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Fam Pract Manag. 1998;5(1):14-17

Docs organize to fight ‘profit-driven’ care

Last month, Massachusetts physicians weary of what they call “profit-driven” health care gathered to re-enact the Boston Tea Party. The object of their dumping was hardly tea, though. Instead, the group heaved symbols of for-profit health care, such as financial reports of large health care systems, into the harbor.
The event was staged by the Ad Hoc Committee to Defend Health Care, a newly formed group of Massachusetts physicians and other health professionals who hope to create an organized voice of protest against profit-driven health care companies. As an encore to its Dec. 2 tea party, the group ran a “Call to Action” petition with over 2,300 signatures in the Dec. 3 Journal of the American Medical Association. The petition attacked for-profit health centers for treating patients as profit centers and said that, in for-profit health care, “Listening, learning and caring give way to deal-making, managing and marketing.”
The group is calling for a moratorium on for-profit takeovers; it plans to hold discussions on the current state of health care in the United States and is asking physicians and other health professionals nationwide to endorse the petition. While the JAMA petition focused primarily on the group's opposition to for-profit entities, committee organizers have said they oppose any health care system that emphasizes profits over patient care.
The authors of the petition and the group's organizers are Drs. Jerry Avorn, Susan Bennett, David U. Himmelstein, Bernard Lown and Steffie Woolhandler, all associated with Harvard Medical School.

Quality of care varies widely among health plans

The first annual State of Managed Care Quality report from the National Committee for Quality Assurance (NCQA) shows surprisingly wide variation in how health plans care for their members. The report documents the performance of 329 health plans in areas such as childhood immunizations, smoking cessation and use of beta blockers in patients who have had heart attacks. Its findings show not only how well individual health plans are doing but what level of performance plans should be striving for.
The report states, for example, that in New England 81 percent of children under the age of two are immunized on time, compared to 59 percent in the Mountain region. Also, within the Mid-Atlantic region, mammography screening rates ranged from 30 percent to 80 percent.
Cary Sennett, MD, PhD, NCQA vice president, notes that while some regional variations are to be expected, such large variations, especially within regions, suggest that “not all health plans are living up to their potential.”
NCQA hopes that regular reporting of performance data will push lower-performing plans to adopt the best practices of higher performers, thereby improving the quality of care overall.

Quote. Endquote.

“What people don't realize is that obtaining health-insurance benefits is an adversarial process.”
Joseph Romano, a liability lawyer in Pennsylvania, who has made a new career of suing health insurance companies on behalf of patients whose claims are denied.

Abortion issue stalls surgeon general vote

The long wait for a new surgeon general is not over yet. Expectations of swift confirmation of President Clinton's nominee, family physician David Satcher, MD, director of the Centers for Disease Control and Prevention, were dashed just before Congress' year-end break when Senate Majority Leader Trent Lott, R-Miss., put off a vote on the nomination until sometime during the second session, scheduled to begin later this month. The delay seems an almost certain signal that the decision to confirm Satcher will be debated on the Senate floor.
Satcher has received the endorsement of numerous professional organizations, including the AMA and the AAFP. His appearance before an admiring Senate Committee on Labor and Human Resources for a confirmation hearing on Oct. 8 lasted barely an hour and gave little hint of trouble ahead. The committee chairman, Republican Sen. James Jeffords of Vermont, voiced approval of the nominee and pledged support for quick Senate action.
The committee vote two weeks later, though, was split: 12 in favor, five against. Two days later, Sen. John Ashcroft, R-Mo., announced that he would oppose Satcher's nomination, citing as a major stumbling block the ever-divisive issue of late-term abortion. In response to private congressional inquiries, Satcher had indicated he was opposed to the practice but said he would not support a ban that did not include exceptions for cases where the mother's life or health was threatened. “This is essentially President Clinton's position,” said a spokesperson for the Department of Health and Human Services. A bill outlawing late-term abortions has been vetoed by the president and is currently in congressiona limbo while supporters try to gather the extra votes needed to bypass his action.
In his statement, Ashcroft charged the nominee with choosing the president over the AMA and associating himself with “a practice that is callous and cruel.” Satcher has not responded publicly, but is reportedly trying to assure congressional leaders that late-term abortion is not part of the public health agenda he intends to pursue if confirmed, an initiative clearly intended to distance his nomination from a heated political issue that threatens to dislodge it.

AMA criticizes unfair contracts, offers model

The AMA has taken two steps forward in helping physicians battle with managed care plans. In a recent 11-page letter to Aetna U.S. Healthcare, the AMA's new Division of Representation voiced concern over physician contracts that allegedly give the HMO unilateral authority to determine medical necessity and to change terms of the contract without physician approval or notice. The AMA also charges that the contracts contain gag clauses, require physicians to release patients' information without their consent and allow Aetna U.S. Healthcare to deny retroactively its coverage for services.
Aetna U.S. Healthcare officials have denied that the contracts are unfair to physicians or patients and say the company conducts ongoing reviews of their contracts with physicians, making changes as necessary.
As a reaction to such contract battles, the AMA unveiled a model managed care contract at its December Interim Meeting of the House of Delegates in Dallas. This model contract, according to Mark Rust, JD, who drafted the document, is intended to be fair to physicians and managed care plans alike and applicable to most practice arrangements. The contract seeks to avoid ambiguity in outlining what services physicians will provide and how they will be paid for those services. The contract also offers definitions of emergency conditions and medical necessity to avoid individual interpretations.


Terms family physicians should know

Reverse capitation: A form of physician reimbursement in which primary care physicians are paid fee for service while other specialists receive capitated payment.
OWA: “Other weird arrangement”; a semi-humorous acronym referring to any new and peculiar method for providing health care, usually conjured up by a managed care plan.

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Copyright © 1998 by the American Academy of Family Physicians.

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