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FOIA Number:
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MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Carolyn Gatz/JenniFer Klein
Subseries:
OA/ID Number:
5107
FolderlD:
Folder Title:
Hassle
Stack:
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s
56
5
5
3
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001a. letter
Jody Thompson to Health Plus; re: Review Claim Number (1 page)
01/04/1993
P6/b(6)
001b. Statement
re: Explanation of Amount Paid (1 page)
12/23/1992
P6/b(6)
001c. letter
Sarah Lynn Campbell to Dr. Martin Golding; re: Reconsider Payment
on Denied Services (1 page)
03/05/1993
P6/b(6)
00Id. letter
Dr. Martin Golding to Sarah Lynn Campbell; re: Appeal of Ruling (1
page)
03/16/1993
P6/b(6)
00 le. statement
re: Explanation of Amount Paid (1 page)
04/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz/Jennifer Klein
OA/Box Number:
5107
FOLDER TITLE:
Hassle
2006-0885-F
ip2650
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - [5 U.S.C. 552(b)l
PI
P2
P3
P4
b(l) National security classified information [(bXl) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency |(bX2) of the FOIAj
b(3) Release would violate a Federal statute |(bX3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information |(bX4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIAj
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office |(aK2) of the PRA|
Release would violate a Federal statute |(aX3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misflle defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
��IRWIN R E D L E N E R
O.E.O.B. Rm. 410
456-2320
Messages: 456-2774
�04/16/93
17:08
©202 835 0442
A.S.I.M. - 7th
i003/005
April 16, 1993
Dr. Jeff Morris
Health Professions Advisory Comm.
President'e Taek Pores on Health Care Raform
Room 410 "- Old Executive Office Building
Washington, DC 20500
Dear Dr. Morris:
Pursuant tb your recent requBst tor intormatlon about the administrative and regulatory burdens
faced by practicing physicians, I am happy to share with you some thoughts based on my own
practice experience ot over 15 years as a meflicai oncologist and subsequently as a primary care
physician. It is difficult to cover all of the issues involved in just a tew short pages. However, i
will try to summarize what I see as some of the major areas in which physicians confront the
•hassle factor^ in today's medioal practice environment.
1 • The accumiilation of rules, regulations and statutory requirements imposed on physicians.
Just within the last few years, Medicare has adopted a completely new payment system for
physicians involving many new codes, coverage policies and claims processing rules. My office
has had to comply with OSHA regulations calling on physicians to establish and document
procedures for controllinQ exposure to blood-borne diseases in their offices and with new
requirements under the Americans With Disabilities Act to ensure that my office is accessible to
patients with disabilities and my staff hiring practices are non-discriminatory 1 chosa to
discontinue providing laboratory services due to the expense and regulations Involved In
performing simple tests such as urinalysis under the Clinical Laboratory Impioverrient Act of 1988.
A colleague of mine, a board-certtfied Infectious disease specialist, can no longer do gram stains
of infected material from hie patients without undergoing an axteneive CLiA-related certification
procedure. As a result, inappropriate and unnecessary delays frequently occur in the delivery of
proper antibiotic therapy to his patients.
All uf tlttiu» iiuw rultts diid lawb wtiru ddupleU with vt)ry wuriliy yuetib in iiiiiid. However, Llie
impact on me as an individual solo-practicing physician has been that I spend considerably more
time making sure l am following the rules and less time caring for my patients, i would urge you
and your colleagues on the task force to assess the cumulative Impact on primary care physicians
of regulatory and statutory changes being contemplated under health care reform,
2. The multiplicity of Illogical, otten-conflicting and Intrusive review rules. Medicare has one set
of review requirements to determine medical necessity of services, Medicaid another. Then, there
are the various policies of commercial insurers and private utilization review firms by which I must
abide. These review requirements often compel physicians to call the carrier and discuss the
patient's care before sen/ices are authorized or paid. Rationing by inconvenience is the result
when 800 numbers are constantly busy (if provided at all), as office staff are put on hold for long
periods of time and when It talces considerable time to educate review personnel authorizing a
service because they are not medically knowledgeable about that care.
An ex£imple of irrational review procedures that springs to mind concerns the practice of several
HMOs in this state in which emergency room care is paid for based on the discharge diagnosis of
the patient. Thu$. a patient complaining of cheat paina to his or her physician may be aant to the
emergency room where it will be detennined that the problem was in tact indigestion. The HMO
proceeds to deny payment for that care even though this retrospective review of tha discharge
diagnosis fails to account for the symptoms that appeared significant enough to the physician to
send the patient to the emergency room In the first place,
I warn to practice appropnate, cost-effective medicine. But, that is very difficult when I'm often not
sure what a third party payer's definition of "medically necessary" is and what information that
payer needs in order to be satisfied. There is also a risk that patients will be denied payment for
�04/16'93
17:09
©202 835 0442
A . S . I . M . - 7th
12004/005
A
appropriate, neftdflfl sflrvififls wtinn the criteria for making payment determinations are kept secret,
Review criteria and documentation required to justify services must be public, consistent among
all payers and should be developed with extensive input from practicing physicians In orrlfir to
ensure they meet the "reality test" of every day health care delivery.
3. Coverage policies that adversely affect primary care physicians most. Both public and private
inaurors often deny coverage of services provided by primary cara phyalclana. The periodic
health evaluation Is routinely denied outside the HMO setting, for example. This exam can serve
as an effective tool in estublibhlng quality pliysician-palienl lalatlunhips, allows ecirlier diagnosis
and potential treatment of serious medical problems and also allows primary care physicians an
opportunity to counsel patients about preventive medical strategies, In addition, primary caro
physicians have had to argue for years with Medicare carriers over coverage of their services
When they manage a patient's hospital care concurrently witn a specialist, l do not osiiBve
continuity of a patient's care is well-sen/ed when insurers refuse to recognize the legitimate place
of the primary care physician in overseeing that patient's care. Furthermore, many primary care
physicians spend a great deal of time in pre- and post-operative consultations concerning the
course of treatment to be given patients, in care plan oversight and in other case management
services provided to patients in nursing homes or who are homebound. Finally, telephone case
management services are also not recognized by insurers yet studies have demonstrated such
oare is both a cost-effective and medically-effective means of managinfl patients' problems,
Either these services are simply not covered by Medicare or the insurer or, if they are, physicians
must complete extAn^^lvR pflpenwork in order to be paid for such services. Coverage policies
under the new health care system must appropriately acknowledge the services of primary care
ptiysicians if the system is to depend so heavily, as I believe it must, on wider atjcess to primary
and preventive care.
I am a member of the Board of Tnjstees of the Amertaan Society of Internal Medicine. ASIM
repreaanta over £6,000 prootioing physioiane In intarnal medicine and ite eubspecialtles and was
an early supporter of comprehensive health care reform. ASIM has developed an array of
materials on the "hassle factor" in mBdicine with specific recommendations on improvcmonte that
can be made In insurer review, payment and coverage policies, not only under Medicare but
under pnvate insuraiicu programs, i have asked ASIM staff to send you under separate cover the
most recent ASIM paper on the crisis in primary care. Titled Rebuilding Primary Care: A BlueprtPt
tor the Future, this paper outlines many or tne problems In the regulatory, reimburseniwiii and
training environments faced by primary care physicians and offers 44 specific solutions to those
problems. I would strongly recommend tnat you and your colleagues review These proposals and
utilize the resources ASIM can offer.
Your interest, and that of the other members of the task force, in the difficulties faced by practicing
physicians in our health care system is deeply appreciated, if there is anything further i can do to
help you in your efforts, please do not hesitate to call upon me.
Sincarely,
J, Leonard Lichtenfeld, MD
400 Old Court Road, Suite 301
Pikesville, MD 21200-20&4
�SHARON H 0 C H W E I & $ .
M D.
aOOA F(FTN AVENUe
NEW
VOftK, NEW
(212)
YORK 1 0 0 2 I
899.3195
Doctors £.re overwlmelmed w i t h frustr^acion and beaurocratic hassels.
A l i s t of d e t a i l s could be endless but the complaints f a l l i n t o f i v e
basic categories.
1- Insurance The lack of u n i f o r m i t y of insurance forms and
requirements i s staggering. There i s also l i t t l e resource against
a r b i t r a r y denials of payment f o r services by Medicare and other
insurance c a r r i e r s . Forms w i l l be returned w i t h nonpa^Tnent when minor
omiissions ( such as the ID number of a r e f e r r i n g physician) are made or
o f t e n when no e r r o r can be discerned a t a l l . Attempts t o c l a r i f y the
problem are met w i t h a computer v o i c i which r a r e l y provides u s e f u l
information before t e r m i n a t i n g the c a l l , "^je review process demeans the
physician t o the p a t i e n t and o f t e n becomes^time consuming that most
physicians do not p a r t i c i p a t e . Instead they simply absorb s i g n i f i c a n t
f i n a n c i a l losses on a regular basis.
The v a r i a b i l i t y of reimbursement i s also f r u s t r a t i n g , leaving
physicians i n the d i f f i c u l t p o s i t i o n of t r y i n g to c o l l e c t payment from
f a m i l i e s stressed by the f i n a n c i a l pressures of i l l n e s s .
Frequently t h i s leads to services being provided f o r f r e e when insurance
w i l l , not cover costs.
Another d i f f i c u l t y i s the lack of education of p a t i e n t s as to how
t h e i r insurance works. O f f i c e s t a f f must navigate the maze of c a r r i e r s
for them p u t t i n g a large nonmedical burden on o f f i c e s t a f f .
The f i n a l i n s u l t i s having t o clear admissions, d i a g n o s t i c
procedures, and surgeries w i t h non-physician personnel who o f t e n have no
clear understanding of the c l i n i c a l parameters involved i n i n d i v i d u a l
case d i c i s i o n s . This i s more than j u s t a nuisance. I t r e s u l t s i n the
d e l i v e r y of bad medicine. These decisions must remain the domain of the
physician.
2- Paperwork i n c l u d i n g b i l l i n g , p a t i e n t c h a r t s , and reports
This area i s consuming more and more time on the p a r t of physicians
and as r e g u l a t i o n s become more d e t a i l e d and more demanding i t i s harder
to delegate t h i s r e s p o n s a b i l i t y t o secret.arial s t a f f . The most important
aspect of t h i s category i s the need f o r l e n ^ i y and accurate notes
R e f l e c t i n g a l l doctor p a t i e n t encounters i n o f f i c e , h o s p i t a l and even
by phone. Almost a l l of t h i s i s due t o the medical malpractice c r i s i s
which can r e s u l t from even the most "innocuous" p a t i e n t encounter. We
have been t o l d by our malpractice insurance c a r r i e r t o keep records of
a l l phone conversations and f o r a busy i n t e r n i s t t h i s can be as many as
50 times a day. I t i s v i r t u a l l y impossible to do.
Insurance i s again a problem, i n a d d i t i o n to lenghty forms f o r
claims, the coding of diagnoses on forms has become so complicated, and
yet c r i t i c a l t o adequate reiraburstment, that physicians are obliged t o
oversee i t on t h e i r own. Insurance companies also r e q u i r e d e t a i l e d
�04-19-96 13:52
DRS FISCH HCFFMRN ROGERS HORBRR RDLER
255 P02
A t t e n d i n g Physician Statements r e v i e w i n g each p a t i e n t v i s i t w i t h
diagnosis and treatment before i s s u i n g coverage t o p a t i e n t s . For t h i s
they a l l o w a nominal fee t o be charged. This d e t a i l e d r e p o r t s a r e
unnecessary t o a d e q u a t e t l y access a p a t i e n t ' s i n s u r a b i l i t y .
F i n a l y t h e r e i s the issue o f p a t i e n t r e p o r t s which are not o n l y
sent t o c o l l e g u e s but are requested f o r anyone from schools t o a i r l i n e s
to h e a l t h c l u b s . Forms must be completed f o r n u r s i n g homes and a l l home
care s e r v i c e s . S t a t e law r e q u i r e s some r e c e r t i f i c a t i o n every s i x months
even i f t h e r e i s no s i g n i f i c a n t change i n the p a t i e n t s t a t u s . This
medical documentation i s an i m p o r t a n t s o c i a l f u n c t i o n but i s extremly
time consuming. Most o f us f e e l c a r i n g f o r p a t i e n t s i s always p r e f e r a b l e
to paper work.
3- M a l p r a c t i c e Fear o f l a w s u i t s overwhelms the way p h y s i c i a n s
p r a c t i c e medicine and leads t o many s l e e p l e s s n i g h t s . P r a c t i c i n g defensive
medicine undoubtedly d r i v e s up costs as t h e r e i s no p h y s i c i a n who t r u s t
his own c l i n i c a l i n t u i t i o n more than the l a t e s t h i g h technology
scanning device.
M a l p r a c t i c e insurance r a t e s are a s t r o n o m i c a l and the emotional t o l l
of involvement i n even a f r i v o l o u s o r unfounded l a w s u i t i s immeasurable.
^~ Phone C a l l s The sheer number o f phone c a l l s a busy p h y s i c i a n may
have t o make d a i l y t o p a t i e n t s has been mentioned. Telephone c a l l s work
i n 2 ways. On the one hand they are u s e f u l i n p a t i e n t f o l l o w up and
d i s c u s s i o n o f d i a g n o s t i c t e s t r e s u l t s e l i m i n a t i n g the need f o r f o l l o w up
v i s i t s . U n f o r t u n a t e l y they are f r e q u e n t l y the e n t r y p o i n t f o r p a t i e n t
care. Physicians are asked t o make d e c i s i o n s and g i v e advice over t h e
phone p l a c i n g them i n jeopardy o f medical l i a b i l i t y . Since t h i s s e r v i c e
i s f r e e i t o f t e n leads t o abuse by p a t i e n t s and i s exceedingly
d i f f i c u l t to control.
5- Time Pressures Because o f f r o z e n f e e s , increased overhead, and
the .csincAre d«=Rirfi on f.hft p a r t o f most p h y s i c i a n s not t o gouge p a t i e n t s
w i t h e x o r b i t a n t fees, most p h y s i c i a n s f e e l the need t o see more and more
p a t i e n t s rjevoting 1e)3S and Ip^.q.c; tiiriR ho ppinh v i K i f . Thf>re i s ohvi'miRly
a p o i n t a t which t h i s becomes an u n s a t i s f a c t o r y and u n s a t i s f y i n g
circumstance f o r both th© p a t i e n t and the p h y s i c i a n .
The most damaging r e s u l t o f a l l these "hassles" i s th© safiping
of the enthusiasm o f p h y s i c i a n s f o r the p r a c t i c e o f medicine. Medical
schools have witnessed a d e c l i n e i n a p p l i c a t i o n s , and the number and
percentage o f U.S, medical school graduates choosing t o go i n t o primary
care f i o l d e i e decreasing. An atmosphera i s c r e a t e d i n which demoralized
and angry p h y s i c i a n s are asked t o c o n t i n u e t o p r o v i d e q u a l i t y care i n a
k i n d and concerned way. Thic i e becoming ir.ore and more d i f f i c u l t t o do
i n the c u r r e n t c l i m a t e .
�INItKNAl MCOIONf
DRS. DCDMAN, GOLDBEI?G & GOLDING, P.A.
CONNfCTICOT BflAlR MEDICAL KARK
^30^ 2 VHRS MILL ROAD
WHEATON, MAKYLAND 20906-451.1
OOlj 942-J.5S0
FAX S.O-3621
DAVIO B. OOMAN, M.O., F,A.CP., r.A.c.c.
HOWARD
April
19,
1993
MARTIN I. OOLDINC, M,D., F A C P T F A C
I r v i n R e d l e n e r , «,D.
P r o f e s s i o n a l Review Group
H e a l t h Taek F o r c e
The White House
Dear Dr. R e d l e n e r ,
atte,»ptid t o s u o c i ^ c t L d ^ ^ c r i S i "
P ' « " i « physicians.
I hav,
. n c o u „ t „ e d by .y QJOUC. t ^ l
f '
'haesl^s- that are
doubt t h a t ^ Z l Z - t . r / r i i o r J V
"^"^^
"
f o r o u r n a t i o n , .any p r l v f ^ i /
•
°^
^reat^.t challenge
burdensome r e o L l a l s L r
, """'^
Physicians v i e . overly
^e t h e . r l J d l t ' l l ' r l l l t^o^^h L ' ^ b u l t r ^ r ^ ^ '
"
c a r e and . a i n t . i n i n , .n . . i a b j ^ d : ; { o r ^ ^ : L : : ; r ; : ^ a ? i ^ n : ; i p ^ ; '
co„tr:tu%'i-?:;-tr:it%,":^h'"HSs ^^^r^??: rr^^r::pa;".ro^r""i:L^=::::,r"d""
..rvice^is ».;^ii:^^^T2y'ii:xziij:,v'
..edic.i expenses
; , ' r " i " r ; ' : T . ^ n t l V ' ' ' - ' " ' ' ' ' ° uncovered
i d e n t i f y v h i c h L.ar t i n, ,
f .
^= r e q u i r e d t o
c o n t r i b u t e s t o our r i s i n o r.v-rK ! ^^^^^"^
e x c e s s i v e and
f r e q u e n t l y 'ehop' l o ^ ^ n L r i ' v"^ ^>'P^nsea.
Insurance co.paniee
technical qualit% o r % : ; t : ; i ^ ^ ^ v ^ ™ : / ^ ^ ^ " " ^ ^ ^ ^ ^
ixx
.t^^ x°"iy: e:/i°a'.or::r:%^^^^ ^^^^^^^^^ ^°
immediate a v a i l a t - . l i t y
implementation
ve a r e
o l L r e ^nd '
'TT
^^^P^^^ ^ h i s
P=^oceB6 o f t e n d e l a y s t h e
ill p.tients li rg:a:^oe;::r:r:.:2f^'^^^^^^^^ v i t h s i t u a t i o n s when ve w i t l
'
^'^''^
^^^^'^
blood c o u n t s on p a t i e n t s J ^ L ^ ^
-^^-^"-^ed l o r p e r f o r m i n g
office visit
AM>
V '^'^"'°^^^s9irig a t t h e time of t h e i r
i l l ^ p . t r : ; j . \ - t ^ L ' T ; ^ . : : . t " : : r : ' I i ^ - - e r emergency e a r e f o r
t h e s t a f f time «nd o f f i c e e ^ p e n ^ ' e ^ ^ . u ' l : ; r : c o % ' : r " : d : ^ ^'^^
�I r w i n Redlener,
n.D.
-2-
i« H^tr.^ T t
P^°P°'r^i°n oi our o f f i c e o v e r h e a d e x p e n s e s
a s devoted to p r o c e s s i n g i n s u r a n c e c l a i m s , f o l l o v i n g d ^ J a y s i n
payments and a p p e a l i n g d e n a a l s f o r b e n e f i t s .
Our b u s i n e s s o j j i c e
the oatient^o I r i l t
I
e r n e e t l y a t t e m p t to a c t aa
rne p a t i e n t e advocate i n insurance claims proceseina
thia
n u l l " "
p o t e n t i a l of p l a c i n g us i n ' a n a d ^ i ^ s L r l a l
r e l a t i o n s h i p with p a t i e n t s p e r p l e x e d and a g g r a v a t e d about t h e i r
coding:
°' d i s p u t e d c l a i m s , ' c l a i m f o r : s and
c o d i n g p r a c t i c e s need to be uniform and c a r r i e r s need t o
accept e l e c t r o n i c claims
tranemiseions.
As a p r e d o m i n a n t l y c o n s u l t a t i v e p r a c t i c e , we r e l y on
p a t i e n t s and t h e i r primary c a r e p h y s i c i a n s to p r o v i d e us w i t h
p r e - a u t h o r i z a t i o r , f o r o f f i c e s e r v i c e s . P a t i e n t s who a r e u n a b l e
t o o b t a i n S i g n e d a u t h o r i z a t i o n forms i n advance of t h e i r a p p o i n t ments have had to r e s c h e d u l e o f f i c e appointments.
T r e a t i n g even
s e r i o u s l y i l l p a t i e n t s without a u t h o r i z a t i o n u s u a l l y r e s u l t s i n
a d e n i a l of b e n e f i t s . P a t i e n t s become dismayed and l o s e f a i t h
an t h e s y s t e m when they have taken time o f f from work and a r e
unable to obtain medical care.
T h i s only s e r v e s t o f u r t h e r
a l i e n a t e p a t i e n t s and provoke resentment v h i c h i m p a i r s our
a b i l i t y to g e n e r a t e t r u s t and c o n f i d e n c e i n our p a t i e n t s . I t i e
u n f o r t u n a t e t h a t primary c a r e p h y e i c i e n e a r e a s k e d t o a u t h o r i z e
c o n s u l t a t i v e s e r v i c e s when the c o s t of t h e s e s e r v i c e s d i m i n i s h e s
t h e pool from which t h e r e s a l a r i e s a r e d e r i v e d .
I n s u r a n c e p r o v i d e r s u t i l i z e a v a r i e t y of c l a i m forms,
c o d i n g of s e r v i c e s f o r m a t s end schemes and r e v i e w p r o t o c o l s .
D e n i a l s f o r c l a i m s a r e o f t e n c a p r i c i o u s and a p p e a l s a r e t i m e
consuming.
Payments a r e w i t h h e l d because of i n s i g n i f i c a n t
t e c h n i c a l f i l i n g e r r o r s or l a c k of r u d i m e n t a r y m e d i c a l
p r a c t i c e knowledge on the p a r t of p r o c e s s i n g c l e r k s e t t h e
insurance c a r r i e r s .
O f f i c e v i s i t s can be d e n i e d when t h e y
a r e accompanied by m i n i m a l l y i n v a s i v e t e c h n i c a l p r o c e d u r e s
based on s u r g i c a l g l o b a l f e e p o l i c i e s .
Such e x t r a p o l a t i o n t o
n o n - s u r g i c a l s p e c i a l i s t s l e u n j u s t i f i e d and r e p r e s e n t s a b l a t a n t
a t t e m p t to c o n t a i n c o s t s and j e a t r i c t our a b i l i t y t o p r o v i d e
q u a l i t y care.
I )iave e n c l o s e d f o r your i n f o r m a t i o n a t y p i c a l
c l a i m s d e n i a l appeal process for a p a t i e n t r e q u i r i n g a
s i g m o i d o s c o p y i n December X'd^2, w i t h a f i n a l payment i n A p r i l
o l 1993.
�I r w i n Redlener,
H, D.
-3-
One of t h e most arduous and time-consuming r e s p o n s i b i l i t i e s
of our o f f i c e s t a f f i s s e c u r i n g a u t h o r i z a t i o n s l o r h o s p i t a l
a d m i s s i o n s and meeting r i g i d g u i d e l i n e s f o r l e n g t h of s t a y .
A common s c e n a r i o i e f o r a n u r s e a d m i n i s t r a t o r t o q u e s t i o n
cur judgement r e g a r d i n g t h e n e c e s s i t y of i n - p a t i e n t c a r e .
These
d e t e r m i n a t i o n s a r e o l t e n based on a r b i t r a r y p h y s i c a l s i g n s and
i u b H ' I ^ t r ' ""^^^-^^'^
^ - g - d ^or p a t i e n t s y m p t o m s % n d
m^^Jtf ^v,'°"^'"y'^"•
" ^^^^^ ^^^
'p^
-^^^^^ to Siscuss the
th! . i r ^ ' ^ ' ^ ' ^ ' ^ r ' '
- physician f a m i l i a r
riauii^
i n t r i c a c i e s of c l i n i c a l p r a c t i c e . Our o f f i c e r e c e i v e s
i n q u i r i e s on a d a i l y b a s i s from some of t h e i n s u r a n c e c a r r i e r s
?airiri"L^
' ^ ' r ' ' ^ ' " '^'^ c o n t i n u a t i o n of h o s p i t a l b e n l ^ i ^ s
a^deni:i':f^:r^^,r^^''^'^'^
^^'^^^^^
d^.l^?^"*''''*^"''^!]"^"^^^''^
^^^<l"^"tly s c r u t i n i z e d f o r t h e i r
d e c i s i o n s r e g a r d i n g t h e n e c e s s i t y of p e r f o r m i n g d i a g n o s t i c
t;?did^rT
endoscopic procedures.
Although m y ^ r o u p h a s
tended t o be very c o n s e r v a t i v e m p e r f o r m i n g e n d o s c o p i e e f we
have e x p e r i e n c e d c o n s i d e r a b l e h a r d s h i p r e g a r d i n g s c h e d u l l n o of
rr'^d^'^-K
""^'^^^ reimbursement ^ o r ^ e g i i i m a t f
^ub^r^^^r ?:::r::cr:;:;^^rg"^:iin
a r e o f t e n based on s t r i c t P ^ a r t ^ ^ ^ ^ r ^ L f ^ ^ . r : : : i S ; : / ^ ; = ^ ^ " ^ "
sta;,5ardi
P ^ ^ - j c i a n s with l i t t l e r e g a r d f o r comS^nity
My s i n g l e g r e a t e s t c a u s e f o r a l a r m and f r u s t r a t i o n h a s been
i n coping with p a t i e n t s ' resentment regarding l i m i t a t i o n s
imposed on t h e i r c a r e .
I n s u r a n c e companies. PROs and M e d i c a r e
have t a k e n g r e a t l i b e r t i e s i n i n f o r m i n g p a t i e n t s t h a t t h e i r
p h y s i c i a n s ' c h a r g e s exceed 'usual and customary' l i m i t s .
This
e e r v e s t o f u r t h e r s t r a i n d o c t o r - p a t i e n t r e l a t i o n s h i p s by
p o r t r a y i n g p h y s i c i a n s as mercenaries without regard f o r p a t i e n t
velfare.
The e x p o n e n t i a l growth of c l a i m p r o c e s s i n g
t e c h n i c a l i t i e s , coding i n t r i c a c i e s and extended p e r i o d s of
payment d e l a y s have a l l r e s u l t e d i n a c a s h - f l o v n i g h t m a r e
f o r our o f f i c e , and s e r v e d ae a s o u r c e of c o n t e n t i o n between
t h e p a t i e n t s and our o f f i c e .
P h y s i c i a n s w i l l demand t h a t
any r e f o r m w i l l mandate s t r e a m l i n e d b i l l i n g and e x p e d i t e
payment f o r l e g i t i m a t e s e r v i c e s .
�I r v i n Redlener, H. o.
The
private
impacted by the c o m b i n ' ^ t L n ' o r ' S ' " "
severely
Lf?rr:t'"
e x p e n d s T ^ ^ ' -^-''urseme^t an'd
i n f l e x i b l e and prafessionari:.d«
f'^'^"
^^^^-^
by regulatory c o n s t r a i n t s '
P o ? ? : r d e c i \ ^ ^ ^ ^ ^ ^ ^
insurance companies and
"^oj-^cy d e c i s i o n making by
based on community stand:;;:"!? —
P^'-^^-- mu^t ^e
cost containment a n a l y s i s
P ^ L a t ' '"^ '"^ '^^^ ^^^^^^ °"
and insurance c a r r i e r s must I I
Pi'^ctice p h y s i c i a n s
^•ather than a n t a g o n i s t i ^ ; : , : : ? : ^ : i n I T ° ' V ' ^ ' ' ^ ^ ^^^^^^^
q u a l i t y patient c ^ r ^ o PObtuilng i n order to promote
be an urgent p J i o r i t ; J ' ' ^ ^ ^ " ^ ^ " "
^^e^e c o n f l i c t s must
policy i H h e o i i v i t
7
national health-care
in the f i t u r i . '
'^'^^'^^^
-^^^^^^ -dure
Sincerely,
Martin I . Golding, MID., FACP,
FACG
KlG:dph
enclosure
G^STK)(^ml)CXOCV
IKTiltHAt. MEOONE
I
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001a. letter
DATE
SUBJECT/1 ITLE
Jody Thompson to Health Plus; re: Review Claim Number (1 page)
01/04/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz/Jennifer Klein
OA/Box Number:
5107
FOLDER TITLE:
Hassle
2006-0885-F
.ip2650
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)l
Freedom of Information Act - |5 U.S.C. S52(b)|
PI National Security Classified Information 1(a)(1) of the PRAl
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA)
P3 Release would violate a Federal statute |(aX3) of the PRA]
F4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRAj
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information |(bXl) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency |(bK2) of the FOIA]
b(3) Release would violate a Federal statute |(bX3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIAl
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001b. Statement
SUBJECT/TITLE
DATE
re: Explanation of Amount Paid (1 page)
12/23/1992
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz/Jennifer Klein
OA/Box Number: 5107
FOLDER TITLE:
Hassle
2006-0885-F
.ip2650
RESTRICTION CODES
Presidential Records Act - 144 U.S.C. 2204(a)l
Freedom of Information Act - 15 U.S.C. 552(b)j
PI
P2
P3
P4
b(l) National security classified information l(bXl) of the FOIAl
b(2) Release would disclose internal personnel rules and practices of
an agency l(bX2) of the FOIA|
b(3) Release would violate a Federal statute l(bX3) of the FOIAl
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIAl
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIAl
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIAl
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAl
b(9) Release would disclose geological or geophysical information
concerning wells l(bX9) of the FOIAl
National Security Classified Information l(aXl) of the PRAl
Relating to the appointment to Federal office l(aX2) of the PRAl
Release would violate a Federal statute |(aX3) of the PRA]
Release would disclose trade secrets or confidential commercial or
financial information l(aX4) of the PRAl
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRAl
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
OOlc. letter
SUBJECT/TITLE
DATE
Sarah Lynn Campbell to Dr. Martin Golding; re: Reconsider Payment
on Denied Services (1 page)
03/05/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz/Jennifer Klein
OA/Box Number:
5107
FOLDER TITLE:
Hassle
2006-0885-F
jp2650
RESTRICTION CODES
Presidential Records Act - (44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. S52(b)l
PI
P2
P3
P4
b(l) National security classified information l(bXI) of the FOIAj
b(2) Release would disclose internal personnel rules and practices of
an agency l(bX2) of the FOIAl
b(3) Release would violate a Federal statute |(bX3) of the FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIAl
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIAl
b(7) Release would disclose information compiled for law enforcement
purposes l(bX7) of the FOIAl
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAl
b(9) Release would disclose geological or geophysical information
concerning wells l(bX9) of the FOIAl
National Security Classified Information l(aXl) of the PRA]
Relating to the appointment to Federal office l(aX2) of the PRAl
Release would violate a Federal statute |(aX3) of the PRAl
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRAl
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors la)(5) of the PRAl
P6 Release would constitute a clearly unwarranted invasion of
personal privacy |(aX6) of the PRAl
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
OOld. letter
DATE
SUBJECT/TITLE
Dr. Martin Golding to Sarah Lynn Campbell; re: Appeal of Ruling (1
page)
03/16/1993
RESTRICTION
P6^(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz/Jennifer Klein
OA/Box Number:
5107
FOLDER TITLE:
Hassle
2006-0885-F
jp2650
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)l
Freedom of Information Act - IS U.S.C. SS2(b)l
PI
P2
P3
P4
b(l) National security classified information |(bXl) of the FOIAl
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIAl
b(3) Release would violate a Federal statute |(bX3) of the FOIAl
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIAj
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIAj
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells l(bX9) of the FOIAl
National Security Classified Information l(aXl) of the PRAl
Relating to the appointment to Federal office 1(a)(2) of the PRAl
Release would violate a Federal statute l(aX3) of the PRAl
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRAl
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors la)(S) of the PRAl
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRAl
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
00 le. statement
DATE
SUBJECT/TITLE
04/1993
re: Explanation of Amount Paid (1 page)
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz/Jennifer Klein
OA/Box Number:
5107
FOLDER TITLE:
Hassle
2006-0885-F
jp2650
RESTRICTION CODES
Presidential Records Act - 144 U.S.C. 2204(a)l
Freedom of Information Act - |S U.S.C. S52(b)l
PI National Security Classified Information l(aXl) of the PRAl
P2 Relating to the appointment to Federal office 1(a)(2) of the PRAl
P3 Release would violate a Federal statute l(aX3) of the PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRAl
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors la)(S) of the PRAl
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRAl
b(l) National security classified information l(bXl) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIAj
b(3) Release would violate a Federal statute |(bX3) of the FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information |(bX4) of the FOIAl
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy l(bX6) of the FOIAl
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAl
b(9) Release would disclose geological or geophysical information
concerning wells j(bX9) of the FOIAj
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
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�X uteu (.u ^;et i n r i g n t away!
— j 3 iiv^x-wi/v.
Ol Well, are you a member of our frequent surgery program?
P I I was l a s t year, but I already redeemed a l l my surgery
c r e d i t s f o r my prostate ultrasound l a s t year.
Ol 1 see. Let me review with you our current plans. Ve have
our standard 1^ point service s^fssmf/. and our discounted
tilnO package i f you can (j/iye up some of the amenities.
P« What kind of amenities are involved i n bypass surgery?
0. Well, cardiac monitoring and v e n t i l a t o r use are extras i f
needed. In a d d i t i o n , you are responsible f o r your own
meals '^''^^^^^^
i n s e r t i o n s , and of course your own
^'^ lextra
i t r l ?f noir'the
t r anesthesia.surprised t h a t you don't charge
Ol S i r , even our base package covers 2 hours of anesthesia.
Pi I've heard that sometimes t h i s kind of operation can take
considerable longer than 2 hours.
°* ' 'can
r i i lprovide
L Z ° ] f ^ ^you
' '^-^^^
w i t h t '^^^^
y l e n o l suppositoriesoperation we
"of sick'peS^u'^
'''' '^'"^ "
'° ^^^^
^dvisorrd?H f J " " J ° ^
^^^sident C l i n t o n and h i s
advisors d i d t h e i r best to make care a v a i l a b l e f o r everyone.
^hat^^: ' T o l l ' / V l
P. I don't care.
11 r.'''
'''''''
n^ber.^."^
I just need t o get my surgery as soon as possible.
^'^^iirfnS'f'^^K'^^'^^^'^^
. / ^ S ^ ^ i ^ e there i s a 10 month w a i t i n g
p. That's unbelievable; Are t h e i r shortages i n everything?
°' ^ T f l t ^ J ^ " ^ ^^^^^^ gastroenterology. i n f a c t McDonalds was
oust begun a prograjn. . . but k happy meal and receive a
complimentary
colonoscopy.
Pi I'm r e a l l y s i c k .
I can't wait that long.
Ol VJell there i s standby service,
Pi You mean l i k e on an a i r l i n e .
Ol Right: You go t b the h o s p i t a l and i f the scheduled p a t i e n t
dies or i s too sick f o r surgery you may be able t o get h i s
place i n l i n e .
PI
HOW
bout
i f
T
inat.
riav
fr,r-
+Kic?
rr.KTe,r^^f
�OI Well then I'M sure I can get you i n next week.
PI fine...GO ahead and get me scheduled.
Ol We are offering f o r our paying customers several specials.
PI What kind o^ specials?
Ol F i r s t of a l l , i f you book your surtfery by midni-jht tomorrow
1 can provide you with a complimentary vasactomy and a set of
GINSU steak knives.
PI No, that's a l r i g h t . I got a set of them last year when I had
my gallbladder out.
Ol I n a d d i t i o n , I f you'd consider haViNG your anesthesia administered i n
Cleveland and your surgery in New York there i s a s u b s t a n t i a l discount.
P: How can you do that? Doesn't the anesthesia wear o f f during the f l i g h t ?
0: We have experienced a few problems wich t h i s plan. We are o f f e r i n g
f r e e c o c k t a i l s on the f l i g h t and a complimentary r e n t a l car from the
airport.
^'
°'
" ° Standby. NO ANYTHING! I j u s t want to
meet the surgeons to ask a few questions.
am; to
'on r 7 t r l l 2 l U L J I Z J ^ ^ ^ r ' " " ^
°^
providers
f o r % n ?J t \
•"
salary there simply i s no time
ss ee ll ff -- rr ee ff ^e ^r rr a. il laws
1 ^ ^ ' " ^would
" " ^ l ^ make
^^^^^"^
the
i t i l^^^^^'^
l e g a l f '^^^^^^^
o r a surgeon
to operate on anyome they've already met to
^'
^(Sssef
<^^est) This i s t e r r i b l e .
dL^uuf
OH NO!
^L'othfr'cus?omJ°
?Pf^^^°^^ ^ t h e l , I t h i n k we l o s t
Ano^ner customer. I cant believe how w e l l a l l these cost
c u t t i n g programs are working a f t e r a l l !
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
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2006-0885-F
Text
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Title
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Hassle
Creator
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Task Force on National Health Care
White House Health Care Task Force
Carolyn Gatz
Jennifer Klein
Identifier
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2006-0885-F Segment 2
Is Part Of
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Box 10
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093616" target="_blank">National Archives Catalog Description</a>
Provenance
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Preservation-Reproduction-Reference
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2/6/2015
Source
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42-t-12093616-20060885F-Seg2-010-003-2015
12093616
-
https://clinton.presidentiallibraries.us/files/original/8bbb350a34d3b4f43fed51db2a7e0353.pdf
2301a99cc9fac4687505fd526c1d1f5a
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the WiUiam J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Carolyn Gat/yjennifer Klein
Subseries:
OA/ID Number:
5107
FolderlD:
Folder Title:
[Legal Audit Group]
Stack:
Row:
Section:
Shelf:
Position:
S
56
5
5
3
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. list
re: Legal Audit List - Clearance List (partial) (1 page)
05/14/1993
P6/b(6)
002. resume
re: Eleanor DeArman Kinney (partial) (1 page)
ad.
