Some surprises are pleasant even when they mean you were dead wrong.
Against all odds the committee charged with drafting financial solvency standards for provider-sponsored organizations finished its work and came to a consensus proposal earlier this month.
I have to admit, especially since I wrote it in my last column, I thought the odds of committee members' agreeing on anything about equaled the odds of Kenneth Starr and President Clinton's double-dating.
On one side were providers: the American Hospital Association, the American Medical Association, the American Medical Group Association and the Federation of American Health Systems. Their motto? "Cut out the middleman and give us all the money upfront."
On the other side were insurers and managed-care groups, including the American Association of Health Plans, the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. Their motto: "Bring us your tired, your poor, your huddled masses yearning to see a specialist." Oops, never mind; wrong gatekeeper, wrong motto. Their real motto: "We can't wait until PSOs have to negotiate lower reimbursement rates with themselves."
The committee meetings were long, boring, marked by a "two steps forward, one step back" rhythm. There were scintillating discussions of the "generally accepted accounting treatment" for intangible assets and stirring presentations from the American Academy of Actuaries. (Their motto: "We became actuaries because we were good in math but didn't have the personality to become accountants.")
Both sides got ridiculous at one point or another. My favorite was the physician groups' explanation of how a PSO fundamentally differs from an HMO and therefore merits lower solvency requirements. If an HMO is in financial trouble, the docs said, it just goes under. But when a PSO bleeds red ink, physicians give free care. Oh boy, if you think doctors complain a lot about reimbursement rates now, wait until they are working for free.
As in every good drama, there were interesting subplots. The insurers and the managed-care plans were not their usual cohesive selves. That's probably because the AAHP has some members that are interested in becoming PSOs, but the Blues and HIAA do not.
The provider camp had intrigue, too. Hospitals, knowing they have sufficient capital to meet fairly strict solvency standards, quickly agreed to a high level of upfront cash. That angered physician groups, which wanted a lower cash requirement and more value for "sweat equity."
But in the end, the groups reached consensus. Much of the credit goes to the HCFA representatives on the panel, Kathy Buto and Maureen Miller, who did an amazing job of separating both sides' self-serving proposals from genuine efforts toward a workable compromise. Recognition also should be awarded to Judy Ballard, who oversaw the negotiations for HCFA. Part kindergarten teacher, part policy wonk, part mob psychologist, Ballard kept the talks going even when it seemed the shape of the table alone was going to be too tough a problem to overcome.
It's hard to say whether the groups signed on to the final agreement because they really thought it was a good compromise or because they didn't want to aggravate HCFA, which must use the panel's framework as a basis for regulations. I suspect a little of both.
HCFA must issue solvency regulations by April 1. In June it will release what it calls a "mega reg," which will include everything else a PSO needs to know to be a PSO.
Then comes the interesting part.
How many PSOs will seek a license? I suspect there are many, many more PSO consultants and advisers out there than would-be PSOs.
I hope I will be pleasantly surprised -- and dead wrong -- again.
Coming as no surprise last week was House Speaker Newt Gingrich's (R-Ga.) admission that House Republican leaders probably can't stop anti-managed-care legislation from passing this year. The coalition of business and managed-care groups that's fighting such legislation has assumed all along something would pass in the House. Its strategy is containment, keeping the bill as small and mandate-free as possible.
In the Senate, the strategy is different. Opponents must keep a bill from coming to the Senate floor at all costs. Because of the loose Senate rules of debate (amendments need not be germane or even make sense), the GOP leadership almost certainly would lose control of any managed-care bill. Such a bill could become a Christmas tree for every arm-and-leg mandate imaginable. The question is, can the Senate leadership control its own members? The most likely renegade is Sen. Alfonse D'Amato (R-N.Y.), who has an anti-managed-care bill of his own and is up for re-election. That makes him a very dangerous wild card.
Thumbs up: To the members of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, which held its final meeting last week. Like all of you, I can't wait for the final report.
Thumbs down: To the AMA for not taking a leadership position on managed-care regulation. There are problems with managed care, and the AMA's members are in a position to do something. They need to lay down a clearly defined set of priorities absent any of the poison pill provisions that would kill the measure completely (for example, allowing health plans to be sued for malpractice). Then the AMA needs to use its considerable influence on Capitol Hill to enact a responsible, conservative package of reforms that benefits patients and physicians alike.