Today's News

Saturday, February 24, 1996

Medicare reform sparks new battle for access to specialty care

With Medicare reform on the legislative agenda in Washington, the Academy's Council on Health Policy and Practice has been engaged in an organized effort to ensure that access to specialty care is included in managed care contracts for Medicare.

"The purpose of the Council is to analyze and monitor federal legislative events and events in the private sector that affect the delivery of health care, to look at the financing of health care, and to monitor professional liability issues," said Michael Graham, MD, chairman of the Academy's Council on Health Policy and Practice and an orthopaedic surgeon in private practice in Portland, Ore.

Reform legislation

The Council sprang into action in 1993 when President Clinton proposed health care reform. It supported the Patient Access to Specialty Care Coalition, which the Academy's Washington office co-founded. "Initially there were about 15 surgical specialty societies in the coalition, and that number has steadily grown to 119 physician and patient-advocacy groups," said Dr. Graham.

The coalition continued after health care reform died in Congress and the debate shifted to Medicare reform. "In the past year, we have been pushing for the same principles as before, and that is timely and appropriate access to specialty care and the removal of any financial incentives to withhold care," said Dr. Graham. "We are also concerned about making sure that any managed care program for Medicare should spend 85 percent of its premium dollars on patient care."

To get its message about access to specialty care across, the Council and the coalition have created two pamphlets for consumers. "One is called Specialty Care Works," he said. "It describes the position of the Patient Access to Specialty Care Coalition and indicates to the public how they can contact their U.S. Representatives and Senators through an 800 telephone number or by fax. From August through December 1995, there were more than 27,000 direct calls or faxes from physicians and the public to members of Congress as a result."

The second pamphlet is called Your Guide to Managed Care. "We tried to write it in neutral language as much as possible and simply describe managed care," Dr. Graham said. "We sent it to all Academy Fellows for distribution to the public and to all other specialty societies and the patient-advocacy groups in the coalition. We don't know what the other specialty societies are doing, but the Academy has sent out more than 300,000 of each of the pamphlets."

The coalition also has placed 488 articles on access to specialty care in newspapers in 28 states and has developed some radio ads. "So, we've made a significant attempt to inform the public," he said. "It's difficult to do in a large country and the effort takes a lot of money, but we've done the best we can."

State legislation

The Council and the coalition have now turned their efforts toward state legislatures, Dr. Graham said. "We've recognized that the same approach may be quite successful in the state legislatures and we have been successful in establishing similar coalitions for access to specialty care in 17 states," he said. "The idea is to involve local medical associations and specialty groups to form a miniversion of the national coalition."

The coalitions are pushing for point-of-service features in managed care contracts. "The point-of-service features would allow individuals in a managed care program to go outside the program to see the physician of their choice if they are unhappy with the advice or care they are receiving from the physician they have been assigned to," he explained. "The patient would pay a small additional fee for this feature. We feel it's basically a quality control issue. Managed care organizations that take good care of their patients shouldn't have a need to worry about it," he said.

About 70 percent of managed care contracts now offer some type of point-of-service feature, Dr. Graham said, but the coalition believes that all contracts should contain the feature. "We think this should not be an option," he said. "We believe a point-of-service feature should be included in everyone's managed care contract. You can compare it to seat belts. If seat belts were offered as an option on cars, some people would not buy them. Point-of-service ought to be an automatic feature in every plan so everyone gets it."

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Last modified 27/September/1996