P6/b(6)
003. resume
re: Paul S. Ceja (partial) (1 page)
04/22/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz/Jermifer Klein
OA/Box Number: 5107
FOLDER TITLE:
[Legal Audit Group]
2006-0885-F
ip2651
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)l
Freedom of Information Act - |5 U.S.C. 552(b)l
PI
P2
P3
P4
b(l) National security classified information ](bXl) of the FOIA]
b(2) Release would disclose Internal personnel rules and practices of
an agency l(bX2) of the FOIA]
b(3) Release would violate a Federal statute )(bX3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
Information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted Invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose Information compiled for law enforcement
purposes ](b)(7) of the FOIA]
b(8) Release would disclose Information concerning the regulation of
financial institutions ](b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells ](bX9) of the FOIA]
National Security Classified Information 1(a)(1) of the PRA]
Relating to the appointment to Federal office |(aX2) of the PRA]
Release would violate a Federal statute |(aX3) of the PRA]
Release would disclose trade secrets or confidential commercial or
financial information ](a)(4) of the PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors ]aXS) of the PRA]
P6 Release would constitute a clearly unwarranted Invasion of
personal privacy ](a)(6) of the PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
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121002/006
HRST AVENUE AT I6TH ?rmr. NEW YORK, NY 1C0O3 (su) 420 2000
May 3, 1993
To:
Legal R«vl9w Group
From: Kathryn M«yer ^|/>y^V^
Enclosed for your r«vl«w are digests of my notes from
Thursday's ina«ting and Barbara McGarey's notes from Friday's
meeting (unfortunately, Barbara's notes are partially illegible
I have tried to f i l l In the missing language where possible.) I t
strikes me that Barbara's notes include most of the issues froir;
Thursday, and that with some alight adit ing we could use h«r
draft as the document we submit, I also think that, given the
amount of flux that remains in the program, i t isn't worth
spending too much time refining these papers.
I can be reached at 212-420-2929.
AmUATBD WnW MOUNT 5INAJ SCMOOT. Of MHDICINE.
MKMBBK OF PEDBRATION OF JfeWISK PHILANTHK 'P1E8,
�SENT BY:D0H COMMR. OFFICE
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BIMC LEGAL DIV
1^003/006
LEGAL REVIEW GROUP MINUTES — APRIL 29, 1993
A.
Legel Issues Raiaed By the Group
1. What standards and procedures w i l l be established to defino
"medioally necessary"? Will there be an administrativ© procee^?
Can states vary in t h e i r definitions?
2. How "governmental" muat the Health Alliances ("HA") be i n
order for them to be able to sot and c o l l e c t premiums? Do the
powers of the HA's constitute an unconstitutional delegation of
the federal taxing power? I s the answer different i f the HA i i a
state agency? I s the answer different i f the employer i a not
required to make contributions to the HA, merely denied the
deduatlbility of h i s premium costs? Should the HA ba a federal
agency?
3. What standards and procedures w i l l be established to
determine the setting of premiums?
4. What ERISA preemption issues are raised by using the HA's ^o
establish premiums for qualified plans?
5. What effect do the states' legal and constitutional
limitations on governmental taxing powers have on the a b i l i t y
the HA's to set and c o l l e c t premiums?
6.
To What extant does the federal program preempt state law?
B.
Legal issues Raised By Task Force Members
1. What options are available to the federal government i f a
state rafusas to comply with federal requirements? can the
federal government intervene and take over a state's program?
2.
IB there a better phrase than "medically neaessary"?
3.
Who can sue whom for what?
C.
Factual Issues Raised By the Group and Not Yet Answered
1. What exactly i a meant by the phrase "the Health Alliances
bear no r i s k " ?
2. How w i l l the HA's c o l l e c t premiums? HOW w i l l premiums be
collected from self-insured individuals?
3.
How w i l l the states' budgets be established?
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BIMC LEGAL OIV
WHITK UOOSE
. . . BIMC LBCAL Olv
Stored as legal.iss; rovJoou April 30, 1993
GENKRAT.
T.S5;M1:S ID£N1''ZFIED
BV LEGAL AUDIT GROUP
General
Wha-t doss pQd*r.'«l pi\:.'\t;utc have: ro include te eneuce
censlatenoy, 'foitwets^ and anfnmnTihn i ty oi the
program?
Hedioal MalpzacLlco/rorc KfrfOi'ffl
KQv can ve Kasp madir:nl mnlprnctios in tha state
oeurtsf
Enterprise
Llnb( Ut:yj wiLcn or without rmpn
Flans must nffsnr^^niT C'&^f.'l.stant with Stats ststutea
elMady in p; ace. cr",: ,•: lu ocfrsm croeting another layer?
What tort rnf'.'u';;i-< mnkft .'innpft - r,«p« on damages, oapa en
p l o i n t l f f a ' n^r^m'ieye' i^8i3M, iiiMiidaT:ory c o l l a t e r a l
o f f s e t , \ir\iffii'<; .::!-iUiic of llmixationo?
What private nausr'ii
ac.V.ion aire necdtisary?
What type &r i Mimploin 1:! cLflLrion w i l l davalop'/
Olsolosure v, l^ifernu^i (-cinttnt - vho.rft tn draw the
botwoon eonsv;:mc<f CLM p.ici.ent
Benefits
/aped
f i. •
line
: .ii.' i L i, uv of ueneti us
What i s meriieai^y w^c^aswy./i'i^dically appropriats i s eonaum«r/p.ch'arvrb <<|jinion or cos-c-sffscxivanesB fie
faetered into rneit'c^iIv AcocD<aory
appropriate
decision-m&Kiiig?
Will IndlvldvoJ v6rto ii».>v(ti<i in and ouc of oinplaymont with
larHtt flrmu (ao, m^onc^d bi> chanoR pi ans. assuming InrgA
f i r m KA docns'^"^
,,i :':it;:c v;i';h cciin* p l a n s ?
Should prorjrAm dfof.Asrr? «taw jiVatutory lanflufiBe or build
an nedicsXi V v^easlSttw>^i^^o<3^.tftIJLy.r^ppropriote?
Foderol/State
Inin-
i.ir:rj.-i.i Aui-liu: iLy for proqrsni
What l a the Uinicnt\^t'l(.i^;2il basi:^ tnr the tinancing of
the progre")'"
Probleme of Ui«^«.or>sti-tuti.c,ial tJ^-icyitrion ot T»xing
authority fu•^ ..
i iifni fJop.onding nn what entity I s
1£1004/00B
iflui^a,-vu«
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BIUvJ UH.\L DIV
WBIIE HOUSE
BIMC LEGAL »1Y i£iuu;>/uu4
2
i
determining sno collecting benchmark premium.
Authority to r.^gulate cor.'sract betv>?Ben non-HA employers
and plans (pro^rv* propor as "'-o regulrs omployer plens
to eeeept QLL da.^eiK'.in!U.«. cci.iect data, e t c . )
Authority for
nc: ft^et© "paysack,"
10th Amendme:')':- Xss^e^
Issues regard;i.i ..j f; c:..t;cis' bBlanoed budget amendment
l e w i , "tnti-desfc'ici^-.'iny" lows
Federal Pre-emption
What State }.avus OBA^pre-errpcsd by tha pragr.-im?
Are State pobl-c.'V)«AJ?l:h auchurlties (suci-i t^n
communieabKi oiise**-**' r*jpori:.1,'.-ig rnquiremonv.ft, quarantine
and detent.lotN
lUifta:. pre-emipted by i.his program?
HOW do nati-'hi3k.^ c^occl I f,v of -^era regulations
state law? ^^.d ^ ro-^.n«")(i»?
pre-empt
Uegel Structure o; H.\
Za the HA a cj»ivof:?ftinsnt:il ii:i;ity (port of State Health
system or othSi- S+ttfttt siitxtyj
la
tha HA a rr^t»^-jsro.f i I- pri./^i:e corporation?
Dlf fer^^mt lagai ;prc k>.(if.nn.^; Fi..uii-t;jia depend incj on structure
and B'jthor:: L-^>{ of4WKA > .i ,e . unconsrj.tutlonol
delectation oF'^^o»/«-'""^rMi-:ncs.l regulatory authorities)
Bit:3.'Luaive v. Fiow-fti«<c!.iJsivp. HAS - how can o large firm
wh.f crli forms iris- '•'JOI*. IIA perform tho governniontal, quaelrisgulatory -•iiriCfe-/«.:n.s of tha MA, such as rntf* setting,
•^iwrtifioaticm .of plDn.?, 8v.-:hority to rejscv c e r t a i n
pXuxi i , and ^,^pri:.vOi..L of iua:o:- expenditures of plana?
Forum ot Dispute Ce-iolu-Ho^/hQc.-r- of Liabilil.y
Who sail BUG \>j\r>orr\
vjhrht
and in whnt fcirum?
What are pro<-a,ciiun8jS (;.,.«., ;:!n:«ndlng) and substantive
•tandards Xoc cA-Vsi^uLe r'fiir;clutiQn
ERISA
How does the- ^.rtgiJKMY;^ j; siiata i;c- ERISA
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DIV
Confidentiality
How do rederal .anA^ S+'aJflfc f0: laws ralijita to information
OOlleotion provi'&rQ.tnA of ,)i*ogram?
Provider qnnf,'dl<a*vtfai i ry > .'
How do inio>TY\CL+i"ar'i Ca I j,rtc ti'LPi prov.L8iohs r e l a t e to
current Fadftro^L .uM si^ie. f.mfidentiolity laws ( i . e , 42
U . S . C . 290,1 '
CD(\ttdK#kl 1 1 • ty of alcohol and drug abuse
treatinent
i• .
1983 Suite AgaxnsL; ^i-t-ioj£^
Transition
IB6U&.«--.
I
Anti-Trust/Anti-K>>''«^i='*^ 15S!JO, J '
Are there (fncsi'>S' S •'*ri?r.<i«e-:' in now program encouraging
provider c.-Qa^cro^-^'(yy-^ .OL,A .'inti-trust prohibitions i n
current PstidiinjsJl i^ci
.mw/
National Manda-ae. vs
-^-^t v,
What i a tho -cx^ev«K' ::.;i iite v n r i a b i l i t y which w i l l be
allowed i n , -finr- «:viar»j.»te, isuppjeinantal insurance,
supplementnl V-n«,.Rfe>7
R e s t r i c t i o n ev^
.1 •ii;.,;Jit-i'.nhrkoting raises questions
of llmltir.fj
1 ;j;|.i,iii;icn by plans or insurers consumers i:. •
i. li it jr •v'oriiiiisnt limiting the
Informatior, «.ga.ilatei-e^ i
iii,-iita plans.
121006/006
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SCOTT HAflSHBARGER
ATTORMVaetUAL
(617) rir'38eo
FACSIMILE COVER SHEET
TO:
ho^^
/5/?^>^€r
ORGANIZATION: A^^g^' "^^-iJC C
TKLEPHONB #:
FACSXHILS #:
t ^ ) 2'^Cl
[HAX)
fL^-
o'^m
FROM:
BUREAU/DIV.:
TELEPHONE #:
($17) 727-2200
FACSIMILE #:
2-
(617) 727-5762
DATS:
PAGES (INCLUDING COVER SHEET)
5-. Z'?^.^
TIME:
NOTES:
••TOWfTPgNTTALITY NOTE**
The documents accotnpeuiying this facoimdle transmission contain
information from the OCClce of the Attomey General which may
_
be CONFIDENTIAL AND/OR PRIVILEGED. The information i s intended
to be for the use of the Individual or entity named on tl^^atransmittal sheet. I f you are not tha intended recipient be
aware that any dlscloaure, copying, distribution or usaof Che
concents of this information i s prohibited. I f you have
received this faceimile tn error, please notify us by teljephone
immediately and retum the original message to us at theabove
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202 456 7739;# 8
tt202 P02
M E M O R A N D U M
TO;
Barbara McGarey
Deputy Director, Office of Technology
Transfer, NIH
FROM!
Barbara Anchony
Chief, Public Protection Bureau
Massachusetts Office of the Attorney General
One Ashburton Place
Boston, MA 02108
Telephone #: (617) 7^7-2200
Fax #: (617) 727-57e2
DATE:
May 3, 1993
Below axe some additional comments on the general issue^
list:
.1.
2.
Re:
Medical Malpractice/Tort Reform
a)
What i s disposition/redistribution of savings
generated by providing tort immunity Cor practitiohers?
b)
Are ths rights of consumers being inadvertently
curtailed by r e s t r i c t i n g tort claims to the health
plans? Are there instances where "enterprise
l i a b i l i t y " w i l l foreclose a right of action that t|he
consun\er may have had against an individual
practitioner? Shoul^a there be some language added to
insure that euch i s not the intent?
Forum of Dispute Resolution
a)
I s the federal claims dispute resolution syetsm
proposed intended co be an exclusive remedy?
b)
Ifl i t intended to preempt access to state agencies or
courts with respects to disputes about benefit
claims? This should be c l a r i f i e d .
BA/bt
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MEMORANDUM
TO:
I r a Magaziner
Larry Gostin
FROM:
Mark Barnes
\
DATE:
May
I
RE:
Public Health Services in the Health Care Reform PackSge
4, 1993
I would l i k e to c a l l to your attention a series of issv.es
related to state and local public health law and practice which, i
believe, require urgent attention during this l a s t stage of the
health reform review process.
I have serious concerns that the
range of public health interventions and services — from free
specialty c l i n i c s treating tuberculosis and sexually transmitted
diseases, to the non-clinical interventions of contact tracing,
directly-observed therapy for tuberculosis control, detention or
c i v i l commitment, and environmental inspection — have not beien
f u l l y considered or integrated into the health care reform
proposals.
This i s of conoern for two primary reasons:
first,
because a national health care reform package that does not
consider and include these services may have unintended preemptive
effects on these laws, regulations, and services; and second,
because not including these essential prevention services w i l l
hinder the overarching prevention and cost-efficiency goals of the
health care reform package. I have summarized below the areas of
concern and possible solutions,
I.
Public Health Specialty C l i n i c s and Treatment Systems
Since the l a s t decade of the nineteenth century, municipal ejnd
county health departments have established and operated systems of
disease-specific c l i n i c s whose primary purposes are not so much the
trgfitmgpt
af
individual paUents ia
tlis
interruption of
transmission
&£
infectious disease.
Interrupting dis lea
transmission takes place through two primary methods:
f i r ^ t,
treatment to render the patient non-infectious, and second, tjhe
triggering of contact tracing, contact evaluation, and offering of
treatment to others who have been exposed to the index pati.er t
For persons with sexually-transmitted diseases, for example, a
specialty sexually-transmitted disease c l i n i c treats, in some casjes
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pseudonymously, the infected patient, but also maintains on-sit«» a
corps of public health professionals who interview each pati€int
about previous sexual contacts and who then personally v i s i t tjhe
sexual contacts to offer counseling and treatment. Similarly,
public health tuberculosis c l i n i c s , treatment of patients to render
them non-infectious
i s accompanied by interviews and
c^se
management by public health professionals, to evaluate the conta
of index cases and to follow the index cases over time to ensdre
completion of anti-tuberculosis treatment.
For tuberculosis
patients, t h i s may include designating a public health worker to
observe the patient take his or her prescribed daily medication
a process referred to as "directly-observed therapy."
By interviewing and case managing these patients, and by
coupling,
on-site, individual treatment with public hea]|th
interventions, we not only can interrupt transmission, but we a] so
can achieve an economy of scale, simply by stationing our corps of
contact tracers and case managers at select locations instead of
throughout the health care system. Further, because treatment may
be given in these settings (as in publicly-run family plann i|ng
c l i n i c s and confidential Hiv testing s i t e s ) on an anonymous or
pseudonymous basis, some persons may come into treatment in th^se
c l i n i c s who otherwise might forego any treatment at a l l .
School-based health c l i n i c s at which children receive primary
care, preventive care and immunizations, and free-standing chi Id
and maternal health c l i n i c s , are other examples of specializ ed
public health c l i n i c s that serve preventive functions and that
promote the health not only of individual patients, but also of
others, including family members.
In these c l i n i c s as we 3|1/
economies of scale are achieved, and public health interventi ens
can be rapidly used, where indicated.
The maintenance of these public health c l i n i c systems se ems
e s s e n t i a l enough, based on h i s t o r i c a l and p r a c t i c a l experience, to
merit t h e i r preservation in the f i n a l health care reform proposall1.
Although the proposals cohtemplate the desighatioh of "essenti al
community providers" (ECPs) and a five (5) year phase-in period
tor
the ECPs' f u l l participation in local health plans, the proposal
do not address the issues of (1) ensuring the continued v i a b i l i s
of these publicly-run c l i n i c s after the phase-in period, based ty
on
their public health importance; (2) leaving options for developing
future specialty public health c l i n i c s , as diseases may emeige
whose infectious nature and a f f l i c t e d population indicate
usefulness of such c l i n i c s ; (3) ensuring sources of anonymous the
or
pseudonymous care when these c l i n i c s otherwise
must s eiek
reimbursement i n every case^by identifying the patient to his or
her health plan; and (4) ensuring the use of t r a d i t i o n a l publji c
health interventions such as counseling about contacts, case
management, and directly-observed therapy in the c l i n i c setting
�SENT BY:D0H COMMR, OFFICE
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As potential solutions, I propose that the Task Force consider
the following:
1 .
For existing disease- or population-specific c l i n i g s ,
especially for those with particular preventive or public
health purposes, a l l health plans i n the c l i n i c s '
catchment areas should be required to reimburse t;he
c l i n i c s for services rendered to plan members, at
standardized rates. This guarantee of payment should be
extended beyond the five (5) year phase-in period. I f
these c l i n i c s do not provide quality care to patients,
then presumably their patient population and sources of
revenue would decline appropriately.
For patients who wish access these services on an
anonymous or pseudonymous basis; the health plans in the
catchment area would make periodic payments to these
c l i n i c s , based on the plans' shares of identifial^le
patients receiving services at the c l i n i c s .
3.
Patient-specific p\iblic health interventions offered by
health department o f f i c i a l s at these c l i n i c s , such as
case management, counseling about contact n o t i f i c a t i cn
disease prevention counseling, and directly-observ
therapy given in a c l i n i c setting, would be reimbui
under the health plans, as part of each persor.
comprehensive benefits package.
4.
Purely anonymous service c l i n i c s , such as anonymous U V
counseling and testing s i t e s , would continue to be funded
through federal, state and local prevention funds, and
not reimbursed through health plans,
II.
Public Health Interventions
Adjunct to C l i n i c Settings
In addition to purely voluntary interventions (counseli4g(
case management) offered i n public health c l i n i c s , public health
personnel i n these c l i n i c s are trained to offer and to provide a
range of other, more aggressive interventions. For tuberculos i s
patients, for example, these interventions can include f i e Id
outreach so that public health workers observe a patient receiving
his or her anti-tuberculosi^ medications voluntarily each day for
s i x (6) to nine (9) months, u n t i l the patient i s cured; givljng
these medications each day by v i s i t i n g the patient at home or in
other non-clinic settings; giving these medications to pat
:iert s
pursuant to a court or public health authority order to th e
patient; or even detaining the patient i n a r e s i d e n t i a l medi ca 1
setting so that the patient remains i n state custody, wii th
medications given every day, u n t i l cured. For sexually transmi ttjed
diseases, these more aggressive interventions can include con t^ct
tracing in the f i e l d and even public health orders for examinatl on
�SENT BY:D0H COMMR. OFFICE
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or treatment. Similarly, for children with elevated blood lejad
l e v e l s , public health inspections of their homes or apartments are
immediately undertaken to identify and abate causes of lead
poisoning. This public health inspection process protects both the
index child, as well as other children in the child's family, fi|om
further lead ingestion and i l l n e s s .
Wild-1"
My understanding of the current reform proposals i s that they
would not regard these interventions as part of a comprehensijve
benefits package, even though these interventions are designed to
prevent disease transmission^to others and therefore are more cos teffective than the treatment whose sole intended beneficiary i s tihe
individual patient.
At the same time, however, such coerc ive
interventions for mental i l l n e s s , such as court- or physici a|nordered day treatment or involuntary c i v i l commitment, wou Id
apparently be reimbursable as part of psychiatric coverage in tjhe
comprehensive benefits package.
Conceptually,
t h i s i s an
inconsistency. Why should a tuberculosis patient who does not tajke
his or her medications and who needs the medical intervention of
c i v i l commitment u n t i l cure, both for his or her own health and ^or
the health of others, not (receive" that intervention, while tihe
involuntarily-committed psychiatric patient e s s e n t i a l l y receives an
entitlement to medically appropriate residential care?
Indeed, we have seen many instances recently of tuberculos i s
patients who have been hospitalized multiple times for the i r
disease, only because they have never had the kinds of publ i c
health follow-up support that would ensure their continx; ed
compliance with medications and their cure. These patients revolve
in and out of acute-care hospitals, receiving only episodic care
because that i s the sole type of care that tfi reimbursed by
existing funding streams.
Discharged from the hospital, they
return to the community, do not take anti-tuberculosis medications,
and reactivate their dised'se, harming themselves and others
Increasingly, these revolving rehospitalizations lead to the
development of drug-resistant strains of tuberculosis, making
treatment more d i f f i c u l t and much more expensive. Health reforms
must find ways to avoid these repetitive human and f i n a n c i a l costs.
VIA not
One could argue that other federal, state and l o c a l public
health funding streams should pick up the costs of these
interventions, as they have in the sexually-transmitted disease
(STD), tuberculosis and lead paint inspection contexts for many
decades.
Yet f a i l u r e to include these interventions in the
benefits package w i l l mean that many states and l o c a l i t i e s w i l l rot
employ them effectively, or at a l l , leading only to more cases of
infection, disease, and increased costs for individual treatment.
Further, some presenters to the legal audit group indicated that
states and l o c a l i t i e s w i l l be barred from adding supplemental
benefits to the comprehensive benefits package.
Since many of
these more aggressive interventions (directly-observed therapy,
intensive case management, c i v i l commitment with good care and
�SENT BY:D0H COMMR. OFFICE
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nutrition, public health inspections for sources of environmental
pathogens) can easily be construed as great benefit to the
individual patient, i t i s unclear the extent to which states and
l o c a l i t i e s would be able to fund and offer such additional
intervention "benefits" to patients. Ultimately, however, the more
mandatory nature of these interventions means that only government
e n t i t i e s may undertake them; and p r a c t i c a l i t y and efficiency
dictates that these public health services should continue to be
centralized i n existing departments of public health.
In summary, then, my concern i s that the f u l l range of public
health interventions has not apparently been included in the
benefits package as "medically
appropriate"
or
"medically
necessary," even when these interventions are the most costeffective available for preventing future i l l n e s s and for treating
individual patients. Further, my concern i s that any bars to state
or l o c a l "add-ons" to the comprehensive package not be construed to
prohibit these non-clinical, " f i e l d " public health interventions,
including such "benefits" as intensive case management and daily
observation of patients' taking medication in their homes or other
non-clinic settings. My recommendations therefore are as follows:
1
I f prevention of future cost i s an overarching goal of
the reforms, then preventive non-clinical interventi cn s
such as case management, directly-observed therapy i n tlh e
f i e l d , preventive detention or c i v i l commitment, and
public health inspections to identify sources of
environmental pathogens, should be covered by
the
bertefits package, and should be reimbursable to the
health
or
social
services agency providing
the
intervention, to tjie extent that these interventions are
patient-specific
rather
than
non-individualize|d,
population-wide efforts.
2.
In any case, even i f these patient-specific interventicjns
are not covered, any bars to state or l o c a l "add-ons" to
the benefits package must be written so that there i s no
prohibition
of
these
necessary
public
health
interventions.
I f e x p l i c i t non-preemption were the
option chosen, there i s a pressing need, as I believe one
c l u s t e r group recommended, for a percentage set-aside of
plan premiums to fund these cost-effective interventions
This percentage would need to be adjusted to conform to
the widely varying public health needs of different
health alliance areas.
Areas with much higher public
health needs, as determined by epidemiologic evidence,
should receive proportionately higher percentages of
premium funds.
III.
The Integration of Public Health Prevention Strategies
into Health Care Delivery
�SENT BY:D0H COMMR. OFFICE
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2129640472-
202 456 7739;»14
A third major area of concern i s the ways in which publi c
health prevention measures w i l l be integrated into the delivery of
medical care to individual patients in general ambulatory c l i n i c s,
private physicians' offices, and acute and
long-term calre
f a c i l i t i e s . For patients with tuberculosis, HIV/AIDS, sexuallJy
transmitted diseases, or other conditions e t i o l o g i c a l l y linked to
environmental conditions or " l i f e s t y l e " factors, and for patien ts
not i l l but who need preventive measures to avoid i l l n e s s , theJre
are a range of public health interventions that are indi.cated
These measures include case management and intensive follow- up
directly-observed therapy, contact evaluation and contact tracinjg
immunizations, prevention counseling and periodic counse ling
reinforcement, family counseling, and in extreme cases, preventive
involuntary confinement, especially for patients with multi-drug
r e s i s t a n t tuberculosis who w i l l not or cannot adhere to medication
regimens, even with case management.
Unfortunately, when patients with these conditions seek care
in settings other than specialty public c l i n i c s , we have d i f f i c u l t y
ensuring that these prevention interventions are integrated into
the delivery of medical care, even though we know that such
integration i s necessary to achieve overall reductions i n morbidity
and transmission.
Further, because they are often preventive
rather than curative, the integration of these interventions into
c l i n i c a l practice i s not generally susceptible to "outcorres
measurements." Yet according to the presentation to our legal
group by the quality assuI^ance and information system cluster
group, the Task Force i s apparently headed toward using "outcomes"
as the primary method of measuring quality of care.
Such a
yardstick i s , in my estimation and experience, i n s u f f i c i e n t to
gauge the most cost-effective public health interventions:
although perhaps counter-intuitive, public health success i s
measured, sometimes impossibly, by disease that does not occur,
rather than by disease successfully treated.
In the presentation made to our legal audit group by Arncld
Epstein and others, we also were told that quality of care
regulations, and even such areas as f i r e safety, patients' rights,
and "sanitation," would be standardized through federal regulations
applicable to a l l health care providers, but enforced through state
health delivery regulators. Presenters to our group seemed, at the
same time, unsure as to whether and how these standardized federal
regulations would preempt existing state and l o c a l health and
public health regulations, such as mandatory retention i n acvte
care f a c i l i t i e s and isolation of infectious patients. These pl4ns
r a i s e two primary areas of concern, and suggest two options;
1.
I f these federal regulations are crafted so as to preempt
existing state and local health and public health
regulations, then public health concerns and traditior.al
public health rules, from disease reporting to i s o l a t l on
to detention/retention
of
infectious patients to
�SENT BY:D0H COMMR, OFFICE
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202 456 7739;#15
2.
frcnt
»n<5 iocal
' " l l t y of h^f'' effect a! ' ' ^ ' i " ' «nl
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t^ar.'"..'""- arl°as
public health^T
federal reguirf® '"P^^on of
longrtfrr*^^ for delivert^!^^'"«'^ts Of ^ „^^^,^ health int^^^^^ ^ore
valuable
delivered^^.
f'o/j^^-V'^ °f ca'e r^'°"^
f^st include
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4."*^^"^ referral o^?^
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t\\'i'^^'^iur\^^,«^^^^^^^^ -/e'fc^,-°"temp\^^^^^^
quality of
wouli^^^^^ ^^nefits^"!^f^« these s t e L ? ^^^^ividual ^''/^f^ration of
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to prevent disease
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�SENT
BY:D0H
COMMR, OFFICE ; 5- 4-93 : 8:20PM :
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�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. list
SUBJECT/TITLE
DATE
re: Legal Audit List - Clearance List (partial) (1 page)
05/14/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz/Jennifer Klein
OA/Box Number: 5107
FOLDER TITLE:
[Legal Audit Group]
2006-0885-F
jp2651
RESTRICTION CODES
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Appointments Center
Room 060, GEOB
Please admit the following appointments on
far
.'fl^nae''
Mo^
Klein
^
nf
, Ifl
J)o>y)fif'.'C
(NAME OF rCRION TO BC VKITEOl
Pff/ay
(*«KNCV)
'
LEGAL AUDIT LIST
CLEARANCE LIST
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�CURRICULUM VITAE
ELEANOR DeARMAN KINNEY, J.D., M.P.H.
Indiana University School of Law — Indianapoli.s
735 West New York Street
Indianapolis, IN 46202
317-274-4091
EMPLOYMENT
Professor of Law, Indiana University School of Law ~ Indianapolis, Indianapolis, IN, Aug. 1990Present; Associate Professor of Law, Aug. 1988-Jul. 1990; Assistant Professor of Law, Aug.
1985-Jul. 1988; Visiting Assistant Professor of Law, Aug. 1984-Jun. 1985; Adjunct Professor of
Law, Jan. 1984-Jun. 1984. Professor of Public and Environmental Affairs, Part Time, Indiana
University School of Public and Environmental Affairs, 1993-Present.
Teaching areas: Health Law, Administrative Law, Insurance Law and Torts.
Recipient, The Best New Professor Award, Student Bar Association, 1986.
Director, The Center for Law and Health, Indiana University School of Law ~ Indianapolis, Jul.
1987- Present; Director, The Program for Law, Medicine and the Health Care Industry, Jul.
1986-Jun. 1987.
Consultant to the Congressional Office of Technology Assessment ("OTA") to study the Impact of State
Tort Reform on the Medical Malpractice System and Physician Behavior for OTA's study on Defensive
Medicine and the Use of Medical Technologies, Sept. 1992-Present; Consultant to the Administrative
Conference of the United States to conduct three studies: (1) The Medicare Appeals System for Coverage
and Payment Disputes, Dec. 1985-Dec. 1986; (2) Procedures for Making National Coverage Policy under
the Medicare Program, Apr. 1987-Dec. 1987; (3) Rule and Policy-Making in the Medicaid Program, Oct.
1988- Dec. 1990.
Principal Investigator on the following grants and contracts: Grant from The Robert Wood Johnson
Foundation to Study Barriers to Private Health Insurance for the Seriously 111, Sept. 1992-1994; Grant
from The Robert Wood Johnson Foundation for Planning Phase of a Demonstration of Quality Assurance
Strategies for Indiana's Community-Based, Long-Term Care Program, Sept. 1992-Aug. 1993; Grant from
The Robert Wood Johnson Foundation to Evaluate Indiana's Medical Malpractice Act, Jul. 1987-Jun.
1990; Grant from the AARP Andrus Foundation to Study Issues Regarding Medicare Appeals for Home
Health Services, Jul. 1988-Jun. 1989; Grant from the National Multiple Sclerosis Society to study barriers
to health insurance for individuals with disabilities and chronic disease, Oct. 1989-Oct. 1990; Contract
from the Indiana Department of Human Services to Study Indiana's Community and Home Option to
Institutional Care for the Elderly and Disabled (CHOICE) Program, Sept. 1989-Dec. 1990; Grant from
the Indianapolis Research Support Committee, Indiana University, to establish the Center for Law and
Health, 1986-1988; Contract with the Maryland Department of Health and Mental Hygiene to Study the
Organizational Structure of and Linkages between the Rate Setting and Health Planning Functions in
States with Mandatory Hospital Rate Setting Programs, May 1985-Aug. 1985.
�Assistant General Counsel, American Hospital A.ssociation, Chicago, I L , Aug. 1982-Jun. 1984.
Directed the State Legal Initiatives Program responsible for all state legislative, regulatory and judicial
issues for AHA's Office of Legal and Regulatory Affairs. Assisted in directing activities of AHA's
Office of Legal and Regulatory Affairs on federal health law issues. Served as Legal Advisor to AHA's
Office of Health Care Coalitions.
Program Analyst, Office of the Assistant Secretary for Planning and Evaluation/
Health, Department of Health and Human Services, Washington, DC, Jun. 1979-Jul. 1982.
Served as coordinator of legislation and regulations; principal analyst for capital financing and regulation
issues with work on Medicaid and civil rights issues.
Recipient of the Office for Civil Rights award for distinguished performance on the New York City
Health and Hospitals Corporation Investigation, May 1979-Sept. 1980.
Estate Planning Officer, Duke University Medical Center, Durham, NC, Sept. 1977-Jun. 1979. Tax
and estate planning work for donors to Duke University Medical Center.
Associate Attorney, Squire, Sanders & Dempsey, Cleveland, OH, Jun. 1973-Jul. 1977. Litigation
and corporate practice specializing in tort and medical malpractice issues.
Summer Intern, Legal Aid Society of Forsyth County, Winston-Salem, NC, Summer 1972. Designed
and implemented a program to improve legal services for the elderly poor.
EDUCATION
J.D., May 1973, Duke University School of Law, Durham, NC (Editorial Board, Duke Law Journal);
M.P.H., Dec. 1979, University of North Carolina School of Public Health, Chapel Hill, NC; M.A., May
1970, University of Chicago, Chicago, IL (Degree in Modern European History); A.B., Jun. 1969,
Duke University, Durham, NC (Graduation with Distinction in History).
ADMITTED TO PRACTICE
Supreme Court of Ohio, 1973; Supreme Court of North Carolina, 1977; United States District Court for
the Northern District of Ohio, Eastern Division, 1974.
PROFESSIONAL SERVICE
Major Service: Member, Executive Board, Indiana State Board of Health, 1989-1993 (Appointed by
Governor Evan Bayh); Member, Advisory Committee for Children with Special Health Care Needs
Program, Indiana State Department of Health (1993-Present); Vice Chair, Committee on Health, and Vice
Chair, Committee on Rulemaking, American Bar Association Section on Administrative Law and
Regulatory Practice, 1990-Present; Member, Subcommittee on Solutions, Indiana Commission on State
Health Policy, 1990-1992.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002. resume
SUBJECT/TITLE
DATE
re: Eleanor DeArman Kinney (partial) (1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz/Jennifer Klein
OA/Box Number: 5107
FOLDER TITLE:
[Legal Audit Group]
2006-0885-F
.ip2651
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)|
Freedom of Information Act - [5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information |(bXl) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute |(bX3) of the FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy |(bX6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions i(b)(8) of the FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIAj
National Security Classified Information 1(a)(1) of the PRAj
Relating to the appointment to Federal office |(aX2) of the PRA|
Release would violate a Federal statute |(aX3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information |(aX4) of the PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Other Service: Member, Subcommittee of Indiana State Legislative Committee to Study the Long-Term
Needs of Persons with Developmental Disabilities and Mental Illness, 1993-Present; Member, Strategic
Planning Committee, Visiting Nurse Service, Indianapolis, IN, 1988-Present; Board Member, Indianapolis Alliance for Health Promotion, 1987-1991; Indiana Advisory Board Member and Private
Judge, The Private Adjudication Center, Inc. (An affiliate of Duke University School of Law), 1987Present; Member, Government Affairs Committee, Community Service Council of Central Indiana, Inc.,
1989-1991; Board Member, Visiting Nurse Service, Indianapolis, IN, 1990-1991; Member, Govemment
Affairs Conmiittee, American Diabetes Association, 1989-1990; Board Member, American Diabetes
Association ~ Indiana Affiliate, 1987-1990; Member, Block Grant Advisory Committee, Indiana State
Board of Health, 1987; Site Visitor, ABA Accreditation Inspection of LLM Degree Program in Health
Law, Depaul University College of Law, Chicago, IL, 1989; Site Visitor, ABA Accreditation Inspection
for Proposed LLM Degree Program in Health Law, Loyola University, Chicago, School of Law, 1987;
Indiana University Institutional Review Board, 1985-1988; Chairperson, Committee on Membership and
ex officio member of the Executive Board, American Public Health Association, 1983; Co-Chairperson
of the Washington Local Health Law Forum of the Forum Committee on Health Law, American Bar
Association, 1982.
UNIVERSITY SERVICE
University committee service: University Affirmative Action Committee (1992-Present); Administrative
Review Committee for the Dean of Indiana University Medical School (1992-Present); Administrative
Review Committee for the Dean of the Law School (1993-Present).
Law school committee service: Dean Search Committee (1986-1987); Curriculum Committee (1986);
Student Affairs Committee (1984-1986; 1988-1990); Library Committee (1987-1988); Faculty
Appointments Committee (1989-1992); Building Committee (1992-Present); Library Conunittee (1992Present); Summer Salary Task Force (1992-1993).
PROFESSIONAL ASSOCIATIONS
American Bar Association, North Carolina State Bar Association; American Association of Law Schools;
National Health Lawyers Association; American Society of Law and Medicine; American Public Health
Association; Indiana Public Health Association.
MISCELLANEOUS
Director and Vice President, Triangle Biomedical Equipment, Inc., Durham, NC, 1977-Present; CoChair, Patrons Committee, 1991 Gala, American Diabetes Association, Indiana Affiliate, 1991; Board
Member, Festival Music Society, Indianapolis, IN, 1984-1988, Vice President, 1987-1988; Member of
China trip for federal health policy makers sponsored by the National Health Policy Forum, George
Washington University, Washington, DC, 1979.
