a report from the New York State Department of Health shows 72 out of 124 women-or 58%-who underwent outpatient mastectomies in 1995 were Medicare fee-for-service patients.
An American Association of Health Plans-commissioned study of outpatient mastectomies performed in 1993-94 found no difference in outpatient rates, whether fee-for-service or managed care. The study was conducted by Medstat Group, an Ann Arbor, Mich.-based healthcare data analysis firm.
The worm is turning a little in the media because "the facts are coming to light," says Susan Pisano, the AAHP's director of communications.
Most people find the issues of childbirth and mastectomy "very compelling. It's everyone's natural inclination to support women and families and someone with breast cancer," Pisano says. "But there are a lot of people who are beginning to look at the issue differently and saying, `Maybe there's more to the story.'
"In many respects, this is a pace-of-change issue," she says. With the rapid pace of technological advances, "it catches people by surprise that it's technically possible to do a surgical procedure the same day a patient goes home from the hospital." But some of these controversial practices are not directly related to managed care, she contends.
"What you wouldn't want to have happen is to lose things that represent progress in medicine," as a result of the assault on managed care, she says.
The AAHP issued a policy statement last November saying a decision to stay in the hospital following a mastectomy should be made by the patient's physician after consulting with the patient. The association also says "creating unfounded concerns about outpatient mastectomy could potentially harm women by discouraging them from considering an alternative that can reduce infection, accelerate recovery and offer familial support. The incidence of outpatient mastectomies in both network-based plans and fee-for-service coverage, including Medicare, reflects changes in medical practice . . . . A clinical mandate for mastectomy length of stay will discourage individualized treatment and stifle medical innovation."
As more data accumulate, are the media now less apt to run with a story about an HMO limiting care in what looks like an attempt to cut costs?
Greg Donaldson, director of corporate communications at Louisville, Ky.-based Humana, says it's too soon to say.
"There's a lot more dialogue between plans and the media. I certainly am encouraged by that. I get a sense that there are less adversarial and more candid discussions," he says. He believes reporting is becoming less driven by anecdote.
The legislative push for mastectomy mandates continues, however. At last count, 32 bills had been introduced in 14 states requiring coverage for at least 24 hours and up to 96 hours following a mastectomy, according to AAHP data. In March, New York became the first state to enact a mastectomy law, followed by New Jersey. Congress is considering federal mastectomy legislation supported by Clinton.
That prompted syndicated columnist Charles Krauthammer to write that this flood of legislation is focused on women's perceived needs. It is, as others have put it more crudely, "legislation by body part"-but only for women. He asks: Where is the justice or logic here? If the legislative mandates make sense for women's diseases and conditions, then illnesses striking men and women would merit legislative mandates, he says.
Krauthammer argues that "these intrusive, often ignorant mandates are cynical pandering dressed up as compassion" because politicians get a lot of points from women voters by introducing such measures.
But hospital-stay mandates are beginning to extend beyond women's issues. For example, legislators in Maryland are considering a bill that would require a minimum of 24-hour coverage following the insertion of a catheter. It's easy to see where this train could be headed.
Meanwhile, as health plans combat what they see as counterproductive legislation, they're concentrating on getting the message out about their value to women's health. In an attempt to minimize the need for mastectomies, under previous National Cancer Institute guidelines all HMOs have been covering mammography for women age 50 and older. Some 98% also have been covering mammograms for women aged 40 to 50 when the procedure is recommended by their physicians.
Following new National Cancer Advisory Board recommendations suggesting regular mammograms for women over 40, Aetna U.S. Healthcare recently announced it now recommends and covers annual mammograms for women beginning at age 40 without the need for physician referral. Other HMOs are reassessing their policies regarding mastectomy coverage.
Meanwhile, all HMOs cover Pap tests, while only 67% of fee-for-service plans routinely cover them, according to the AAHP. A study in the American Journal of Public Health found that HMO enrollees with breast, cervical and other types of cancer were diagnosed at significantly earlier stages than fee-for-service patients.
And according to a study by the Alan Guttmacher Institute, managed-care plans are more likely to cover annual gynecological exams than fee-for-service plans.