What's good for the goose isn't necessarily good for the gander.
In a recent and rare display of collaboration, the American Hospital Association and the American Medical Association went to Capitol Hill to persuade lawmakers to force managed-care plans to disclose key quality-related information to the public through an easy-to-read "label."
What the AHA and AMA didn't tell lawmakers was that for years both organizations have fought any attempt to force hospitals and physicians to cough up the same information.
Both argued that their organizations and professions are too complex to be reduced to a simplified-format description or report card.
Not so for HMOs and PPOs, according to the AHA and AMA. They insist that consumers need to know more about their health plans.
The AHA's and AMA's top brass espoused that position in testimony last December before the president's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. AHA President Richard Davidson and AMA Secretary-Treasurer D. Ted Lewers, M.D., said their proposed label for managed-care plans presents consumers with basic information about four variables:
Choice of physicians or providers.
Covered services and limitations.
Quality improvement and patient care.
"People who have information are at the source of power, and that becomes key to making decisions about healthcare," Davidson told the commission. "In our view, the power has to be shared . . . between all of us and the consumers who have every right to a lot more information about healthcare than they have today."
The label is still a work in progress, the associations said.
The American Association of Health Plans, predictably, was not pleased with the AHA-AMA proposal and said it should have been consulted.
Its president and chief executive officer, Karen Ignagni, said: "I wish that the AHA and AMA had talked to us about their proposal. Ours is much broader. They should think about broadening their standards and making them applicable to their own members."
As of Jan. 1, she pointed out, health plan members of the AAHP must subscribe to mandatory standards listed in its "Putting Patients First" initiative. That covers a range of issues, Ignagni said, from information disclosure to verification that physician-enrollee communication is unobstructed to appeals for denial of care.
"We have a label in Putting Patients First. Our principles and guidelines are very comprehensive and follow very closely the president's commission's ideas," Ignagni added. The next version is in the works.
The HMO industry's attempt at creating disclosure standards is more than the hospital industry has been able to come up with. For years, hospitals have argued that they shouldn't have to release data for publication.
Alan Zwerner, M.D., president and CEO of the Medical Quality Commission in Seal Beach, Calif., an accreditor of capitated medical groups and independent practice associations, said he believes the more information consumers get, the better the market will work. But when one group advocates disclosure by another, the disclosure is being used as a tactical weapon, Zwerner said.
"Isn't it fair, wouldn't it be helpful to the consumer, to look at the hospital and doctor and have them disclose in the same way?" Zwerner asked.
But the demand for such information has yet to be a major industry force. At least that's the reason the MQC is going out of business later this month, Zwerner said (Jan. 19, p. 39).
Commissioner Steven Sharfstein, M.D., a hospital CEO, asked the same question about hospital and physician disclosure at the December hearing.
Davidson answered, "Information and data about doctors and hospitals is so fragmented today that there isn't a simple way to get the same kind of information."
There's a reason for that. Physicians and hospitals have been suppressing publication of quality information for years.
In 1993 hospitals squelched the Medicare mortality index. Until then, HCFA had released mortality statistics annually for every Medicare-participating hospital by name. Hospitals said the statistics were not reliable because the measurement was too crude and the data too prone to miscoding and other errors. HCFA Administrator Bruce Vladeck agreed and suspended release of the statistics.
In 1994 the Joint Commission on Accreditation of Healthcare Organizations proposed a five-star rating system for hospitals that would incorporate the results of their accreditation surveys. The idea was to make complex quality information easy for laypeople to understand.
The AHA immediately attacked the plan, saying it trivialized quality data by resorting to a rating system normally applied to restaurants and movies. The Joint Commission replaced the star-rating system with a complicated numerical system.
Similarly, the Joint Commission, which purports to serve the public interest, has been gradually moving away from public disclosure of problems at hospitals.
For a while, hospitals that had serious patient-care problems were listed as "conditionally accredited," and their probationary status was public information.
Under hospital industry pressure, the Joint Commission replaced the conditional accreditation system with a less-offensive "accreditation watch" system in which hospitals with quality problems are simply identified on a list while maintaining their full accreditation status.
But that, too, made hospitals anxious.
So, starting April 1, hospitals with quality problems can keep their names off the accreditation watch list if they self-report adverse patient incidents to the Joint Commission.
The hospital industry, led by the AHA, also has opposed the mandatory public reporting of hospitals' patient staffing ratios. Such reporting has been pushed by organized labor and the American Nurses Association, which have accused hospitals of trimming their work force to reduce costs, thereby jeopardizing patient safety.
A bill introduced on behalf of the ANA, the Patient Safety Act, is pending in Congress. It would require hospitals to release patient staffing ratios. It's the same sort of information the AHA and AMA want managed-care plans to disclose on their labels (See chart, p. 22).
But hospitals oppose the bill.
"They collect the information, but they don't want to part with it," said Sara Foer, ANA spokeswoman. "The public should have access to it."
The Pennsylvania Legislature is of a similar mind. It has ordered the publication of a report detailing outcomes of coronary artery bypass graft surgery at the state's hospitals. The report shows which hospitals exceed the expected mortality rate for the surgery.
Yet hospitals disparage the report. "This is a meaningless document," said an executive at a hospital that had poor mortality and high costs. "We regret it still goes out to the public," said the executive, who requested anonymity.
Another quality measure that hospital critics think should be published is nosocomial infection rates. A patient in Iowa, Karen Burton, was considering elective surgery at University of Iowa Hospital and Clinics in 1994. She requested its nosocomial infection rate. The hospital refused to release it, so she sued. The Iowa Supreme Court ruled in the hospital's favor, noting that publication of infection rates would have a chilling effect on voluntary reporting by physicians and hospital staff.
"If this weren't the healthcare arena, where there's a tradition of guildlike behavior, people wouldn't think twice about releasing this," Burton said.
Physicians haven't been any more eager than hospitals to have measures and labels applied to their quality. "As they step out on this issue," Ignagni said, "I'm sure they've gotten the question about their own members. The information that's in the National Practitioner Data Bank is not widely disclosed. I'm sure the AMA is looking at how that applies to its own members."
The NPDB is a federal registry that records malpractice lawsuits and disciplinary actions against physicians. Congress created it in 1986 and, in exchange, gave physicians antitrust immunity stemming from their participation in internal peer review procedures. The data bank, though, is not open to the public or the media.
Consumer groups and other special interests want the data bank opened, but the AMA has fought that effort for years.
In fact, at the AMA's December House of Delegates meeting in Dallas, a resolution proposing limits on those malpractice claims payments reported to the NPDB was modified to reaffirm that the AMA supports abolishing the NPDB.
Meanwhile, the AMA has been rolling out with great fanfare its American Medical Accreditation Program. The plan is supposed to create a stamp of approval for quality physicians. It looks at five areas: physicians' credentials, personal qualifications, environment of care, clinical performance and patient-care results.
In essence, the AMA wanted to control physician accreditation before any other public or private organization did.
However, the last two accreditation criteria -- those dealing with physician performances and patient outcomes -- are the most ambitious and complicated. They are still in the planning stages and haven't yet been included in the program, which is being launched in selected states. So, AMAP will be an accreditation program without quality standards.
The whole idea of AMAP, a spokesman explained, "is to raise the bar for physicians." But a key aspect is, it's voluntary. Doctors don't have to apply for AMAP certification unless they want to.
Similarly, if a physician doesn't qualify, that will not be made public. Callers will be told only whether or not a specific physician is AMAP accredited. The public will not see how the doctor scored.