PERSONAL
Husband: Charles M. Clark, Jr., M.D.
Children: Janet Marie, Brian Alexander & Margaret Louise
Birth Date:
P6/(b)(6)
�PUBLICATIONS
Kinney, Medical Practice Guidelines: Evolutionary Trends and Future Implications, in HEALTH CARE
DELIVERY AND TORT: SYSTEMS ON A COLLISION COURSE? (E. ROLPH, ED.), RAND, The Institute for
Civil Justice, 1991.
Kinney, The Role of Judicial Review in Medicare and Medicaid Program Policy: Past Experience and
Future Expectations, 35 ST. LOUIS UNIVERSITY LAW JOURNAL 759 (1991) (Health Law Symposium).
Kinney & Gronfein, Indiana's Malpractice System: No Fault By Accident?, 54 LAW AND CONTEMPORARY PROBLEMS 169 (1991).
Kinney, Gronfein & Gannon, Indiana's Medical Malpractice Act: Results of a Three Year Study, 24
INDIANA LAW REVIEW 1275 (1991).
Gronfein & Kinney, Controlling Large Medical Malpractice Claims: The Unexpected Impact of Damage
Caps, 16 JOURNAL OF HEALTH POLITICS, POLICY AND LAW 441 (1991).
Kinney, Legal and Ethical Issues in Mental Health Care Delivery: Does Corporate Form MaJce a
Difference, 28 HOUSTON LAW REVIEW 175 (1991).
Kinney, Rule and Policy-Maldng Under the Medicaid Program: A Challenge to Federalism, 51 OHIO
STATE LAW JOURNAL 855 (1990) (Insurance Law Symposium) (Based on: E. Kinney, Rule and PolicyMaking Under the Medicaid Program: A Challenge to Federalism, 1990 ACUS
. See ACUS
Recommendation 90-8, Rulemaliing and Policymaking in the Medicaid Program, 1 C.F.R. § 305.90-8).
Kinney, In Search of Bureaucratic Justice in the Medicare Program: Adjudicating Medicare Home
Health Benefits in the 1980s, 42 ADMINISTRATIVE LAW REVIEW 251 (1990).
Kinney, Setting Limits: A Realistic Assignment for the Medicare Program? 33 SAINT LOUIS UNIVERSITY
LAW JOURNAL 631 (1989) (Health Law Symposium).
Kinney & Wilder, Medical Standard Setting in the Current Malpractice Environment: Problems and
Possibilities, 22 U.C. DAVIS LAW REVIEW 421 (1989) (Health Law Symposium).
Kinney, National Coverage Policy Under the Medicare Program: Problems and Proposals for Change,
32 SAINT LOUIS UNIVERSITY LAW JOURNAL 869 (1988) (Health Law Symposium) (Based on: Kinney,
National Coverage Policy Under the Medicare Program: Problems and Proposals for Change, 1987
ACUS 833. See ACUS Recommendation 87-8, National Coverage Determinations under the Medicare
Program, 1 C.F.R. § 305.87-8).
Kinney, The Medicare Appeals System for Coverage and Payment Disputes: Achieving Fairness in a Time
of Constraint, 1 ADMINISTRATIVE LAW JOURNAL 1 (1987) (Based on: Kinney, The Medicare Appeals
System for Coverage and Payment Disputes, 1986 ACUS 339. See ACUS Recommendation 86-5,
Medicare Appeals, 1 C.F.R. §305.86-5).
�Kinney, Coordinating Rate Setting and Planning in States with Mandatory Hospital Rate Regulation:
What Makes a Difference? 8 JOURNAL OF LEGAL MEDICINE 397 (1987).
Kinney, Making Hard Choices under the Medicare Prospective Payment System: One Administrative
Model for Allocating Medical Resources under a Government Health Insurance Program, 19 INDIANA
LAW REVIEW 1151 (1986).
Kinney, Medicare Payment to Hospitals for a Return on Capital: The Influence of Federal Budget Policy
on Judicial Decision-Making, 11 JOURNAL OF CONTEMPORARY LAW 453 (1985).
Kinney & Lefkowitz, Capital Cost Reimbursement to Community Hospitals Under Federal Health
Insurance Programs, 7 JOURNAL OF HEALTH POLITICS, POLICY AND LAW 648 (1982).
Maynard & Kinney, The Statute of Limitations in Medical Malpractice Law, in DEFENSE OF MEDICAL
MALPRACTICE CASES ( D . HIRSCH, ED.). The Defense Research Institute, Inc., No. 4, 1977.
Comment, "The Know Your Customer" Rule of the NYSE: Liability of Broker-Dealers under the UCC
and Federal Securities Laws, 1973 DUKE LAW JOURNAL 489.
Other Articles
Kumar & Kinney, Indiana Lawmakers Face National Health Policy Issues, 25 INDIANA LAW REVIEW
1271 (1992).
Clark & Kinney, Standards for the Care of Diabetes: Origins, Uses and Implications for Third-Party
Payment, 15 DIABETES CARE 10 (Supplement 1, 1992).
Kinney, New Standards for the Standard of Care, LEGAL TIMES 22 (Supplement, Nov. 18, 1991).
Kinney, Murders and Madness: Medicine, Law and Society in the Fin de Siecle by Ruth Harris, 14
LEGAL STUDIES FORUM 435 (1990).
Kinney, Elderly Health Care: For Many, Insurance an Empty Promise, LEGAL TIMES, 16 (Jul. 25,
1988). Same article in the following papers: Kinney, Medicare is it Fulfilling its Promise? THE
RECORDER, 6 (Aug. 1, 1988); Kinney, Shedding Light on Medicare: Decisions on Coverage Need More
Input from Public, FULTON COUNTY DAILY REPORT, 2 (Jul. 27, 1988); Kinney, Government Must Stop
Making Rules on Medicare Coverage Behind Closed Doors, MANHATTAN LAWYER, 14 (Aug. 2-8, 1988).
(Kinney, What Health Care Should the Medicare Program Pay For? IU LAW-INDIANAPOLIS: ALUMNI
MAGAZINE OF THE INDIANA UNIVERSITY SCHOOL OF LAW-INDIANAPOLIS 11 (Summer 1989).
Kinney, Better Safe than Sorry: Federal Antitrust Laws have a Major Impact on Payment, Efficiency,
and Expansion Activities, MULTIES, Vol. 1, No. 2 (Jun. 1983).
Kinney, Federal Policy on Hospital Capital Investment: Review and Outlook, HOSPITALS, Vol. 55, No.
15 (Aug. 1, 1981).
�Reports and Monographs
E. KINNEY, THE IMPACT OF CURRENT AND PROPOSED TORT REFORM ON THE MEDICAL MALPRACTICE
SYSTEM AND PHYSICIAN BEHAVIOR (Background paper for the U.S. Congress, Office of Technology
Assessment, Study on Defensive Medicine and the Use of Medical Technologies, Apr. 1993).
E. KINNEY & K. JORDAN, THE SOCIAL CONTRACT FOR HEALTH CARE IN INDIANA: REPORT OF THE
SOLUTIONS SUBCOMMITTEE TO THE INDIANA COMMISSION ON STATE HEALTH POLICY (Jul. 1992).
E. KINNEY, S. STEINMETZ & J. RANDOLPH, BARRIERS TO PRIVATE HEALTH INSURANCE:
INDIVIDUALS WITH MULTIPLE SCLEROSIS AND THEIR FAMILIES
IMPACT ON
(Final Report to the National Multiple
Sclerosis Society, Oct. 1991).
E. KINNEY, S. STEINMETZ, R. SAYWELL & M. ROSENTRAUB, EVALUATION OF INDIANA'S COMMUNITY
AND HOME OPTION TO INSTITUTIONAL CARE FOR THE ELDERLY AND DISABLED
(CHOICE) PROGRAM
(Final Report to the Indiana Department of Human Services, Jan. 1991).
R. SAYWELL, M . ROSENTRAUB, E. KINNEY & S. STEINMETZ, PART I : A N OVERVIEW OF INDIANA'S
CHOICE PROGRAM (Report to the Indiana Department of Human Services, 1990).
E. KINNEY, A. ZIEGERT, C. MELFI & T. QUIGLEY, HOME HEALTH AGENCY RESPONSE TO THE
MEDICARE CLAIM DENIAL CRISIS OF THE 1980s (Final Report to the AARP Andrus Foundation, 1989).
E. KINNEY, HOSPITAL CHALLENGES TO STATE MEDICAID PAYMENT RATES SINCE THE OMNIBUS BUDGET
RECONCILIATION ACT OF 1981 (American Hospital Association, State Legal Developments Memorandum
No. 1, 1984).
AMERICAN HOSPITAL ASSOCIATION, STATE REGULATION OF PREFERRED PROVIDER ORGANIZATIONS:
A SURVEY OF STATE STATUTES (State Legal Developments Report No. 4, 1984) (Kinney with Kopit,
Rose & Shapiro).
AMERICAN HOSPITAL ASSOCIATION, STATE RATE-SETTING LEGISLATION: LEGAL ISSUES IN THE
NEGOTIATION AND IMPLEMENTATION OF A STATUTE (State Legal Developments Report No. 3, 1984
(Kinney with Ahern & Kopit)).
AMERICAN HOSPITAL ASSOCIATION, HOW STATES CAN OPT OUT OF THE FEDERAL MEDICARE DRG
SYSTEM: A SUMMARY OF LEGAL ISSUES (State Legal Developments Report No. 1, 1983) (Kinney with
Peterson & Kopit)).
AMERICAN HOSPITAL ASSOCIATION, MEDICAID PAYMENT FOR HOSPITAL SERVICES: PLAIN TALK ABOUT
WHAT HAS HAPPENED AND WHAT SHOULD BE DONE (Conference Proceedings, E. Kinney, ed. (1983)).
Kinney & Lefkowitz, Chapter I I : Legislative History, and Chapter VIII: Implications for Hospitals, in
B . LEFKOWITZ, HEALTH PLANNING: LESSONS FOR THE FUTURE (1983).
�MAJOR PROFESSIONAL PRESENTATIONS
1987: Major Planner and Speaker, Conference on Medicare Procedures, American Bar Association's
Commission on Legal Problems of the Elderly and the Administrative Conference of the United States,
Leesburg, VA, Oct. 1987; Luncheon Speaker, Conference on Medicare Appeals, National Senior Citizens
Law Center, Washington, DC, Oct. 1987.
1988: Panelist, National Advisory Council on Health Care Technology Assessment, Department of Health
and Human Services, Washington, DC, Jan. 1988; Moderator, Conference sponsored by Senator Dan
Quayle of Indiana on Health Insurance for the Uninsured, Indianapolis, IN, Mar. 1988; Speaker, Lecture
Series of the Class of 1988 on Medicine: Topics of the Future, Indiana University School of Medicine,
Indianapolis, IN, Apr. 1988; Panelist, Research Conference on Health Care Improvement and Medical
Liability, DHHS, Washington, DC, May 1988; Panelist, The Robert Wood Johnson Foundation Medical
Malpractice Program Annual Meeting, Washington, DC, May 1988; Panelist, TeKolste Forum, Indiana
Hospital Association, Indianapolis, IN, May 1988; Speaker on Medicare Recommendations,
Administrative Law Section of the American Bar Association, Toronto, Canada, Aug. 1988; Panelist,
Conference on Long Term Care, Indiana Fiscal Policy Institute, Inc., Indianapolis, IN, Sept. 1988;
Speaker, Symposium on Setting Limits: Medical Goals in an Aging Society, St. Louis University School
of Law, St. Louis, MO, Oct. 1988; Panelist, Health Law Forum, American Public Health Association,
Boston, MA, Nov. 1988; Panelist, Conference for Minority Recruitment, Indiana University School of
Law—Indianapolis, IN, Nov. 1988.
1989: Panelist, The Robert Wood Johnson Foundation Medical Malpractice Program Annual Meeting,
Seattle, WA, May 1989; Participant, Invitational Conference on Medical Quality and the Law, The
Roscoe Pound Foundation, Washington, DC, Jun. 1989; Presentation on Indiana's Medical Malpractice
Act, Medical-Legal Committee of the Marion County Medical Society and Indianapolis Bar Association,
Indianapolis, IN, Jul. 1989; Panelist, Conference on Families in Transition, Indiana State Board of
Health, Oct. 1989; Moderator, Workshop on In Sickness and in Health at the Indiana Conference on
Social Concerns: 1989 Legislative Forum, Indianapolis, IN, Nov. 1989.
1990: Testimony, Hearing of the Subcommittee on Aging of the Senate Labor and Human Resources
Committee on Public/Private Partnerships: Innovative Approaches to Long-Term Care of the
Subcommittee on Aging of the Senate Committee on Labor and Human Resources, Indianapolis, IN, Jan.
1990; Speaker, Legal and Ethical Issues in Mental Health Care Delivery: Does Corporate Form Make
a Difference? Conference on Mental Health Law, University of Houston, Houston, TX, Mar. 1990;
Speaker, Workshop on Access to Health Insurance, American Diabetes Association Annual Meeting,
Atlanta, GA, Jun. 1990; Speaker, Results of Evaluation of Indiana's Medical Malpractice Act, Annual
Meeting of The Robert Wood Johnson Foundation's Medical Malpractice Program, Washington, DC,
Oct. 1990; Moderator, Health Care Summit, Indiana State Medical Association, Indianapolis, IN, Oct.
1990; Speaker, Results of Medical Malpractice Evaluation, Board of Trustees, Indiana Hospital
Association, Indianapolis, IN, Oct. 1990; Speaker, Results of Medical Malpractice Evaluation, Committee
on Malpractice, Indiana State Medical Association, Indianapolis, IN, Oct. 1990; Speaker, Medical
Malpractice, Ethics for Lunch Series, Indiana University School of Medicine, Indianapolis, IN, Oct.
1990; Speaker, Uses and Abuses of Judicial Review: Litigation as a Political Strategy in the Medicare
and Medicaid Programs, at a Conference on Medicare and Medicaid: Litigating Payment, Access and
Rationing, St. Louis University School of Law, St. Louis, MO, Nov. 1990; Presentation, Medicaid
Rulemaking Recommendations to the Plenary Session of the Administrative Conference of the United
States, Washington, DC, Dec. 1990.
7
�1991: Speaker, Results of Medical Malpractice Evaluation, Medical/Legal Committee of the Indianapolis
Medical Society and Indianapolis Bar Association, Indianapolis, IN, Jan. 1991; Moderator for Task Force
on Risk Management/Quality Assurance Activities for a Conference on Issues in Medical Liability: A
Working Conference, convened by the DHHS Agency for Health Care Policy and Research, Washington,
DC, Feb.-Mar. 1991; Speaker, Results of Medical Malpractice Evaluation, Annual Meeting of the
Continental Gynecologic Society, Indianapolis, IN, May 1991; Presentation, Research in Medical
Malpractice to the Family Practice Fellows, Indiana University School of Medicine, Indianapolis, IN,
May 1991; Speaker, Annual Meeting of the Alumni Association of the Indiana University School of
Social Work, Indianapolis, IN, May 1991; Luncheon Speaker, Annual Meeting of the Visiting Nurse
Service of Indiana, Inc., Indianapolis, IN, May 1991; Moderator, Panel on Appropriate Standards of
Care, Conference on The Changing Health Care Delivery System and its Implications for Liability Law,
RAND Institute for Civil Justice, Dallas, TX, Jun. 1991; Presentation on Opportunities for Research,
Fellowship Training Program, Division of General Medicine, Indiana University School of Medicine,
Indianapolis, IN, Jul. 1991; Speaker, Health Care Law: Medical Malpractice and Selected Issues, Indiana
Law Update, Indiana Continuing Legal Education Forum, Sept. 1991; Speaker, Indiana Compensation
Act for Patients Workshop, Indiana State Medical Association, Bloomington, IN, Nov. 1991.
1992: Keynote Address, Perspectives of Medical Malpractice, Good Samaritan Hospital's Winter
Seminar, New Harmony, IN, Feb. 1992; Moderator, Panel on Medical Decision-Making by and for the
Terminally, Geriatric Education Center, Center for Law and Health and Health Law Society,
Indianapolis, IN, Feb. 1992; Commentator, Conference on Justice and Health Care, The Law-Medicine
Center of Case Western Reserve University School of Law, Cleveland, OH, Mar. 1992; Speaker,
Barriers to Health Insurance for Persons with Multiple Sclerosis, American Occupational Therapy
Association, Houston, TX, Mar. 1992; Testimony, Senator Dan Coats' Health Care Forum, Indianapolis,
IN, Apr. 1992; Speaker, Legislative Models on Malpractice, Conference on Conflict Resolution in
Medical Malpractice: History and Images of the Future, Wayne State University, Detroit, MI, May
1992; Speaker, Indiana Compensation Act for Patients Workshop, Indiana State Medical Association and
Indiana Hospital Association, Culver, IN, Jun. 1992; Speaker, Health Care Liability Costs, Indiana Public
Health Foundation, Inc., Indianapolis, IN, Aug. 1992; Testimony, Medical Malpractice, Interim Study
Committee on Insurance Issues, Indiana General Assembly, Indianapolis, IN, Aug. 1992; Presentation
on Opportunities for Research, Fellowship Training Program, Division of General Medicine, Indiana
University School of Medicine, Indianapolis, IN, Aug. 1992.
1993: Panelist, Panel on New Proposals on Professional Liability, National Leadership Conference,
American Medical Association, Atlanta, GA, Feb. 1993; Provocateur for Socratic Dialogue Panel, 1993
TeKolste Forum on Public Trust: Reclaiming or Preserving? Indiana Hospital Association, Indianapolis,
IN, May 1993; Speaker, Quality Assurance Strategies for Community-Based, Long-Term Care Programs,
Indiana Association for Home Care Annual Conference, Brown County, IN, May 1993; Speaker,
Proposed Regulations to Expand the Field for Private Accreditors, and Suits by Disappointed Applicants:
Due Process and Other Issues, Conference on Private Accreditation in the Regulatory State, American
Bar Association Section of Administrative Law and Regulatory Practice, Washington, DC, May 1993.
�Clinton Presidential Records
Digital Records Marker
aa^iMW.{«a'.8Mg}ia-5!MM«CtMIM
This is not a presidential reeord. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�V O L U M E 42
SPRING 1990
ADMINISTRATIVE
REVIEW
I N T H I S ISSUE
ST A IE ADMINISTRATIVE
POLICY FORMULATION
THE CHOICE OF LAWMAKING
ME THODOLOGY
hy Arthur Earl Bonfield
AND
IS EUROPE R E A D Y FOR THE ADMINIS ERA TIVE LAW
REMEDIAL REVOLU TION?—LITIGA TION BEFORE
N A T I O N A L C O U R T S OE T H E EEC MEMBER S l ATES
AND IN l ERIM RELIEF
by Enrique Alonso Garcia
AN ADMINISTRATIVE
LAW • MIGHT HAVE BEEN"—
CHIEF JUSTICE BURGER'S BOWSHER V. SYNAR DRAFT
by Bernard Schwartz
IN SEARCH OF BUREAUCRATIC J U S T I C E ADJUDICATING MEDICARE HOME H E A L T H BENEFITS
IN THE 1980s
by Eleanor D. Kinney
ABA SECTION OF ADMINISTRATIVE LAW & REGULATORY PRACTICE
MARSHALL-WYTHE SCHOOL OF LAW, COLLEGE OF WILLIAM & MARY
�Clinton Presidential Records
Digital Records Marker
mmm mmMmmiwmwamamammmmwnmmimimim
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�OHIO STATE
LAW JOURNAL
Volume 51
Number 4
1990
Rule and Policy Making for the Medicaid Program:
^
A Challenge to Federalism
Eleanor D. Kinney
. . ..
4}
i
I- "7
•' . -.•
\
//
II
» 'I
�RPR 2 2
'93
PAGES:
PAGES
PAGE.001
17:47
1 r\
J
(not counting cover page)
TO;
FAX NUMBER:, M T C - , ^ - > 2 | ^
ATTEmiON:
FROM
WiUiam J Hughes, Chairman
House Select Committee on Agin.
712 House Annex I
^
Washington, D.C. 20515
Phone:
FAX Phone:
202-226-3375
202-225-5505
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003. resume
DATE
SUBJECT/TITLE
04/22/1993
re: Paul S. Ceja (partial) (1 page)
RESTRICTION
P6/b(6)
COLLECTION:
Clmton Presidential Records
Health Care Task Force
Carolyn Gatz/Jennifer Klein
OA/Box Number:
5107
FOLDER TITLE:
[Legal Audit Group]
2006-0885-F
jp2651
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)j
Freedom of Information Act - [5 U.S.C. 552(b)j
PI National Security Classified Information 1(a)(1) of the PRAj
P2 Relating to the appointment to Federal office 1(a)(2) of the PRAj
P3 Release would violate a Federal statute I(aK3) of the PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |aX5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRAj
b(l) National security classified information |(bXl) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency |(bX2) of the FOIA|
b(3) Release would violate a Federal statute |(bX3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information |(bX4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIAj
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIAj
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�PfiGE.002
APR 22 '93 17:47
PAUL 8. CEJA
ADDRESS:
P6/(b)(6)
P6/(b)(6)
PHONE:
(202)
EDUCATION:
226-3375 (Work)
J.D., U n i v e r s i t y o f Colorado School o f Law
Boulder, CO.
B.A., Siena College, Loudonville, NY.
BAR MEMBERSHIP:
D i s t r i c t o f Columbia
Pennsylvania
EMPLOYMENT:
1988 — Present
8«l«ot CoBaittOtt on Aging
U.S. House of Representatives
RooB 712, Bouse Annex z
Washington, D.C. 20515
Duties; General Counsel. Responsible f o r
the l e g a l , o r g a n i z a t i o n a l , and a d m i n i s t r a t i v e
n a t t e r s i n v o l v i n g the Conanittee. P r i n c i p a l
l e g a l advisor t o the Conunittee Chairman.
Directed the Committee's review on issues
w i t h i n the Committee's j u r i s d i c t i o n a l areas.
Reviewed and developed p o l i c i e s , l e g i s l a t i o n
and regulations, and engaged i n o v e r s i g h t o f
f e d e r a l agencies. Organized nmnerous
hearings, d r a f t e d l e g i s l a t i o n and Committee
r e p o r t s , i n i t i a t e d and monitored s t u d i e s and
i n v e s t i g a t i o n s by the General Accotinting
O f f i c e . Represented the Committee Chairman,
and the Committee, a t various n a t i o n a l
conferences, for\ims, and workshops.
1985 — 1988
Office of tbe General Counsel
U.S. Department of Health and Human services
Region ZZZ
P.O. Box 1371C, 3535 xarket Street
Philadelphia, PA 19101
Duties: Assistant Regional Counsel. Worked
on l i t i g a t i o n f o r the Department o f Health
and Human Services. Prepared b r i e f s and
pleadings i n conjunction w i t h U.S. Attorneys
o f f i c e s , f o r siibmission t o U.S. D i s t r i c t
Courts and C i r c u i t Courts o f Appeals.
Conducted o r a l arguments before U.S. C i r c u i t
Courts o f Appeals. Drafted memoranda on
l e g a l issues o f concern t o the Department.
�APR 22 '93 17:47
1979 —
1984
PAGE.003
Center on Social welfare Policy and Law
1029 Vermont Avenue, H.W. Suite 850
Washington, D.C. 20005
Duties: Monitored and analyzed l e g i s l a t i o n
and r e g u l a t i o n s . P a r t i c i p a t e d i n
Congressional committee hearings and markups. Prepared comments on proposed
r e g u l a t i o n s . Provided research f o r
l i t i g a t i o n . Assisted Congressional s t a f f .
Met w i t h representatives o f n a t i o n a l
organizations.
1977 —
1979
U.S. Bouse of Representatives
Congressional Hispanic caucus
House Annex 2
Washington, D.C. 2 0515
Duties: Legislative/Legal Assistant.
Provided l e g a l and l e g i s l a t i v e research.
Developed the l e g a l s t r u c t u r e o f t h e
Congressional Hispanic Caucus. A s s i s t e d i n
l i a i s o n a c t i v i t i e s w i t h other Congressional
o f f i c e s , f e d e r a l agencies, and t h e White
House.
1975
Department of the Army
Office of the Judge Advocate General
Fort Carson, CO
Duties: Legal A s s i s t a n t . A s s i s t e d m i l i t a r y
defense attorneys i n t h e p r e p a r a t i o n o f cases
f o r c o u r t m a r t i a l . Provided l e g a l research.
Carried out f a c t u a l i n v e s t i g a t i o n s .
ADDITIONAL QUALIFICATIONS:
Member, National Hispanic Bar Association
Student Attorney, Legal Aid and Defender Program
u n i v e r s i t y o f Colorado School o f Law: Advised and represented
c l i e n t s i n c i v i l and c r i m i n a l cases.
References a v a i l a b l e on request.
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MEMORANDUM
TO;
Jcmiifer Klii\e
FROM:
Margaret Farrell
RE:
Legal Audit - Questions
DATE:
May 3,1993
I have posed some questions about the Health Care Task Force options
that we may want to circulate to the Legal Audit group. Again, I would preface
the questions with as clear an articulation as we can come up with about the
purposes of their audit.
The auditors cannot be asked to react to all of the combinations and
permutations of options discussed last week. If they arc asked only to sketch the
boimdaries witiiin wliich all options must operate, I am afraid we will get very
general, not very useful, comments. Thus, for the purposes of tliis exercise. I
would ask them to assume that certain basic elements of a reform package arc
included in proposed legislatioii, even though these elements could change in the
next several weeks. That is, rather than preface each question with a statement of
assumptions , I would ask the Legal Auditors to assume that legislation is
proposed that would enact a combination of the major options being considered
by the Task Force. In order for them to focus on fairly concrete issues, we could
change the assumptions upon which individual questions arc based. For
example, we might ask a question that assumes that Plans could sell policies with
additional benefits and that they could not. If certain features of the reform we
ask them to assume are not part of the final package, we can take that into
account in evaluating and using their comments, or we could follow up,putting
more questions to thom based on the changes.
I would ask that the auditors assume that reform legislation would require
the compulsory purchase of standard he^ilth insurance coverage (to be
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determined at the federal level) by all individuals (employed, self-employed, and
unemployed) and employers (i.e.of less than a size to be determined by each
state for themselves and their dependents. Employers would be required to
contribute 80% of the benchmark premium charged in each Health Alliance area
for standard benefits. Employees would be required to pay the balance. Selfemployed and unemployed individuals be required to pay 100% of the cost, with
80% of the cost to unemployed workers being paid by a state/federal
unemployment compensation program. All would be permitted to deduct from
their taxable income, their expenditures up to the benchmark premium price.
Low income individuals would receive a state/federal subsidy amounting to the
difference between the benchmark price an a given percentage of their gross
income. Employers would also receive a subsidy after they had paid 7% of their
total payroll for employee health insurance.
Health insurance would be sold by Plans (providers that assume risk by
accepting capitation payments) and by at least one indemnity, fee for service plan
in each area. Health care would be provided by physicians, hospitals, and other
providers who sell their services through Plans or directly to patients iiisured by
an indemnity plan. Alliances(one not for profit or public agency in each
geographic area designated by the state) would bargain with Plans, on behalf of
their subscribers, for the lowest price each plan can provide mandated coverage
to its er\rollees at a community rate (i.e. the rate at which that plan could serve a
population reflecting the risk level of the geographically relevant commuruty).
Open enrollment periods would guarantee each Alliance subscriber the choice of
enrolling in any Plan offered by the Alliance at a benchmark premium, based on
the lowest or some average rate at which all those Plans offer the standard
benefit package. Plans would be paid by the Alliance a "risk adjusted" rate
reflecting the enrollment of higher or lower risk people that compose the
community as a whole.
Admimstration of the program would be shared by the state and federal
governments, with the federal goverrunent responsible for setting the standard
benefit package, determine the size of the subsidy, establishing standards for
Alliance and Plans, designating a uniform data collection system, creating
voluntary practice guidelines, conducting technology assessment States would
be responsible for certifying and supervising Alliances, setting standards
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through licensure for Plans and providers, collecting and reporting uniform data
and enforcing state laws not preempted by the new legislation such as insurance
regulations. In states that failed or refused to carryout such state functions, the
federal government may withhold federal funds, withhold federal subsidies,
withhold favorable tax treatment for individuals and businesses in the state,
operate the Alliance system itself and/or set insurance and provider prices.
Finally, in an effort to control prices, the federal goverrunent may limit the
subsidy it wrill pay for low income individual insurance to a percentage of a
benchmark premium that conforms to federally set budget caps or capped
increases in the benchmark price.
On the basis of these assumptions and the discussions that they had last
week about the options, I would ask broadly:
• Whether, because of their legal consequences, the health care reform
proposal will not have the effects they are expected and hoped to have.
• What private rights of action (implied or under 42 USC 1983) for
Alliance subscribers. Plan enrollees and patients will be or should be created by
the new legislation? What private rights of action for such persons should the
reform legislation preclude?
• What private rights of action for Plans against providers, enrollees and
the Alliance are or should be created? precluded?
• What private rights of action for Alliances against the State, subscribers.
Plans and providers does/should the reforms create? preclude?
• What administrative and judicial procedures should be created to settle
disputes that arise among all the players - subscribers. Alliances, Plans, providers
and the state and federal governments?
• What state laws will necessarily be preempted by the reforms; should
be preempted and thus expressly addressed by reform legislation; and should
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not be preempted. E.g. state antitrust laws, malpractice laws, liceitsure,
irisurance regulation, securities laws, I IMO laws and anti-networking laws.
• What are the constitutional boundaries within which the Congressional
legislation must operate with respect to 1) enlisting state efforts in carrying out
the reform, 2) providing adjudicatory procedures for the resolution of disputes,
3) delegating rulemaking authority to federal and state bodies; 4) taxing and
delegating taxing authority to state and quasi-pubUc bodies.
More specifically, I would group some questions this way:
National Governance
Assuming there was interest in establishing an independent National
Health Board:
1. Can Congress prohibit President from reviewing NHB budget and/or
rulemaking?
2. Could NHB be an "off budget" agency?
3. Can Congress veto NHB action through joint resolutions?
4. Can Congress require the President to permit the NHB to lobby its own
budget before Congress?
State-Federal Relations
What constitutional provisions govern the procedural rights of states to
proceed against the federal government for violation of federal statutes? i.e. to
what process is a state due in such disputes? What forum must be provided,
what notice, hearings etc.? Are the procedures different if the state claims that
the federal goveniment has violated the Constitution? Can Congress control the
jurisdiction of Article III courts to hear such disputes? i.e. Could a federal
administrative procedure be created to determine the compliance of states with
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federal plan requirements with no judicial review, or with limited judicial review
under the APA?
Assuming some states may not find federal funds a sufficient incentive to
join the new program, does the tenth amendment prohibit federal legislation
requiring states (as opposed to the federal government) to 1) license providers in
accordance with federal standards; 2) regulate health insurers doing business in
the state; 3) pay part of the cost for the purchase of health insurance for low
income individuals? New York v. United States, 112 S. Ct. 2408 (1992)(tenth
amendment restrictions).
Can the federal government enforce maintenance of effort commitments
made by states with balanced budget requirements in their constitutions? What
action can the federal government constitutionally take in states that cannot
make such commitments? North Carolina ex rel. Morrow v. Califano, 445 F.
Supp. 532 (E.D.N.C. 1977)(federal spending powers may condition receipt of
funds on state legislation held to violate N.C. constitution) - but how about in the
absence of federal spending powers?
Is there a point at which exercise of Congressional spending powers
would be seen as coercive and thus violative of state rights under the tenth
amendment? i.e.. if the federal government made all federal funding (health
funds, highway funds, education funds, etc.) dependent on a state cooperating in
the reform program, including its "agreement" to exercise state sovereign
prerogatives as directed by the federal government, could such legislation
withstand a tenth amendment challenge?
Can federal legislation create a federal causes of action (e.g. against Plains
for provider negligence) that can be enforced only in state courts? Jones Act
precedent?
Can the federal government impose a federal payroll tax to collect funds
to be spent by the states that have qualified plans and not at all in states which
do not? State workman's compensation model? Equal protection issues?
�SENT BY:FED.. JUDICIAL CTR.
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RESEARCH DIV.-
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Does equal protection permit the federal government to provide favorable
tax treatment for private contributions to the purchase of health insurance only
in states that have a qualified plan?
Does equal protection permit the federal government to pay subsidies to
individuals and business only in states that have qualified plans?
Federal Legislative Issuer
Can the federal government proliibit the piurchase, outside of Alliances, of
services found not efficacious, but not harmful? e.g. Laetrile - rationality
standard? Docs such a prohibition implicate a substantive due process right to
obtain treatment of ones choice.
Do elements of the Clinton plan requirement amendment of ERISA
to regulate self insuring plans? McGann v. H&H Music, 946 F.2d
401 (5 th Cir. 1991)
to permit states to regulate self-insuring employers. Metropolitan
Life Ins. v. Massachusetts, 471 U.S. 724 (1985).
to narrow the definition of "insurance" in order to narrow the area
for state regulation Royal Drug, U.S. (19 );
Pilot Life V. Dedeaux, 107S,Ct. 1549(1987).
to permit indigent subsidies to be paid out of premiums paid by
exempted large firms. Recent New Jersey and New York
cases invalidating state rate setting and indigent care pools
as they apply to ERISA plans.
Does Parker Brown antitrust iminunity for state action cover the actions of
Alliances? Health Plans? Providers certified and qualified by states who seek to
cooperate with each other to jointly provide services (HIV treatment and
preventative education) not economical to provide separately? Cf. National
Gerimedical I-Iosp. & Gerontology Center v. Blue Cross of Kansas City, 452 U.S.
378 (1981).
�SENT RY:FED.. JUDICIAL CTR.
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RESEARCH DIV.-
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Would federal legislation providing that all individuals are entitled to
subsidized health insurance on the basis of income create an individual
entitlement to such, enforceable under 43 U.S.C. § 1983? Under implied cause of
action theories? Cort v. Ash 422 U.S. 66 (1975). Through a writ of mandamus?
Can/should such causes of action be limited? Recent Souter case.
Would providers. Health Plans and Alliances also have §1983 causes of
action to enforce statutorially determined conditions of their participation in the
program? If the market for their services is restricted or eliminated by the new
programs? Wilder v. Virginia Hospital Assoc., 110 S. Ct. 2510 (1990).
Can federal funds be used to provide more benefits, such as education and
training, for minorities and women in those fields, such as primary care, where
those characteristics might be reasonably related to their abiHty to provide
appropriate care to those in need of health care? I.e. affirmative action for benefit
of patients, not for benefit of the providers of the favored treatment.
Would the immunization of good faith, quality assurance determinations
in the Health Quality Improvement Act of 1986 (42 U.S.C. 11101 et seq (1987)
from defamation and antitrust attack apply to Plans (or Alliances) so as to
miiumize their malpractice enterprise liability? Cf. Patrick v. Burget, U.S.
(1988); FTC v. Indiana Federation of Dentists, 476 U.S. 447 (1986).
Does the due process clause or the 7th amendment prohibit federal
legislation eliminating or capping malpractice actions against providers? Boyd v.
Bulala 647 F. Supp. 781 (W.D. Va. 1986), 877 F.2d 1191 (4th 1989) Would it
violate state constitutions? If it docs, is there any reason that state constitutional
provisions would not be preempted? Garnett v. Renton School District No. 403,
CA No. 91-36036, 61 U.S.L.W. 1137 (March 23,1993). Could it be regarded as a
direct infringement of state sovereignty - i.e. telling the states how they are to
regulate private action? or is it a standard exercise of commerce power that
preempts inconsistent state laws?
Federal Regulatory Issues
I
/
I
�SENT BY:FED.. JUDICIAL CTR.
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RESEARCH DIV.-
202 456 7739:# 9/10
Does the authority of Alliances (public or private)to set benchmark
premiums constitute rulemaking authority and thus raise non-delegation issues?
Would it if there is a guiding "intelligible principle" providing legislative policy?
Does it constitute non-delegable taxing authority? Cf. National Cable Television
Assn, V. United States, 415 U.S. 336,342 (1974).
Does the due process clause permit a private non-profit Alliance to finally
determine individual entitlement to federal proscribed benefits, without state or
federal administrative or judicial review? By a Plan? Medicare private fiscal
intermediary precedents ~ McClure and Gray Panthers, supra. Are due process
requirements met if the Alliance making final individual coverage
determinations is a state agency but no judicial review is permitted?
What due process rights are enrollees entitled to when Alliances and/or
Plans make benefit coverage determinations? What notice, hearings, judicial
review are constitutionally required? Mathews v. Eldridge, 424 U.S. 319 (1976);
Schweiker v. McClure, 456 U.S. 188 (1982); Gray Panthers v. Schweiker, 652 F.2d
146 (D.C. Cir. 1980). Are federal due process requirements met by state
administrative procedures and state judicial review alone?
