If Nixon Could Go To China...
The following was taken from a piece written by Abigail Trafford, Washington Post, 1/7/95:
"If Nixon could go to China, why can't the Republicans pass a national health plan? Health care reform is still on the public mind and it's not too far-fetched to envisage the GOP trying to pass some health care legislation. Robert J. Blendon, polling expert at the Harvard School of Public Health: 'If the Republicans want the independent voters in 1996, they shouldn't leave health care to the Democrats.' A Republican version of health care reform would hardly resemble the Clinton plan that foundered in the last Congress. But even a plan so lite as rain water could have a major impact on health care -- and on voters."
"The underlying issues that put the debate in the public spotlight remain. According to a post-election Voter News Service survey and a Harvard/Kaiser poll, health care was the most important issue in deciding who to vote for in the U.S. House of Representatives. The message, according to various polls, is that people want action on health care but they don't want the Clinton administration to take the lead and they don't want a mega-plan that involves more government control over services thereby, it is feared, accelerating costs and eroding quality."
"A GOP-lite plan would likely include changes in insurance to make it easier for people with illnesses to get coverage and keep it when they change or lose their jobs. It might expand services for children and uninsured workers and their families."
"But passing any health bill is not going to be easy. The Republican leadership has to decide this spring to push for legislation so that a bill could pass by the end of 1995 or early 1996. It has to get passed before the primaries in Iowa and New Hampshire in '96."
"Surveys show that 70 percent of people support universal access -- but only 30 percent support universal coverage. But even legislation that encourages universal access by establishing public community health centers for the uninsured, for example, is likely to need some financing from the government cupboard."
Reducing Medicare Geographic Inequity
Depending in which of eleven geographic areas a Wisconsin physician practices, the standard Medicare payment is different for the same service. The State Medical Society of Wisconsin (SMSW), with encouragement and support from the Rural Health Development Council, has formally petitioned HCFA to reconsider their original request for Wisconsin to be designated a single Medicare payment area. The following reasons support this action:
In 1991, the Congressional Physician Payment Review Commission recommended that Wisconsin become a single payment locality.
In 1992, the SMSW House of Delegates voted, 117 to 1, in support of a single payment area. In 1993, another resolution was passed in support of this issue.
HCFA has announced its intent to reduce the number of payment localities, nationwide. The SMSW wants to make sure that Wisconsin is reduced to one locality, not several so that equity in Medicare reimbursement is achieved.
Implementation of the Resource Based Relative Value Scale (RBRVS) transition period for physician fees is nearly complete, but the payment disparities between Wisconsin's rural and urban physicians remain due to a continuation of regional geographic payment adjustments.
All Wisconsin provider and consumer groups interested in rural-urban payment equity have been asked to formally support this action with letters to Tom Adams at SMSW and to members of the Congressional delegation. It is important that these letters be received by January 31st.
What Are Anti-Competitive Acts?
The final word is still a year or more into the future as the legal dispute between Blue Cross and Marshfield enters its next phase. Even if the lower court decision is upheld, whether or not a rural area such as northern Wisconsin can or should be encouraged to sustain fully competitive markets is a separate and ultimately more important issue. The whole policy debate yet to happen in Wisconsin around the implementation of our existing Certificate of Public Advantage statute will need to address that question.
Leaving any judgment of the particulars of this lawsuit to the courts, the issues presented in the case will probably effect most of us in rural health for the foreseeable future. Paraphrasing from the complaint filed by Blue Cross, we can begin to develop a sense of several key situations that raise significant legal concerns:
Now Blue Cross Gets To Play Defense
When Rosabeth Moss Kanter wrote the award winning corporate management guide, When Giants Learn To Dance, I don't think she had the current emerging legal battles in mind.
A class-action lawsuit was filed on January 12th against Blue Cross & Blue Shield in St. Croix County Court, one week after they were awarded damages in their antitrust suit against the Marshfield Clinic.
Blue Cross traditional indemnity health insurance plans typically include a benefit that requires the enrollee to pay 20% of charges. This law suit, like others filed with mixed results around the country, claims that the consumer should share in the discounts negotiated by Blue Cross with providers. Currently, any provider discount is applied only against the 80% of charges paid by Blue Cross.
The Internet Comes To RWHC
The Internet's E-Mail capabilities are obvious but there is something of a Catch 22 - until enough of us start using it, it isn't worth using. As it seems that the critical mass of users in Wisconsin rural health is getting close, I've taken the plunge. You can reach me at:
The RWHC office should have its own account shortly, if you have one and we haven't yet corresponded, please send me a message so I can put your address in my file. Thanks.
