Clash of the Titans: Doctors, HMOs, Insurers On Health Care

July 03, 1994|By JOHN FAIRHALL

While health reform gets the headlines, another health battle with important implications for consumers rages in Washington, attracting little of the public attention it deserves.

This fight is over control of America's health care system. Who will run it? Who will decide what care patients receive? One special-interest titan, the American Medical Association, is pitted against two others, insurance companies and health maintenance organizations, in one of the fiercest lobbying contests on Capitol Hill.

The AMA seeks legislation that it says would give patients and doctors more control over the care provided by HMOs and insurance plans. But HMOs and insurers charge that the AMA really wants to enrich doctors.

There's no love lost between these old foes.

To hear the AMA talk, HMOs and insurance companies are conspiring to rig the health care system against patients and doctors.

"Would you rather trust your life to an MD or an MBA?" declares one highly provocative advertisement run by the AMA, the largest doctors' group, to stir up public support.

The ad warns that without action, "government and insurance company administrators could end up determining which types of treatment are appropriate for patients like you."

Bristling at the ads, which play to public distrust of their business, insurance companies and HMOs have retaliated with a media campaign intended to inflame suspicions about greedy doctors trying to protect their own incomes.

"There are many groups out there with a vested interest in maintaining the failed elements of the old health care system who want to undermine HMOs," asserts Karen Ignagni, president of Group Health Association of America, a major HMO trade group. GHAA recently trooped HMO-employed doctors to Capitol Hill to pierce the perception that the AMA, which has 300,000 members, represents the entire medical profession.

This rancorous conflict arises from the AMA's attempts to prod Congress into intervening in a revolution sweeping the private health care marketplace.

The system of health insurance most Americans grew up with, which gives patients and doctors pre-eminent authority to make decisions about medical care, is being replaced by HMOs and insurance programs.

The AMA angrily complains that doctors' decisions are often second-guessed by company bureaucrats more interested in saving money than preserving good health. Specialists protest because HMO guidelines govern when patients may see them.

Doctors also fret over their incomes. Traditional insurance plans, paying physicians for each service, have made many doctors wealthy -- their average income is $170,000. But HMOs insist on paying a flat fee, often in the range of $10 a month per patient, putting doctors at risk. No matter how often a patient comes in for treatment, or for how long, the physician is paid the same monthly amount.

A greater financial threat to many doctors is the power HMOs have to take away their patients. HMOs contract with only a certain number of physicians, requiring patients to choose from that list; other doctors are left out in the cold.

AMA concerns have been mounting for years as HMOs, and other health insurance programs that manage care, have grown. Barely half of all Americans remain in traditional plans that give patients and doctors the broadest freedom; more than 45 million people are in HMOs, including roughly 25 percent of Marylanders.

But health reform triggered an alarm at the AMA. While the group espouses reforms that would guarantee health care for all Americans, it recognized that reform plans under consideration in Congress would accelerate the trend toward HMOs and managed care.

The AMA dispatched lobbyists to Capitol Hill to push two kinds of legislation: the "Patient Protection Act" and bills that would give antitrust protection to doctors in a community who want to organize to compete with HMOs and insurers.

According to the AMA, the Patient Protection Act protects physicians against unjust firing by HMOs, requires full disclosure of the means by which HMOs pay and monitor doctors, and guarantees consumers the right to see a doctor outside their HMO.

But the HMO group terms that description "misleading," arguing that the bill is designed to protect the economic interests of doctors at the expense of patients and employers who pay health care premiums. It would undercut HMOs' ability to control whom they employ, undermining efforts to assure quality and hold down costs, the group contends.

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