By Neil Bohnert, FACHE, CAE

Vice president of the Hospital Council of Western Pennsylvania.

 

 

Published July 1997

 

 

 

• React to this article in the Discussion Forum.

Under current circumstances it is much more manageable to "fix" a "problem" that has generated public outcry than to address this larger matter. Focusing on the minutia rather than on the greater questions, however, only serves to further complicate without offering any real solutions or positive change. Consider these developments:

In the wake of intense media scrutiny, Congress mandated 48-hour hospital maternity stays in 1996 and in 1997 bills have been introduced that would set mastectomy stays.

Removal of "gag clauses" in managed care contracts that prevent physicians from discussing treatment options with patients is again a top media and legislative priority in 1997.

Several state legislatures are considering mandating that health insurers pay for minimum hospital stays for mastectomies. Articles in the Wall Street Journal and other major news outlets precipitated these activities.

The Mikulski-Hutchinson-Cardin proposal seeks a federal remedy preventing managed care organizations from denying patient services administered in emergency departments in serious or life-threatening situations.

What do these "abuse of the month" activities tell us?

One, public confidence is seriously eroded. There is widespread belief that no one in health care is concerned for the patient's best interest. Two, managed care is in peril of becoming regulated to the point of discouraging real innovation in health care delivery. Three, legislators—federal and state—are quick to step into the breech.

And all the while the struggle over who controls clinical decision-making continues to deepen.

We fail to see that in the ever volatile—even hostile—managed care environment, the benefits of drastically cutting price exact an enormous price in themselves in terms of patient satisfaction, public trust and clinical outcomes. There is some movement at both the federal and state levels to sponsor global legislation to increase oversight of managed care plans. The progress of this legislation, however, depends on yet another unresolved question: Is it a federal responsibility or a state government responsibility to regulate health plans? In addition, we must ask, To what extent should government be involved?

In the meantime, the American Medical Association (AMA) House of Delegates recently passed a resolution identifying 16 clinical decisions that should be left to physicians. These include: determining what diagnostic tests are appropriate; when non-emergency hospitalization is indicated; when hospitalization from the emergency department is indicated; hospital length of stay; when and what surgery is indicated; recommendations to patients of other treatment options, including non-covered care; and termination of a physician-patient relationship.

However, some health care industry observers indicate that there will be strong resistance to giving physicians such broad discretion over medical treatment decisions.

The Hospital Council of Western Pennsylvania (HCWP) believes that the most effective step in ensuring a rational, patient-focused system of care is by taking a collaborative approach to identifying and adopting appropriate, new care delivery protocols.

Through its Medical Director's Forum, HCWP has proposed the formation of a Western Pennsylvania Quality Care Forum that brings together appropriate clinical and administrative expertise from physicians, insurers, health care providers, long term care, home health care and others. Although, each of these organizations has competing interests, HCWP maintains that they can be united around powerful common objectives: balancing health care resources while assuring optimal outcomes when patient care delivery protocols are changed. Everyone is concerned about costs, but the real measurement of cost is more than short term resource

Through this collaborative process, the ultimate goal is to provide a rational alternative to current government intervention in clinical practice.

The underlying principle of the Western Pennsylvania Quality Care Forum is that a scientifically founded, collaborative process yields greater returns on total cost than any unilateral mandate. No one organization can, by itself, optimize a complex system of clinicians, insurers, payors, providers and a myriad of others. If we persist in the approach of independent self-interests, we can expect and deserve nothing more than escalated inefficiencies and government interference. We need to focus on managing health—the needs and concerns of our patients—and not on managing one another.

Initial response to the establishment of the Forum has been quite positive, indicating support for collaborative solutions from within the system. Although the Forum is necessarily limited in its scope of activity, we hope it will serve as a model for similar initiatives.

In the absence of such action, our opportunity to shape how health care is delivered diminishes rapidly. If we are to preserve innovation and rational clinical discretion, the time to act is now, for the benefit of all.