The State of Managed Care in the Union | to pdf >>
by Donald W. Parsons, MD

On January 27, 1998, President Clinton, like a dog climbing out of a lake, shook off a brewing White House scandal and delivered a much-favored oration on the State of the Union. His popularity shot up during the next several days, an outcome presaged by the 104 interruptions of his speech by an enthusiastic audience. The loudest cheers followed his statement about managed care plans: "These plans save money, and they can improve care. But medical decisions ought to be made by medical doctors, not insurance company accountants." Those who have seen the Jack Nicholson/Helen Hunt movie As Good as It Gets will remember the spontaneous audience response to similarly disparaging remarks about managed care. What does this mean for us?

In urging that Congress enact a "Consumer Bill of Rights," the President followed the recommendation of his Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Phil Nudelman (President of Kaiser/Group Health) and his fellow commissioners delivered to President Clinton in November several recommendations that will be the basis of the President's legislative agenda during the 1998 session. Not surprisingly, they read as if from the September 1997 Kaiser Permanente, Group Health, HIP, AARP, Families USA script of Principles on Consumer Protection. And they sound like our Permanente Practice.

First, Doctors make medical decisions. How novel! After 53 years, we've caught their attention. Sadly, in much of the world of "managed care," physician decision-making is second-guessed by condescending bureaucrats. The negative response to this practice affirms our organization's very different approach.

Second, "You have the right to know all your medical options." Three years ago, all Permanente Medical Groups clarified to all our group and contract physicians that we expect full and open communication between physicians and their patients. This policy has existed since day one of the Program, but only recently because of a suspicion that "gag" policies are pervasive in all HMOs, has it been necessary to affirmatively state our values. Again, right on the money!

Third, "You have the right to choose the doctor you want for the care you need." In the context of managed care, the President did not intend that all physicians in the universe are available but that all within the boundaries of the health plan/medical group should be available. Certainly we ascribe to that principle for patient access to qualified primary care physicians, and many specialties welcome direct access for specific problems.

Fourth, "You have the right to emergency room care, wherever and whenever you need it." Last year, we worked with the American College of Emergency Physicians to craft the Cardin Bill, enunciating the prudent lay person definition of what constitutes an emergency and the importance of coordination of care after stabilization in the ER. Much of this language was adopted and was applied to Medicare and Medicaid in the Balanced Budget Act of 1997. What remains is to apply the same principles to commercially insured persons. We're eager to see this happen.

Fifth, "You have the right to keep your medical records confidential." This is a basic premise, that we have honored for the life of our Program. New legislation is likely this session, pushed by eager privacy advocates who would have patients carry their own records with them to assure that there is never any leak. This practice would present challenges. Fortunately, the Administration's remarks to Congress last year do not reflect this extreme approach. We will try to find a reasonable compromise.

Finally, "Traditional care or managed careevery American deserves quality care." Bravo, Mr. President! We are committed to quality of care in every part of our Program. Sadly, traditional care has fallen behind managed care in demonstrating quality through such tools as National Committee for Quality Assurance (NCQA) accreditation and Health Plan Employer Data and Information Sheet (HEDIS) reporting. Just possibly, the President envisions holding fee-for-service accountable for quality. We support that!

Mention by the President of the need to find a way to help uninsured individuals between the ages of 55 and 65 yearsand who are thus not yet eligible for Medicareis laudable. The details of his proposal are not available, and Kaiser Permanente has taken no position yet on this notion. But we certainly are behind the idea of expanding health insurance coverage.

Wrapping up his remarks on health, the President focused on our need to help parents protect their children from "the gravest health threat that they face: an epidemic of teen smoking, spread by multimillion-dollar marketing campaigns." In calling for dramatic hikes in the price of cigarettes over the next ten years and restrictions on tobacco marketing, the President is squarely aligning his administration with public health advocates. We espouse the same principles.

In summary, President Clinton captured much of our values and Permanente Practice principles in his agenda. This Congressional session will be a short, pre-election one, ending in early October, and there may be distractions along the way. It is reassuring that our messages calling for legally enforceable national standards for consumer protection are now embraced by the President and by his administration.

Washington, D.C. Update On Health Care
By Tom Janisse, MD

Clinicians
I have just returned from the American Association of Health Plans, 1998 Annual Legislative Conference in Washington, D.C. As NWP's liaison to HP, government relations is one of my areas of responsibility.

Washington analysts, health care experts and senators see through complexity in health care issues and find common ground. Through simple images and stories they communicate to individuals and groups the personal and professional effect of these issues. Consumers have concerns about managed care based on confusion and a feeling that quality and choice was taken away from them to cut costs for profit. People may not recognize the advantages of Kaiser Permanente unless we clarify our value and tell a better story. To share what I learned I would like to relate three stories I heard, and offer some suggestions.