George Halvorson's Strong Medicine
Roger Wiste, an ex-RWHC board member (and now a rural quasi-consumer advocate from Black River Falls) has been encouraging me to get hold of a copy of Strong Medicine. He was right - it is a "must read" for anyone interested in a clear, direct description about why the future of American medicine will be different from what all of us have known.
Halvorson is president and CEO of HealthPartners in Minnesota and is chair of the Group Health Association of America.
"Our current system does exactly what we pay it to do. We reward providers for volume and complexity and underpay them for efficiency and quality... Our insurers are rewarded for their ability to avoid risk, and so they do... The villains of this book are the incentives we've created for our caregivers and insurers... Any health care reform effort in this country to be successful in achieving both quality and efficiency should include the following:"
UW Policy Program Outreach To State
The UW Health Policy Program recently established by then Dean Larry Marton and David Kindig is taking another step in establishing itself as a statewide resource. The program will now to be known as the Wisconsin Network for Health Policy Research in recognition of its growing network of researchers inside and outside of the University along with individuals interested in data driven health policy.
An initial round of studies is currently being concluded related to (1) Wisconsin's future need for generalist physicians and (2) state policy options re the development of health plan performance indicators.
Assessing Rural Market Driven Reform
RUPRI, the Rural Policy Research Institute, an increasingly well known and respected network of four rural focused land grant universities (Arkansas, Iowa, Missouri and Nebraska) has initiated an assessment of "market-driven reform in health care delivery and finance: impacts on rural health care delivery systems." Most of the Institutes work is not specific to health and my understanding is that they enjoy an excellent reputation in Washington.
As this is a topic of critical interest to rural providers, I am glad to have been invited to be part of an initial focus group they are holding in Washington following the upcoming NRHA Policy Board. Extensive research will follow through the winter and early spring. The resulting paper will be featured during a panel discussion of RUPRI activities at the NRHA May conference in Atlanta.
A Personal WI Wish List For '95
The Wisconsin Office of Rural Health asked their ORH Reporter readers for their '95 Wisconsin focused policy wish list, here's mine:
Cost Containment Commission Discontinued
States have two separate choices re containing health costs - regulate individual providers or regulate the market. We believe that assuring competitive markets is the right policy direction. Wisconsin's healthcare markets are becoming very competitive - providers are working hard to do more, better for less.
We believe that the "protection" to existing rural providers through a cost containment commission is totally illusionary - if one of the giants wants to come to your town, they have the lawyers and dollars to out flank any three commissions. The future for rural communities to retain local services under local control is through private sector regional alliances such as the Cooperative, coupled with strong public antitrust and OCI oversight.As rural hospitals and physicians we are working to develop enough presence in the market to balance the more extreme examples of mega-corporate opportunism as well as to advocate for rural sensitive regulation of the market place, not the individual provider. We believe that the time is right to terminate the Commission.
Achieve Medicare Payment Equity
Through a united state effort, gain federal approval for Wisconsin to become a single payment area for Medicare Part B and federal cooperation in developing a Medicare Part B prohibition against payment discrimination based on locality.
Protect Additional Rural Collaboration
Implement Wisconsin's Certificate of Public Advantage statute to facilitate local and regional rural based provider networks working together to develop balanced, fair relationships with multiple HMOs and tertiary care based systems.
Support Rural Collaboration
Development of a privately funded multi-sector Wisconsin Cooperative Center of Excellence for research, education and demonstration projects relevant to cooperative or collaborative health enterprises.
Unify Primary Care Enhancement
Establishing the Consortium for Primary Care in Wisconsin as the principal forum to enhance statewide collaborative approaches for primary care training, recruitment & retention.
Fully Implement the Rural Medical Center
Complete Wisconsin's statutory and regulatory implementation of the new unified rural provider classification, the Rural Medical Center, and initiate the federal waiver process.
The Most Dangerous Stage Is Respect>
"When we try to bring about change in our societies, we are treated first with indifference, then with ridicule, then with abuse and then with oppression. And finally the greatest challenge is thrown at us: We are treated with respect. This is the most dangerous stage." A. T. Ariyaratne
While I am certainly not equating rural advocacy or rural networking to Ariyaratne's paraphrasing of Mahatma Gandhi, I agree with Peter Senge's use of this quote in The Fifth Discipline Fieldbook as a reminder that "it is easier to begin initiatives than to bring enduring change to fruition."
The Fifth Discipline Fieldbook is like it sounds, a practical and welcome sequel, guide to implementing the theory described in one of the decade's major modern management books (the original, often referred to but less often actually read - don't ask). "The Fieldbook is brimming over with collective wisdom about how to bring the five learning disciplines to life in your organization - Kathryn Johnson, President and CEO, The Healthcare Forum."
The "learning disciplines" constitute a lifelong program of management study and practice re: