The American Hospital Association's opposition to patient-protection legislation doesn't put the group at odds with just physicians and other providers. It also pits them against some of their hospital brethren.
As the AHA pursues a private-sector quality-improvement framework, groups representing public and children's hospitals are supporting, if not specific bills, the concept of federal patient-protection legislation.
That split in the hospital community has manifested itself in the withering of a coalition of hospital and physician groups, which calls itself the Coalition for Accountable Managed Care (See chart).
The coalition last year published a document titled Principles for Accountable Managed Care, which detailed ways for plans and providers to guarantee access, quality and informed choices (May 12, 1997, p. 30).
The AHA is the only hospital group that signed the principles that now opposes federal standards. The AHA objects to federal legislation because it fears it could result in burdensome regulation.
The group's opposition has caused some critics to question whether the AHA's loyalties lie with providers or insurers (May 11, p. 2).
Meanwhile, the National Association of Public Hospitals and Health Systems and the National Association of Children's Hospitals are backing federal standards.
The Catholic Health Association, the Association of American Medical Colleges and the American Protestant Health Alliance-which signed on under the name of a precursor organization, InterHealth-have not taken a stand on the issue, but leaders in some of those organizations express sympathy with advocates for managed-care regulation.
Numerous bills regulating managed care have been introduced on Capitol Hill.
They range from measures aimed at guaranteeing mastectomy patients an adequate hospital stay to a comprehensive measure authored by Rep. Charlie Norwood (R-Ga.) that would dictate coverage of emergency and specialty care, as well as expand legal remedies when a health plan improperly denies or delays coverage (See related stories, p. 8).
Because of the differences, the coalition now is "in remission" but has not disbanded, said CHA lobbyist Jack Bresch.
The coalition was formed at the urging of first lady Hillary Rodham Clinton in the wake of the defeat of President Clinton's healthcare reform bill in 1994.
Its initial members, which did not include the AHA or the physician groups, had been leaders in the efforts to expand coverage of the uninsured.
The coalition represents thousands of hospitals and physicians that are members of its constituent organizations. It is a loose affiliation that is staffed by the employees of its member organizations.
Its first product was a document on ensuring that healthcare competition benefits patients first, not institutions or investors, and leads to expanded access.
"We have gone as far as we can go," Bresch said of the managed-care accountability document. "We all knew that once we got beyond principles, the task would be harder."
The document, released last year, said plans should:
Not discriminate in enrollment.
Offer a comprehensive benefit package with access to a wide range of providers without regard to pre-existing medical conditions.
Ensure an adequate number and mix of providers with appropriate training and certification.
Structure financial incentives to promote quality care.
Give providers autonomy to make appropriate clinical decisions.
Support medical education and research.
Provide enrollees with clear and understandable information about premiums, financial incentives, benefits and providers.
Involve the community in governance.
The document did not, however, say how the principles should be implemented. The coalition said it wanted to "provide guidelines for public and private policymakers, including federal-state legislative and regulatory bodies."
It came long before Congress began serious work on quality and patient-protection legislation or the White House's advisory commission on healthcare quality had published its own "Patient Bill of Rights."
"I think we provided a really meaningful direction to start the debate," said Christine Burch, executive director of the NAPH.
It was the next step in the discussion, how to transform the principles into draft legislation, that bogged the group down.
"When they said, `Let's see what legislation would look like,' we said, `Wait a minute,' " said Richard Wade, the AHA's senior vice president for communications. "There were others in the room who had no appetite for legislation."
But some of the members privately criticized the AHA because it was the last group to sign the principles and then was the only organization that objected to pushing for legislation, effectively throttling the coalition's work.
"I just don't see how you can reach agreement" on federal standards when the AHA dissents, said a representative of one of the coalition members who asked not to be identified.
Wade, however, said such complaints are off base because the principles do not prescribe a regulatory solution.
"The federal government isn't mentioned in there once," he said.
Bresch said the AHA did not obstruct the work of the coalition. But he said he believes if the rest of the group decides to back federal standards, any opponents would "self-select out."
The CHA's own position is up in the air. William Cox, its executive vice president, said at the association's annual meeting last week that it is studying current legislation and expects to come out with a position sometime before the end of the month.
The NACH, meanwhile, is supporting federal standards that will guarantee some access to appropriate pediatric care, said Peters Willson, the group's vice president for public policy.
He said without those access standards, plans do not have a marketplace incentive to provide adequate pediatric coverage, because children represent only 15% of healthcare expenditures.
"There's not a whole lot of market demand to focus on performance for children," Willson said.