TV News
Anne Richards, former Texas governor told a story about crime perception that has distinct parallel for us in HMOs. She said, "When I became governor I was determined to reduce crime, and did that every year I was in office. But do you think people felt any safer? No. Because every night on the news they saw a crime on TV. And if it wasn't in Dallas, then it was in Houston, and if not there, then in Thailand. The media reported what was sensational and not what was representative. So every person watching the news saw a crime that day and Texas didn't seem one bit safer. Your circumstance in health care is the same. Media-related anecdote creates the perception that there are big problems with HMOs, when this is not the reality. You must create positive perceptions of your industry to offset this."

"As Good As It Gets"
Everyone is citing this recent movie as an example of the public perception of the problems with HMOs. One scene in the movie universally drew groans from the audience. The scene involves a young single mother of an asthmatic child who is a waitress in a small diner. She takes a shot at the HMO care her child is receiving because she's often rushing him to the ER with an asthma attack.

The good part about why I am relating this is that Abigail Trafford of The Washington Post wrote a very positive article about HMOs entitled, "Is Movie Slap at HMOs A Cheap Shot?" In it she says, "Audiences love the scene. Who has anything good to say about managed care these days? The irony is that some HMOs have been pioneers in putting together comprehensive asthma programs that help children control their symptoms and reduce the need for emergency hospitalization. In theory, HMOs with an emphasis on prevention may be the kind of health plan most likely to offer a range of medical and social services that can effectively 'manage' a chronic illness. Kaiser Permanente, a well-established network of HMOs, is one example. In New York they launched a special program that focused on early diagnosis, proper monitoring, aggressive treatment of symptoms, and home care. The Kaiser plan distributed devices called peak flow meters that enabled parents to test their child's breathing, recognize a problem before it occurs and administer treatment."

The second point she made addressed the improved access to health care for working people through HMOs. "This is how John M. Eisenberg, head of the federal Agency for Health Care Policy and Research views the scene. 'Wow! A single mother who works in a diner has health insurance. That's fabulous.' According to an agency survey, only 56% of 4.2 million unmarried women who work in establishments with fewer than 10 workers have some form of employment-related insurance.'"

What Can I Do To Enhance Public Perception?
When you as a clinician interact with a person seeking your medical services, you have a powerful opportunity to positively influence public perception. If that person has a good encounter, when they sit at home watching the news and see a bad HMO story they will have a counterpoint "real life" experience to offset this anecdotal TV incidentprobably occurring in some other state.

Secondarily, you can actively create a favorable public image of KP by sounding your voice through print or appearing on TV, or better, through a speaking appearance at a community event or helping out at a local function. Doctors and health care providers are strong forces for affecting public perception.

Our Oregon Senators
When I visited the Washington offices of Senators Ron Wyden and Gordon Smith, their personal policy staff both remarked that they don't hear any problems with KP or Oregon HMOs from their constituents. That is a good sign that people are satisfied. This is supported by recent national studies that show that 76% of people surveyed are very satisfied with their HMO vs. 23% of people satisfied with their fee for service insurance plan.

I had a personal experience observing the mastery of a legislator reading actual public sentiment rather than perception. When I attended the hearings last year of the CRNA Bill, one woman senator cut through the rhetoric. After listening to many anesthesiologists testify as to how their presence in the O.R. was the standard for anesthesia care, and that every Oregonian deserved that care, and quality was compromised if they weren't present, a momentary pause occurred. The senator queried the group, "You know doctor, I'm confused about something, and I'm sure you can help me out. I get calls all the time about the pot holes in the street. It seems like not a day goes by that I don't get a call about a pot hole. But you know what? I can't remember getting one call about a CRNA quality problem. And, given what you all say, I just can't figure that out. Can you help me on this?"

Well, there was no forthcoming answer. Public expression through calls and letters is an important measure of public reality, and that reality at the state and federal level is one of people satisfied with managed care and KP. It is equally important to remember that many government employees and officials are KP members, and if they leave your office with a positive encounter you have altered public perception in a large way. You couldn't have done better speaking to them at a legislative hearing.

Keep Doing A Good Job
It has become clearer to me that what each of us do to communicate and relate better with the people we see in primary practice or specialty consultation has a large and important impact on people's perception of KP. This will help to see us through this anti-managed care backlash, as we attend to creating superior medical care for our members, gradually outdistancing other HMOs and HPs and distinguishing ourselves.

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