Does the APA exception for rulemaking concerning "matters relating to ...
benefits" or "interpretive rules and policy statements" 5 U.S.C. § 553(b) apply to
NHB and agency rulemaking defining the scope of benefits? coverage? budgets?
technological assessment? Can that exception be waived by legislation?
Does the Constitution, due process, permit NHB rulemaking be exempt
from the APA requirements? Morton v. Ruiz 415 U.S. 199 (1974)?
Would federal legislative requirement that some subscriber/plan and
Alliance/plan disputes be settled by mandatory, binding arbitration violate the
7th amendment guarantee of a jury trial? Boyd v. Bulala, supra. Or does the
workman's compensation model of consent and waiver apply?. Would it violate
the "take care" provision of Article II requiring execution of the laws be carried
out by executive officers? See OLC opinion that it does. Or, does it
imconstitutionally infringe on the judicial function? would subscriber consent to
/
�SENT BY:FED, JUDICIAL CTR.
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RESEARCH DIV.-
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mandatory binding arbitration in the Alliance context be a fiction if all Plans
required it?
Is enterprise liability tantamoimt to strict liabiUty? How can "adverse
events" be defined for enterprise liability and compensation purposes? Can
enterprise liability be frustrated through use of patient consent and waiver
forms? Assuming enterprise liability applies to approved Health Plans and plans
selling outside the Alliances, can federal legislation infringe on a patients right to
contract for treatment outside Alliances ~ i.e. the right to treatment as a matter of
substantive due process ~ by prohibiting patient consent to waive enterprise
liability as a condition to treatment?
State Legislative Issues
Do individuals and providers need a statutory cause of action for
negligent disclosure of confidenhal information collected under the national data
collection system envisaged, or are current state laws protecting privacy (e.g.
defamation etc.) sufficient? Should the federal privacy protections applying to
Medicare information be extended?
State Regulatory Issues.
Docs state law (judicial common law) imposing due process requirements
on the procedures of private organizations making determinations affecting
livelihood need to be expressly preempted, if Alliances and Plar\s are permitted
to adjudicate the rights of providers to participate in the new system.? Pinsker v.
Pacific Coast Society of Orthodontists, 75 Cal. Rpt. 712 (Ct. App. 1969) Falcone v.
Middlesex County Medical Soc'y, 34 N.J. 582,170 A.2d 791 (1961) or, can
Alliances and Plans be required to provide procedures that will meet such due
process requirements?
Do most state Administrative Procedure Acts provide judicial review for
the actions of private bodies carrying out state functions (See Calif, code
provisions to that effect) and if so, would/should such acts apply to Alliances?
Plans?
�HAY- 5-93 WED 10:32
WESTERN PSYCH
FAX NO. 6811261
P.02
University of Pittsburgh
Medical Center
Center for Medical Ethics
3900 ForOes Avenue
PiUSburgh. PA 15260
412-648-1384
Fax: 412-848-2649
Alan Melsel, JD
Director
Cenlar for Medical Ethics
To:
Jennifer Klein
From:
Alan Meisel
Date:
May 5, 1993
^iles?W^r^\^*'^^?"'^
with very many
SJf
^°
^ ^ ^ a l auditors," i n large part because i
yo2^?)^But\:r«^/°°^
'
^
I K V ' to
' ^^^^
s ? e mi\tn'is be?
you.l) But here's some stuff
think about. B yHope
h e l p ftoo
il.
"CONSCIENTIOUS OBJECTION"
I f reproductive health services are included i n the basic olan
but a l l professionally qualified individuals i n the A S I arS as a
w??^L?LTr^^"°^'/"^^^^^"^
provide somS or a U o l ?hem
w i l l patient haye a right to have the service provided by the
? r o J i d e " ? ? r s e w i i e f ^ professionals have a r i ^ h t to ? e ? L e ' ? o
JreatSpj;?^?i!? f ^ ^ ^ f "^^^^H^ obliged to continue to provide a
t o ^ oS™^^
i s already i n process - eg, ventilatory support
^ e a ? t ? S a ? ^ ? 5 ^ ^ ^ ^ ^ ^ " J '".^^^
continuation of treatment h a f
di?iciTv^
S^^" refused (eg by the patient through an advance
ha^e a r L h ?
I ^ ^ ^ f i ^ y authorized surrogate), w i l l the patient
Si^hln
L P ? ^^l^J^"^^ treatment discontinued nonethelesS?
%
""^^^
^^^^^
"° °ther physician w i l l i n g to
terminate treatment (within the AHP? outside the AHP)?
^Latm^^J^'''^^" feels morally obliged to discontinue to provide a
t J ! ^^^^^ 7"
ventilatory support to a comatose patient — but
the provision of treatment has been requested (eg by the patient
sSr?o^ate? "^T??'?H^'"f^'"" °"
^
ai?LrLeS
oro^?SS
J l i ^ 11^ patient have a right to have the treatment
i?
physician's stance? within the AHP? what
t(witnin
^ i t M n the
t i S AHP?
?Sp?^^^f
physician
w i l?l i n g to provide treatment
outside
the AHP)
usu!nv^Ti-So,7r'' l^^^^""' ^''^
^° ^he above questions are
usually (though not always) unclear. I s there anything about the
C o u i S ^ n r !^^\^«<3^i^«^ C l a r i f i c a t i o n i n the legisYa^ion or tha?
would seem to change the balance of equities?
�HAY- 5-93 WED 10:32
May 5,
Page 2
WESTERN PSYCH
FAX NO. 6811261
P.03
1993
STATE ANTITRUST LAWS
MEDICARE/MEDICAID FRAUD AND ABUSE PROVISIONS
assuTn?^^''?^^; i£
""^^^^ "^^'^ t°
"'ade i n these statutes
for soSI p e ? L ? : r t ? m : ^ o r " ' " ^ - ^ r ^ - k s " i n some'^^rm
necessa?v ?o
J2n ^ permanently? w i l l the arrangements
necessary to create AHPs run afoul of these provisions?
NATIONAL PRACTITIONER DATABANK
SaS?i2icnerDlta£aiU?
°'
^°
^^^--^
INTERNAL REVENUE CODE
?La?™^n?'o5^r^?fw''^^^ ''^^'^ ^° ^« contemplated i n the tax
emotovov^
insurance benefits both i n the case of
a^loSed
«°^^ver, w i l l so-called Flex Plans be
allowed to continue, eg to provide the use of tax-sheltered
l l l T l ^ T i l T ^ ^ ^ ' " J ^ ^ ^ " ^ i^enefits not inc?Gded i n t i e basic
premiiml'foS
f ^ ^ ^ " ^ ' transportation to appointments,
etc^? ? l f x p J l n f e J L S ^ f J h
deductibles, co-insurance,
drm^£V\?
?o use ? f oaJ for 2?}°^?'
"
employer'
insurance.^
medical expenses not covered by health
PRACTICE GUIDELINES AND MALPRACTICE
dfv?^?Lri'^^"^^^''y Y^^"®'
^^y' s^°^ld adherence to or
co^formaScf ST.E^'^^i^^ guidelines play i n establishing ?o
?^
yf^?
departure from the standard of care i n
?o eJSouJaL\'^^^^^^°"I
^ ^ ' ^ ^ ^ ^ l goveriment? I S order
t h i s ' ^ J i l const??.?- ^ ^ ^ ' ^ J ^ ^ ! guidelines, attempt to l e g i s l a t e
Of
ffi^lD^actLrr^Ji^
^°
especially i f other aspects
comply??
^""^ voluntary (though with incentives to
�'
Lot / f i j
(fCi
^-
Pai
iCintj
hn
MEMORANDUM
Date:
A p r i l 27, 1993
To:
Jennifer Klein
From:
B i l l Sage
Subject:
Questions f o r Legal A u d i t Group
Assuming t h a t a dual d e l i v e r y system (some c a p i t a t e d , some
f e e - f o r - s e r v i c e ) w i l l e x i s t f o r some t i m e , how can safe
h a r b o r s or o t h e r pronouncements/assurances w i t h respect t o
f r a u d & abuse or a n t i t r u s t be e s t a b l i s h e d t o a v o i d
" c h i l l i n g " e f f i c i e n t i n t e g r a t i o n f o r c a p i t a t e d care b u t n o t
open t h e door t o abuses i n c o - e x i s t i n g f e e - f o r - s e r v i c e ?
Assuming t h a t s t a t e s and h e a l t h a l l i a n c e s w i l l have p r i m a r y
r e s p o n s i b i l i t y f o r h o l d i n g plans accountable f o r q u a l i t y
w i t h i n a budget, how can the f e d e r a l government i n s p i r e
p u b l i c c o n f i d e n c e i n t h e q u a l i t y o f t h e o v e r a l l system
w i t h o u t d u p l i c a t i n g work or c r e a t i n g unnecessary
bureaucracy?
3.
5.
Assuming t h a t h e a l t h plans ( i ) are r e q u i r e d t o d i s c l o s e " a l l
m a t e r i a l i n f o r m a t i o n " t o consumers i n e n r o l l m e n t documents
as a way t o f o s t e r consumer c h o i c e , and ( i i ) are p r o h i b i t e d
from f r a u d u l e n t or m i s l e a d i n g d i s c l o s u r e ( i n c l u d i n g
a d v e r t i s i n g ) , should t h e r e be a p r i v a t e r i g h t o f a c t i o n ? I f
so, what should t h e remedies be?
Assuming t h a t a unique p a t i e n t and p r o v i d e r i d e n t i f i c a t i o n
number i s needed t o assure i n t e g r i t y o f i n f o r m a t i o n i n t h e
new system, what l e g a l c o n s i d e r a t i o n s should a t t a c h t o t h e
s e l e c t i o n and use o f t h a t i d e n t i f i e r ? What i f t h e s o c i a l
s e c u r i t y number i s used as t h e p a t i e n t i d e n t i f i e r ?
Assuming t h a t h e a l t h plans are intended t o be f u l l y l i a b l e
f o r n e g l i g e n t i n j u r i e s t o e n r o l l e e s caused by a f f i l i a t e d
p r o v i d e r s ( " e n t e r p r i s e l i a b i l i t y " ) , how should t h e l i a b i l i t y
be c r e a t e d so t h a t m a l p r a c t i c e a c t i o n s s t i l l a r i s e i n s t a t e
court?
Assuming t h a t the f e d e r a l government chooses t o encourage
c e r t a i n general t o r t reforms a f f e c t i n g medical m a l p r a c t i c e ,
but does n o t choose t o preempt s t a t e law, how should
i n c e n t i v e s be c r e a t e d t h a t induce s t a t e s t o enact t h e
d e s i r e d reforms? What i f s t a t e c o u r t s have p r e v i o u s l y h e l d
s i m i l a r reforms t o be u n c o n s t i t u t i o n a l ?
�7.
Assuming t h a t the f e d e r a l government chooses t o preempt
s t a t e laws t o accomplish c e r t a i n g e n e r a l t o r t reforms
a f f e c t i n g medical m a l p r a c t i c e ( e . g . a noneconomic damage
c a p ) , b u t does n o t d e s i r e t o preempt e x i s t i n g schemes t h a t
may, i n v a r i o u s ways, be more "defendant f r i e n d l y , " how can
i t preempt " s e l e c t i v e l y " ?
Assuming t h a t the f e d e r a l government d e s i r e s t o c o n d i t i o n
payment o f graduate medical e d u c a t i o n funds t o achievement
of r e s u l t s ( s p e c i a l t y mix, d i v e r s i t y , t r a i n i n g i n
ambulatory/community s i t e s ) r a t h e r than j u s t f u n d i n g any
r e s i d e n t i n an a c c r e d i t e d t e a c h i n g h o s p i t a l , what would be
the best way t o s e t these c r i t e r i a , update them and a l l o c a t e
funds w i t h o u t unnecessary bureacracy?
9.
Assuming t h a t s t a t e p r a c t i c e a c t s f o r p h y s i c i a n s , nurses and
o t h e r p r o v i d e r s o f t e n e r e c t p o l i t i c a l b a r r i e r s t h a t prevent
c o s t - e f f e c t i v e d e l i v e r y o f s e r v i c e s , what type o f f e d e r a l
preemptive l e g i s l a t i o n could best "open up" p r a c t i c e w h i l e
s t i l l p r o t e c t i n g p a t i e n t s ? Would l e g i s l a t i o n dependent on
non-governmental p r a c t i c e d e s c r i p t i o n s ( e . g . p r o f e s s i o n a l
a c c r e d i t i n g bodies) c r e a t e a d e l e g a t i o n problem?
tp.
'
Assuming t h a t r a c i a l and e t h n i c d i v e r s i t y i s a goal i n
f u n d i n g t r a i n i n g programs f o r d o c t o r s and o t h e r p r o v i d e r s ,
what types o f g o a l s / t a r g e t s / r e q u i r e m e n t s f o r d i v e r s i t y
should be e s t a b l i s h e d and how much can f u n d i n g f o r the
o v e r a l l t r a i n i n g o f p r o v i d e r s depend on meeting these
criteria?
�QUESTIONS
FOR THE LEGAL AUDITORS
1.
Assuming t h a t t h e s t a t u t e c r e a t e s a s t r u c t u r e o f " u n i v e r s a l
access" s h o u l d a c i t i z e n a l l e g i n g d e n i a l o f access, i . e .
r e j e c t i o n by an AHP have an immediate remedy?
Should t h e s t a t u t e t a l k about a " r i g h t " t o h e a l t h care?
Should p r o o f o f " r e f u s a l t o e n r o l l " t r i g g e r t h e r i g h t ?
Should any o t h e r a c t i o n by t h e HIPC o r t h e AHP t r i g g e r t h e
right?
What p o s s i b l e range o f a c t i o n s , by whom, c o u l d r a i s e t h e
specter o f the v i o l a t i o n o f t h i s r i g h t ?
How s h o u l d t h e p a t i e n t / c o n s u m e r proceed, w i t h what r i g h t s
and what p r o t e c t i o n s ?
What remedies s h o u l d be a v a i l a b l e t o t h e consumer?
Should t h e i n a b i l i t y o f t h e HIPC o r t h e AHP t o have persons
s k i l l e d i n t h e language o f t h e c o n s u m e r / p a t i e n t be h e l d t o
be a d e n i a l o f s e r v i c e ?
What o t h e r c i r c u m s t a n c e s might be h e l d t o be tantamount t o
denial?
2. Assuming t h a t undocumented persons w i l l n o t be covered i n t h e
system, b u t t h a t t h e y m i g h t have r e l a t i v e s o r c h i l d r e n who would
be:
Should undocumented persons who a p p l y f o r coverage f o r t h e i r
c h i l d r e n o r r e l a t i v e s be p r o t e c t e d from i n v e s t i g a t i o n s by
the INS?
Should any r e c o r d s o f t h e HIPC o r t h e AHP be a v a i l a b l e t o
the INS o r t o any o t h e r government s e r v i c e ?
3.
Assuming t h a t t h e s t r u c t u r e o f t h e h e a l t h p l a n s and t h e
r e l a t i o n s h i p o f t h e HIPCs and t h e AHPs w i l l be l a r g e l y a m a t t e r
of s t a t e p o l i c y :
What s t a n d a r d s s h o u l d t h e F e d e r a l government have t o d e c i d e
whether o r n o t a s t a t e has f a i l e d t o f u l f i l l i t s
obligations?
What remedies s h o u l d t h e F e d e r a l government have a v a i l a b l e
to enforce the d i r e c t i v e s of the statute?
4.
Assuming t h a t t h e b e n e f i t package w i l l s p e c i f y c a t e g o r i e s o f
s e r v i c e s and w i l l n o t s p e l l o u t t h e e n t i r e menu o f " m e d i c a l l y
necessary and a p p r o p r i a t e " s e r v i c e s , how s h o u l d disagreements
over c o v e r e d s e r v i c e s be r e s o l v e d ?
Should t h e r e be a mandatory " m e d i a t i o n " process w i t h i n t h e
AHP?
At what p o i n t s h o u l d a p a t i e n t have access t o an independent
h e a r i n g o f f i c e r , and s h o u l d t h a t be i n t h e c o n t e x t o f a
" f a i r h e a r i n g " o r i n some o t h e r s e t t i n g ?
5.
Assuming t h a t t h e r e i s an appeal process, how s h o u l d i t be
t r i g g e r e d and how s p e c i f i c s h o u l d a s t a t u t e be about t h e r i g h t s
�o f t h e p a t i e n t s and t h e o b l i g a t i o n s o f t h e AHPs?
I n g e n e r a l s h o u l d t h e s t a t u t e be more o r l e s s s p e c i f i c about
t h e r i g h t s , d u t i e s and o b l i g a t i o n s o f t h e HIPCs and t h e AHPs
, o r s h o u l d many o f t h e d e t a i l s be l e f t t o t h e
r e g u l a t o r y process?
6.
What new remedies, i f any, s h o u l d be a v a i l a b l e t o p h y s i c i a n s
o r o t h e r h e a l t h c a r e p r o v i d e r s who a l l e g e d i s c r i m i n a t i o n on t h e
b a s i s o f r a c e , d i s a b i l i t y o r s e x u a l p r e f e r e n c e as t h e reason f o r
t h e d e n i a l o f t h e i r r e q u e s t t o j o i n an AHP as a p r o v i d e r ?
7. What remedies, i f any, s h o u l d be a v a i l a b l e t o an AHP t h a t i s
not s e l e c t e d by a HIPC as an approved plan?
Should t h e s t a t u t e s p e c i f y t h e c r i t e r i a f o r t h e d e c i s i o n o f
a HIPC t o approve o r d i s a p p r o v e o f t h e p l a n s u b m i t t e d by any
s p e c i f i c AHP?
Could t h e s t a t u t e s p e c i f y t h e s e c r i t e r i a and s t i l l l e a v e
maximum room f o r s t a t e e x p e r i m e n t a t i o n and r e g u l a t i o n ?
I f t h e s t a t u t e does n o t s p e c i f y t h e r o l e o f t h e HIPCs i n
s e l e c t i n g AHPs how w i l l u n i f o r m n a t i o n s t a n d a r d s on t h i s
most b a s i c element o f t h e p l a n be s u s t a i n e d ?
8.
Assuming t h a t most disagreements a r e r e s o l v e d a t t h e l e v e l
o f t h e AHP, what i n f o r m a t i o n s h o u l d be g a t h e r e d and d i s s e m i n a t e d
to t h e general p a t i e n t population?
Should t h e AHP be r e q u i r e d t o r e p o r t t h e r e s u l t s o f t h e
m e d i a t i o n s ( i n schematic form w i t h o u t p a t i e n t names o r
recognizable c h a r a c t e r i s t i c s - - i . e . , Pre-natal t e s t f o r
C y s t i c F i b r o s i s DENIED) and i f so how o f t e n and t o whom?
Should t h e AHP be bound i n anyway by t h e outcome o f s i m i l a r
d i s p u t e s i n l i k e circurtistances? I f so, how so? I f n o t what
w i l l prevent d i s c r i m i n a t i o n against less aggressive o r
h o s t i l e patients?
Should t h e AHP be r e q u i r e d t o p r o v i d e a f o r m a l w r i t t e n
n o t i c e o f d e n i a l i f t h e r e q u e s t f o r s e r v i c e s i s denied? I f
an e x i s t i n g s e r v i c e i s reduced o r t e r m i n a t e d and t h e p a t i e n t
or f a m i l y objects?
9.
Should t h e AHP be r e q u i r e d t o have a s t a t e d and d i s s e m i n a t e d
p o l i c y on c o n t r o v e r s i a l b i o e t h i c a l i s s u e s , i . e . , a b o r t i o n ,
t e r m i n a t i o n o f c a r e f o r t h e t e r m i n a l l y i l l , where s t a t e law would
p e r m i t a range o f p o l i c y o p t i o n s ? I f so s h o u l d t h i s be r e q u i r e d
by s t a t u t e o r by r e g u l a t i o n ?
I f by s t a t u t e what language might
be a p p r o p r i a t e ?
�REGULATORY RELIEF
Over the years, layers of federal regulation have been established that impose unreasonable burdens on
physicians' practices, often duplicating private sector activities. These regulations are often not cost
effective and significantly increase the cost of medical care. Medicare is one of the most complex
laws, with literally thousands of pages of regulations, instructions and directions. Peer Review
Organizations (PRO) have the authorization to begin review in every physician's office. The National
Practitioners Data Bank is expensive and does not provide the necessary operational safeguards to
ensure confidentiality. EPA regulates disposal of medical waste. OSHA regulates workplace safety.
The Americans with Disability Act has established new requirements on physicians, both as employers
and in the area of pubUc accommodations. The Clinical Laboratory Improvement Act of 1988
regulates over 100,000 physician practices, is overly complex and will increase the cost of medical
care and create new barriers to access. Even the Federal Communications Commission is estabUshing
requirements which are of doubtful benefit.
While taken individually, each regulation is well intended, the practical effect is a regulatory overload
that is often impossible to deal with. Regulations emanate from multiple sources with multiple goals
that do not always work when applied to the physician's practice. Many agencies do not have
adequate experience in the health care area or physician practice in general and are not sensitive to the
unique challenges faced in a physician's practice. Multiple enforcement agencies, unclear standards,
rules that are not tailored to the individual's circumstances all lead to hassle,frustrationand anger. It
also must be recognized that regulatory requirements raise the costs of providing health care services
and divert resources from direct provision of necessary care.
Recommendation:
Create a Presidential commission to review the multiple regulatory burdens
that impact on the health care system and physicians. Such a commission
should inventory the regulations and rules now applicable, analyze them from
a cost-effectiveness standpoint, appropriateness of the requirement and make
recommendations for the elimination of unnecessary, inappropriate, duplicate,
ineffective or overly costly regulations and coordinate the implementation and
enforcement of the remaining items.
We have also developed conmients on specific regulatory areas that now are causing problems for
physicians. Below is a discussion of some of these regulatory problems and suggestions for reform in
the following areas:
Clinical Laboratory Improvement Amendments of 1988 (CLIA)
Peer Review Organizations (PRO)
National Practitioner Data Bank (NPDB)
Occupational Safety and Health Administration (OSHA)
Americans with Disabilities Act (ADA)
Medicare Administrative Burdens
�Clinical Laboratory Improvement Amendments of 1988 (CLIA)
CLIA regulates all clinical laboratory testing, wherever provided, no matter how simple. Expensive
compliance requirements are forcing some physicians to close their labs rather than put up with
inspections, paperwork and daily administrative requirements. This massive regulatory program,
effecting hundreds of thousands of sites, was developed due to problems with certain cytology tests,
specifically pap smears. However, the authorizing legislation went way beyond pap smears to cover
all testing, no matter where provided, without clear docimientation that there was a major problems
that needed to be addressed.
Initial regulations were so out of touch with reality, that over 60,000 comments were filed and major
changes have been made. In many cases, it appears the goal of accurate tests has taken a back seat to
meeting bureaucratic requirements. What is important is not whether the person performing the test is
a high school graduate or has an associate degree from a jimior college. What is important is that the
test is done correctly with accurate results and that the patient gets the care they need. Proficiency
testing should be the key as well a recognition of private accreditation efforts.
Although many changes have occurred since the CLIA regulations were first published in 1989,
physicians remain concemed about the following problems:
PHYSICIAN TEST CATEGORY
Problem:
Federal statutes and regulations must not deny a physician the right to practice
medicine by implicitly establishing unprecedented and unwarranted federal licensure or
certification standards. In many cases, however, the requirements of the CLIA
moderately complex category are forcing physicians to discontinue necessary testing in
their offices. Consequently, patient access to needed laboratory tests may be unduly
restricted and burdens on patients, including delayed diagnosis or prolonged treatment
and increased travel time, and repeat office visits, resulting in additional health care
costs may occur.
Solution:
The criteria we recommend to establish an expanded and modified category of
waivered tests that are provided by physicians in their offices as follows:
1.
Establish a range of tests based on the physician's training and experience and
performed by or under the direction and control of the physician, and
2.
Ensiu-e prompt test results to provide quality medical care and/or to avoid
additional burdens on the patient which could result in noncompliance with the
request for the test; and
Ensure low risk of erroneous results through the training or experience of the
physician performing or supervising the test, successful participation in a
proficiency testing program for the specific test and examination of the full
history and records of the patient along with direct observation of the patient.
�There is no specific predetermined list of tests for this recommended broad category.
With the apphcation for a "physician" certificate, each physician will identify specific
tests that he or she will personally perform or closely supervise. These tests could
include tests otherwise foimd in any other category except for cytopathology. In
addition, the physician will submit documentation indicating successful participation in
an independent proficiency testing program, if available, for each non-waivered test
listed on the certificate. The fee for this certificate should be no more than $150.
The following standards would appjx to the broad "physician" category:
1.
The physician must successfully complete a proficiency testing program, if
available.
2.
Quality controls and Commission on Office Laboratory Assessment (COLA) or
other accreditation are strongly encouraged.
3.
Tests must be consistent with the physician's specialty, training or experience.
4.
Tests must be physician interpreted with no other personnel involved except
those under the physician's direction and control.
5.
Laboratories would be subjected to on-site inspection if suspected of being out
of comphance with the certificate.
This new physician category would allow physicians to practice medicine without
inappropriate federal intrusion and at the same time ensure that patients have access to
high quality laboratory tests.
DEEMED STATUS
Problem:
At this time, laboratories do not have a clear option of selecting a private accrediting
entity such as the Commission on Office Laboratory Accreditation or the College of
American Pathologists. The lack of granting "deemed" status to private entities has
created confusion and uncertainty. We understand that entities seeking "deemed"
status have submitted applications several months ago. These entities are constantly
getting requests from the Health Care Financing Administration (HCFA) for additional
information. The most recent request concemed the new physician category. Since
the CLIA regulations are constantly evolving, these requests could continue
indefinitely.
Solution:
HCFA should immediately issue "deemed" status to qualified private accrediting
entitieFwhcThave already submitted their applications. HCFA must ac( on the
information that they currently have and issue "deemed" status to qualified entities to
avoid further complicating a very complex process. We urge that HCFA give this
issue the highest priority and issue "deemed" status to qualified entities immediately.
�PATIENT ACCESS
Problem:
Currently, the regulations provide no consideration of problems of patient access to
laboratory services in "health professions shortage," "underserved" or "rural" areas.
Laboratories in these areas would have to close if they find it fmancially impossible to
comply with the regulations or if there is an inadequate supply of trained personnel.
At best, these patients would have to travel a great distance with added expense and
great inconvenience or suffer delay in receiving results as samples are transported to
qualified laboratories. Under these conditions some patients might elect not to have
the laboratory tests performed-possibly jeopardizing their health. Modifications to the
regulations are imperative to assure patients continued access to laboratory services in
"health professions shortage," "underserved" or "rural" areas.
Solution:
An ^ception to the CLIA regulations also should be given to laboratories which are
the "sole_£ommimit^
laboratory services, so that such services remain
reasonably available in a geographic area. This special classification should be similar
to the "sole community hospital" exception provided under Medicare Part A (Section
1886(d)(5)(C)(ii) of the Social Security Act). Consideration in determining a "sole
community" laboratory should be given to such factors as isolated location, weather
and travel conditions, and the absence of or accessibility to an independent laboratory
in the area.
FINANCIAL IMPACT
Problem:
While physicians beUeve that high quality laboratory tests are essential, we believe that
some of the proficiency testing (PT), quality control (QC) and quality assurance (QA)
requirements as proposed are too expensive to be practical for all laboratories.
Solution:
For moderately complex laboratories, the QC requirement should be reduced from
twice to once per day and that PT events (the number of times the laboratory is tested)
should be reduced from three to two per year. This would save approximatelv $110
million per year. Since most of the financial burden of CLIA will be borne by
physicians who provide in-office testing, this would alleviate much of the fmancial
burden for these physicians and still provide adequate safeguards for padents.
"SHARED" LABORATORIES
Problem:
Confusing infonnation conceming "shared" laboratories has been given by HCFA and
clarification is needed. At one time, HCFA indicated that one certificate was
necessary for each physician "sharing" laboratory equipment with other physicians.
Later, the decision was reversed and now HCFA indicates that each physician in a
"shared" laboratory situation who submits a Medicare claim form for a laboratory test
needs an individual certificate.
7
�Solution:
A single CLIA ID number should be utilized by^ll physicians using the jgme
laboratory for their testing. CLIA was designed to regulate toboraMy_sgryices,CLIA
was not enacted to regulate the^individuals^ordMj^
from the laboratory.
Whether the physicians are organized in a formal group practice or are merely
"sharing" laboratory equipment should make no difference for CLIA purposes as long
as there is only a single laboratory. To require each physician to have a different
CLIA ID number is not supported by the stamte and would cause the laboratory to
imdergo several redundant inspections as well as incur redundant fees for proficiency
testing (PT), and quality control (QC).
ANNOUNCED INSPECTIONS
Problem:
The Secretary of Health and Human Services clearly indicated in a press release on
September 1, 1992 that the physician would have 3 days notice prior to an inspection.
However, survey guidelines and recent discussions with HCFA indicate that physicians
may not receive 3 days notice. HCFA has indicated that notice is only to be given if
patient care would be at jeopardy because of the inspection.
Solution:
The CLIA regulations need to clarify that the physician's office will not be subjected
to unannounced routine inspections. An imannounced CLIA inspection in a
physician's office will always dismpt patient care. The regulations at Section
493.1175(a), Section 493.1777(a) and Section 493.1780(a) should be modified by
adding a sentence that states: "Physicians' offices will be given 3-day advance notice
of a routine inspection. If a complaint has been received or a problem is suspected,
then the inspection of the physician's office may be unannounced."
CLINICAL LABORATORY IMPROVEMENT ADVISORY COMMITTEE (CLIAC)
Problem:
The breadth and scope of the CLIA regulations and the impact of these regulations
have on the practice of medicine need to be continually assessed to determine whether
there is any measurable impact on the quality of laboratory testing and medical care.
Solution:
Charge the CLIAC with the responsibility of evaluating program operation, making
recommendations for modifications in regulations and other program requirements and
evaluate the impact of the program.
Problem:
Although the physicians support the use of CLIAC to implement CLIA, more CLIAC
members should be physicians with experience with in-office laboratory testing.
Solution:
Since the largest newly regulated population under CLIA are physicians who perform
in-office laboratory testing for their patients, the majority of the members of CLIAC
should be these physicians who have direct knowledge and expertise with in-office
laboratory testing. Positions should be identified for physicians who have in-office
laboratories.
�Peer Review Organizations (PRO)
Enacted as a federal watchdog over physician practices, the PRO program started out as very intrusive
and burdensome on physician practices. Individual case review and pre-approvals for certain
conditions created a level of animosity that will be difficult to overcome.
Many improvements were incorporated into the final version of the Fourth Scope of Work, resulting in
a PRO program focused primarily on education instead of punitive actions. However, the following
issues still need to be resolved.
PRO DENIAL OF PAYMENT FOR SUBSTANDARD QUALITY CARE
Problem:
The Consolidated Omnibus Budget Reconciliation Act of 1985 gave PROs the
authority to deny Medicare payments for services provided that are determined by a
PRO to be of substandard quality. On January 18, 1989, HCFA published a proposed
rule in the Federal Register detailing its plan for implementing this provision of the
Medicare law. HCFA's proposed regulations, for various reasons, have not yet been
implemented. On November 3, 1992, HCFA pubUshed an annoimcement in the
Federal Register indicating that "final action" on the proposed 1989 rule was "pending
the resolution of complex policy issues."
Solution:
HCFA should not implement a final mle for PRO denial of "substandard quaUty care"
until its has redrafted its proposed rule in a manner consistent with the spirit and
requirements of the current PRO Fourth Scope of Work, and until it has provided the
medical community with an adequate opportunity to conduct discussions with HCFA
on the appropriateness and direction of such regulations.
PRO AMBULATORY REVIEW
Problem:
The Omnibus Budget Reconciliation Act of 1986 called for PROs to review the care
provided to Medicare patients in physicians' offices. Following that legislative
mandate, HCFA funded three pilot projects to test the viabiUty of altemative
approaches to PRO ambulatory review. At this time, however, HCFA has no firm
timetable for implementing PRO review of physicians' offices.
Solution:
Enact amendments to the PRO law that would repeal the legislation authorizing
physician office reviews. If repeal is unsuccessfiil, such review should not be
expanded_beyond the pilot stage until HCFA has^deinonstrated that its review
methodologies are focused, based on medically sound processes and outcomes, and
consist^t^wTth the educaSonal, non^unitive^proach in the current f K U hourth
Scope of Work. Reviewing the care in hundreds of thousands of physicians' offices
would be a massive, expensive imderlaking that would divert resources from providing
services to patients.
�PRO PREPROCEDURE REVIEW
Problem:
HCFA has made an administrative decision to eliminate 100 percent PRO
|
preprocedure/readmission review of 10 surgical procedures in die Fourth Scope of
/
Work. However, federal legislation remains in force that requires PROs to conduct I
such review.
Solution:
Urge Congress to repeal the appUcable legislation mandating 100 percent review of at |
least 10 surgical procedures.
ATTESTATION REQUIREMENTS
Problem:
Attestation requirements for hospital discharges and their use by the PRO program
create unnecessary burdens for physicians. Annual written certification is required for
primary and secondary diagnoses and procedures pertaining to each case, and failure to
so attest results in a mandatory PRO denial to the hospital. Improper attestations by
physicians may result in civil monetary penalties. Each physician must annually sign a
written acknowledgment that she or he is aware of the penalties for improper
attestation, which the hospital maintains on file. If the PRO finds improper or
outdated statements on file, it may result in payment denial for all care associated with
physician orders executed by such physician.
Solution:
To reduce the administrative burden, the attestation requirement should be required
only when hospital privileges are granted. Any additional requirements should only
involve verification as to the legibiUty of the signature and to ensure that the signature
matches the attestation.
PHYSICIAN REVIEWER EDENTITIES
Problem:
As currently drafted, the Fourth Scope of Work does not require PROs to reveal the
identities of PRO physician reviewers. Instead, it requires that PROs only assess the
potential impact on physician reviewers if the names of individual reviewers are
disseminated to physicians under review. Physicians remain frustrated by the
anonymity granted to PRO reviewers by HCFA and their inability to confront their
accusers (a basic tenet of American due process).
Solution:
Support changes in regulations and the Fourth Scope of Work to require PROs to
release to physicians imder review the identities of PRO physician reviewers.
National Practitioner Data Bank (NPDB)
The National Practitioner Data Bank was created to deal with the problem of physicians and other
health care practitioners losing their license or privileges in one state and moving to another.
However, the legislation went way beyond that problem and established elaborate reporting
requirements well beyond licensure actions. The Act also failed to recognize that there was a private
�8
sector activity with the Federation of State Medical Licensing Boards that dealt with the perceived
problems of physicians moving between states.
Problem:
The data bank is another example of the federal govemment initiating a new activity
rather than utilizing existing mechanisms at the state level and in the private sector.
Man;y individuals involved in the credentialing area have expressed doubts as to
whether the NPDB provides significant benefits, especially in light of its costs and
additional burdens.
Solutions:
Consider a private sector altemative such as the service of the Federation of State
Medical Licensing Boards.
Review its operation focusing on cost-effectiveness and matters relating to
confidentiality.
If the NPDB is not privatized, reduce die existing burden by enacting legislation to
establish a $30,000 threshold for reporting of medical liability payments.
Do not impose user fees for practitioners who self-query to determine the accuracy of
the data regarding their files.
Occupational Safety and Health Administration (OSHA)
Physicians recognize that employees have a right to a safe work place, but it is clear that OSHA has
very little, if any understanding of the operation of physician practices. Regulatory requirements that
may be appropriate for large institutions or where high risk procedures are performed, are not always
necessary for other settings.
Problem:
OSHA has imposed very strict and biudensome workplace and record keeping
standards for physicians offices that in many cases are unrealistic to the risk posed.
OSHA has previously issued press releases after inspecting physicians' offices Uiat
were inflammatory.
Solutions:
There is a conflict between the bloodbome pathogens recordkeeping
requirements and the general OSHA recordkeeping requirements that
makes it impossible to fully comply with both regulations. OSHA
acknowledged part of this problem in the preamble to the bloodbome
pathogens regulation and stated that the general recordkeeping
requirements would be amended. Such an amendment was never
made, and OSHA officials now explain it will not be done.
A related recordkeeping matter concems the requirement in the
bloodbome pathogens standard that employee medical records be
maintained for at least thirty years. This is extremely biudensome for
the small practice that may have a high level of turnover.
�Another example of employee medical records which must be
maintained for at least 30 years after employment is the retention of
material safety data sheets (MSDSs) as required by the hazard
communication standard. The 30 year retention requirement is imduly
burdensome on physician practices. Also, material safety data sheets
should not be required for products, such as bleach or vinegar, that can
be bought in grocery stores.
OSHA has expanded its regulation of infection control by requiring
employers to adopt work practices and provide equipment to prevent
the transmission of TB. There are several "guidelines" on TB conti-ol,
but no clear regulations. Physicians tiierefore caimot anticipate what
OSHA inspectors might be looking for, and may in fact, disagree with
the recommendations of the particular set of guideUnes being appUed
by the inspector. OSHA should be required to go through the
rulemaking process prior to enforcing TB control measures in
physician offices, except for a few, noncontroversial, clearly
communicated requirements. OSHA should also avoid expensive self
contained respiratory systems until the clear risk and benefit can be
estaWished.
