California's HMOs and physicians appear to have a common goal: reducing the tensions in healthcare. Whether they can find common ground on how to get there is an open question.
"I see no higher priorities than to ease tensions," says Walter Zelman, CEO of the California Association of Health Plans. "I think we remain very optimistic that we can move beyond the bashing of managed care, that we can search for solutions."
But he also says "the hospital association, and even more so the medical association, may not have the same cooperative agenda in all circumstances. They have interests, at least it seems to us, that undermine managed care or make it something it isn't."
California's low capitation rates and healthcare costs--among the lowest in the nation--keep millions of people insured and are something of which to be proud, Zelman says. He also says capitation rates haven't decreased over the past several years as some physicians have claimed.
"If our health plans got paid what they get paid in Massachusetts, we wouldn't know what to do with that kind of money . . . We'd be bringing people to the clinic in limousines."
In an interview, Jack Lewin, M.D., CEO of the California Medical Association, says he agrees improving relations is the only way for California's healthcare system to survive. But, he says, there aren't many olive branches being extended.
"(Zelman's) comments about capitation rates and contributions of health plans to
the viability of this environment qualify him as an emerging stand-up comedian," he says. "He is a great advocate for HMOs but certainly not for patients or providers."
Both agree money is the core of the debate and that the public needs to make some difficult decisions. And they agree there needs to be a way to resolve billing and other disputes without having to go through the courts and the California Legislature.
"If things go as they are, unchecked, Congress and the legislatures will create those mechanisms," Lewin says. "Government will be the mediator of the dispute."
Health plans must make sure the medical groups with which they contract are solvent and can take care of enrollees, Zelman says.
"Managed care has to serve two masters. We have to serve the user of the service and the payer of the service," he says. "It's a very, very difficult situation."
No more difficult than the situations physicians face, Lewin says.
"I think there are two essential global issues in California that need to be resolved between HMOs and physicians," he says. "The first is we need a means of preventing insolvencies and promoting adequate patient care by working together on actuarial soundness or what fair reimbursement will be in the complex environment of managed care."
Zelman says there are three options for the current financial squeeze: increase the premiums, reduce the cost of services and place some restrictions on where people can get care through such mechanisms as gatekeepers and network hospitals.
"That doesn't mean rationing. That doesn't mean we won't get the necessary medical services. It may mean the use of a gatekeeper or use of generics and higher co-payments."