This year's budget debate has been particularly hard on the always tenuous relationship between hospital lobbying groups in Washington.
Was it really less than six months ago that representatives of nearly a dozen hospital groups joined together at the American Hospital Association's annual meeting in Washington to announce the formation of a "Unity Coalition"? They joked that they had a unity wave and handshake, and it really appeared they were going to face the next wave of budget balancing with more cooperation than they did in 1995.
Since then, the strain caused by $115 billion in Medicare spending reductions has turned the relationship between members of the Unity Coalition into something resembling that of U.S. Gen. Patton and British Gen. Montgomery in World War II. Sure, they were allies, but they spent a lot of time and effort devising ways to stick it to each other.
All the hospital fights have two things in common. The first is money. The second is that the AHA, by not taking a consistent stand on interhospital squabbles, became a lightning rod for criticism and was unable to be the mediator it should be.
The two interhospital skirmishes with the highest profiles have been over Medicare capital payments.
As it did in 1995, the Federation of American Health Systems got its Republican allies to add a provision to this year's House and Senate budget bills that would have reimbursed investor-owned hospitals for taxes paid through the Medicare capital payment system.
The measure, which ultimately was dropped from the bills, would have redistributed about $80 million from fiscal 1998 to 2002. While some not-for-profit hospitals that make payments in lieu of taxes also would have benefited, the vast majority of the winners under the provision would have been investor-owned facilities.
The Catholic Health Association opposed the measure.
The two sides fought the same battle in 1995, but it ended with no clear winner because the GOP budget was vetoed by President Clinton.
As both sides acknowledged, the fight was about more than just the $80 million in capital payments. It was philosophical. It was about ownership structure.
The fight consumed an incredible amount of time and resources at the federation and the CHA that could have been used on one of the many issues in the budget affecting all hospitals.
Tom Scully, president of the federation, is a talented and tenacious lobbyist. He is also one of the hospital industry's best assets when it comes to dealing with Republicans.
To offset that advantage, the CHA hired former Republican National Committee Chairman Haley Barbour to lobby on its behalf. Barbour's firm also works for the AHA, which, oddly enough, was aligned with the federation on this issue.
It was an example of creative (and somewhat lucky) grass-roots lobbying by the CHA. Sen. Connie Mack (R-Fla.) has a sister who's a nun. The father of Sen. Kent Conrad (D-N.D.) works in a Catholic hospital. The children of House Ways and Means Committee Chairman Bill Archer (R-Texas), who cast the dramatic tie-breaking vote against the measure in the House, were born in a Catholic hospital in Houston.
That kind of influence can't be bought, and it really did make a difference.
In the end, the CHA got the provision stripped from both the House and Senate bills, but not until several state hospital associations unsuccessfully called on the AHA to reverse its support of the federation. In the aftermath of the bruising battle, Scully vowed to make life rough for the CHA on tax issues, while the CHA was very unhappy with the AHA for taking sides.
Another typical example of Washington hospital group infighting centers around a "special exceptions" provision for Medicare capital payments, added to the House and Senate budget bills at the behest of a small group of large urban hospitals.
The provision would redistribute between $350 million and $1 billion over the next five years from nearly all hospitals to a very few.
Needless to say, that has some hospitals, particularly competitors of the hospitals that would benefit from the change, a little upset. They hired their own lobbying firm and enlisted several hospital groups to oppose the measure.
The AHA, whose 24-member Board of Trustees includes three from the beneficiary hospitals, decided not to take a position on the issue, arguing it was not important enough to warrant any interest. What's more, it chose not to inform any of its members about the potential impact. That angered several state hospital associations, which thought the AHA should have at least brought the issue to its members' attention.
A compromise probably will be reached, but not before both sides spend precious resources kicking the heck out of each other.
There have been a number of other flare-ups.
For example, Larry Gage, president of the National Association of Public Hospitals and Health Systems, recently attacked the AHA for opposing his group's proposal for distributing Medicaid disproportionate-share payments to public hospitals.
Speaking at the NAPH's annual conference under a slide projection that read, "There is always one more S.O.B. than you counted on," Gage said. "We don't want to break our relations with (the AHA). . . . We want to make their lives miserable for a little while, though."
It would be naive to think hospital groups, with billions of dollars at stake, would not find themselves at odds from time to time.
The problem is the AHA, which likes to think of itself as the parent group for all hospitals, has been impaired because it hasn't addressed the hospital fights consistently. The association should be able to act as a moderator but can't because one side or the other in the battles doesn't trust it.
In the case of the property-tax reimbursements and disproportionate-share payments, the AHA took sides. On Medicare capital special exceptions, it did not.
By sticking to a neutral position every time, the AHA might be able to contain these fights and keep the hospital community focused on larger issues.