Codify OSHA's pohcy of only inspecting physician offices in response
to complaints, and not to conduct special emphasis inspections (ie.
when there is no reason to beUeve their is a violation) of physician
offices.
In cases when an iaspection is warranted, OSHA inspectors only
should cite violations of specific standards and not cite the general
duty clause (which requires that employers fiunish a workplace free
from recognized hazards but contains no guidance as to how that
general duty should be met) so that physicians have notice and an
opportunity to comply with specific OSHA requirements.
The bloodbome pathogens standard permit the off-site laundering of
uncontaminated uniforms and imcontaminated personal protective
equipment, however some OSHA compliance officers are enforcing the
contaminated laundry requirements in the context of imcontaminated
laundry. OSHA inspectors should be directed to allow reasonable offsite laundering of uncontaminated material.
Americans with Disabilities Act (ADA)
Problem:
The American with Disabilities Act has created an entire new set of federal regulatory
issues for the physician's practice. These relate to the physician's obligations as an
employer and as a public accommodation. One of the major problems with ADA
regulations is that the regulatory requirements are not well articulated. It is expected
�10
that these issues will be resolved only through expensive litigation. Clear federal
enforcement standards should be established and made available so that people
required to comply with the law understand the requirements.
Solutions:
Provide clear regulatory guidance to physicians and others as to what they are
expected to do to comply with ADA.
Require Medicaid reimbursement for sign language interpreters
required by Medicaid patients.
Expand tax incentives available to physicians who make expenditures
for the purpose of creating greater accessibility to facilities for
individuals wiUi disabilities. Specifically expansion of the Disabled
Access Tax Credit to cover all of tiie costs associated with the
provision of interpreters. This could be accompUshed by eliminating
the minimum and maximum dollar amounts in the existing tax credit
(between $250 and $10,250) and calling for an increase in the tax
credit from 50% of the expenditure to 100% of the expenditure.
Review regulatory requirements for their impact on physician offices and other small
business. For example, the FCC has required that all telephone headsets in workplaces
be hearing aid compatible by May 1, 1994. (For workplaces over 20 employees, the
conversion must take place by May 1, 1993). AU phones manufactured before August
of 1989 must be checked to see if they comply. [Note: This is not an ADA
requirement, but stems from the Hearing Aid Compatibility Act of 1988.]
Medicare Administrative Burdens
The Medicare program is one of the most complicated and confusing programs administered by the
Federal govemment. The statute covers hundreds of pages, and there are tens of thousands of pages of
regulations, instmctions, decisions and other determinations. HCFA has attempted to resolve various
regulatory burdens but more needs to be done. Each year, physicians are faced with increased layers
of requirements and inconstant implementation.
To further improve Medicare-physician relations, the foUowing issues merit special attention.
PRACTICING PHYSICIAN ADVISORY COMMITTEE
Problem:
The Practicing Physician Advisory Committee was created by the Congress to review
new regulatory proposals and provide the input of physicians on implementation
issues. While a good idea, the Committee has not properly utilized by HCFA. The
agendas of the Committee have been relegated to relatively minor items, with the real
issues of concem to physicians not being addressed. The Committee has the talent in
its membership to facilitate resolution of many problems facing physicians in the
Medicare program.
.
�11
Solution:
Instinct HCFA to use the Practicing Physician Advisory Committee to review all major
Medicare regulations and policy decisions and make recommendations for
improvement, consolidation or elimination of the existmg body of rules and regulation.
Provide adequate staff to the Committee to conduct tiiis review m a timely fashion.
DISCLOSURE OF COVERAGE CRITERIA
Problem:
Medicare has utUization, coverage and screening criteria for review of claims fliat it
keeps hidden from physicians. This creates tiie situation where claims are challenged
or denied based on the results of a |1>lack_box" review. Physicians are kept in tiie dark
as to what the program considers proper and the credibility of the criteria is questioned
because they are not held up to scientific scmtiny and review. Congress authorized a
demonstration project for release of the criteria to see the impact on physician
behavior, but no report has been issued. Since these criteria relate to medical care
issues, it is only fair that physicians be informed of the review criteria and have a
chance to evaluate the accuracy of the standards.
Solution:
Make available to physicians and their representative professional organizations all
medical review employed by carriers and PROs to review Medicare claims.
DOWNCODING
Problem:
Arbitrary downcoding by carriers has been one of the major problems experienced by
physicians. Based on analyses of physician coding practices, carriers have sometimes
changed a physician's assigned level of service to a lower level. In such downcoding
situations, Uie carriers would usually allege that physicians in tiie area routinely used
two or three levels of service and did not routinely provide higher level services.
Regardless of what the physician coded, and not based on a review of the records, the
carrier would reassign the physician's services at a lower level.
Solution:
Codes should be altered only after a review of the documentation and after notification
to the physician. Prior to a final determination to downcode, carriers should request
additional information from the physician.
DUE PROCESS/MEDICARE AUDITS
Problem:
The use of "sampling" and exU-apolation have proven to be particularly onerous as the
civil monetary penalties allow for an assessment of twice the inappropriate charge plus
a $2,000 fme for each incident. This penalty quickly adds up as the carrier, by statute,
can go back at least four years (there is no time limitation for instances of fraud). The
lack of an adequate due process appeal procedure under these circumstances is
especially oppressive.
Such sample audits are often accompanied by coercive audit letters to physicians
stating that repayment must be forthcoming immediately or they may be subjected to a
blanket audit of all claims submitted for the previous fours years.
�12
Solution:
Physicians strongly object to this heavy handed approach and believes that carriers
transcend the limits of their authority by proceeding in this manner. In supporting the
"anti-hassle" legislation, extrapolation should be used only to identify claims for which
payment may be disallowed. Further, if the physician requests that the claims at issue
be identified individually, the carrier may not recoup or offset payment amounts or
charge interest until an appeal is heard at the ALJ level.
LIMITING CHARGE ENFORCEMENT
Problem:
In many cases, mistakes in the limiting charges have occurred because carriers did not
have adequate lead time to notify physicians of changes in the new physician payment
system. Also, carriers supplied physicians with some of the charge limits, but not for
aU services. So physicians had to do their own calculations for the unlisted services.
In addition, some services which were separately billed, are now "bundled" by the
carriers into a single global fee. This "bundling" results in a lower Medicare fee and a
lower limiting charge. Since physicians do not receive the "Explanation of Medicare
Benefits" they may never know that Medicare payment and the allowed charge were
less than they anticipated.
In spite of these problems, HCFA hastightenedenforcement by more aggressively
requiring physicians to refund overpayment to Medicare beneficiaries.
Solution:
Physicians do not condone over-charging tiie patient and supports appropriate
enforcement of the relevant statute. However, we are concemed that the physician
may be imduly penalized for an inadvertent error. Prior to enforcing penalties and/or
sanctions or notifying the beneficiary, physicians should be properly informed as to the
problem and given an opportunity to object (with full due process) or correct the enor.
Experience shows that physicians, once aware of any problem, wUl act responsibly.
MEDICARE SECONDARY PAYER
Problem:
Under Section 1862(b)(2) of the Social Security Act, the carrier can refuse to
reimburse the physician for a Medicare claim if the beneficiary has not filled out and
submitted a questionnaire designed to determine whether Medicare is a secondary or
primary insurer. This denial of payment penalizes the physician for the beneficiaries'
inaction—sometiiing over which the physician has no control.
Solution:
This policy is unfair and should be curtailed. Instead, the carriers should gather
information on insurance directiy from the beneficiary with no penalty placed on the
physician.
CONTRACTOR FUNDING
Problem:
We are particularly concemed that cost per claim reductions in HCFA's contractor
funds will hamper HCFA's efforts to enhance canier-physician relationships. HCFA
should be encouraged to assure that claims processing is efficient and cost effective.
At the same time, HCFA must not short change needed educational efforts to increase
physicians' knowledge about claims processing requirements.
�13
Solution:
Adequate funding for competent staff and outi-each activities such as "SOO" telephone
service is essential. HCFA must aggressively pursue adequate contractor funds to
properly administer the Medicare program.
CARRIER FEES
Problem:
Pressures on restraining carrier administrative costs have resulted in consideration of
passing legitimate program costs on to the physicians through user fees. For example,
carriers in some geographic areas reportedly have charged physicians for information
necessary to comply with the Medicare program such as obtaining a unique identifier
number (UPIN), responding to inquiries, and providing information used in the
medical review of services. HCFA has proposed
a fee for each paper claim filed, or for an error in filing a claim, and charging for an
appeal of a denial of a claim.
Solution:
The Medicare system was designed as an entitlement insurance program, not a user
supported system. Therefore, HCFA should be prohibited from charging physicians
for claims processing functions.
CARRIER PERFORMANCE
Problem:
Many times physicians and/or medical societies are fmstiated in their relationship with
the Medicare carriers in that there is no recourse if a Medicare carrier violates or does
not fulfill its Medicare contract. The only action that can be taken is to protest to
HCFA and HCFA's only major recourse is to terminate the carrier's contract. No
intermediate action or sanction is available to an aggrieved beneficiary or provider.
Solution:
Medical societies should be allowed to submit evaluations and information conceming
the canier's performance to the Secretary of Healtii and Human Services. This
information should be considered in the annual canier performance evaluation.
In addition, we also beUeve that a new policy of intermediate sanctions be estabUshed
if a carrier fails to carry out policies established through regulation, carrier manual, or
regional and central office transmittal, a hearing process to correct this should be
aUowed at the request of any individual (includmg a physician) or representational
organization (including a medical society). For a hearing to be held, damages must be
at least $500 (claims could be aggregated). If a carrier is found to have violated the
contract, the Secretary should order the carrier to compensate the aggrieved
individuals.
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Legal Audit Group]
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Carolyn Gatz
Jennifer Klein
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 10
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093616" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
2/6/2015
Source
A related resource from which the described resource is derived
42-t-12093616-20060885F-Seg2-010-004-2015
12093616
-
https://clinton.presidentiallibraries.us/files/original/a1970f0ce52a1bdb5291eb89df04b2d4.pdf
1c3dd99067bd671a3619b38a0704389a
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Carolyn Gatz/Jennifer Klein
Subseries:
OA/ID Number:
5107
FolderlD:
Folder Title:
Policy Papers/Topics
Stack:
Row:
Section:
Shelf:
Position:
s
56
5
5
3
�t
f'HOTOcopY
^RESERVATION
\ /
0 ).
�^1
�/
�A p r i l 26, 1993
HEALTH REFORM: AN AMERICAN SOLUTION TO AN AMERICAN PROBLEM
ANTHOLOGY OF POLICY PAPERS
TABLE OF CONTENTS
I.
C o n t r a c t w i t h t h e American People
II.
E t h i c a l Foundations o f t h e New H e a l t h Care System
III.
The Case f o r Comprehensive Reform ( f r o m Report t o
Congress)
IV.
Design o f t h e New System
I n t r o d u c t i o n : C o n s t r u c t o f t h e New System -- Zelman
*
I.
P r i n c i p l e s o f Consumer H e a l t h A l l i a n c e s
—
2.
How t h e New System W i l l C o n t r o l Costs and Achieve
Savings
3.
Encouraging D e s i r a b l e I n n o v a t i o n i n H e a l t h Care
D e l i v e r y Under t h e New System --
4.
H e a l t h P r o v i d e r s i n t h e New System -- Roz
Lasker and Bob Berenson
5.
A c h i e v i n g A c c o u n t a b i l i t y Under t h e New System -Roz Lasker
6.
A l t e r n a t i v e s i n Geographic Areas Where C o m p e t i t i o n
May Not E x i s t : R u r a l and Urban Underserved -L o i s Quam and C l a u d i s Baquet
7.
New System Governance --
8.
Budgets i n t h e New System --
9.
Reforming t h e Insurance M a r k e t p l a c e -- Gary
Claxton
- Community R a t i n g
- ERISA
- Pre-existing Conditions
- Underwriting
10.
Experience w i t h Managed C o m p e t i t i o n --
II.
The Role o f S t a t e and L o c a l Government i n t h e New
System (???) --
�V.
Assuring Q u a l i t y (Separate papers or one with
s u b s e c t i o n s ) Arnie E p s t e i n and R i s a
Lavizzo-Mourey
1.
Overview
2.
Conditions of P a r t i c i p a t i o n i n Health P l a n s
3.
Reporting of Standard Information f o r Comparison
4.
Requirements for D i s c l o s i n g Information to
Consumers
T e c h n i c a l A s s i s t a n c e for Q u a l i t y Improvement
5.
6.
VI.
VII.
S i m p l i f i c a t i o n of E x i s t i n g Q u a l i t y Assurance
Programs and Research Guidelines
Coverage
1.
Coverage for Working I n d i v i d u a l s and F a m i l i e s
- How the New System W i l l Look to Consumers
- How the New System W i l l Look to Employers
2.
Coverage f o r the Temporarily Unemployed
3.
Coverage for Low-Income F a m i l i e s
4.
Coverage for R e t i r e e s
5.
Medicare i n the New
6.
I n t e g r a t i o n of Veterans A d m i n i s t r a t i o n
7.
I n t e g r a t i o n of Department of Defense Programs
8.
P u b l i c Employee Groups i n the New
System
System
Benefits
1.
The Comprehensive B e n e f i t Package
- Services
- R a t i o n a l e Behind a Comprehensive B e n e f i t Package
- Role of the National Health Board
Linda Bergthold and Bob
2.
Valdez
Cost Sharing
- Cost Sharing L i m i t s
- Role of Cost Sharing
- Balance Between Choice and S i m p l i c i t y
�VIII.
IX.
X.
Mental Health B e n e f i t s -- Bernie Arons, Sharman
Stevens and colleagues
1.
Overview of Comprehensive B e n e f i t Approach
2.
Overview of Substance Abuse Treatment
3.
Areas of Concern, R i s k s and Solutions
4.
I n t e g r a t i n g the P u b l i c Sector
5.
D i s t i n c t Populations of Concern
- Children
- S e r i o u s l y Mentally 111
- Homeless Population
Long-Term Care -- Robyn Stone
1.
The Need f o r Long-Term Care Coverage
2.
P o l i c y and Program
3.
Non-Elderly Disabled -- Susan D a n i e l s and Simi
Litvak
Assuring Access f o r Underserved Populations
1.
I n t e g r a t i o n of Protection f o r Vulnerable
Populations i n the New System -- Shoshana
Sofaer
2.
Health P o l i c y I n i t i a t i v e s f o r Underserved
Populations — Bonnie Lefkowitz and E l l e n
Benavitas
Investments i n I n f r a s t r u c t u r e ( R u r a l and
Urban
Investments i n S e r v i c e s (Enabling, e t c )
XI.
3.
Medicaid i n the New System -- Diane Rowland
(???)
4.
P a t i e n t s with AIDS and other Chronic Disease i n
the New System — Mark Smith
5.
People with D i s a b i l i t i e s i n the New System -Rick Brown ( ? ? ? ? )
Financing the New System
—
1.
Sources of Revenues
2.
Economic Impact -- Labor Market E f f e c t s -- Sherry
�Glied
3.
XII.
Budget Impact: How Financing Arrangements
A f f e c t Both Federal and State/Local Governments
i n the Short-Term and Long-Term
T r a n s i t i o n t o the New System -1.
State Entry i n t o the New System
—
2.
T r a n s i t i o n of Small Business
3.
Removing Competitive B a r r i e r s --
4.
Tax-Exempt Organizations i n the New
—
System --
XIII.
P r o t e c t i n g Against Fraud and Abuse -- Berneson/Sage
XIV.
Dispute Resolution and Medical Malpractice Reform
(separate papers or one paper w i t h subsections) -Berenson/Sage
XV.
1.
Enterprise L i a b i l i t y
2.
A l t e r n a t i v e Dispute Resolution and Research
I n i t i a t i v e s i n Dispute Resolution
3.
Tort Reform
4.
National Provider Databank
I n f o r m a t i o n i n the New System (separate papers or one
paper w i t h subsections) -- Tim H i l l and Shana
Kass/ John Silwa
1.
Administrative Simplification
2.
Data System t o Implement National Health Care
Reform
3.
Point-of-Service Information Systems
4.
Improving C l i n i c a l Practice Through I n f o r m a t i o n
5.
Privacy, C o n f i d e n t i a l i t y and Security
6.
Technical Standards f o r C l i n i c a l and
A d m i n i s t r a t i v e Information
XVI.
Public Health and Population-Based
New System -- Joanne Lukumnik
Prevention i n the
XVII.
Developing a Health-Care Workforce -- Sage and c l u s t e r
�1.
Physician Supply and Distribution
2.
Nurses and Other Health Care Providers
3.
The Health Care Workforce for Underserved People
and Areas
4.
Consortia for Community-Based Health Education
5.
Workforce Diversity
6.
Health Care and the National Service I n i t i a t i v e
Missing?: Consumer
Adequate
Override
Academic
Protection?
Statement of the Problem?
of State Laws
Health Centers
�1.
Physician Supply and Distribution
2.
Nurses and Other Health Care Providers
3.
The Health Care Workforce for Underserved People
and Areas
4.
Consortia for Community-Based Health Education
5.
Workforce Diversity
6.
Health Care and the National Service I n i t i a t i v e
Missing?: Consumer
Adequate
Override
Academic
Protection?
Statement of the Problem?
of State Laws
Health Centers
/U
la
:2
3,
4
�A p r i l 26, 1993
HEALTH REFORM: AN AMERICAN SOLUTION TO AN AMERICAN PROBLEM
ANTHOLOGY OF POLICY PAPERS
TABLE OF CONTENTS
I.
C o n t r a c t w i t h t h e American People
II.
E t h i c a l Foundations o f t h e New H e a l t h Care System''^^
Ill
The Case f o r Comprehensive Reform ( f r o m R e p o r t t o
Congress)
IV.
Design o f t h e New System
I n t r o d u c t i o n : C o n s t r u c t o f t h e New System -- Zelman
1.
^/4c -
P r i n c i p l e s o f Consumer H e a l t h A l l i a n c e s --
^
How t h e New System W i l l C o n t r o l Costs and Achieve
Savings
Encouraging Desirable Innovation in Health Care
Delivery Under the New System -0"^-^
^Hoaflth Prov/lders i n t h e New System -- Roz
Lasker and Bob Berenson
^
A c h i e v i n g A c c o u n t a b i l i t y Under t h e New System -Roz Lasker
Where C o m p e t i t i o n
^
x i s t : x R u r a l and Urban Underserved -- 1
^ < C l ^ ^ Q u g i n ^ a n ^ Y ^ l a u d i s Baquet
V
New System Governance -- 2<-X^>>'^^
Budgets in the New System — j
.
Reforming t h e Insurance M a r k e t p l a c e —
Claxton
- Community R a t i n g
- ERISA
- P r e - e x i s t i n g Conditions
- Underwriting
2
Experience w i t h Managed Competition' -The R o i ^ o f \ S t a t e and >ocal^Government
Sy§ufe^ (???)
Gary
^
^
/^^^^^
�V.
Assuring Q u a l i t y (Separate papers or one w i t h
subsections) Arnie Epstein and Risa
Lavizzo-Mourey
1.
Overview
2.
Conditions of P a r t i c i p a t i o n i n Health Plans
3.
Reporting o f Standard Information f o r Comparison
4.
Requirements f o r Disclosing Information t o
Consumers
Technical Assistance f o r Q u a l i t y Improvement
5.
6.
VI,
S i m p l i f i c a t i o n of E x i s t i n g Q u a l i t y Assurance
Programs and Research Guidelines
Coverage 1.
^.^ij^
Coverage f o r Working I n d i v i d u a l s and Families
- How the New System W i l l Look t o Consumers —
- How the New System W i l l Look t o Employers
Coverage f o r the Temporarily Unemployed
Coverage f o r Low-Income F a m i l i e s — ^ ( c f C
Coverage f o r Retirees
Medicare i n the New System
I n t e g r a t i o n o f Veterans A d m i n i s t r a t i o n
7.
I ^ n t o g r a t i o n of) Department of Defense Programs
Public Employee Groups i n the New System
Benefits
1.
The Comprehensive Benefit Package
^^^^''^•-<^<L/.
- Services
- Rationale Behind a Comprehensive B e n e f i t Package
- Role o f the National Health Board
Linda Bergthold and Bob Valdez
2.
Cost Sharing
- Cost Sharing L i m i t s
- Role of Cost Sharing
- Balance Between Choice and S i m p l i c i t y
�VIII.
IX.
Mental H e a l t h B e n e f i t s -- B e r n i e Arons, Sharman
Stevens and c o l l e a g u e s
1.
Overview o f Comprehensive B e n e f i t Approach
2.
Overview o f Substance Abuse Treatment
3.
Areas o f Concern, Risks and S o l u t i o n s
4.
I n t e g r a t i n g t h e P u b l i c Sector
5.
D i s t i n c t P o p u l a t i o n s o f Concern
- Children
- S e r i o u s l y M e n t a l l y 111
- Homeless P o p u l a t i o n
Long-Term Care —
Robyn Stone
1.
The Need f o r Long-Term Care Coverage
2.
P o l i c y and Program
3.
N o n - E l d e r l y D i s a b l e d -- Susan D a n i e l s and S i m i
X.
iring
Integration of Protection for Vulnerable
\\\
Populations in the New System -- Shoshana / / ^ / '
H e a l t h P o l i c y I n i t i a t i v e s f o r Underserved
P o p u l a t i o n s -- Bonnie L e f k o w i t z and E l l e n
Benavitas
Investments i n I n f r a s t r u c t u r e ( R u r a l and
Urban
Investments i n S e r v i c e s ( E n a b l i n g , e t c )
md
P a t i e n t s w i t h AIDS and o t h e r Chronic Disease i n
the New System -- Mark Smith
People w i t h D i s a b i l i t i e s i n t h e New System
Rick Brown (????)
F i n a n c i n g t h e New System
--
--
1.
Sources o f Revenues
2.
Economic Impact -- Labor Market E f f e c t s -- Sherry
�Glied
3.
XII.
-72
Budget Impact: How F i n a n c i n g Arrangements
A f f e c t Both Federal and S t a t e / L o c a l Governments
in the Short-Term and Long-Term ^
^
T r a n s i t i o n t o t h e New System --
—
1.
S t a t e E n t r y i n t o t h e New System --
„^
2.
Transition of Small Business --
4.
Tax-Exempt O r g a n i z a t i o n s i n t h e New System -
A
y
J
XIII.
P r o t e c t i n g A g a i n s t Fraud and Abuse -- Ber^ejon/Sage
XIV.
D i s p u t e R e s o l u t i o n and Medical M a l p r a c t i c e Reform
( s e p a r a t e papers o r one paper w i t h s u b s e c t i o n s ) -Berenson/Sage
XV.
1.
Enterprise L i a b i l i t y
2.
A l t e r n a t i v e Dispute R e s o l u t i o n and Research
I n i t i a t i v e s i n Dispute R e s o l u t i o n
3.
T o r t Reform
4.
N a t i o n a l P r o v i d e r Databank
I n f o r m a t i o n i n t h e New System ( s e p a r a t e papers o r one
paper w i t h s u b s e c t i o n s ) -- Tim H i l l and Shana
Kass/ John S i l w a
1.
Administrative Simplification
2.
Data System t o Implement N a t i o n a l H e a l t h Care
Reform
3.
P o i n t - o f - S e r v i c e I n f o r m a t i o n Systems
4.
I m p r o v i n g C l i n i c a l P r a c t i c e Through I n f o r m a t i o n
5.
P r i v a c y , C o n f i d e n t i a l i t y and S e c u r i t y
6.
T e c h n i c a l Standards f o r C l i n i c a l and
Administrative Information
XVI.
P u b l i c H e a l t h and Population-Based
New System -- Joanne Lukumnik
XVII.
Developing
Prevention i n t h e
a Health-Care Workforce —
Sage and c l u s t e r
�1,
Physician Supply and D i s t r i b u t i o n
2.
Nurses and Other Health Care Providers
3,
The Health Care Workforce f o r Underserved People
and Areas
4.
Consortia f o r Community-Based Health Education
5.
Workforce D i v e r s i t y
6,
Health Care and the National Service I n i t i a t i v e
9
M i s s i n g ? ^ Consumer
Adequate
Override
^—Academic
Protection?
Statement of the Problem?
of State Laws
Health centers"
�Assuring Quality (Separate papers or(/one with
subsections) Arnie Epstein and Risa
Lavizzo-Mourey
1.
Overview
2.
Conditions of Participation i n Health Plans
3.
Reporting of Standard Information for Comparison
4.
Requirements for Disclosing Information to
Consumers
Technical Assistance for Quality Improvement
5.
6.
VI.
Simplification of Existing Quality Assurance
Programs and Research Guidelines
Coverage
1.
Coverage for Working Individuals and Families
- How the New System Will Look to Consumers
- How the New System Will Look to Employers
2.
Coverage for the Temporarily Unemployed
3.
Coverage for Low-Income Families
4.
Coverage for Retirees
5.
Medicare i n the New System
6.
Integration of Veterans Administration
7.
Integration of Department of Defense Programs/^"^M^^ ^
8.
Public Employee Groups i n the New System
1.
The Comprehensive Benefit Package
- Services
- Rationale Behind a Comprehensive Benefit Package
- Role of the National Health Board
.
'<
VII,
Linda Bergthold and Bob Valdez
2.
Cost Sharing
- Cost Sharing Limits
- Role of Cost Sharing
- Balance Between Choice and Simplicity
�A p r i l 26, 1993
HEALTH REFORM: AN AMERICAN SOLUTION TO AN AMERICAN PROBLEM
ANTHOLOGY OF POLICY PAPERS
TABLE OF CONTENTS
I•
C o n t r a c t w i t h t h e American People
II.
E t h i c a l Foundations o f t h e New H e a l t h Care System
III.
The Case f o r Comprehensive Reform ( f r o m R e p o r t t o
Congress)
IV.
Design o f t h e New System
I n t r o d u c t i o n : ^ o n s t r u c t o f t h e New System
By W a l t e r ZelAman
1.
P r i n c i p l e s o f Consumer H e a l t h A l l i a n c e s -- By _
2.
How t h e New System W i l l C o n t r o l Costs and Achieve
Savings -- By
3.
Encouraging D e s i r a b l e I n n o v a t i o n i n H e a l t h Care
D e l i v e r y Under t h e New System -- By
4.
H e a l t h P r o v i d e r s i n t h e New System -- By Roz
Lasker and Bob Berenson
5.
A c h i e v i n g A c c o u n t a b i l i t y Under t h e New System -By Roz Lasker
6.
A l t e r n a t i v e s i n Geographic Areas Where C o m p e t i t i o n
May Not E x i s t : R u r a l and Urban Underserved -- By
L o i s Quam and c o l l e a g u e s and C l a u d i e Baquet and
colleagues
7.
New System Governance -- By
8.
Budgets i n t h e New System -- By
9.
Reforming t h e Insurance M a r k e t p l a c e -- By Gary
Claxton
- Coiiununity R a t i n g
- ERISA
- Pre-existing Conditions
- Underwriting
10.
Experience w i t h Managed C o m p e t i t i o n -- By
11.
The Role o f S t a t e and L o c a l Government i n t h e New
System (???) — By
�V.
A s s u r i n g Q u a l i t y (Separate papers o r one w i t h
s u b s e c t i o n s ) By A r n i e E p s t e i n and Risa
Lavissa-Mourey
1.
Overview
2.
C o n d i t i o n s o f P a r t i c i p a t i o n i n H e a l t h Plans
3.
R e p o r t i n g o f Standard
4.
Requirements f o r D i s c l o s i n g I n f o r m a t i o n t o
Consumers
T e c h n i c a l A s s i s t a n c e f o r Q u a l i t y Improvement
5.
6.
VI.
VII.
I n f o r m a t i o n f o r Comparison
S i m p l i f i c a t i o n o f E x i s t i n g Q u a l i t y Assurance
Programs and Research G u i d e l i n e s
Coverage
1.
Coverage f o r Working I n d i v i d u a l s and F a m i l i e s
- How t h e New System W i l l Look t o Consumers
- How t h e New System W i l l Look t o Employers
2.
Coverage f o r t h e T e m p o r a r i l y
3.
Coverage f o r Low-Income F a m i l i e s
4.
Coverage f o r R e t i r e e s
5.
Medicare i n t h e New System
6.
I n t e g r a t i o n o f Veterans A d m i n i s t r a t i o n
7.
I n t e g r a t i o n o f Department o f Defense Programs
8.
P u b l i c Employee Groups i n t h e New
Unemployed
System
Benefits
1.
The Comprehensive B e n e f i t Package
- Services
- R a t i o n a l e Behind a Comprehensive B e n e f i t Package
- Role o f t h e N a t i o n a l H e a l t h Board
By Linda B e r g t h o l d and Bob Valdez
2.
Cost Sharing
- Cost Sharing L i m i t s
- Role o f Cost Sharing
- Balance Between Choice and S i m p l i c i t y
�VIII.
IX.
X.
Mental H e a l t h B e n e f i t s -- By B e r n i e Arons, Sharman
Stevens and c o l l e a g u e s
1.
Overview o f Comprehensive B e n e f i t Approach
2.
Overview o f Substance Abuse Treatment
3.
Areas o f Concern, Risks and S o l u t i o n s
4.
I n t e g r a t i n g t h e P u b l i c Sector
5.
D i s t i n c t P o p u l a t i o n s o f Concern
- Children
- S e r i o u s l y M e n t a l l y 111
- Homeless P o p u l a t i o n
Long-Term Care -- by Robyn Stone and c o l l e a g u e s
1.
The Need f o r Long-Term Care Coverage
2.
P o l i c y and Program
3.
N o n - E l d e r l y D i s a b l e d -- By Susan D a n i e l s and Simi
Litvak
A s s u r i n g Access f o r Underserved P o p u l a t i o n s
1.
I n t e g r a t i o n of Protection f o r Vulnerable
P o p u l a t i o n s i n t h e New System -- By Shoshanna
Sofaer and c o l l e a g u e s
2.
H e a l t h P o l i c y I n i t i a t i v e s f o r Underserved
P o p u l a t i o n s — By Bonnie Lefkoswiek, and E l l e n
Benavitas
'"f^A
Investments i n I n f r a s t r u c t u r e ( R u r a l and
Urban
Investments i n S e r v i c e s ( E n a b l i n g , e t c )
XI.
3.
Medicaid i n t h e New System -- By Diane Rowland
(???)
4.
P a t i e n t s w i t h AIDS and o t h e r Chronic Disease i n
the New System -- By Mark Smith
5.
People w i t h D i s a b i l i t i e s i n t h e New System -- By
Rick Brown and c o l l e a g u e s (????)
F i n a n c i n g t h e New System -- By
1.
Sources o f Revenues
2.
Economic Impact -- Labor Market Effects
"^ikuuM^^^^^
�3.
XII.
Budget Impact: How F i n a n c i n g Arrangements
A f f e c t Both Federal and S t a t e / L o c a l Governments
i n t h e Short-Term and Long-Term
T r a n s i t i o n t o t h e New,System -- By U^-^^"^^^"-^ -f-^^^J^-^**^'
1.
Removing C o m p e t i t i v e B a r r i e r s -- By
2.
Tax-Exempt O r g a n i z a t i o n s i n t h e New System -- By
XIII.
P r o t e c t i n g A g a i n s t Fraud and Abuse ^ - By
XIV.
D i s p u t e R e s o l u t i o n and Medical M a l p r a c t i c e Reform
( s e p a r a t e papers o r one paper w i t h s u b s e c t i o n s ) -- By
Bob Berenson and c o l l e a g u e s
XV.
XVI.
1.
Enterprise L i a b i l i t y
2.
A l t e r n a t i v e Dispute R e s o l u t i o n and Research
I n i t i a t i v e s i n Dispute Resolution
3.
T o r t Reform
4.
N a t i o n a l P r o v i d e r Databank
I n f o r m a t i o n i n t h e New System ( s e p a r a t e papers o r one
paper w i t h s u b s e c t i o n s ) -- By Tim H i l l and Shana
Kass and c o l l e a g u e s
1.
Administrative Simplification
2.
Data System t o Implement N a t i o n a l H e a l t h Care
Reform
3.
P o i n t - o f - S e r v i c e I n f o r m a t i o n Systems
4.
I m p r o v i n g C l i n i c a l P r a c t i c e Through I n f o r m a t i o n
5.
P r i v a c y , C o n f i d e n t i a l i t y and S e c u r i t y
6.
T e c h n i c a l Standards f o r C l i n i c a l and
Administrative Information
P u b l i c H e a l t h and Population-Based
New System -- By Joanne Lukumnik
XVII.
—Developing
Prevention i n the
a Health-Care Workforce
1.
P h y s i c i a n Supply and D i s t r i b u t i o n
2.
Nurses and Other H e a l t h Care P r o v i d e r s
3.
The H e a l t h Care Workforce f o r Underserved People
�and Areas
4.
Consortia f o r Community-Based Health Education
5.
Workforce D i v e r s i t y
6.
Health Care and the National Service I n i t i a t i v e
Missing?: Consumer Protection?
Adequate Statement of the Problem?
Override of State Laws
�A p r i l 23, 1993
POLICY COMPENDIUM
TABLE OF CONTENTS
I.
C o n t r a c t w i t h t h e American People
II.
E t h i c a l Foundations o f t h e New H e a l t h Care System
III.
The Case f o r Comprehensive Reform ( f r o m Report t o
Congress)
III.
Design o f t h e New System
I n t r o d u c t i o n : Construct
1.
o
/t /
'
P r i n c i p l e s o f Consumer H e a l t h A l l i a n c e s
Encouraging D e s i r a b l e I n n o v a t i o n i n H e a l t h Care
D e l i v e r y Under t h e New System
^
OZ-
\^
"i_
3^!
A c h i e v i r i g ^ A c c o u n t a b i l i t y f o r Access and Q u a l i t y o f
Care Under t h e New System
4.
A l t e r n a t i v e s i n Geographic Areas Where C o m p e t i t i o n
May Not E x i s t : R u r a l and Urban Underserved
5.
New System Governance
6.
Budgets i n t h e New System
7.
Reforming t h e Insurance M a r k e t p l a c e
- Community R a t i n g
- ERISA
- Pre-existing Conditions
- Underwriting
/
\\l.
8.
Experience w i t h Managed C o m p e t i t i o n
Benefits
1.
2.
The Comprehensive B e n e f i t Package
- Services
- R a t i o n a l e Behind a Comprehensive B e n e f i t Package
- Role o f t h e N a t i o n a l H e a l t h Board
Cost S h a r i n g
- Cost Sharing L i m i t s
- Role o f Cost Sharing
- Balance Between Choice and S i m p l i c i t y
�Coverage
F i n a n c i n g t h e New System
- How t h e New System W i l l Look t o Consume
- How t h e New System W i l l Look t o Employer
- Economic Impact A n a l y s i s -- Labor Market
- Budgetary Impact: How t h e F i n a n c i n g Arrangement
A f f e c t Both Federal and S t a t e / L o c a l Governments^
i n t h e Short-Term and Long-Term
Early Retirees
Coverage f o r t h e T e m p o r a r i l y Unemployed
Coverage f o r Low-Income F a m i l i e s
A s s u r i n g Q u a l i t y and Access f o r Low-lncoine
^^amilies
— — —
\
I n t e g r a t i o n o f Medicaid
Medicare i n t h e New System
I n t e g r a t i o n o f Veterans A d m i n i s t r a t i o n
I n t e g r a t i o n o f Department o f Defense Programs
P u b l i c Employee Groups i n t h e New
System
Mental H e a l t h B e n e f i t s
v.iU
1.
Overview o f Comprehensive B e n e f i t Approach
2.
Overview o f Substance Abuse Treatment
3.
Areas o f Concern, Risks and S o l u t i o n s
4.
I n t e g r a t i n g t h e P u b l i c Sector
5.
D i s t i n c t P o p u l a t i o n s o f Concern
- Children
- S e r i o u s l y M e n t a l l y 111
- Homeless P o p u l a t i o n
H e a l t h P o l i c y I n i t i a t i v e s f o r Underserved P o p u l a t i o n s
Long-Term Care
VIII.
A s s u r i n g Q u a l i t y i n t h e New System
1•
Overview
�2.
Conditions
3.
Reporting
4.
Requirements f o r D i s c l o s i n g I n f o r m a t i o n t o
Consumers
5.
Technical
6.
S i m p l i f i c a t i o n o f E x i s t i n g Q u a l i t y Assurance
Programs
^
7.
Research
IX.
I n f o r m a t i o n i n t h e New System
Plans
o f Standard I n f o r m a t i o n f o r Comparison
A s s i s t a n c e f o r Q u a l i t y Improvement
Guidelines
1.
Administrative Simplification
2.
Data System t o Implement N a t i o n a l H e a l t h Care
Reform
3.
Point-of-Service
4.
I m p r o v i n g C l i n i c a l P r a c t i c e Through I n f o r m a t i o n
5.
P r i v a c y , C o n f i d e n t i a l i t y and S e c u r i t y
6.
