Call 1998 Washington's year of healthcare quality. Driven by consumer pressure and election-year worries, Congress is almost sure to debate--and may be more likely than ever to pass--broad legislation governing healthcare quality and patient protections.
The debate probably will center around such issues as "gag clauses," or contractual restrictions on what physicians can tell health plan enrollees about their treatment options, as well as access to emergency and specialty care.
The first salvo of 1998 was fired in November 1997 when President Clinton endorsed the "Consumer Bill of Rights and Responsibilities" approved by his Advisory Commission on Consumer Protection and Quality in the Health Care Industry (See chart).
Clinton called on federal agencies that administer health insurance plans and providers to abide by the patient protection provisions in the bill of rights and called for "appropriate" legislation to reinforce those protections.
The guidelines in that document will join a bubbling stew of legislation introduced in the past year by numerous members of Congress.
"There's a 100% probability they're going to consider legislation under the quality banner," says Brent Miller, vice president of public policy and political affairs for the American Medical Group Association.
"Whether or not the process results in convoluted legislation that's unworkable and never gets signed, or whether it becomes a pitfall to trap unwary legislators, or whether it becomes a pig in a poke, remains to be seen," Miller says.
In Congress, it will not become simply a Republican vs. Democrat issue. Many of the chief sponsors of patient-rights legislation are Republicans, such as Rep. Greg Ganske (R-Iowa), a reconstructive surgeon; Rep. Charles Norwood (R-Ga.), a dentist; and Sen. Alfonse D'Amato (R-N.Y.), who's up for re-election in 1998.
But the chief opposition to patient-rights legislation also will come from the Republican Party, including some members of its leadership. Their claim is that patient protections will saddle employers with new costs and lead to a greater number of uninsured.
In a memo sent to House Republicans, House Majority Leader Richard Armey (R-Texas) warned members that quality mandates "are not well-suited to enhance the quality of our market-based healthcare system."
Armey also alerted members that patient protection legislation could be "hijacked" to implement Clinton's failed 1994 healthcare reform plan.
Those more conservative members appear to have many employers and insurers on their side. Among the voices opposing the potential for regulation stemming from the consumer bill of rights were the National Federation of Independent Business, the Health Insurance Association of America and the Business Roundtable.
Those groups were all part of a coalition that eventually torpedoed Clinton's 1994 healthcare reform.
But some employers support the protections. GTE Corp., which sent a representative to the advisory commission, announced it would voluntarily abide by the bill of rights through its health plans and their providers.
The probability that Congress will debate patient protection issues also raises the question of what health plans could demand in return for accepting some new regulation.
In an act of political jujitsu, managed-care organizations could demand, for example, that Congress also impose quality-related regulations on physicians and other providers.
The American Association of Health Plans, for example, is emphasizing that the White House quality commission's work needs to examine all parts of the healthcare sector, not just managed care, says spokesman Donald White. The group also points out that while managed-care organizations now must disclose more and more quality-related indicators, similar disclosure is not required of providers.
Physician group representatives, however, warn against such ideas as giving consumers greater access to mortality statistics from individual physicians, which could give consumers a skewed view of a doctor's skills. They say such numbers often don't reflect patients' severity of illness.
"When you get down to the individual physician level, you have to be very careful about giving access to data that could be misleading," says Robert Doherty, vice president for governmental affairs and public policy at the American Society of Internal Medicine. "You don't want to scare physicians away from treating the more complex patients."
Although the patient protection debate is likely to take the highest profile of the healthcare matters before Congress this year, others are likely to have an impact on physicians.
The continuing interspecialty feud over how Medicare compensates physicians for their overhead costs is likely to end up before Congress once again--or perhaps before a federal court.
Specialists and surgeons, who stand to see their Medicare income shrink with the implementation of a new practice-expense reimbursement formula, say they believe HCFA, as it develops that formula, will ignore congressional directives included in the balanced-budget law enacted last August. The law delayed until Jan. 1, 1999, implementation of "resource-based" Medicare practice-expense compensation, which represents about 41% of physicians' Medicare fees.
That compensation schedule, which will shift an estimated $4 billion a year from specialty procedures to office visit services, aims to compensate physicians for such expenses as staff salaries, supplies and rent based on the complexity of the practice-related resources needed to deliver a clinical service.
It's similar to the system used since 1992 to compensate physicians' professional work, but a departure from the current practice-expense system, which bases payment on historical charges.
In delaying implementation of resource-based practice-expense payment, as well as a phase-in through 2002, Congress ordered HCFA to rework proposed regulations it issued in June to enforce the payment formula. Heeding specialists' arguments that HCFA was using flawed data, Congress ordered the agency to use "actual" data, rather than estimates, and to use "generally accepted cost accounting principles."
"I think we're going to be back in front of Congress," says Randolph Fenninger, co-chairman of the Practice Expense Coalition, which has challenged HCFA's data and analysis of that data.
Proposals to expand healthcare coverage also could return to Capitol Hill. The Clinton administration has hinted that its fiscal 1999 budget request could propose coverage expansions for temporarily unemployed workers and for early retirees ages 55 to 64.