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It's not taking place in the White House or Congress. The show to watch is the boisterous, free-market affair, precipitated by employers fed up with rising medical costs, and carried on by insurers and HMOs scrapping for turf.
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"Outcomes data are meaningless or misleading unless they are adjusted for severity of illness, presence of comorbidities, documentation of advance directives, and other factors not under the control of providers," observes Ohio State University Professor Timothy Jost, JD. Health care analysts also contend that the time that is required to analyze, complete, and report data can lessen the value of those data. Currently, health care report cards often require several years to produce. Hence, the data that are reported may not accurately reflect a health plan's or other provider's current performance, which can be affected by changes implemented since the data were collected. Also, some experts question the value and wisdom of giving report cards to consumers, who may not understand what the reports are measuring. As UHC official Sheila Leatherman summarizes: "There is no agreement about who should receive the data, in what format, and with what kinds of interpretative materials." "Physicians and others who utilize health care report cards need to be aware of their limitations," summarizes Don Nielsen, MD, associate medical director and quality consultant with Kaiser Permanente. However, the burgeoning efforts at national, state, and community levels to develop report cards should not be ignored, he says. Dr. Nielsen recommends that surgeons and other physicians work with health plans and other entities that are developing report cards to identify limitations in health care measures and data systems and to create better measures of provider performance.
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The American Medical Association, as presented on the opposing page, wants to protect patients from managed care's profit-oriented approach. That view is disingenuous, say insurance executives, who argue an opposing view on this page.
This final rule replaces the current method of per diem billings to one based on diagnostic related groups, expands the single outpatient billing category to as many as sixty, and expands the billing for outpatient services to include land ambulance service, air ambulance service and hyperbaric services. This final rule improves billing methods for both inpatient and outpatient care. This expansion creates a greater level of specificity which more accurately reflects the cost of the care provided. In addition, this final rule identifies additional outpatient services for which recovery of costs will be sought.
The interest groups that helped defeat health care reform aren't uncorking the champagne yet. Some fear a new push for regulation and cost cutting in Washington and in state capitals. And some want to salvage pieces of the President's reform plan that would have benefited them.
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From its earliest days, healthcare in the United States has been controlled by providers, that is, by physicians and by hospitals (which, in turn, were also usually controlled by physicians). But this situation is changing. In the 1920s and 1930s, providers created health insurance companies like Blue Cross and Blue Shield to help patients pay for healthcare--to pay, in other words, for those services offered by providers. After World War II, the Hill-Burton program covered the nation with new hospitals. In the 1960s, Medicare and Medicaid eased the healthcare burden of older Americans--and also recapitalized hospitals. Thus providers called the shots in the creation of both the delivery and the payment systems. But in the 1970s, payers began to become more powerful. Now, in the 1990s, they have joined employers in acting to contain rapidly escalating healthcare costs. But even those long disturbed by the arrogance of some healthcare providers are now asking themselves: Is this really what we wanted? Payers are governed by the market; they may well seek, not the best, but the cheapest healthcare available. This is not in the interest of either patients or physicians. A middle ground--a new power alignment--will have to be worked out by patients, physicians, payers, and government.
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