X.
o f P a r t i c i p a t i o n i n Health
I n f o r m a t i o n Systems
T e h c n i c a l Standards f o r C l i n i c a l and
,,Adrministrative I n f o r m a t i o n
D i s p u t e R e s o l u t i o n and Medical
Malpractice
1.
Enterprise
Liability
2.
Alternative Dispute Resolution
3.
T o r t Reform Proposals
4.
National Provider
-
J
P
—^
[/
Databank
5-.—=Rgsearch In±t±airtves' i n D i s p u t e H e s o i t i t i ^ n - ^ ^ ^
XI.
D e v e l o p i n g a Health-Care Workforce
1.
P h y s i c i a n Supply and D i s t r i b u t i o n
2.
Non-Physician H e a l t h Care Workers
3.
The H e a l t h Care Workforce f o r Underserved People
and Areas
4.
Consortia
5.
Workforce D i v e r s i t y
f o r Community-Based H e a l t h
Education
i
�6.
Health Care and the National Service I n i t i a t i v e
C<yHrO
XII.
Financing Health Care Reform —
XIII.
Economic Impact of Health Reform_ y ^ ^ ^ j ^
p
�A p r i l 23, 1993
POLICY COMPENDIUM
TABLE OF CONTENTS
I.
C o n t r a c t w i t h t h e American People
II,
E t h i c a l Foundations
III,
fhe"Case* for Comprehensive Reform (from Report to ,
\ fi li
Congress)
(!/\ I - 2 /
IV.
Design o f t h e New System
o f t h e New H e a l t h Care System
I n t r o d u c t i o n : C o n s t r u c t o f t h e New System
1.
P r i n c i p l e s o f Consumer H e a l t h A l l i a n c e s
2.
How the New System Will Control Costs and Achieve
Savings
n
I
jO
s
1^
fO eAAW
^^f-tl^y^—
'D^ h -h- fx
Encouraging D e s i r a b l e innovation i n Health Care
D e l i v e r y Under the New System
'p l-i^ S {. c I
j
3.
4.
Achieving
Accountability
foar-Access
and Quality
ot
Care Under the New System
(pocic^hiy
<-^<->nn]^i nt^. wit-h
other accpiSR papar)
Ro ^
, s i n GeogjFaphic Area« Where^ompetition
xigt-i^/Rural andXuafhan Ohdprserved
l—ois +'
-=.=^New System Governance
^X/ST^" //^ L^O/-^
Budgets i n t h e New System
Reforming t h e Insurance Marketplace
- Community R a t i n g
- ERISA
- Pre-existing Conditions
- Underwriting
9.
Experience
w i t h Managed C o m p e t i t i o n
A s s u r i n g Q u a l i t y i n t h e New System
~
1.
Overview
2.
C o n d i t i o n s o f P a r t i c i p a t i o n i n H e a l t h Plans
�3.
Reporting
4.
Requirements f o r D i s c l o s i n g I n f o r m a t i o n t o
Consumers
T e c h n i c a l A s s i s t a n c e f o r Q u a l i t y Improvement
5.
6.
o f Standard I n f o r m a t i o n f o r Comparison
yAchieving A e c ^ n t ^ b i l v i t y for--Access^
?eNjftd6r t h e N e w Sysl
S i m p l i f i c a t i o n o f E x i s t i n g Q u a l i t y Assurance
Programs/and Research G u i d e l i n e s ^
VI,
VII,
VIII
Coverage
1.
Coverage f o r Working I n d i v i d u a l s and F a m i l i e s
- How t h e New System W i l l Look t o Consumers
- How t h e New System W i l l Look t o Employers
2.
Coverage f o r t h e T e m p o r a r i l y
3.
Coverage f o r Low-Income F a m i l i e s
4.
Coverage f o r R e t i r e e s
5.
Medicare i n t h e New System
6.
I n t e g r a t i o n o f Veterans A d m i n i s t r a t i o n
7.
I n t e g r a t i o n o f Department o f Defense Programs
8.
P u b l i c Employee Groups i n t h e New System
Assuring
Unemployed
Q u a l i t y and Access f o r Ajr^=^Sfer¥Garr^
1.
i n t e g r a t i o n o f Medicaid
2.
AJ^y^
^
./ U ^ J - e ^ ^ ^ ^
^
C'='t
—- I — Q — f — i ^
2.
H e a l t h P o l i c y I n i t i a t i v e s f o r Underserved
Populations
- Rural
^/x^t-w^-*-^ -A- ft^t^tyt,.*^
~
iJcTi.
- Urban
/
3.
P r o t e c t i o n f o r P a t i e n t s w i t h AIDS and o t h e r
C h r o n i c Disease
Benefits
1.
The Comprehensive B e n e f i t Package
- Services
- R a t i o n a l e Behind a Comprehensive B e n e f i t
- Role o f t h e N a t i o n a l H e a l t h Board
Package
�2.
IX.
^
'
Cost Sharing
- Cost Sharing L i m i t s
- Role o f Cost Sharing
- Balance Between Choice and S i m p l i c i t y
Mental Health B e n e f i t s
1.
Overview o f Comprehensive B e n e f i t Approach
2.
Overview o f Substance Abuse Treatment
3.
Areas o f Concern, Risks and S o l u t i o n s
4.
I n t e g r a t i n g t h e P u b l i c Sector
5.
D i s t i n c t P o p u l a t i o n s o f Concern
- Children
- S e r i o u s l y M e n t a l l y 111
- Homeless P o p u l a t i o n
X.
Long-Term Care
XI.
F i n a n c i n g t h e New
•
^
-r-^ . A
<-p
System
1.
Sources o f Revenues
2.
Economic Impact -- Labor Market E f f e c t s
3.
Budget Impact: How F i n a n c i n g Arrangements
A f f e c t Both Federal and S t a t e / L o c a l Governments
i n t h e Short-Term and Long-Term
X.
P r o t e c t i n g A g a i n s t Fraud and Abuse
XI.
D i s p u t e R e s o l u t i o n and Medical M a l p r a c t i c e Reform
XII.
1.
Enterprise L i a b i l i t y
2.
A l t e r n a t i v e Dispute R e s o l u t i o n and Research
I n i t i a t i v e s i n Dispute R e s o l u t i o n
3.
T o r t Reform
4.
N a t i o n a l P r o v i d e r Databank
I n f o r m a t i o n i n t h e New
System
1.
Administrative Simplification
2.
Data System t o Implement N a t i o n a l H e a l t h Care
�Reform
3.
Point-of-Service Information Systems
4.
Improving C l i n i c a l Practice Through I n f o r m a t i o n
5.
Privacy, C o n f i d e n t i a l i t y and Security
6.
Technical Standards f o r C l i n i c a l and
A d m i n i s t r a t i v e Information
V
•—i(^AjL^n^J-^^^/^cAy^;y^^
XIII.
Developing a Health-Care Workforce
1.
Physician Supply and D i s t r i b u t i o n
2.
Non-Physician Health Care Workers
3.
The Health Care Workforce f o r Underserved People
and Areas
4.
Consortia f o r Community-Based Health Education
5.
Workforce D i v e r s i t y
6.
Health Care and the National Service I n i t i a t i v e
�ISSUES FOR POLICY PAPERS ~
CLUSTER I I (NEW SYSTEM COVERAGE)
1. THE COMPREHENSIVE BENEFIT PACKAGE
-
The
The
The
The
services to be included, excluded
rationale behind a comprehensive benefit package
rationale behind standardization of benefits
role of the National Board
2. COST SHARING
- The cost sharing l i m i t s chosen and why
- The role of cost sharing
- The balance between choice and s i m p l i c i t y
3. THE NEW FINANCING SYSTEM
- What people are expected to pay with examples for people i n
different situations.
- What businesses are expected to pay, both inside and outside
the a l l i a n c e .
- Economic impact analysis — labor market e f f e c t s .
- Budgetary impact: how the financing arrangements affect both
federal and s t a t e / l o c a l governments i n the short term and long
term.
4. EARLY RETIREES
- Background on early r e t i r e e s with contractual guarantees for
health benefits and how they are treated under the new system.
5. COVERAGE FOR THE TEMPORARILY UNEMPLOYED
- I f s p e c i a l provisions are made for the recently unemployed.
6. COVERAGE FOR LOW-INCOME FAMILIES
- F i n a n c i a l guarantees for low-income persons (and possibly
those with d i s a b i l i t i e s or chronic conditions) through
subsidies
for premiums, cost-sharing
and supplemental
benefits.
7. ASSURING QUALITY AND ACCESS FOR LOW-INCOME FAMILIES
- The measures to address non-financial b a r r i e r s to access.
8. MEDICAID INTEGRATION
- Who i s folded into the new system
- What remains of the Medicaid program
- Treatment of special Medicaid populations and services i n
the new program
- Medicaid financing issues
�ASSURING ACCESS FOR UNDERSERVED POPULATlbTJfS
WORKGROUP CHARGE
A n a l y s i s o f c u r r e n t s y s t e m and p o t e n t i a l b a r r i e r s t o
e n s u r i n g t h a t t h e h e a l t h and h e a l t h - r e l a t e d needs o f
v u l n e r a b l e p o p u l a t i o n s a r e met i n t h e new s y s t e m , i n c l u d i n g
t h e p r o m o t i o n o f p u b l i c h e a l t h and p r e v e n t i o n a c t i v i t i e s
aimed a t t h e g e n e r a l p u b l i c .
o underserved,
h o m e l e s s and
undocumented
disabilities
l o w income and h i - r i s k p o p u l a t i o n s i n c l u d e
HIV i n f e c t e d i n d i v i d u a l s , m i g r a n t w o r k e r s ,
p e r s o n s and p e r s o n s w i t h c h r o n i c d i s e a s e s and
i n u r b a n and r u r a l a r e a s .
o p o p u l a t i o n based p u b l i c h e a l t h and p r e v e n t i o n a c t i v i t i e s
i n c l u d e i m m u n i z a t i o n , s c r e e n i n g , a c c i d e n t p r e v e n t i o n and
p u b l i c e d u c a t i o n campaigns.
II.
ASSUMPTIONS
o C l i n i c a l " p u b l i c h e a l t h " s e r v i c e s s u c h as EPSDT, p r i m a r y
and p r e v e n t i v e s e r v i c e s w i l l be i n c l u d e d i n t h e Benchmark
b e n e f i t s e t and w i l l be s u b s i d i z e d f o r l o w income p e r s o n s
o The e x p e r t i s e o f " t r a d i t i o n a l " p r o v i d e r s f o r v u l n e r a b l e
p o p u l a t i o n s w i l l be b u i l t upon i n t h e new s y s t e m t h r o u g h
t h e d e s i g n a t i o n o f " E s s e n t i a l Community P r o v i d e r s "
o The F e d e r a l g o v e r n m e n t w i l l c o n t i n u e i t s f i s c a l and
assurance r o l e f o r s e r v i c e s t o these p o p u l a t i o n s , w h i l e
f o s t e r i n g maximum s t a t e and l o c a l f l e x i b i l i t y
o F r a g m e n t a t i o n o f s e r v i c e s , and a d m i n i s t r a t i v e c o m p l e x i t y
w i l l be r e d u c e d i n t h e new s y s t e m t o f a c i l i t a t e consumer
and p r o v i d e r a c c e s s t o c a r e and f u n d i n g
o C u r r e n t s a f e t y n e t s y s t e m f u n d i n g and s e r v i c e s t r u c t u r e
s h o u l d be m a i n t a i n e d t o p r o t e c t v u l n e r a b l e p o p u l a t i o n s
during t r a n s i t i o n period
I I I . CONSIDERATIONS
o Service
Delivery
Capacity/Organization
M a i n t a i n i n g and a s s u r i n g a d e q u a t e i n f r a s t r u c t u r e , i e . p h y s i c a l and m a n a g e r i a l c a p a c i t y o f c u r r e n t " s a f e t y n e t "
d e l i v e r y system v i a t e c h n i c a l a s s i s t a n c e
(training,
capacity building) to "level playing f i e l d "
C r e a t i o n o f e d u c a t i o n , payment and g r a n t
providers t o locate i n underserved r u r a l
incentives for
and u r b a n a r e a s
—
�o Service
I n i t i a t i v e s and E s s e n t i a l Conununity P r o v i d e r s
c o n t r a c t u a l r e l a t i o n s h i p o r rexmbursement
^^^^^^^^^^
p r o v i d e d by e s s e n t i a l c o m m u n i t y p r o v i d e r s t o e n s u r e t h a t
s e r v i c e s a d d r e s s c u l t u r a l and k n o w l e d g e b a r r i e r s
Development o f a l t e r n a t i v e s e r v i c e s i t e s t o f a c i l i t a t e
a c c e s s t o c a r e , i e . - s c h o o l based c l i n i c s , h o m e l e s s
s h e l t e r s ! p e r i n a t a l care c e n t e r s , f a m i l y planning
Support f o r comprehensive p r i m a r y
o P o p u l a t i o n Based P u b l i c
care
services
H e a l t h and P r e v e n t i o n
Services
Expansion o f funding f o r core P u b l i c " - ^ ^ ^ I j / ^ ^ ^ ^ ^ ^ ^ . ^ ^ . h
i m p r o v e p u b l i c h e a l t h a s s e s s m e n t , '"^'^^^^^^^, ^"^^
a c t i v i t i e s w i t h an emphasis on women and c h i l d h e a l t h ,
c h r o n i c and i n f e c t i o u s d i s e a s e s , and i n j u r y r e d u c t i o n
Redirect current funding
geographic areas
to target hi-risk
p o p u l a t i o n s and
o HIV/AIDS AND CHRONIC ILLNESSES
F e d e r a l , s t a t e and l o c a l p u b l i c h e a l t h and f u n d i n g
r e s p o n s i b i l i t i e s f o r t r e a t m e n t and r e s e a r c h
P u r c h a s i n g C o o p e r a t i v e and AHP r e s p o n s i b i l i t y f o r s e r v i c e
d e l i v e r y , q u a l i t y a s s u r a n c e and consumer p r o t e c t i o n
o R e g u l a t i o n and A d m i n i s t r a t i v e P o l i c i e s
Promote c o o r d i n a t i o n and i n t e g r a t i o n o f c a t e g o r i c a l
f u n d i n g , a p p l i c a t i o n and r e p o r t i n g r e q u i r e m e n t s t o
improve a d m i n i s t r a t i v e e f f i c i e n c y and reduce f r a g m e n t a t i o n
Remove l e g a l and a d m i n i s t r a t i v e b a r r i e r s t o c o o p e r a t i v e
r e l a t i o n s h i p s among c o m m u n i t y p r o v i d e r s o f c a r e
o Unresolved
Issues
A p p r o p r i a t i o n v s TAP
Risk adjusted
c a p i t a t i o n vs g r a n t s
f o r enabling
services
�4/11/93
POLICY PAPERS
MENTAL HEALTH AND SUBSTANCE ABUSE
1.
Overview paper of comprehensive b e n e f i t approach
management of service use, examples from managed
care industry, HMOs, p r i v a t e sector (WBGH paper)
(possibly do examples as a separate paper)
2.
Overview paper s p e c i f i c a l l y focused on substance abuse
3.
Areas of concern / r i s k s
over use
under treatment
linkages
/ solutions
r i s k adjustment
standards and monitoring
linkages requirements and enabling
I n t e g r a t i n g the p u b l i c sector
mental health
substance abuse
e s s e n t i a l community providers
D i s t i n c t Populations of concern -- separate paper on each
Children
Seriously mentally
Homeless
ill
�MEMORANDUM
Date: April 9,1993
To: Carolyn Gatz
From: Cluster III Working Groups
Subject: Proposed Policy Papers
Quality
0:K^VUAf
1.
Conditions of Participation for Health Plans
2.
Standardized Reporting of Comparative Information
3.
Mandatory Disclosure of Information to Consumers
4.
Technical Assistance for Quality Improvement
5.
Simplification of Existing Qua|lity Assurance Programs
Information Systems
1.
Administrative Simplification
2.
Data Systems to Implement National Health Care Reform
3.
Point-of-Service Information Systems
4.
Improving Clinical Practice Through Information
5.
Privacy, Confidentiality and Security
6.
Technical Standards for Clinical and Administrative Information
�Dispute Resolution and Medical Malpractice
1.
Enterprise Liability
2.
Alternative Dispute Resolution
3.
Tort Reform Proposals
4.
The National Provider Databank
5.
Research Initiatives in Dispute Resolution
Health Care Workforce
1.
Physician Supply and Distribution
2.
Non-Physician Health Care Workers
3.
Underserved People and Areas
4.
Consortia for Community-Based Health Education
5.
Workforce Diversity
6.
Health Care and the National Service Initiative
�To: Group Leaders, Cluster One
From: Walter
RE: F i n a l Papers
wii-h ^ t J ' ^ r ^° S^'^f^a^e a series of policy papers to be released
P^^?: Carolyn Gatz and Paul Starr are coordinating the
e f f o r t to p u l l them together.
i«
.-^^''Sw^'"
suggested that papers be about 20-25 pages i n
?i ;
^5?"^"^
thoughtful analysis of t h i s issues
n^i-^n^?;/''°f"ff''^' P®f°ei^ed f a i l i n g s i n the current system, the
choice etc?
solution chosen, the rationale for ^:hat
Papers might include some "rhetoric," but should be
primarily academic, or journal-like i n quality.
There i s no precise format that papers should take. I
^^S^^P^^f^"" compiling the paper submit a proposed outline
to Paul and Carolyn, and get their feedback before proceeding.
Each of you should consider who you think should take charge
hLlJf'' ? ? ^ P^Pf""- F^^'^'^ly' while the task may appear to be a
burden, i t may also present you with an opportunity to describe
your product and you think i t should be described. These paperS
w i l l be used to policy backgrounders for Members of Congress the
press, interest^groups, and other knowledgeable sets of play4rs.
Impose
we produce papers along the lines of our groups.
,
.
S^-^i^
Principles of Purchasing Coo^rative.s^Allitnc^:
Encouraging desirable innovation in health care delivery - A? ^ " /
under the new system.
0>
n \ n
'
, ,. .
fob
() ii^io^x
-
Achieving accountability for access and quality of care
under the new system.
r\
. n,
^
Where Competition May Not Work: 3 sectioi
a. Where i t doesn't r e a l l y exist, but might
b. Rural areas
rl/ n '
c. The urban underserved
5.
New System Governance: national board, federal-state
relations, governance of Alliances, etc.. O
/
^
6.
Budgets i n the new system: importance, how to,"^h'^ e t p T j ^
^'
™5o'^'"''"'^^
insurance marketplace: c o m m S u t J ^ a t i r S f ^
ERISA, pre-existing conditions, underwriting e t c . . ^
Please see me about wnp should/^ill write these ^''^^'^f
^
^
.^J^U^t
��
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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Policy Papers/Topics
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Carolyn Gatz
Jennifer Klein
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 10
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093616" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Preservation-Reproduction-Reference
Date Created
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2/6/2015
Source
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42-t-12093616-20060885F-Seg2-010-005-2015
12093616
-
https://clinton.presidentiallibraries.us/files/original/38307274e8c520754ff81b9c299d7539.pdf
449d011992ca6ca431ffbf00741e405a
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Gatz, Carolyn/Klein, Jennifer
Subseries:
OA/ID Number:
5107
FolderlD:
Folder Title:
[WorkGroup 17 Ethical Foundations] [1]
Stack:
Row:
Section:
Shelf:
Position:
s
56
5
5
3
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. table
DOB's (Partial); SSN's (Partial); Phone No.'s (Partial) (5 pages)
n.d.
P6/b(6)
002. table
Addresses (Partial); DOB's (Partial); SSN's (Partial); Phone No.'s
(Partial) (3 pages)
n.d.
P6/b(6)
03/09/1993
P6/b(6)
03/04/1993
P6/b(6)
03/04/1993
P6/b(6)
003. letter
004a. fax
004b. fax
Address (Partial) (1 page)
Phone No. (Partial) (1 page)
Phone No. (Partial) (1 page)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz; Jennifer Klein
OA/Box Number:
5107
FOLDER TITLE:
[Work Group 17 Ethical Foundations] [1
2006-0885-F
im861
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |S U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information |(b)(l) ofthe FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) ofthe FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA|
National Security Classified Information |(a)(l) ofthe PRA|
Relating to the appointment to Federal office |(a)(2) ofthe PRA|
Release would violate a Federal statute 1(a)(3) ofthe PRA)
Release would disclose trade secrets or confidential commercial or
financial information |(a)(4) ofthe PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) ofthe PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Economic
T^fc
•
!/••
Bnefmg Paper
1730 Rhode Island Ave., NW • #200 • Washington, DC 20036 • 202/775-8810
THE IMPACT OF HEALTH CARE
FINANCING ON FAMILY BUDGETS
By Edith Rasell, Jared Bernstein, and Kainan Tang
Introduction
The problem of high expenditures for health care is well known. In 1992, 14
percent of national income, a total of $840 billion, was used to purchase medical
care. What is not well known is who bears the burden of these high expenditures. A
quick look at the statistics shows that federal and state governments, businesses,
and insurance companies are major funding sources. However these are just intermediate sources of funds. Ultimately, individuals and families pay all health care
costs through some combination of threefinancingstreams: out-of-pocket spending;
insurance premiums; or federal, state, and local government taxes. Even insurance
premiums paid by employers are, for the most part, offset by reductions in wages and
salaries. Thus, high expenditures for health care, while causing problems for business and government, ultimately are borne by and have their greatest impact on the
budgets of families and individuals.
The $752 billion spent on health care in 1991 was the equivalent of approximately $7,860 for each of the 96 million households in the country, or over half the
annual income of more than 24 percent of all households (U.S. Bureau of the Census
1992). When dealing with amounts of this magnitude, for services which, for the
most part, are nondiscretionary andj essential to well-being, how the costs are distributed among families and individuals is of major importance. This information is
particularly relevant for policymakeiis at a time when major changes in health care
financing are under consideration. |
Using data from the 1987 National Medical Expenditure Survey, the "gold
standard" for health expenditure information, and statistics from the Consumer
Expenditure Survey and the Internal Revenue Service's Individual Tax Model, this
1
Financial support for this project was received from the Heniy J. Kaiser Family
Foundation, the Robert Wood Johnson Foundation, and the David and Lucile
Packard Foundation, Center for the Future of Children.
�study examines the distribution of health care spending among families by income
level. We find that health expenditures—including out-of-pocket spending, premium
purchases, and the share of taxes which ultimately purchase health care—are regressively distributed. In addition, these threefinancingstreams have quite different
distributional consequences. More progressive health care financing requires a shift
toward increased reliance on taxes and a reduction in the share of expenditures
financed through out-of-pocket spending and premiums. In particular, we find:
1
i'
•
Low-income families pay over twice the share of income for health care as do
high-income families;
•
Out-of-pocket spending is particularly regressive with low-income families'
expenditures, as a share of income, nearly nine times the level of those of
high-income families;
|
•
As a share of income, expenditures for premiums by low-income families are
nearly four times the level of tiigh-Income families, even though many of the
poor do not purchase health insurance;
•
If everyone purchased health insurance, premium costs as a share of income
for low-income families would!be five times the level for high-income families;
•
Tax-financed health care spending is the only portion of the health care financing system which is progressive, and even some components of tax financing
are regressive; and,
j
•
Compared to the nonelderly, the elderly pay a larger share of income for health
care and face a more regressive distribution of spending.
The regressive distribution of health care spending is of particular concern
since families cannot escape consumption of health care. Therefore, they are subject
I
to the regressivity of the system which potentially can lead to two adverse outcomes.
ji
First, the more regressive the cost distribution, the greater is the possibility that
health care expenditures will leave low-income families with too little income for other
necessities. Second, to the extent that the costs of the system prevent low-income
persons from receiving the level of health care they require, society as a whole becomes worse off. There can be negative effects from cost-induced underconsumption
of health care.
This study is the first part of a larger project which will examine the distributional effects of various health-financing reform proposals. This first stage estimates
and analyzes the distribution of health care spending by families in 1987. Although
describing conditions that existed six years ago, the analysis is important because it
is based on the 1987 National Medical Expenditure Survey (NMES). The data from
this survey are only now being released. NMES is by far the best source of information on family health expenditures, and for this reason we have chosen to report the
distribution of spending for 1987.
f
2
�In future work, we will "age" the NMES data to 1992 to reflect more current
conditions taking into account changes in demographics, the national economy,
health insurance status, and health expenditures. The aged data and the resulting
distribution of health costs will be a more accurate representation of the current
situation. We will then examine how various health-financing proposals would affect
the distribution of spending. However, when we modify the 1987 NMES data, we also
lose a certain amount of accuracy. For this reason, we have chosen to report findings
from both 1987 and 1992. The 1992 analysis will be released at a later date.
This study focuses on families' spending for health care, not the level of benefits received from the expenditure. For nearly every family, benefits and spending
diverge because of the tax financing 'of and the subsidies provided to health care.
The purpose of this analysis is to determine the existing distribution of health costs
against which proposed changes in financing can be measured.
Data and Methodology
We examine health care spending by single and multiple person families. To
determine the distribution of spending across society, all families are assigned to one
of ten groups (deciles) of equal size, with the one-tenth of families with the highest
Incomes in the first group, the one-tenth of families with the next highest incomes in
the second group, and so on to the tenth group which contains the one-tenth of famii
lies with the lowest incomes. Incomes in the highest decile vary widely, from a "low"
of $72,153 to a high of millions of dollars. For this reason, we separate the highest
income decile into two parts: the five percent of families with the highest incomes
(above $92,912) and the next highest five percent with family incomes of $72,153 to
$92,912. Together, these two group|s comprise the tenth decile.
This examination rests upon calculations of shares of income used to purchase
health care. This measure is subject to error, particularly for the lowest income
families in the tenth decile whose expenditures may exceed incomes. Placing too
much reliance on data from the tenth decile may be misleading. For this reason, our
determinations of distributional regressivity or progressivity will compare the ninth,
not the tenth, decile with the top five percent of families. For ease of expression, we
will call the families in the ninth decile "low-income families" even though families in
the tenth decile have even lower Incomes.
This study examines income prior to taxes, transfers, and receipt of benefits
from public programs. The definition of income used throughout this report includes, in addition to money income, employer contributions to health insurance, the
employer-share of payroll and unemployment insurance taxes, and corporate taxes.
2
3
�The Distribution of Family Health Care Expenditures
Table 1 shows the distribution of expenditures from the three main health care
funding sources: out-of-pocket spending, premiums, and taxes. Total health expenditures in dollars and as a share of income for families in each decile are shown in
i
column 4. The table shows that the average family expenditure for health care in
1987 was $4,370, or about 15 percent of family income. However there was a wide
Table 1
Family Expenditures for Health Care, 1987
(By Farifiily Income Decile)
Out of Pocket
1
2
la
Public Sector
(2)
Family Income Decile
(Income Range)
Total Premiums
(3)
(1)
Percent
of
Dollars Income , Dollars
Total Expenditures
(4)
Percent
of
Income Dollars
Percent
of
Income Dollars
Percent
of
Income
Top 5%
(Above $92,912)
$1,222
lb
($72,153-92.912)
1,056
1.3
2,302
2.8
5,396
6.6
8,754
10.8
2
($52,558-72.152)
1,033
1.7
2,149
3.5
3,807
6.2
6,989
11.4
3
($41,968-52.557)
857
1.8
2,002
4.3
2,743
5.8
5,602
12.0
4
($33,700-41.967)
917
2.5
1,864
5.0
2,046
5.4
4,827
12.9
5
($26,799-33,699)
768
2.6
1,590
5.3
1,547
5.1
3,905
12.9
6
($21,098-26,798)
767
3.2
M61
6.1
1,158
4.9
3,386
14.2
7
($15,998-21,097)
739
4.0
1,187
6.4
828
4.4
2,755
14.9
8
($10,956-15,997)
721
5.4
883
6.5
542
4.0
2,146
15.9
9
10
($6,240-10,955)
Lowest 10%
(Below $6,240)
728
8.5
680
7.9
348
4.1
1,756
20.5
432
11.6
314
8.6
214
6.8
960
26.9
Average, All Families
$814
Ratio ( 9 / , )
3
a
Sum of Funding Type
as a Percent of
Total Expenditures
Notes:
1
2
3
$2,362
1.0%
\
4.2% I $1,459
2.0%
5.6%
$9,650
$2,097
7.3%
5.4%
$13,234
10.2%
$4,370
15.1%
8.5
4.0
0.6
2.0
24%
31%
45%
100%
All premium expenditures, including Medicare, minus tax savings.
Tax revenues spent on health care plus tax expenditures.
The ratio of low-income families (ninth decile) to the top five percent.
�Table 2
Effective Federal Tax Rates for
All Families, 1992'
Income Group
Effective Rates
All
Top 10%
Next 10%
27.5
24.5
Second Fifth
Middle Fifth
Fourth Fifth
Fifth (Lowest) Fifth
Note:
23.3%
22.3
19.6
15.6
8.7
'Projected rates. Congressional Budget Office tax simulation model.
range of spending among families at different income levels. Low-income families
spent, on average, $1,756, or 20.5 percent of their income for the year. The top five
percent of families spent an average of $13,234, or 10.2 percent of income. The next
wealthiest five percent paid $8,754 or 10.8 percent of income. Thus, as a share of
income, the burden on low-income families was two times the burden on high-income
families. This distribution is shown in Figure 1.
In comparison to the regressive burden of health care spending, the progressive
distribution of 1992 federal taxes is shown in Table 2. Families in the lowest income
quintile pay on average 8.7 percent of income in taxes while families in the highest
income decile average 27.5 percent. In this progressive distribution, as incomes rise
and the ability to pay increases, taxes also rise as a share of income. The distribution of health care spending is just the opposite. As incomes rise, the share of income paid for health care falls.
This analysis of the cost burden ignores one of the other major problems of our
current health care system—the uninsured and underinsured. Not only are financial
costs high, but in addition, too many people cannot even afford to purchase the care
they need. In 1987, there were 30.7 million people without any health insurance, or
14.4 percent of the population (see also U.S. House of Representatives, Committee on
Ways and Means 1992). There are people at every income level who are uninsured,
but the problem is particularly acute for those with low incomes. The percent of
individuals in each decile who were without health insurance in 1987 is shown in
Table 3. In low-income families in the tenth decile, 33.9 percent of people were
uninsured. Only 29.3 percent had private insurance, including 13.4 percent with
employer coverage. Almost half, or 46.7 percent had Medicaid, Medicare, or other
4
�Figure 1
Family Expenditures for Health Care, 1987
(by Family Income Decile)
10
9
8
Poorest 10%
Family Income Decile
�Table 3
Percent of Persons with Health Insurance Coverage, 1987
(By Family Income Decile)
Family Income Decile
(Income Range)
la
Insured
(1)
Employer
Coverage Other Private Total Private
(3)
(4)
(2)
Medicare
(5)
Medicaid
(6)
Other Public
(7)
Total Public
(8)
Uninsure
(9)
Top 5%
(Above $92,912)
95.4%
80.7%
16.1%
94.6%
5.8%
0.2%
0.0%
lb
($72,153-92.912)
95.7
82.8
13.9
93.5
5.0
0.5
0.2
10.8
4.3
2
($52,558-72.152)
93.1
81.5
11.1
90.3
5.4
0.9
0.1
11.8
6.9
3
($41,968-52.557)
93.1
78.6
13.8
90.1
5.8
1.7
0.2
11.9
6.9
4
($33,700-41,967)
91.2
75.2
14.3
86.8
7.6
2.5
0.4
14.2
8.8
5
($26,799-33,699)
87.7
67.0
16.7
81.3
12.0
3.6
0,7
20.1
12.3
6
($21,098^26,798)
84.9
59.4
18.7
76.0
15.5
5.7
0.7
24.6
15.1
7
($15,998-21,097)
80.1
49.5
18.9
65.9
18.0
9.1
1.6
32.0
19.9
8
($10,956-15,997)
72.5
31.5
20.3
50.5
20.1
16.5
3.4
40.4
27.5
9
($6,240-10,955)
71.2
17.5
22.3
39.5
27.2
23.8
3.7
50.7
28.8
10 Lowest 10%
(Below $6,240)
66.1
13.4
15.9
29.3
20.3
30.0
3.5
46.7
33.9
All Persons
85.6%
60.5%
16.2%
74.7%
12.3%
1.2%
23.4%
14.4%
Note:
7.5%
9.9%
4.6%
Some individuals have more than one type of insurance, therefore the sum of the types of coverage may exceed the totals. For example, an individual with both
employer and other private health insurance would be counted in both catagories. but once in the total private and once in the insured catagories.
�public insurance. The number of people with insurance and the percent of the insured covered by private policies rise with income until, among families with the
highest incomes, 94.6 percent had private insurance. Insurance status has important implications for health expenditures, as will be discussed below.
Out-of-Pocket Spending
Table 1 also shows the expenditure distribution within each of the three health
care funding sources. The major cause of the regressive distribution of total expenditures was out-of-pocket spending, shown in column 1. Out-of-pocket spending includes deductibles, all forms of cost sharing such as copayments and coinsurance,
and expenditures for services not covered by insurance which might include prescription drugs or mental health care. For people without insurance or for those who are
inadequately insured, out-of-pocket costs can be large, provided families have sufficient funds to purchase health care services. In addition, for those with insurance
which requires cost sharing, out-of-pocket spending rises with the use of services. A
seriously ill person covered by insurance with stiff cost-sharing requirements can
face enormous out-of-pocket expenses. Health care expenses have become one of the
leading causes of personal bankruptcy.
Column 1 in Table 1 shows that low-income families spent 8.5 percent of income, on average, on out-of-pocket health care purchases compared to 1 percent for
those with the highest income. Thus, the burden on low-income families was nearly
nine times the burden on high-income families. This regressive distribution existed
despite the inherent limits on out-of-pocket spending by the poor due to their low
incomes. Any increase in out-of-pocket spending requirements, without careful
safeguards to protect the poor and the near poor, will worsen the regressivity of this
distribution.
5
Insurance Premiums
The distribution of expenditures for insurance premiums was also very regressive in 1987. Spending for premiums is shown in column 2 of Table 1, and in more
detail in Table 4. Column 1 in Table 4 shows expenditures for nongroup insurance
premiums purchased directly by families, and employee contributions to premiums
obtained through employers. (Expenditures by employers for employee insurance are
shown in column 2.) Low-income families spent, on average, 4.1 percent of income,
although few of the poor purchase private insurance. The highest income (top five
percent) of families spent less than one percent of income on direct and employee
purchases of premiums.
Spending on premiums by employers is shown in column 2. Not unexpectedly,
we find that for middle- and upper-income families, employer-sponsored insurance
i
8
�Table 4
Family Expenditures for Health Insurance Premiums, 1987
(By Family Income Decile)
Individual
& Employee
(1)
Employer
(2)
Dollars
Percent
of
Income
Dollars
Percent
of
Income
l a Top 5%
(Above $92,912)
$829
0.7%
$2,604
2.2%
l b ($72,153-92.912)
769
1.0
2.555
2
($52,558-72.152)
750
1.2
2.264
3
($41,968-52,557)
737
1.6
4
($33,700-41,967)
653
5
($26,799-33.699)
6
Family Income Decile
(Income Range)
Tax Savings
(3)
Net Employer
(4)
Total Private
(5)
Percent
of
Dollars Income
Percent
of
Dollars Income
Percent
Percent
of
of
Dollars Income Dollars Income
$1,492
$2,321
0.9%
$1,112
1.3%
2.0%
Medicare
(6)
$41
0.0%
Total Premiums
(7)
Dollars
Percent
of
Income
$2,362
2.0%
3.2
1.057
1.3
1,498
1.8
2,267
2.8
35
0.0
2.302
2.8
3.7
902
1.5
1,363
2.2
2,113
3.5
37
0.1
2.149
3.5
1.876
4.0
648
1.4
1.228
2.6
1,965
4.2
36
0.1
2.002
4.3
1.7
1.678
4.5
513
1.4
1,165
3.1
1,818
4.8
46
0.1
1.864
5.0
579
1.9
1.321
4.4
371
1.2 _
950
3.1
-1,528
5.1 _
62
0.2
1.590
5.3
($21,098-26,798)
570
2.4
1,094
4.6
274
1.1
821
3.5
1.391
5.8
70
0.3
1.461
6.1
7
($15,998-21,097)
485
2.6
797
4.3
172
0.9
625
3.4
1.110
6.0
78
0.4
1.187
6.4
8
($10,956-15.997)
373
2.8
491
3.6
68
0.5
423
3.1
796
5.9
87
0.6
883
6.5
9
($6240-10.955)
349
4.1
235
2.7
13
0.1
222
2.5
571
6.6
108
1.3
680
7.9
10 Lowest 10%
(Below $6,240)
161
4.8
79
2.0
0
0.0
79
2.0
240
6.8
74
1.8
314
8.6
Average, All Families
Ratio ( 9 / i • ) *
$550
2.4%
5.9
.
$1,255
3.7%
1.2
N o t e : 'The ratio of low-income families (ninth decile) to the top 5 percent.
