June 1999 Bulletin

Collective bargaining heads NOLC agenda

Orthopaedists tell Congress legislative interests include centers of excellence, patient protections

Senate Majority Leader Trent Lott, MD, (R-Miss),left, met with Robert D. D'Ambrosie, MD, second from left, President of the American Association of Orthopaedic Surgeons, and members of Board of Councilors during the National Orthopaedic Leadership Conference in Washington, D.C.

In their annual visit to Capitol Hill this spring, orthopaedic surgeons from throughout the nation left no doubt about their legislative interests-collective bargaining, "centers of excellence" for joint replacements and patient protections under managed care.

More than 90 members of the Board of Councilors, state societies and specialty organizations visited with 136 senators, representatives or their key staff during the National Orthopaedic Leadership Conference. They strongly urged their legislators to support the Quality Health Care Coalition Act (H.R. 1304). The bill would allow physicians and other health care professionals to collectively negotiate with health care plans without violating antitrust laws or having to join a union.

The orthopaedists' position is that the insurance industry is exempt from the antitrust laws, enabling health care plans to engage in anticompetitive practices. Orthopaedic surgeons are faced with "take it or leave it" contracts which jeopardize the autonomy of physician-decision making. Health plans have placed limits on the time a doctor can spend with a patient and they have placed restrictions on medical tests and treatment options. At the same time, the insurers have not devoted enough of the total premium dollar to patient care.

Approval of the legislation would not open the door to strikes by physicians because ethical and legal duties require them not to abandon their patients.

The controversial concept of "centers of excellence" has surfaced again, this time as part of President Clinton's fiscal year 2000 budget. Several years ago, the Health Care Financing Administration (HCFA) began a demonstration project to provide for a single comprehensive payment for high volume Medicare procedures. The first procedures were coronary artery bypass graft (CABG) and cataract surgery. HCFA's next targeted hip and knee replacement, but the startup has been delayed for two years because of problems at HCFA.

The Clinton proposal would allow the Department of Health and Human Services to competively pay selected facilities a single bundled rate for all service. In 2001, HHS would establish nationwide, "centers of excellence" for CABG surgery and other heart procedures, hip and knee replacement surgery and other procedures.

Orthopaedists want Congress to wait and see the results of the demonstration projects before it mandates this payment and delivery model for the entire country.

Orthopaedists point out that all Board-certified orthopaedic surgeons can do hip and knee replacements and that data indicate these procedures are commonly performed with success in almost all community hospitals throughout the nation. Limiting the procedures to selected sites, would remove these procedures from many hospitals, causing patients the inconvenience of traveling to Medicare-desig- nated facilities. Also, removing patients from their local medical community would interfere with continuity of care, resulting in an adverse effect on both pre- and postoperative care and on the ability of the family to provide assistance and support.

Councilors made a strong case to their legislators to support six patient protection principles in any health care bill moving through Congress. The legislation should allow access to specialists in the health plan's network; provide timely, expedited independent appeals; require insurers to provide comprehensive consumer information to compare health plans; and ban gag clauses which prevent physicians from informing patients about all treatment options. Health care legislation also should prohibit financial incentives that result in the withholding of care or denial of a referral and allow patients to seek treatment out-of-network at a non-prohibitive fee.

Although some health care plans are instituting many of these provisions, many have not. Some states have passed patient protection bills, but they do not apply to the majority of health plans covered under ERISA.

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