[The second area is] the challenges of new technology, assessing the efficacy of new technology, and struggling from a purchaser perspective with how employee benefit plans absorb the new tech, incorporate the new tech, and make it available to their beneficiaries.
The third area is continuous health care inflation and increases in costs. The rule ought to be, for legislation, first do no harm in this area. That's a rule that has been violated, and in part that's why we're seeing now a major uptick in inflation. That's something that ought to cause members of Congress and legislators at the state level to look very clearly and carefully at that.
The third area is addressing benefit challenges in Medicare, because Medicare is a benefit package and structure that reflects what was the case in the '60s, when Medicare was passed. Now we need to update it, modernize it, and reflect what the expectations of beneficiaries are in the twenty-first century. And they're different. It begins with prescription drugs, but it also will extend to issues such as long-term care and other matters that will continue to be talked about.
Also, the matter of safety of our health care system is a major area. The Institute of Medicine issued a report which suggested that up to 100,000 people per year were dying as a result of medical errors, and we need to do something about that. We need to address it.
[In] the area of medical malpractice, we need to be looking at new models to address malpractice. Physicians have been very compelling in their decrying the current malpractice system. We should be listening to them and we should be looking at alternative dispute resolution models, et cetera, and not pursuing the agenda of the trial lawyers in this regard.
Patient protection is an issue that there is a solution on policy grounds. The major barrier to that is the political discussion and the political jockeying that's going on in this election year.
Q: What can or should the government do to address these problems?
A: You're asking a very important question. The subject is, what's the role of government in health care. This has been a question that we've been debating, inadvertently, throughout the last fifty years, and it's still unsettled. In fact, the legacy of the 20th century is that we've either tried to accomplish too much in health care in terms of the role of government, or not enough.
It's important for politicians, as they debate the health care issues, to talk about their very specific views about where you put the balance between competition and regulation. For an industry group, it's important and incumbent on them to step up and talk about these issues very specifically.
For us, we believe that the government has a role in establishing standards, and ought not to descend to micromanagement, but has a strong role in establishing performance standards with respect to expectations for performance for all parties, whether they be health plans, physicians, hospitals, or what have you.
In the area of the uninsured, there's a more direct role, which is to say that we can use the tax system to in fact move forward very productively in making it possible for more people to have access to coverage they do not have now. At the same time, we can look at public programs for the unique populations that are best served by public programs, and have blended solutions in terms of the uninsured.
In the area of safety, in the area of patient protection, there is an important balance to be struck between government setting performance standards, requiring disclosure of information, but at the same time, leaving opportunity for innovation, new product development, new procedures for safety, and new opportunities for individuals to collaborate under those rules and guidelines that are established by the government.
Q: In recent years, has the increased popularity of managed care cut costs at the expense of the quality of care?
A: In fact, the evidence is entirely the opposite. We've been very successful at containing costs, and a range of economists, including those at the Congressional Budget Office, have spoken quite compellingly that our efforts have in fact made it possible for working families to have more money in their pocketbooks, which is a very good thing.
But, also, the research -- not done by us, but by academics -- has demonstrated that we are doing a better job at providing high quality care to individuals who are chronically ill -- people who have diabetes, people who have certain kinds of cancer, and a whole range of other chronic conditions. We're very proud of that track record. Unfortunately, in a political environment, candidates sometimes don't drill down to that very significant track record.
Q: Some experts claim that additional regulations will cause some people to lose coverage. How can policy makers balance availability of care against quality of care?
A: I think that's also a very, very good question, and in terms of testimonials about prognoses with respect to loss of coverage, I'd yield to the employers. Many employers, both individually and collectively, have made it very clear that were legislation, such as the Norwood-Dingell legislation, that has been much discussed in this campaign, to pass, they would have a strong incentive, and would be forced out of the health care system, because they couldn't afford to take on the additional liability in a non-core business for them; also, they couldn't afford to absorb the additional costs of premiums.
This is not idle speculation. We have precedent for what is projected to happen under this legislation based on what is happening to physicians in the malpractice arena, and that is something that I think members of Congress should look very closely at.
Having said that, that does not lead our members to make the argument that we should not move ahead with patient protection. It leaves us to make the argument that, in fact, we should move ahead with a balanced, workable and effective strategy for patient protection which would not increase costs very much -- and we have a great deal of research to support this contention -- and would, in fact, guarantee all Americans access to a solution that would give them comfort and would give them confidence that the health care system is working objectively and working fairly. That solution lies in the area of independent external review.
Q: If a health plan's decision to deny coverage harms patients, should the plan be subject to lawsuits? Why or why not?
A: The health plans are being subjected to lawsuits right now. Anyone who is not aware of that, or who says otherwise, should look at the summaries of the numbers of court cases that are proceeding in the various circuits around the country. If there is a problem in terms of quality, the health plans can be sued and have been sued, and there are a number of cases pending.
This issue in Washington that we're debating now is about whether or not health plans should also be sued on the grounds of coverage decisions, which would mean then that no employer, no union, no state government could ever again make decisions about benefit packages that wouldn't be second-guessed in the courts. We don't think that the research suggests that the American people believe that that's the right thing to do, particularly when the matter of whether an employer can provide health care coverage is such an open question and very much related to the market the employer is in and the size of the market, et cetera.
There's a little bit of misinformation out there, which I think is often promoted by individuals who are looking to extend these suits to the whole coverage arena and superimpose governmental decisions on the decisions that should be made by unions, employers and state governments.
Q: Each side in the debate over the patients' bill of rights claims that the other side will put the wrong people in charge -- either "insurance company accountants" or "trial lawyers." What's the best way to ensure that the decisions are made by patients and doctors, and the patient gets the necessary treatment?
A: To move forward with an independent, external review process that is controlled by docs -- that is to say, the decisions are made by physicians in an objective way, physicians that have no relationship to a plan, no relationship to the particular physician [who is] recommending a particular procedure, and no relationship to any other party, so that he or she would be completely objective.
The decisions ought to be based on the science, and the decisions ought to be in the best interests of the patient. That's the best way to balance all of the interests here, and to move forward on an agenda that actually works, we have experience with, would be affordable, and would go a long way toward giving people peace of mind, knowing that there's an objective third-party process from which they can seek a second opinion.
Karen Ignagni is president and CEO of The American Association of Health Plans, a trade organization representing managed care companies.
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Dr. Thomas R. Reardon
Karen Ignagni