$409
0.9%
0.1
$845
2.7%
1.9
5.1%
$1,395
3.3
0.5%
$63
n/a
$1,459
5.6%
4.0
�accounts for the largest share of health care spending after taxes. As a share of
income, spending on employer-sponsored insurance rose from the tenth through the
sixth deciles, then declined. There are two major reasons for this pattern. Many
people who are poor or lower-middle class do not receive health insurance on the job,
therefore as a group their expenditures of this type are low (see Table 3). As incomes
rise, workers are more likely to receive health insurance on the job, and the policies
offered are more comprehensive and thus more expensive, so average costs for the
decile rise. Further, although the costs of policies vary with the comprehensiveness
of the coverage, the variation in premiums between the least and most comprehensive policies is much smaller than the variation in income across society. Thus,
expenditures as a share of income decline across the higher income deciles.
These data include families with and without health insurance. Thus, they
understate the burden for families who do have private insurance since families
without insurance (and those with Medicaid) make no premium payments. They also
overstate the burden for those without insurance. Later, we show the distribution
restricted to families with private insurance.
There is ongoing debate over who actually pays for premiums obtained through
employers. In this study we adopt the predominant view and assume that all employer payments for premiums are completely offset by lower wages to workers. This
view rests on the following logic. Since health insurance is received as a fringe benefit of employment, it is a part of the total compensation workers receive. If employers did not purchase insurance, the entire amount of money they would have spent
would instead be received by workers as higher money wages. Therefore, workers—
through their lower wages—are bearing the entire cost of premiums. However, others
argue that the cost of health insurance is not completely offset by lower wages and
that part of the cost is borne by employers, or passed on to consumers through
higher prices. In the future we will consider this alternative hypothesis.
In any case, employees do receive some relief from the costs of their premiums.
Health insurance received as compensation for employment is a form of income, but
unlike income received as wages, federal law exempts from taxes income received in
the form of health insurance coverage.
For example, consider a worker with a tax rate of 25 percent who receives
$4,000 in money income. The worker would pay $1,000 in taxes and take home
$3,000. If instead of cash income, the employee received compensation in the form of
a $4,000 health insurance policy, no taxes would be assessed. The worker would be
exchanging $3,000 in (after-tax) income for a $4,000 health insurance policy. The
health insurance is actually costing the worker just $3,000 since this is the amount
of income he is giving up in exchange for the policy. This $1,000 difference is a tax
6
7
10
�savings to the worker, essentially a federal subsidy to facilitate the purchase of
health insurance. But the $1,000 not paid in taxes by the worker is a tax expenditure that requires all taxpayers to pay more taxes as an offset. In addition to favorable income tax treatment, health insurance is also exempt from payroll taxes—a
further increase in both tax savings to workers and tax expenditures.
All workers who receive health insurance as part of their compensation receive
a tax savings, and the size of this subsidy rises with the cost of the insurance and
with the worker's marginal tax rate. Thus, tax savings disproportionately accrue to
those with higher incomes, higher marginal tax rates, and more expensive insurance.
The higher taxes which result from the tax expenditure are distributed among all tax
payers in proportion to their federal tax burden, with those with higher incomes
paying a greater share. The net effect of the tax savings and tax expenditure is discussed below.
The tax savings received by families who obtain health insurance on the job are
shown in column 3 of Table 4. As expected, this distribution also favors higher ini
come families. Families with the lowest incomes received essentially no subsidy,
while those with the highest income received a subsidy that is greater than $1,000,
although this constituted only about one percent of their income.
The net cost of employer-paid health insurance is shown in column 4. This is
the difference between what employers (actually workers) paid for health insurance
minus the workers' tax savings. For the reasons mentioned, the distribution of the
net cost was more regressive than was the distribution of all employer expenditures.
In 1987, employers spent approximately $130 billion for health insurance, or
about 27 percent of the national health care total (see also Levit and Cowan 1991).
(This does not include the employer share of health insurance payroll taxes, workers'
compensation, or health services provided at the workplace. These amounted to
another $37 billion or 8 percent of national health spending.) However, the tax savings received by workers were approximately $40 billion, or eight percent of total
spending. Thus the share of national health care expenditures paid for by employers
through health insurance premiums, net of the tax expenditure, was 19 percent of
the national total. The share of totalj health spending financed through the public
sector was about 45 percent when tax expenditures are included.
The two parts of the Medicare program have separate funding sources. The
first and larger component, absorbing slightly more than 60 percent of all Medicare
8
i
dollars, is hospital insurance and is funded primarily through the payroll tax. This
will be discussed below. The second Ipart of the Medicare program (Part B) pays for
doctors' and outpatient services. This is funded through premiums paid by the elderly and the disabled, through required deductibles and coinsurance paid by enroll11
�ees, and through general federal revenues. In 1987, premiums accounted for slightlyless than one-quarter of Part B program costs.
The distribution of Medicare premiums is shown in column 6 of Table 4. These
costs were somewhat regressive, but were a small share of income, even for families
with the lowest incomes. However, if the Part B program were completely funded
through premiums, this would raise the level of premium expenditures by a factor of
approximately four, exacerbating the regressivity of the distribution.
9
i
Total spending on premiums is shown in column 7. This total includes spending for premiums for individual nongroup policies and Medicare as well as employer
and employee spending, net of tax savings. The distribution was regressive with lowincome families spending a share of income approximately four times that of highincome families.
Premiums for Nonelderly Families with Private Insurance
The figures in Table 4 portrayithe spending patterns of families in 1987, Including the spending or the lack of spending by the millions of people who were
uninsured and did not purchase premiums. However, most health reforms propose
to cover everyone with premium-financed insurance purchased either through the
workplace (by employers and employees) or through a public plan. To gain some
insight into the distribution of the costs if everyone were required to pay insurance
premiums. Table 5 shows the distribution of premium costs in 1987 among only
those nonelderly families that paid private insurance premiums. These costs are
more regressive across the income distribution than are those shown in Table 4.
Low-income families spent 9.4 percent of income on premiums, while those with high
incomes spent just 1.9 percent, about one-fifth as much.
Requiring all families (or theiri employers) to purchase health insurance premiums locks in place a regressive distribution of health care funding unless large subsidies are available to low-income families (which some reforms do include). The regressive distribution occurs because premium costs for low-income families are not
i
very different than those for families with high incomes. So, as a share of income,
there is a much greater burden on families in the lower deciles. As long as the variation in premium costs among families is less than the variation in income, the distribution of premiums will be regressive.
The Public Sector and Health Care Spending
In 1987, approximately 45 percent of all health care spending flowed through
the tax systems of federal, state, and local governments. Tax dollars pay for most of
Medicare and Medicaid; public health programs; research and construction; health
care for veterans, military personnel and their dependents; and special services such
12
�Table 5
Premium Expenditures by Nonelderly Privately Insured Families, 1987
(By Family Income Decile)
Individual
Employer
& Employee
(1)
(2)
Percent
Percent
of
Family Income Decile
of
Dollars Income Dollars Income
(Income Range)
la
Tax Savings
(3)
Dollars
Net Employer
Total Private
(4)
(5)
Percent
Percent
Percent
of
of
of
Income Dollars Income Dollars Income
Top 5%
(Above $96,122)
$845
lb
($75,440-96.122)
785
0.9
2.722
3.2
1,168
1.4
1.554
1.8
2.339
2.8
2
($55,790-75/439)
822
1.3
2,636
4.1
1,108
1.7
1,528
2.4
2.350
3.7
3
($45,112-55,789)
780
1.6
2,120
4.3
795
1.6
1,325
2.7
2.104
4.2
4
($36,792-45,111)
686
1.7
1,971
4.8
644
1.6
1,328
3.3
2.013
4.9
5
($30,254-36.791)
596
1.8
1,673
5.0
523
1.6
1,150
3.4
1.746
5.2
6
($23,851-30253)
642
2.4
1.393
5.2
401
1.5
993
3.7
1.635
6.1
7
($18,558-23,850)
545
2.6
1201
5.7
307
1.4
894
4.2
1,439
6.8
8
($12,842-18.557)
517
3.3
889
5.6
178
1.1
711
4.5
1228
7.8
9
($6,877-12.841)
412
4.3
555
5.5
45
0.4
510
5.1
921
9.4
10
Lowest 10%
(Below $6,877)
214
6.9
176
3.8
0
0.0
176
3.8
390
10.8
$1,688
4.6%
Average, All Families
Ratio ( V i a )
0.7%
$637
2.3%
6.1
1
$2,718
$1,196
2.2%
1
2.5
1.0%
$589
1.3%
0.4
$1,521
1.3%
3.3%
$1,100
3.9
1.9%
$2,367
5.6%
$1,737
5.0
N o t e : "The ratio of low-income families (ninth decile) to the top five percent.
as maternal and child health programs. This money is raised through all the ways in
which taxes are collected, including personal and corporate income taxes at the federal and state levels, sales and excise taxes, and others. To fully calculate the health
cost burden on families, this study includes health care purchased through the tax
system. After estimating the various tax liabilities of families, those portions of their
taxes which go to purchase health care are calculated and the distribution of these
costs is determined.
Most of the money spent by governments for health care is raised as part of
their general revenues. The major exception is the payroll tax earmarked for Medicare, discussed below. The distribution of the burden of health care purchased
through the tax system is shown in the third column in Table 1 and in more detail in
10
13
�Table 6
Family Health Care Expenditures Through the Public Sector, 1987
(By Family Income Decile)
Federal
Total Public
Federal Tax
2
3
State Taxes
Sector
Payroll Taxes
Taxes
Expenditures
(4)
(5)
(2)
(3)
(1)
Percent
Percent
Percent
Percent
Percent
of
of
of
of
Family Income Decile
of
(Income Range)
Dollars Income Dollars Income Dollars Income Dollars Income Dollars Income
1
l a Top 5%
(Above $92,912) $4,386
3.2%
l b ($72,153-92,912)
21097
2.6
1.169
1.4
998
1.2
1.133
1.4
5,396
6.6
2
($52,558-72,152)
1,347
2.2
758
1.2
732
1.2
970
1.6
3,807
6.2
3
($41,968-52,557)
875
1.9
490
1.0
570
1.2
808
1.7
2,743
5.8
4
($33,70041,967)
605
1.6
339
0.9
452
1.2
650
1.7
2,046
5.4
5
($26,799-33,699)
435
1.4
243
0.8
363
1.2
506
1.7
1,547
5.1
6
($21,098-26,798)
289
1.2
162
0.7
318
1.3
389
1.6
1,158
4.9
7
($15,998-21,097)
185
1.0
103
0.6
258
1.4
282
1.5
828
4.4
8
($10,956-15.997)
93
0.7
51
0.4
210
1.6
189
1.4
542
4.0
9
($6,240-10,955)
52
0.6
29
0.3
171
2.0
97
1.1
348
4.1
0.0
149
4.9
64
1.9
214
6.8
$2480
1.8%
$1,682
1.3%
$1,102
0.9%
$9,650
7.3%
i
10 Lowest 10%
(Below $6,240)
Average,
All Families
Ratio ( V i a )
Notes:
1
2
3
4
1
$720
4
0.2
0.0
1.4%
0
$404
0.0%
0.2
$460
1.5
1.7%
$512
1.2
1.5%
$2,097
5.4%
0.6
Includes federal personal and corporate income taxes, unemployment insurance premiums, and gift and estate taxes
• for health care.
Includes state personal and corporate income taxes plus state sales and excise taxes.
Includes federal taxes and tax expenditures, state taxes, and payroll taxes.
The ratio of low-income families (ninth decile) to the top five percent.
Table 6. The total distribution was progressive, with low-income families paying 4.1
percent of income while the highest income families averaged 7.3 percent. For the
most part, this parallels the distribution of the national tax burden. Tax-financed
spending is the only component of the health-financing system that is progressive.
14
�Federal Income Taxes. In 1987, personal and corporate federal income taxes
provided 56 percent of total federal revenues. Both of these taxes are progressively
distributed with the wealthy paying a larger share of income than the poor (Table 2
and Pechman 1985). Health care spending through federal taxes is also progressively
distributed, as shown in column 1 of Table 6. In 1987, low-income families paid 0.6
percent of income while the highest income families paid 3.2 percent of income.
11
Federal Tax Expenditures. As mentioned above, federal law exempts employer-paid health insurance from income and payroll taxes. This means that recipients of employer-sponsored insurance receive subsidies to help purchase their insurance. However, to offset these tax expenditures, additional taxes must be raised.
Column 2 in Table 6 shows the level and distribution of these replacement taxes.
Like federal income taxes, the distribution of tax expenditures was progressive. However, the net effect, by decile, of the tax savings and expenditures is shown in Table
7. Both the lowest and the highest income families paid more in additional taxes
than they received in tax savings. For the five percent of families with the highest
incomes, net taxes equaled $1,368 or nearly one percent of income. However, lowincome families also had a net tax liability that averaged $16 or 0.2 percent of income. Over the broad middle range ofthe income distribution, (deciles 2 through 8),
on average families had a net savings.
In addition to being a burden on the lowest income families, the tax exclusion
is troublesome for another reason. The net incidence of the tax savings and expenditures, shown in column 3 in Table 7, is the average for all families in a decile. However, since all taxpayers bore the added taxes, the tax savings went to families with
employer-sponsored health insurance only, within each decile there was a transfer
from taxpayer families without employer-sponsored insurance to those that did have
this benefit. If a family that did not receive health insurance through an employer
purchased a nongroup policy, it would not receive the tax savings. The subsidy for
employer-sponsored health insurance' is paid by taxpayers without such insurance,
whatever their income level, and by the highest and lowest income families.
The tax exclusion for employer payments for health insurance enables families
at all income levels to afford health insurance. But, it provides no help to families
who do not receive employer-sponsored insurance, while increasing their taxes.
However, eliminating the tax exclusion is not the answer. We need increased tax
financing of health care and health insurance, not less. But, we must distribute the
tax benefits and the tax burdens more equitably.
12
13
State and Local Taxes. State and local revenues for health care are raised
primarily through income and sales taxes. The resulting distribution of health care
spending is shown in column 3 in Table 6. Because states raise more revenue
15
�Table 7
Family Tax Savings and Tax Expenditures, 1987
(By Family Income Decile)
Tax Savings
(1)
Tax Expenditures
(2)
Percent
of
Income
Difference Net Savings
(3)
Dollars
Percent
of
Income
$-1,368
-0.9%
Dollars
Percent
of
Income
Dollars
l a Top 5%
(Above $92,912)
$1,112
0.9%
$2480
l b ($72,153-92.912)
1,057
1.3
1,169
1.4
-111
-0.1
Family Income Decile
(Income Ranges)
1.8%
2
($52,558-72.152)
902
1.5
758
1.2
145
0.2
3
($41,968-52.557)
648
1.4
490
1.0
158
0.3
4
($33,700-41.967)
513
1.4
339
0.9
174
0.5
5
($26,799-33.699)
371
1.2
243
0.8
128
0.4
6
($21X398-26,798)
274
1.1
162
0.7
112
0.5
7
($15,998-21,097)
172
0.9
103
0.6
69
0.4
i
8
($10,956-15,997)
68
0.5
51
0.4
17
0.1
9
($6240-10,955)
13
0.1
29
0.3
-16
-0.2
0
0.0
0
0.0
0
0.0
10 Lowest 10%
(Below $6,240)
Average, All Families
Ratio ( V i a )
Notes:
'
2
2
$409'
0.9%
$404'
0.8%
0.2
0.1
0.2%
$5
0.2
Average tax savings and tax expenditures differ due to rounding errors.
The ratio of low-income families (ninth decile) to the top five percent.
through regressive sales and excise taxes than through progressive income taxes,
low-Income families paid a larger share of income in state taxes than did families
with high incomes, although the differences were not great.
Payroll Taxes. The hospital component of the Medicare program is funded
through two sources. The elderly pay deductibles and coinsurance when they receive
Medicare services. These expenditures are included in out-of-pocket costs as shown
in Table 1. The majority of funding, however, comes from the health insurance portion of the payroll tax. In addition, a! portion of the social security component of the
16
�payroll tax buys health care. The distribution of payroll taxes is shown in column 4
in Table 6. Both low- and high-income families paid an average of about one percent
of income for health care through the payroll tax. The share of income paid rose from
the bottom through the middle of the income distribution, then declined. Overall,
the incidence in 1987 was fairly flat.
Payroll tax liabilities are driven by two factors. First, the tax falls only on labor
money income (wages and salaries) and not on other types of income such as dividends, interest, fringe benefits, or rents. Therefore, as the share of income received
from nonlabor sources rises, as is the case as we move up the income ladder, a
smaller and smaller share of total income is subject to the tax. Thus, payroll tax
liabilities as a share of income will decline. Second, the amount of labor income
subject to the tax is capped, further contributing to regressivity. In 1987, earnings
above $43,800 were not subject to the payroll tax. However, since 1987, the cap has
been raised and in 1992 stood at $130,200 for the health insurance portion and at
$55,500 for the social security component of the payroll tax. This further flattens the
distribution and makes it more progressive.
14
The Distribution of Spending Among Funding Sources
Thus far, the discussion has focused on the distribution of spending among
family income deciles within each of the three types of health care funding: out-ofpocket, premiums, and taxes. But the distribution of total health care spending
depends upon two factors. One is the distribution across deciles within any single
funding source. But since each type of funding has a different incidence, the second
factor is the funding mix, an equally important determinant ofthe final expenditure
distribution. For example, if out-of-pocket spending were reduced by $20 billion and
replaced by an equivalent increase in public funding, and if the incidence within
these funding sources were maintained, then regressivity would be reduced.
In 1987, approximately 24 percent of all health care was financed through outof-pocket spending (see the last row of Table I ) . Another 31 percent was paid for
through premiums, including payments by individuals for nongroup policies, and
employee and employer contributions to employer-sponsored insurance minus tax
savings. This total also includes the $23 billion in premiums paid by federal, state,
and local governments in their role as employer and $6 billion in Medicare Part B
premiums. Forty-five percent of health care ($207 billion) was purchased through
the public sector. If Medicare and public employee premiums are added to this total,
the public sector paid for 51 percent of health care in 1987. An additional $14 billion
was raised through nonpatient revenues such as donations.
1
15
17
�The ratio showing the regressivity or progressivity of each type of spending is
also shown in Table 1. The regressivity of the total expenditure distribution would be
lessened by either reducing out-of-pocket expenditures, with a low-income to highincome family incidence ratio of 8.5, or by reducing reliance on premiums, which
have an incidence ratio of 4.
i
Expenditures of Elderly and Nonelderly Families
There are major differences in the funding of health care for people under and
over age 65. Nearly everyone age 65 and above has Medicare coverage; there are few
uninsured in this age group. As we have seen, the costs of Medicare are spread
among all adults, not just the elderly. However, seniors do pay deductibles and coinsurance when they use services, and most also purchase supplemental Medicare
insurance which covers doctors and outpatient services. In addition, many seniors
purchase private "Medigap" insurance policies to cover some of their cost-sharing
obligations and additional services.
The spending requirements for people under 65 years old are very different.
Most receive insurance coverage through their employer. Some policies provide first
dollar coverage that requires no contribution from the patient, while others have large
cost-sharing requirements. Some cover a broad package of benefits, while people
with more limited policies may have to pay for some services entirely out of pocket.
People without insurance (numbering nearly 31 million in 1987) must forego care,
pay out of pocket, or receive charity care.
These differences in insurance, cost sharing, and access to care have large
effects on the distribution of costs among the elderly and the nonelderly. In addition,
seniors use more medical services than do the under-65. However, many of these
costs are covered by taxes paid by the elderly and nonelderly alike.
Tables 8 and 9 show the health cost burden for elderly and nonelderly families. The average family expenditure for each group is shown in the third from the
bottom row of each table. In 1987, the average elderly family paid $3,707 for health
care while the average nonelderly family paid $4,529. But because incomes of the
elderly were generally lower than those of the nonelderly, seniors, on average, paid a
larger share of income for health care than did the under 65, 20.5 percent compared
to 13.8 percent, respectively.
The distribution of the burden across the income spectrum is worse for the
elderly than for the nonelderly. Low-income elderly families paid 27.4 percent of their
income for health care, a share which was nearly three times the 9.7 percent paid by
high-income families. Among the nonelderly, low-income families paid 16.1 percent
of income, while the highest Income families paid slightly more than 10 percent.
Compared to the nonelderly, seniors paid a larger share of income for health care and
16
18
�Tabled
Elderly Family Expenditures for Health Care, 1987
(By Elderly Family Income Decile)
Out of Pocket
Elderly Family
Income Decile
(Income Range)
la
Total Premiums'
2
Public Sector
Total Expenditures
(4)
(3)
(2)
(1)
Percent
Percent
Percent
Percent
of
of
of
of
Dollars Income Dollars Income Dollars Income Dollars Income
Top 5%
(Above $67,027)
$1,552
lb
($47,665-67,027)
1,951
3.4
2449
4.4
2,657
4.7
7,057
12.5
2
($32,292-47,664)
M24
3.6
2.159
5.6
1,593
4.1
5,176
13.3
3
($24,719-32291)
1456
5.2
1,860
6.6
1.082
3.8
4,398
15.6
4
($19,658-24,718)
1,545
6.9
1,682
7.6
832
3.8
4,060
18.3
5
($15,837-19,657)
1263
7.3
1497
8.5
637
3.6
3,396
19.4
6
($12,679-15.836)
1273
8.8
1230
8.6
539
3.8
3,042
21.3
7
($9,768-12,678)
1,061
9.5
984
8.9
430
3.8
2475
22.1
8
($7,608-9,767)
1,124
12.8
842
9.7
318
3.7
2,284
26.2
9
($4,956-7,607)
808
12.7
694
11.0
244
3.7
1,746
27.4
10
Lowest 10%
(Below $4,956)
582
15.4
492
14.0
127
3.3
1202
32.7
Average,
All Elderly Families
1.5%
$1239
8.3%
$2403
2.5%
$1407
8.3%
$6,333
$1,062
5.7%
3.9%
$10,287
$3,707
9.7%
20.5%
Ratio ( V ) *
8.5
4.4
0.7
2.8
Total Funds From This
Source as a Percent
of Total Expenditures
41%
34%
25%
100%
1 a
Notes:
'
2
3
All premium expenditures, including Medicare, minus tax savings.
Tax revenues spent on health care plus tax expenditures.
The ratio of low-Income families (ninth decile) to the top five percent.
19
�Table 9
Nonelderly Family Expenditures for Health Care, 1987
(By Nonelderly Family Income Decile)
Nonelderly Family
Income Decile
(Income Range)
la
Out of Pocket
(1)
Percent
of
Dollars Income
2
Total Premiums' Public Sector
(2)
(3)
Percent
Percent
of
of
Dollars Income Dollars Income
Top 5%
(Above $96,122)
$1,147
lb
($75,440-96,122)
1,040
1.2
2,323
2.8
2
($55,790-75439)
970
1.5
2,188
3
($45,112-55,789)
842
1.7
4
($36,792-45,111)
761
5
($30,254-36,791)
6
0.9%
$2,342
1.9% $101185
Total Expenditures
(4)
Percent
of
Dollars Income
7.5% $13,574
10.3%
5,772
6.8
9,136
10.8
3.4
4,148
6.4
7,305
11.3
1,976
4.0
3X154
6.1
5,871
11.8
1.9
1,883
4.6
2,319
5.7
4,963
12.2
804
2.4
1,663
5.0
1,863
5.6
4,330
12.9
($23,851-30,253)
626
2.3
1,469
5.5
1,396
5.2
3491
13.0
7
($18,558-23,850)
529
2.5
1,245
5.9
1,042
4.9
2,817
13.3
8
($12,842-18,557)
529
3.3
930
5.9
693
4.4
2,152
13.7
9
($6,877-12,841)
558
5.9
599
6.1
398
4.1
1,555
16.1
10
Lowest 10%
(Below $6,877)
360
9.8
247
6.7
251
7.8
857
24.3
Average,
All Nonelderly Families
Ratio ( V i a )
3
Total Funds From This
Source as a Percent
of Total Expenditures
Notes:
$712
3.2%
$M71
4.9%
$2,345
$4,529
6.6
3.2
0.6
1.6
21%
31%
49%
100%
'All premium expenditures, including Medicare, minus tax savings,
^ a x revenues spent on health care plus tax expenditures.
3
5.7%
The ratio of low-income families (ninth decile) to the top five percent.
20
13.8%
�faced a more regressive distribution of the costs. Seniors paid much more out of
pocket than did the nonelderly. The .average elderly family's out-of-pocket expenditure was $1,239, compared to $712 for the nonelderly. Elderly low-income families
made out-of-pocket expenditures which, as a share of income, were over eight times
those made by high-income elderly. The ratio for the nonelderly was 6.6. Seniors
also faced a more regressive distribution of premium costs. While the elderly paid, on
average, slightly less through premiums than the nonelderly, $1,407 compared to
$1,471, the distribution of premium costs was more regressive for the elderly.
The last row in Tables 8 and 9 shows, the distribution of health care spending
among the three types of funding. Nonelderly families made 49 percent of their
health care purchases through the public sector. Premiums accounted for 31 percent, and just 21 percent of health care was purchased out of pocket. The picture
for elderly families is quite different. Their lower incomes and lower consumption
levels meant lower taxes. Just 25 percent of expenditures by the elderly occurred
through the public sector. Premiums accounted for 34 percent, similar to the
nonelderly. But fully 41 percent of spending was done out of pocket, and out-ofpocket spending for the elderly was even more regressive than for the nonelderly.
17
Conclusion
The U.S. spends a huge sum of money for health care, all of it ultimately paid
by families. Costs are high, and the distribution of this spending is very regressive.
In 1987, low-income families spent over 20 percent of income for health care, while
families with the highest Incomes paid about 10 percent. Low-income families paid
over twice the share of income for health care as did high-income families.
Out-of-pocket spending was the most regressive type of financing with lowincome families paying a share of income which was over eight times the share paid
by those with high incomes. This occurred even though spending by the poor was
limited by their low incomes. Premium expenditures were also regressively distributed with low-income families paying a share of income nearly four times the level
paid by high-income families. But this picture was complicated by the uninsured,
who spent nothing on premiums, thereby making the distribution less regressive
than it would have been if everyone had insurance. Among only those families that
did have insurance, the share of income spent on premiums by the poor was nearly
five times the share paid by the wealthy.
i
Overall, health care spending financed through taxes is progressive. However,
taxes at the state level are regressive, since the states raise more revenue through
regressive sales and excise taxes than through more progressive income taxes. At the
21
�federal level. Income taxes are progressive. The incidence of payroll taxes in 1987
was nearly flat.
As a share of income, health costs for the elderly were higher than for the
nonelderly. Seniors also faced a more regressive distribution of spending. In large
part this was due to large, out-of-pocket expenditures which accounted for 41 percent of all health care spending by the elderly, compared to 21 percent for the
nonelderly.
There are many possible goals of health care financing. This analysis has
focused on equity. Some would argue that other goals such as cost containment or
severing the link with employment should also receive high priority. For the foreseeable future, health care will continue to be funded through all of the sources examined here: out-of-pocket spending, premiums, and taxes. Within this mix of financing, there must be balance between competing goals. However, we argue that equity
in health carefinancinghas been a neglected consideration. In the current evaluations of health-financing proposals, concern with equity should be central.
Equity can be improved by making the distribution within each funding source
less regressive. There are numerous policies which could begin to move us in this
direction. Some possibilities includel lower limits on cost-sharing obligations, or
subsidies for all premium purchases, not just those by employers. Equity can also
be enhanced by changing the mix of funding—by reducing out-of-pocket spending
and premiums, and by raising the portion of health carefinancedthrough the least
regressive taxes.
In this paper, we have quantified what is all too well known by Americans
struggling to pay for health care. The currentfinancingsystem is highly regressive,
and this is particularly true for out-of-pocket spending and premiums, which together account for 55 percent of all health care expenditures. As potential solutions
to the health care crisis are considered, improving equity in the distribution of health
care spending should be an important goal.
April 1993
22
�Appendix
To obtain data by family income decile on all the types of health spending, it
was necessary to use data from three different sources. The primary data set came
from the National Medical Expenditure Survey (NMES) which was conducted in 1987
by the Agency for Health Care Policy and Research of the U.S. Department of Health
and Human Services. NMES provides a nationally representative sample of the civilian, noninstitutionalized population. During a series offivevisits over the course of
the year, interviewers obtained information on the use of health services and on
expenditures. Employers, unions, and other groups that provided health insurance
to survey participants, as well as insurance companies, were also surveyed for infor mation on premium costs. Because there was no premium information obtained on
38 percent of policyholders, we imputed premiums for these records.
NMES is unquestionably the best source of health expenditure data. However,
the disadvantage of using this survey is that it is only conducted once every 10 years.
In future work, we will estimate the distribution of family health expenditures across
the Income spectrum for 1992, by using these 1987 data and incorporating changes
in health care financing and utilization patterns that have occurred in the interim.
(For similar research based on the 1977 NMES, see Cantor (1990).) We will then
examine the effects of various health-financing proposals on the 1992 baseline distribution.
The NMES, however, provides no information on health care purchased
through income, sales, or excise taxes. Since the health care purchased with tax
revenues accounts for over one-quarter of all health care spending, it should not be
omitted. We calculated the incidence of payroll taxes from the NMES wage data and
1
i
used the 1987 Consumer Expenditure Survey (CEX) to derive the incidence of sales
and excise taxes. The CEX provides nationally representative data on consumption
of all types. We statistically matched consumer units in the CEX with families in
NMES using family income, age of household reference person (above or below 65),
family size, urban/rural location, and region of residence as match variables. Data
on the share of income spent on a variety of consumption goods were assigned to
similar families in the NMES.
Information on personal income taxes was obtained from the Internal Revenue
Service's (IRS) 1987 Individual Tax Model (ITM). IRS data were also used to assign
liabilities for some business taxes. A statistical match ofthe ITM and NMES could
not be performed reliably at this timei because data on components of income for
NMES families have not yet been released. However, a matrix of filing units was
created in the IRS data based on total income, structure of the filing unit, size of the
18
23
�filing unit, and the number of tax filers in the filing unit age 65 and above. For each
cell of the array, average marginal and effective tax rates, and the percent of income
derived from capital were determined. After identifyingfilingunits in NMES, a similar matrix based on the same set of variables was created. The cell-based averages
from the IRS data were then applied to the corresponding NMES records.
Information on public sector revenues and their sources and public expenditures for health care is available for the federal government in the Budget qf the
United States Government, Historical Statistics, FY1990 and for states and localities in
the U.S. Department of Commerce's Census of Governments Government Finances in
1986-87. Having determined tax liabilities for each family in the NMES sample, and
knowing the share of total revenues these liabilities comprise as well as the share of
revenues expended for health care at each level of government, we were then able to
calculate spending for health care through the tax system.
24
�Endnotes
1
Regressivity is a term that describes an expenditure pattern where as incomes rise
(fall) across the income distribution, there is an associated decline (rise) in the share
of income spent on health care. The opposite of regressivity is progressivity, where
higher (lower) incomes are accompanied by larger (smaller) shares of income being
spent.
2
The best measure of family resources devoted to health care is health expenditures
expressed as a share of lifetime average annual income (LAAI). LAAI smoothes out
the highs and lows of current annual income and provides a better estimate of average annual spending. For example, for retired people who are dissaving (using savings to finance current consumption), current income is probably less than LAAI.
People just entering the labor force usually earn less than LAAI while for others at the
peak of their careers, current income exceeds LAAI. However, information on LAAI is
not readily available. The second best measure of the share of resources devoted to
health care would express health care spending as a share of annual consumption,
since for any family or individual, this also fluctuates less over time than does current income. However, we also lack good consumption data. Thus, we are forced to
measure spending as a share of income, but must do so with caution, since year-toyear fluctuations in income can cause spending shares to be over- or understated.
We did however, correct for some of the income variability. In any year, some
families that usually receive high incomes instead experience transient low or negative incomes due to capital losses. These families' incomes may place them in the
lowest income decile, but their expenditure patterns are often little changed, paralleling those of wealthy families. In these cases, calculating shares of income spent on
health care may be meaningless (for example, if incomes are zero or negative), or may
greatly skew averages for low-income families in the tenth decile, since the expenditures may be large (typical of more wealthy families) but are calculated as a share of
a very small income. Therefore, we have identified families with negative or very low
incomes (below $500) and their health care expenditure shares are not included in
the tenth decile averages.
3
A complete accounting of family health expenditures includes not just direct purchases of health care, but also all health care spending which is funded by tax revenues and employer spending for health insurance. When these indirect health care
costs are ultimately borne by the family, then these expenditures must be included in
the families' health care purchases. In addition, since some taxes which finance
health care are not routinely included in family income, for example, corporate income taxes, we must add the portion of these taxes which finances health care to
family income as well.
A complete accounting of econpmic income includes noncash income such as
fringe benefits, pension earnings, imputed rents, accrued capital gains, and the value
of the noncash benefits from public programs such as food stamps and Medicaid.
Including all these components woulcl more heavily concentrate income In the upper
brackets and increase the regressivity of the health care financing burden. However,
we lack data on most of these income components. Therefore, we are including in
25
�our calculation of income only those elements of economic income which are used to
purchase health care.
4
In determining insurance status, the income share problems in the tenth decile
which are mentioned above are no longer relevant. Therefore, we can look at the data
for the tenth decile as representative of the lowest income families.
5
Lacking from the National Medical Expenditure Survey (NMES) household data
and, therefore, not shown in any of the decile calculations in this report are out-ofpocket expenditures for nursing home care ($19 billion in 1987) and nonprescription
medicines ($13 billion).
6
A family is considered to have health insurance if all family members are insured
all year, either with private or public insurance.
7
People who hold this view make the point that during recent years as premiums
have been rising rapidly and wages have been stagnant, it has been difficult to reduce
wages to fully offset health costs. And many employers are reluctant to eliminate
coverage since this benefit is important to workers. So, to attract and retain good
employees, firms continue to provide insurance, even when not all the costs can be
passed immediately through to workers in lower wages. If this view best describes
what is actually happening, then it would be incorrect to place the entire cost burden
of employer-sponsored insurance premiums on workers. Some of the costs would
result in lower profits tofirmsor would be passed through to consumers in higher
prices for goods and services.
8
Others have calculated the expenditures at $45 billion. See citation in Feldstein
(1988, p. 482).
9
The Medicare Part B premium is not a true premium since these payments cover
less than the full cost ofthe program.
10
For example, assume total federal tax revenues were $100, and of this total, $20
(20 percent of the total) was spent on health care. A citizen whose federal income
taxes were $10, or one-tenth of total government revenues, would bear a health care
expenditure of $2, or 20 percent of the $10 tax liability.
11
We assign all federal health care spending to taxes and to fees and charges which
the Census of Governments reports as specific to health care. However, deficit
spending and other fees and charges are fungible revenue and may support health
care, thus lowering and redistributing funding burdens In the current year.
12
This study assumes that federal tax expenditures are offset by higher personal and
corporate income taxes.
13
The self-employed were allowed to deduct from their income 25 percent of the cost
of insurance purchased for themselves and their families.
26
�14
Labor income in the NMES data set is undercounted, which makes calculating
payroll tax liabilities very difficult.
15
The NMES provides data only on about three-quarters of the $109 billion in out-ofpocket spending estimated by the U.S. Health Care Financing Administration. Since
the NMES household survey does not include the institutionalized, it omits out-ofpocket spending for nursing homes (about $19 billion in 1987) and it also omits
spending for nonprescription medications ($13 billion in 1987). Therefore, we cannot
estimate the incidence of these expenditures. However, we have added $32 billion to
the total expenditures and total out-of-pocket spending.
16
An elderly family is one in which the reference person is age 65 or above. All other
families are considered nonelderly.
17
This figure includes 71 percent ofthe $32 billion not included in the NMES out-ofpocket totals. Of the $80 billion in out-of-pocket spending that is accounted for in
the NMES, 71 percent comes from the nonelderly. This same share of the $32 billion
increases nonelderly out-of-pocket spending by $23 billion to $79 billion.
18
Because of the major tax reform of 1986, estimates of income tax-based health
care spending should be viewed with caution; the tax incidence of 1987 may be atypical of subsequent years.
27
�Bibliography
Burner, Sally T., Daniel R. Waldo, and David R. McKusick. "National Health Expenditures Projections Through 2030." Health Care Financing Review. Vol. 14, Fall
1992, pp. 1-29.
Cantor, Joel. "Expanding Health Insurance Coverage: Who Will Pay?" Journal of
Health Politics, Policy and Law. Vol. 15, Winter 1990, pp. 755-78.
Feldstein, Paul J. Health Care Economics. 3rd ed. Albany, NY: Delmar Publishers,
1988.
Levit, Katherine R. and Cathy A. Cdwan. "Business, Households, and Governments:
Health Care Costs, iggo." Health Care Financing Review. Vol. 13, Winter 1991, pp.
83-93.
Pechman, Joseph A. Who Paid the Taxes, 1966-1985. Washington, DC: Brookings
Institution, 1985.
U.S. Bureau of the Census. Money Income of Households, Families, and Persons in
the United States: 1991. Current Population Reports. Series P-60. No. 180. Washington, DC: U.S. Government Printing Office, 1992.
U.S. House of Representatives, Committee on Ways and Means, Subcommittee on
Human Resources. Background Material on Family Income and Benefit Changes.
