New Referee on Health Care

In tackling managed care, Congress will try to keep quality high and costs from rising.

Washington is gearing up for a battle royal next year over how much the federal government should regulate "managed care" - health-maintenance organizations and their increasingly popular alternative, preferred-provider organizations.

Congress already has before it dozens of bills to increase federal regulation of managed care. President Clinton entered the fray last week with his proposal for a patient "bill of rights."

HMOs and PPOs have changed the face of health care in America by corralling runaway medical costs. But they've done so by limiting how much and what kind of care patients can receive. This has opened managed-care systems to sharp public criticism.

Doctors and others say it interferes with treatment decisions. Patients say they have been denied what they believe was crucial treatment when insurance providers refused to pay.

Now Congress is taking on the role of referee - trying to ensure quality care while keeping costs from rising.

The plans for achieving this tough balance are legion.

The guarantees in Mr. Clinton's "bill of rights" include the right to accurate information about health plans and facilities; "sufficient" choice of providers; paid emergency-room visits; confidentiality of records; and the ability to appeal treatment denials to an outside board.

Among the most comprehensive congressional proposals is a bill sponsored by Sen. Alfonse D'Amato (R) of New York and Rep. Charlie Norwood (R) of Georgia. That measure would require paid emergency care, 24-hour access to emergency care, and an appeal process.

Another bill, sponsored by Sen. Edward Kennedy (D) of Massachusetts and Rep. John Dingell (D) of Michigan, contains similar provisions, but would also allow a woman to designate an obstetrician/gynecologist as her primary caregiver and require plans to refer patients to a specialist when necessary. Both bills would amend federal law to allow individuals to sue health plans for medical malpractice under state laws.

The proposals are the latest in a series of moves by the White House and its allies on Capitol Hill to achieve at least part of what the president failed to get in his all-encompassing 1994 proposal to reform health care.

IN the past two years, lawmakers have passed a flurry of measures to try to protect consumers or extend coverage to more of the 41 million Americans without it. The Hatch-Kennedy bill, part of this year's budget deal, provides the states money to extend coverage to low-income children. And the Kassebaum-Kennedy measure of 1996 allows some workers to take their insurance with them when they change jobs.

"While people may not have wanted to bite the whole apple at once in 1994, almost the whole populace wants to keep nibbling away at the apple until we actually have solved the problem of cost, accessibility, and quality for all responsible American citizens," Clinton said last week.

But conservative opposition to further measures is building. House majority leader Dick Armey (R) of Texas recently sent his troops a tough memo as a preemptive strike. "If enacted, [Clinton's proposals] will drive up prices and liability costs, force employers to drop or reduce coverage, swell the ranks of the uninsured, and increase the pressure for a government-run health system, even as it creates the regulatory apparatus needed to operate such a system," Representative Armey wrote.

Insurance and employer groups also view the measures with unease. "We would be very concerned about micromanagement ... about any activity that limited the private sector's ability to problem-solve in the way it has been doing [recently]," says Susan Pisano, a spokeswoman for the American Association of Health Plans, an industry group.

In an effort to evaluate the many proposals, Sens. John Chafee (R) of Rhode Island and Joseph Lieberman (D) of Connecticut Monday announced creation of a House-Senate task force on health-care quality.

"We should ensure that consumers can choose their own path - but at the same time, we need to ensure that they aren't stranded at the trailhead without a map," Senator Lieberman says.

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