Washington, DC: U.S. Government Printing Office, 1991.
28
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1
PREAMBLE
OUR COMMON STAKE
i
The way we care for each other is a measure of our nation's greatness.
Preventable diseases, untreated illness, and neglected disability tear at the fabric of our
society. Access to health care is by no means a guarantee of health, rather it signifies
our commitment to each other. Those among us who have been denied access to health
care remind us that we have fallen short of our ideals and short of what is possible. The
time has come for the richest nation on earth to ensure that all who live within its borders
are secure in the knowledge that they will have ready access to good health care.
A good health care system responds to our most pressing needs. It keeps
expectant mothers healthy, assists in the safe delivery of our babies, prevents polio and
measles, repairs children's broken bones, treats diseased hearts, eases the agony of
arthritis, counsels the emotionally disturbed, provides wheelchairs for those who cannot
walk, and comforts the dying.
As our lives change, our health care needs shift. We move from the dependence
of childhood through the ambiguities of adolescence and on to responsibilities of
adulthood and finally to the contenment and losses of old age.
Our lives are
unpredictable. We change our jobs, move from place to place; we have children,
accidents and diseases strike unexpectedly. Our well-being and sense of security
depends upon a health care system that works and spans the discontinuities of our lives.
Most of us will be caregivers and be cared for. At times we are properly called to
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help others who need our aid.
2
At other times we need the support of those who can
help us. Given the complexity and cost of modern health care and the unpredictability
of personal need, we cannot do this alone. Government must help us help each other
in providing health care.
No one may be left out. A fair system must work for those
who speak different languages or follow diverse cultural traditions. It must reach to those
who live on farms, in towns, in suburbs or cities. It must look with equal favor upon the
rich and the poor. None should be denied the care they need. No one should find their
opportunities limited for want of health care. We must remember that those in need are
our loved ones, our neighbors, our employees, our taxpayers, our future care-givers and
ourselves.
When people are excluded from health care, they suffer a triple deprivation—the
misery of illness, the desperation of no treatment, and the cruel proof that they do not
really belong. They become strangers in their own land.
When individuals lack care, the promise of our common life together is diminished.
In relieving private distress the nation also enables its people to contribute to the common
good. A health care system is important not only to each of us individually but to the
collective well-being of the American people.
THE CASE FOR REFORM
There is much about our health care system that we should be proud of and
conserve. It has enlisted the devotion of millions of health care professionals, created
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splendid hospitals, clinics and research institutions, dazzled the world with its
achievements while empowering patients to make choices in their health care and in
their lives. Any reform of our system must preserve its virtues.
But, in important ways, our health care system is itself unhealthy. It fails to
reach many of us and in so doing fails to provide the security that a comprehensive
system would. It does not offer sufficient primary, preventative, mental health and
long-term care. It supplies too many specialists and not enough generalists; it pays
for procedures performed rather than good outcomes achieved; it often over-treats,
yet insurance coverage sometimes disappears when most needed. It exposes people
who have lost their jobs to financial ruin. It burdens health care practitioners with too
many regulations and forms. It artificially pits generation against generation in the
competition for resources when in fact we are bound by love with those younger and
older than ourselves. We must remove these burdens, fears and divisions from the
people of our nation.
Our system also costs more to operate than any other health care system in
the world; right now it consumes one seventh of everything we make or do. The costs
of the current system continue to spiral out of control. But, these facts, as harsh as
they are, do not fully measure the real cost of the current system. The 'fringe benefit'
of health care is anything but a fringe cost of producing cars, computers and
refrigerators. In some industries, health care is the largest source of cost after wages
and salaries. The staggering cost of health care reduces the competitiveness of
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4
American businesses. The draining of our economic resources into the current health
care system imperils the viability and vitality of our society. For our own sake and the
sake of our children that we be more responsible stewards of our nation's resources.
THE MORAL IDEALS JUSTIFYING HEALTH CARE REFORM
Because this health care reform is a sweeping social change that profondly
affects the lives of all Americans, it must rest upon the moral ideals to which our
nation is dedicated. Our long held beliefs and our highest aspirations about
community, equality, justice, and liberty justify so grand an undertaking. No one of
these ideals must be pursued at the cost of the others.
Community
Our nation began life with the proclamation "We the people". Later, we tested
and affirmed that declaration through the bitter ordeal of the Civil War. Our sense of
'we the people' has continued to expand throughout our history to include people of all
races, religions, and nationalities, women as well as men, and those with disabilities.
The test continues to this day. We cannot stand divided between the sick and the
well, the protected and the uninsured. Our flourishing as a people rests upon our
ability to create a health care system that binds us together as one community.
At the time of the American Revolution, a commonly invoked moral ideal was
"public virtue"—the readiness to sacrifice self-interest for the community. When
called upon, we have shown a readiness to make such sacrifices when we are
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convinced that they will fall upon us fairly and that the resources which these
sacrifices make possible will be expended wisely. In our own time, the need for health
care reform calls us to renew our commitment to the good of our community.
Equality
As a nation we began by dedicating ourselves to the proposition that "all men
are created equal". We have come to understand the importance of expanding the
moral reach to all. Over the decades, we have come to understand that each
individual, regardless of birth, luck, and fate, deserves equal respect and should be
accorded equal dignity. Our long-standing reverence for the dignity of individuals and
our commitment to equality require that health care depend on need, not money.
The ideal of equality applies to protection from disease, disability, and suffering
just as it applies to the protection from crime, fire, and other disasters. We would find
it absurd to limit these protections solely to those who could afford insurance against
them. Similarly, access to health care ought not to depend upon a person's income,
employment, or insurance. An expensive treatment may be a matter of life or death
for a patient and should not be denied solely on the grounds of ability to pay.
Justice
Our nation was founded upon the belief that all individuals deserve a fair
chance to pursue their chosen goals in life. By providing the benefits of health care to
all, we move toward the attainment df that ideal. When we are in pain, when we
suffer from untreated illness, when we are consumed with the fight against disease,
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those goals remain elusive.
But we cannot commit all our resources to fighting illness and pain. Justice
demands that we conserve our resources for other valuable activities. Our religious
and secular traditions recognize the importance of responsible stewardship of
resources. We cannot spend on everything we might want. We must be keenly
aware of the need for the wise and efficient use of resources.
Liberty
Our revolution began with a protest against overbearing governmental authority.
Our Constitution enshrines the value of personal choice and tolerance of diversity.
However, liberty for Americans has meant more than simply freedom from interference
and coercion. It has also meant enabling our people to have the means to make
choices. Access to health care undergirds liberty; if people do not have access, they
are not free.
When our lives, goals, and very existence are threatened by illness and
disease, we are particularly concerned to control our fate. Health care, or the lack of
it, affects individuals in such deeply personal ways that their choices must be
respected.
In our generation, as we have widely expanded the liberty of people of both
genders and all ethnic backgrounds to be eligible for jobs, schools, and housing, we
also recognize we must limit our liberty so that we can enjoy the benefits of
community.
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THE MORAL VALUES AND PRINCIPLES SHAPING THE NEW HEALTH CARE
SYSTEM
The moral values and principles shaping our health care system must reflect
and honor our long held beliefs as a nation about community, equality, justice, and
liberty. These beliefs cannot directly determine the details of health reform, but
anchor them in the moral traditions we share as a nation. Conflicts among these
values and principles arise in designing the new health care system. The values and
principles will help us recognize the tradeoffs involved in decisions about the design of
the system. They will also help us critique the current system, guide reforms, and
evaluate future performance.
1
Health care is of fundamental moral importance to us because it protects the
opportunities open to us to pursue our goals in life, reduces our pain and suffering,
prevents premature loss of life, and gives us information we need to pursue our lives.
COMMUNITY CARING FOR ALL
Because health care is fundamental, the moral ideals of community and
equality require that the health care system be universal, comprehensive, and
equitable in the sharing of benefits and costs.
UNIVERSAL ACCESS: Everyone must have entry into the health care system without
financial or other barriers.
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No one should fear that a change or loss of a job, part-time or temporary
employment, or economic plight will deprive them of health care coverage.
No one
should lose access to health insurance due to pre-existing conditions, age, race,
genetic background, or disability. The barriers to access arising from linguistic and
cultural differences, geographical distance, and prejudice must come down. The
principle of universal access is the soul of reform. It can no longer be a distant ideal;
we must offer it with all deliberate speed.
COMPREHENSIVE BENEFITS: The health care system must meet the full range of
our health care needs.
We should offer primary, preventive, chronic and long-term care, as well as
acute care; home, as well as hospital care; treatment for mental, as well as physical,
illness. An observer saw the problem of lopsided allocations with a steady eye when
he wrote, "Our system's philosophy might be condensed in the motto, 'Millions for
[acute] care and not one cent for prevention!'" Those lines were written in 1886.
When we attend too little to primary, preventive, and mental health care, the cost of
acute care increases: we mistarget funds; and we fail to enable people to take
responsibility for their own health.
EQUAL BENEFITS: Health care services should reflect only differences in our health
care needs, not other individual or group differences.
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The system must not create two tiers among citizens, dividing the nation over
these fundamental services. Ability to pay should not give some people access to
important medical services that others cannot afford. Health care differs from other
important goods like housing. Modest housing will suffice for shelter, but inadequate
health care services can profoundly limit our opportunities and even cost us our lives.
SHARING COSTS FAIRLY: We should spread the uneven costs and burdens of
meeting our health care needs across the entire community; our payments for health
care should be based on our ability to pay.
The astronomical costs of some acute and long-term services can impoverish
the sick and the disabled and their families. They imperil the sense of security of those
of us who have not yet been stricken. How likely we are to be sick or to stay well
should not determine how much we must pay for health care.
We pay for health care in various ways — through taxes, insurance premiums,
and copayments for services — and these should be based on people's ability to pay.
A fair sharing of burdens can draw the community together.
GENERATIONS STANDING TOGETHER: The health care system must respond to
our needs at each stage of our lives, and we must share its benefits and burdens
fairly across generations.
We have a common stake in meeting our needs as they change throughout our
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lives. We must renounce the "us" versus "them" mentality that pits generations against
each other and undermines our sense of community.
MAKING THE SYSTEM WORK
ALLOCATING WISELY: The nation must balance wisely what we spend on health
care with other important national priorities.
We do not value health care alone. We must also educate our children, provide
housing, and defend our nation. In the past, the structure and funding of the health
care system has not permitted us to make clear choices among these priorities. By
limiting national health care expenditures, we will be in a better position to meet all our
other social needs.
TREATING EFFECTIVELY: We must deliver effective services, avoid ineffective ones,
and support research that leads to new treatments that work.
As wise stewards of our health care resources, we must not waste them on
treatments that do not work. We must support research to learn what benefits different
treatments provide. We must expand our research on the outcomes of health care to
the broader range of services the system must offer, not just acute care.
ENSURING QUALITY: We must ensure that high quality services are available and
that individuals receive the information necessary to make informed health care
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choices.
Our new system must strive to eliminate waste and deliver services efficiently,
but we must not allow it to compromise the high quality we expect when our health is
at stake. Assuring quality requires an environment that fosters health care
professionals' best work and weeds out the unethical and incompetent practitioner.
MANAGING EFFICIENTLY: The health care system should be simply organized,
easy to use for patients and professionals, and should minimize administrative costs.
Managing efficiently is a moral, not just an economic imperative. Efficiency must
be defined with a wise heart, not just a calculator. We must reduce the cumbersome
administrative burdens on providers and patients; they interfere with quality care and
divert resources from the delivery of effective services.
CHOICE AND RESPONSIBILITY
INDIVIDUAL CHOICE: The health care system should enable all of us to make
effective choices about our providers; health care plans, and the treatments we
receive.
Health care affects individuals and their families too fatefully not to build
effective choice into the system. The system must provide us with adequate
information
and counsel to let us make informed choices. Honoring choice in the health care
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system not only respects liberty; it also engages the patient in the success of
preventive, acute, rehabilitative and long-term care.
PERSONAL RESPONSIBILITY: The health care system should help us take
.responsibility for protecting and promoting our health and the health of our families.
Much of what we do affects our health. We need information, education, and
counseling that empower us to make effective choices about'liow we protect our health.
PROFESSIONAL INTEGRITY AND RESPONSIBILITY: The health care system must
respect the clinical judgments of professionals, protect the integrity of the
professional-patient relationship, while ensuring that the profession fullfils its public
responsibilities.
All of us have a stake in ensuring that the integrity of the professional-patient
relationship is protected and preserved. A huge social investment has helped to form
and educate health care professionals. A good health care system needs to foster
ways in which those who have received can give back to their community through
national service or work in underserved areas. The health care system needs healers
•who seek to serve the common good through their art and who see their profession as
a calling not just a career.
FAIR PROCEDURES: To protect these values and principles, fair and open
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democratic procedures should exist for making decisions about the operation of the
health care system and for resolving disputes about individual patient care.
Even in a caring community, reasonable people will disagree about how to
translate our moral ideals, values, and principles into a well-functioning health care
system. Difficult decisions will have to be made. We are a democracy that respects
the value of all people and everyone must have access to the reasons for the
decisions that affect them so fundamentally and must have a fair procedure for
resolving disputes.
Conflicts between these convictions may well arise but they help us identify
what is at stake morally as we design health care system, implement reform and
evaluate future performance.
A TIME TO ACT
We cannot treat health care reform as a partisan or ideological issue. Our
founders assumed that if a nation could create a common good it should make that
good common. We can deliver health care to all our people, and this health care will
secure and enhance life, liberty, and welfare that is our nation's promise to its citizens.
Health care reform asks us to declare our nation a community. Americans see the
need for this redefinition and commitment. This commitment must reflect our national
and personal values; it must recognize our interdependence; it must embody our care
for those we love and our willingness to acknowledge and accept our neighbor's help
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in our own hour of need. We must commit ourselves to universal and comprehensive
health care as a way to fulfill our national promise. It is time to make that promise to
each other.
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�A p r i l , 29,
1993
MMRNU
EOADM
TO:
Those w i l l i n g to l i s t e n
FROM: Nancy Neveloff Dubler
RE: PRISON AND
JAIL HEALTH CARE IN THE NEW
SYSTEM
I.
INTRODUCTION
One m i l l i o n 300,000 persons are incarcerated every day i n
our nations prisons, j a i l s and detention centers. These persons
range i n age from young c h i l d r e n , age 7 or 8, t o those i n t h e i r
e i g h t i e s . Indeed, i n t h i s area, as i n many others, the "graying"
of the p r i s o n population i s noticeable.
This population of i s composed of three major groups: those
i n prisons serving sentences of year or more; those i n j a i l s who
are awaiting t r i a l and have been denied or are unable t o r a i s e
b a i l ; and those i n j a i l who are serving short-term sentences of a
year or l e s s . Prisons confine approximately 800,000 inmates,
w h i l e j a i l s confine 500,000. A j a i l population census, however,
may be misleading. For example, Rikers I s l a n d , the major New
York C i t y j a i l confines about 15,000 inmates; t h i s number may
represent 110,000 separate admissions a year, some o f which may
be readmissions. The budget f o r the health services a t Rikers
I s l a n d i s 70 m i l l i o n ; there i s a s t a f f of approximately
1200
employees c o n s i s t i n g of 200 physicians, 200 nurse p r a c t i o n e r s and
physician a s s i s t a n t s , 200 mental h e a l t h workers and the r e s t
support s t a f f .
The c o r r e c t i o n a l i n s t i t u t i o n s of the n a t i o n are
d i s p r o p o r t i o n a t e l y inhabited by the poor and people of c o l o r . I n
many s t a t e s upward of 90% of incarcerated persons are poor and i n
some more t h a t 80% are people of c o l o r , African-American and
Hispanic.
Data produced by "The Sentencing P r o j e c t " i n 1990
showed t h a t 25% of Black men between the ages of 19 and 29 are
under the j u r i s d i c t i o n of the c r i m i n a l j u s t i c e system. ( I n the
D i s t r i c t of Columbia, the number i s 42%)
Since 1976, when the Supreme Court decided the case of
E s t e l l e v. Gamble, the states have been responsible f o r p r o v i d i n g
h e a l t h care f o r those incarcerated i n prisons or j a i l s .
The
Federal government i s also responsible f o r p r o v i d i n g h e a l t h care
i n i t s d e t e n t i o n centers and Federal C o r r e c t i o n a l F a c i l i t i e s .
�The constitutional standard fashioned by the court for
judging the adequacy of care i s : "Deliberate indifference to the
serious medical needs of inmates" constitutes the w i l l f u l and
wanton i n f l i c t i o n of pain that the Eighth Amendment i s designed
to prohibit. That indifference may be demonstrated by denying
access to the care system, by f a i l i n g to provide access to the
appropriate l e v e l of health professional necessary to diagnose or
treat the ailment, or by f a i l i n g to follow the provider's orders.
The court reasoned that to put someone i n a correctional
f a c i l i t y , where they cannot secure their own care, and then not
to provide that care, i s to produce precisely the kind of pain
and suffering that the Eighth Amendment i s designed to prohibit.
Despite the fact that inmates are the only persons i n the
nation with a Constitutionally guaranteed right to health care,
the quality of care provided—medical care, mental health care,
chronic care and r e h a b i l i t a t i v e c a r e — ( a l l of which are required
by various Federal Court cases) varies widely among the
j u r i s d i c t i o n s and i s often found inadequate.
Since 1976 every state has been faced with challenges to the
adequacy of systems developed to provide correctional health care
services. Some states, Alabama and Texas among them have had
t h e i r correctional medical services i n v i r t u a l , or actual,
receivership for a decade or more. Assuring quality, always a
problem i n segregated services that serve powerless populations,
i s further complicated by the explosion of inmates over the l a s t
decade.
Since 1980 the prison and j a i l population of the country has
more than doubled. This has resulted i n huge c a p i t a l
expenditures for new c e l l s i n some states and i n heavily
overcrowded f a c i l i t i e s i n others. The reasons for t h i s growth
include: the increasing fear of c i t i z e n s at the increase i n
violent crimes and crimes against persons; the resultant "lockthem-up" philosophy of p o l i t i c i a n s and judges; the "war on
drugs" that may not have done much to stem the flow of prohibited
substances but has led to the incarceration of ever larger
numbers of drug users and dealers; and the increase i n "mandatory
sentencing guidelines" that has produced longer sentences for a
vast number of repeat offenders. I n addition, women are entering
correctional systems i n escalating numbers, and many children,
who used to be t r i e d and confined i n juvenile f a c i l i t i e s are now
t r i e d and sentenced within the adult system.
The huge numbers of inmates, the budgets required for
confinement and care, the problems inherent i n providing decent
medical care i n correctional settings, and the constant pressure
of the advocate groups i n the Federal Courts have made the
provision of correctional health care a major concern of the
�states.
II.
CORRECTIONAL HEALTH CARE: THE DILEMMAS
Providing h e a l t h care i n a p r i s o n or j a i l i s an a l i e n
experience f o r most h e a l t h care providers, one t h a t i s
uncomfortable and scary. The goal o f a c o r r e c t i o n a l f a c i l i t y i s
t o confine and punish. The goal o f medicine i s t o diagnose,
comfort and cure. These goals must co-exist i f inmates are t o
receive decent and appropriate care; medicine must u l t i m a t e l y be
i n charge o f the care d e l i v e r y system, the protocols used, and
the consultant arrangements made, i f the care i s t o meet the r e a l
needs o f inmates.
The c o n s t i t u t i o n a l standard requires t h a t the inmates be
able t o gain access t o the h e a l t h s t a f f , be examined by an
appropriate h e a l t h provider, be able t o gain access t o the care
ordered and be provided w i t h consultant care o r h o s p i t a l i z a t i o n
when necessary. Whereas a l l o f these elements are r e l a t i v e l y
easy outside o f p r i s o n , they present major management challenges
f o r c o r r e c t i o n a l h e a l t h administrators. Many o f the obstacles
stem from the unwillingness o f those not d i r e c t l y i n v o l v e d i n
c o r r e c t i o n a l h e a l t h care t o provide services. Often t h i s
reluctance extends t o i n d i v i d u a l s p e c i a l i s t s , t o the l o c a l
ambulance corp, and t o the area h o s p i t a l .
Given the adversary r e l a t i o n s h i p between c o r r e c t i o n a l
a d m i n i s t r a t o r s , c o r r e c t i o n o f f i c e r s and inmates, gaming t h e
system i s p a r t o f inmate c u l t u r e . Conversely, d e n i a l o f access
and d e n i a l o f treatment i s a constant t h r e a t o f the o f f i c e r s .
Because o f f i c e r s c o n t r o l the space, i t i s impossible, i n t h e
f i r s t instance, t o d i s t i n g u i s h a r e f u s a l o f care from a d e n i a l o f
care i n any c o r r e c t i o n a l s e t t i n g .
I n a d d i t i o n , data i n d i c a t e t h a t many persons e n t e r i n g t h e
c o r r e c t i o n a l system have f a r more acute medical problems than one
might assume from age alone. Prevalence o f hypertension, cardiac
problems, untreated orthopedic conditions, epilepsy and major
mental i l l n e s s e x i s t i n t h i s population t o a f a r greater degree
than found i n a matched non-incarcerated cohort. This a d d i t i o n a l
burden o f unaddressed d i s a b i l i t y , i l l n e s s and disease e x i s t e d
even before the advent o f AIDS, the reemergence o f Tuberculosis
and the development o f d r u g - r e s i s t a n t s t r a i n s o f the bacterium.
III.
POSSIBLE SOLUTIONS
There are three possible options f o r considering t h e
r e l a t i o n s h i p o f the new system t o c o r r e c t i o n a l h e a l t h care. Each
must consider the problems o f p r o v i d i n g service and paying f o r
the s e r v i c e separately:
�1.
Fold a l l s t a t e p r i s o n and j a i l inmates and a l l Federal
inmates i n t o the new system;
2. Phase i n a plan t h a t w i l l gradually charge AHPs f o r some
p a r t s o f the care provided during stays i n the j a i l system,
e s p e c i a l l y t h a t p a r t o f care t h a t continues treatment f o r
p r e v i o u s l y i d e n t i f i e d medical problems.
3. Continue the present system of separate s t a t e o r f e d e r a l
funding f o r h e a l t h programs i n c o r r e c t i o n a l f a c i l i t i e s w h i l e
using the HA t o ensure t h a t consultant care, s p e c i a l t y care
and h o s p i t a l i z a t i o n are a v a i l a b l e t o inmates.
Under none o f the options, would the AHP a c t u a l l y be i n a
p o s i t i o n t o provide primary care services (although the AHP might
be c r i t i c a l f o r the e f f o r t t o provide consultant care, s p e c i a l t y
care and h o s p i t a l i z a t i o n ) .
Given the general s e c u r i t y problems, the l e g a l mandate o f
the c o r r e c t i o n a l services, a d m i n i s t r a t i v e management, c o u r t
appearances, f a m i l y and attorney v i s i t s , the frequent "lockdowns" t h a t o v e r r u l e a l l p r i o r scheduling decisions, and the
custom o f most p r i s o n systems t o t r a n s f e r inmates r e g u l a r l y t o
prevent a l l i a n c e s and power organizations, i t would be impossible
for providers outside o f the system t o enter i n t o the p r i s o n t o
provide primary care t o a stable population over which they could
have some management c o n t r o l . I t would be e q u a l l y impossible f o r
inmates t o be brought t o the l o c a t i o n o f the AHP t o receive care.
Option #1: Given t h i s i n a b i l i t y t o i n t e g r a t e services o r t o
give the AHPs any r e a l c o n t r o l o f the t i m i n g o r substance o f care
i t seems n e i t h e r f a i r nor reasonable f o r the AHP t o bear the
a d m i n i s t r a t i v e o r the f i n a n c i a l burdens o f care.
I t might be possible, i n the t r a n s i t i o n , t o consider the
j a i l a s i t e f o r e n r o l l i n g those persons who have not p r e v i o u s l y
j o i n e d a plan under some n o t i o n of a Point o f Service enrollment.
Given the f a c t t h a t many inmates w i l l be unemployed and some w i l l
be homeless, t h i s might seem a t t r a c t i v e . I t would, however, be
d i f f i c u l t t o administer, run counter t o the focus o f the c r i m i n a l
j u s t i c e system and ignore the f a c t t h a t inmates may be i n the
j a i l f o r a matter o f only hours o r days i f they can manage t o
post b a i l . Educating an inmate about h e a l t h care when h i s goal
i s b a i l and freedom i s n e i t h e r f a i r nor l i k e l y t o be e f f e c t i v e .
Option #2: This makes sense a t some p o i n t i n the f u t u r e
but c e r t a i n l y not i n the t r a n s i t i o n . Some years from now, once
a l l persons are e n r o l l e d i n an AHP, i t might make sense t o charge
the AHP f o r some o f the care provided by j a i l h e a l t h services, a t
l e a s t those charges f o r continued care f o r " p r e - e x i s t i n g
problems" (although the mere statement o f the language r a i s e s the
specter o f bad f a i t h and u n f a i r r e s t r i c t i o n s i n coverage) i n the
period before the inmate i s sentenced t o p r i s o n .
�There i s another reason t o consider t h i s r o u t e i n t h e
f u t u r e . I t may be t h a t an AHP would reap a " w i n d f a l l " from
having some o f i t s e n r o l l e e s incarcerated. I f an AHP had a large
number o f i n c a r c e r a t e d p a t i e n t s f o r whom i t had been paid a
c a p i t a t i o n and f o r whom i t had no r e s p o n s i b i l i t y , i t might be
moire e q u i t a b l e t o t r a n s f e r some o f t h a t c a p i t a t i o n payment t o t h e
jail.
Option #3: This o p t i o n probably makes the most sense given
the r e a l i t i e s o f c o r r e c t i o n a l health care, the plans f o r s i m i l a r
i n s t i t u t i o n a l populations and the general requirement f o r t h e
maintenance o f s t a t e e f f o r t i n presently funded s t a t e r u n
programs and systems.
Responsible c o r r e c t i o n a l health administrators would l i k e
the new system t o encompass inmates f o r two reasons: f i r s t , so
t h a t i t might provide e x t r a resources f o r the care o f inmates;
and, second, so t h a t i t might import community q u a l i t y assurance
and performance measurement standards i n t o the universe o f
c o r r e c t i o n a l h e a l t h services. Since h e a l t h care budgets have n o t
r i s e n n e a r l y as q u i c k l y as population i n the l a s t decade, even
those h e a l t h services t h a t were r e l a t i v e l y adequate some years
ago are now s t r u g g l i n g t o meet the c o n s t i t u t i o n a l standard o f
care w i t h f a r fewer resources per inmate.
For t h i s same set o f reasons i t i s l i k e l y t h a t s t a t e
governments might object t o the p a r t i c i p a t i o n o f the new system.
I f q u a l i t y assessment i s taken s e r i o u s l y a new voice might emerge
c a l l i n g f o r increased c o r r e c t i o n a l — i . e . s t a t e — s p e n d i n g on
h e a l t h care.
N a t u r a l l y , t h i s analysis does not preclude the s t a t e s from
t r y i n g t o devise c r e a t i v e and innovative plans t o i n v o l v e the HAs
or the AHPs i n the process o f improving the q u a l i t y o f care i n
s t a t e prisons o r i n j a i l s , f o r which county governments are
responsible. States might, f o r example, r e q u i r e a l l c o r r e c t i o n a l
f a c i l i t i e s t o have an independent bidder on the h e a l t h care
services and then ask the HA t o supervise t h a t process. Given t h e
f a c t t h a t the HA should have the best data on what care should
cost i n the area, and the most relevant experience i n managing
the c o s t - n e g o t i a t i o n process, t h i s assignment might improve t h e
value f o r the d o l l a r t h a t c o r r e c t i o n a l services could expect.
The r e a l issue i s : should t h i s new plan mandate a r o l e f o r
the HAs and the AHPs over s t a t e objection?
IV.
THE ROLE OF THE NEW SYSTEM
I would argue that certain obligations regarding
correctional health services should be mandated by statute i n the
�new system.
The HA could play an Important role i n structuring service
capacity. One of the major problems i n correctional health care
i s the problem of finding consultant and specialty care providers
w i l l i n g to serve inmates, and finding hospitals w i l l i n g to
provide services. Inmates may not be paid for by the new system
and might not be t o t a l l y integrated into the normal care plans,
yet, as part of their management of care available i n i t s area,
the HA should have the obligation of ensuring that specialty
services and hospitalization are available to the prison and j a i l
health s e r v i c e s . Most providers do not want to serve inmates.
Yet, inmates are a disadvantaged and underserved population to
whom the system owes the ethical obligation of attempting to
improve care.
The state might also involve the HA i n the process of
auditing the quality of care according to the established
standards i n the free commimity.
There are two f i n a l reasons why the care of inmates should
be as i n t e g r a t e d as possible i n t o the community standard o f care.
Most inmates stay i n p r i s o n f o r s l i g h t l y l e s s than three years.
At the end of t h a t time they reenter the community and w i l l be
e n r o l l e d i n an AHP.
I f the care i n p r i s o n or j a i l i s inadequate
the subsequent costs t o the system w i l l be g r e a t e r . Untreated
and neglected h e a l t h problems tend t o cost more i n the long-run.
I n a d d i t i o n , untreated h e a l t h problems t h a t present p u b l i c
h e a l t h challenges w i l l f o l l o w the inmate i n t o the community and
subject others t o the r i s k of i n f e c t i o n and disease. This l a s t
phenomenon i s most obvious now i n discussions of HIV Disease and
M u l t i p l e d r u g - r e s i s t a n t Tuberculosis. I n New York, f o r example,
approximately 25% of inmates e n t e r i n g the system from New York
C i t y are HIV p o s i t i v e ; f u l l y 25% of the TB i n New York C i t y i s
r e s i s t a n t t o the f i r s t two standard drugs; persons w i t h HIV and
TB are t e n times more l i k e l y t o progress t o TB disease than those
not d u a l l y i n f e c t e d . I t i s not hard t o foresee the p u b l i c h e a l t h
catastrophe t h a t would r e s u l t i f the prisons and j a i l s were not
dealing adequately w i t h the dual epidemic.
V.
EQUITY IN THE NEW SYSTEM
The most basic d e f i n i t i o n of j u s t i c e i s t r e a t i n g l i k e cases
a l i k e . Maintaining s t a t e programs and s t a t e f i s c a l
r e s p o n s i b i l i t y f o r persons i n the c r i m i n a l j u s t i c e system i s
c o n s i s t e n t w i t h decisions made p r e v i o u s l y i n regard t o person i n
the f o r e n s i c mental h e a l t h system, and persons
d e i n s t i t u t i o n a l i z e d from long-term mental i n s t i t u t i o n s .
�Person i n the f o r e n s i c system, ( t h a t i s i n a mental h e a l t h
f a c i l i t y t o assess a b i l i t y t o stand t r i a l o r t o confine as an
a l t e r n a t i v e t o prison—based on the judgment o f not g u i l t y by
reason o f i n s a n i t y ) w i l l be cared f o r and paid f o r by the s t a t e s .
The f o r e n s i c system and the general c r i m i n a l j u s t i c e system share
c e r t a i n c h a r a c t e r i s t i c s t h a t argue f o r uniform treatment. I n
both systems i t i s the J u d i c i a l system and the c r i m i n a l j u s t i c e
system t h a t makes the decisions about where and how a person w i l l
be t r e a t e d . I n both cases i t would be impossible f o r an AHP t o
"manage" care. The key decisions regarding care are outside o f
the a u t h o r i t y o f the plan. Thus the states must bear the e n t i r e
burden.
I n c o n t r a s t , consider the treatment o f the
d e i n s t i t u t i o n a l i z e d mentally i l l .
These people w i l l , upon
placement i n the community, be e n r o l l e d i n an AHP. Whereas the
AHP might be e l i g i b l e f o r a r i s k adjustment, given the d i f f i c u l t y
of p a t i e n t management, i f the AHP subsequently decides t o
r e i n s t i t u t i o n a l i z e the p a t i e n t , i t w i l l be responsible f o r the
costs o f t h a t i n s t i t u t i o n a l i z a t i o n ; i t manages the care; i t
decides t o r e i n s t i t u t i o n a l i z e ; i t i s l i a b l e f o r payment.
Contrast t h i s w i t h the course o f an inmates career d u r i n g
which the c r i m i n a l j u s t i c e system decides when t o i n c a r c e r a t e and
when t o release, when t o t r a n s f e r t o a new f a c i l i t y , when t o send
f o r s p e c i a l t y care, o r when t o release f o r h o s p i t a l o r hospice
care. Imposing burdens on the AHP under these circumstances
would serve no u s e f u l purpose.
1
VI.
POSSIBLE QUALITY IMPROVEMENT FOR INMATES IN THE NEW SYSTEM
Inmates may yet b e n e f i t i n other ways under arrangements i n
the new system. They may be e n t i t l e d t o more services i f the
b e n e f i t package comes t o be seen as the p r e s c r i p t i o n f o r
minimally adequate care. On the other hand, given the f a c t t h a t
f e d e r a l cases have required dental care, mental h e a l t h care and
r e h a b i l i t a t i o n under the r u b r i c o f "serious medical needs" t h i s
might not provide the basis f o r an expansion o f care.
There w i l l be the need t o coordinate e x i t from the c r i m i n a l
j u s t i c e system w i t h enrollment i n a AHP. I t i s p r e s e n t l y the
case t h a t inmates discharged from a p r i s o n o r j a i l have no sure
way o f l i n k i n g up t o services, even i f they are e l i g i b l e f o r
Medicaid. The chaos and confusion o f the systems, and the f e a r
of ex-prisoners as a danger t o providers and p a t i e n t s , tends t o
discourage contact and enrollment. States should be r e q u i r e d t o
develop plans t o e n r o l l inmates i n AHPs a t the p o i n t o f release.
Given the prevalence o f AIDS, mental i l l n e s s and substance abuse,
the existence o f post i n c a r c e r a t i o n care o p p o r t u n i t i e s w i l l
provide a r e a l , new b e n e f i t t o inmates. High r a t e s o f r e c i d i v i s m
might also d e c l i n e i f these services were provided.
�States should be required t o Involve the HA I n the bidding
out and monitoring of care i n the prisons and, perhaps i n the
j a i l s also. Any developments that encourage the general medical
community t o monitor and assess quality w i l l help those providers
genuinely concerned with quality t o improve the system of care.
Thus, even though inmates should not be enrolled i n the new
system, they w i l l l i k e l y benefit from the organization and
management of a universal coverage sustem and from enhanced
q u a l i t y assessment i n the future.
8
�Brock and Daniels
DRAFT
page 1
ETHICAL FOUNDATIONS OF THE NEW HEALTH CARE SYSTEM
Dan W. Brock and Norman Daniels
1
The design of our new health care system is shaped by basic moral principles and values
that are widely shared in our society. In the first section ot this paper, we articulate fourteen
principles and values that guide policy decisions and choices about central features of the new
health care system. These principles and values are neither pulled from thin air nor selected
simply to conform to the new system. They are deeply anchored in the moral traditions we share
as a nation, reflecting our long standing commitments to equality, justice, liberty, and
community. Different moral, religious, and cultural traditions within our society may emphasize
different elements among these principles and values or give them different weight when they
conflict. Nevertheless, there is a widespread consensus on them and on their central role in
defining our common community, as we show in the second section of this paper.
These principles and values will conflict in various ways, and trade-offs among them must
be made in designing a health care system. People may disagree about just how these tradeoffs
should be made, reflecting their different philosophical, cultural, and religious traditions, as
well as the different values we affirm as individuals. In the third section, we discuss some
important tradeoffs that arise in key choices about the design of the system and show how the
principles illuminate what is at stake in these decisions. These trade-offs occur not only among
the principles and values, but with judgments about what is politically feasible as well.
SECTION I: ETHICAL PRINCIPLES AND VALUES OF THE NEW HEALTH CARE SYSTEM
Although we tolerate many inequalities between people in our society, the great
inequalities that have arisen in access to health care services seriously undermine our
achievement of a just and caring community. Because health care is so important, access to it
should not depend on the contingencies of our job status or our ability to pay, our prior medical
history or where we happen to live. We can explain this importance by considering the profound
effects health care can have on our lives:
�Brock and Daniels
DRAFT
page 2
THE FUNDAMENTAL MORAL IMPORTANCE OF HEALTH CARE: Health care is of
fundamental moral importance because it protects the opportunities open to us to pursue
our goals in life, reduces our pain and suffering, prevents premature loss of life, and
gives us information we need to plan our lives.
2
This statement of the value of health care displays the diverse benefits it provides us. For
example, reducing pain and suffering, preventing the premature loss of life, and providing
information are all among the ways in which health care protects the range of opportunities open
to us. Health care services protect our opportunities in various ways: some services prevent
disease and disability and help us to maintain our health; others cure disease and repair the
effects of injury; others compensate for losses of function and capability; still others keep us
3
from losing further function. In reducing pain and suffering, and in preserving our lives, health
care also directly serves our well-being. Having health care available to us also importantly
serves to affirm our moral status as full members of society and the moral community.
CARING FOR ALL
Because health care is a fundamental good, the moral ideals of justice, equality, and
community require that the health care system be universal, comprehensive, and equitable in the
sharing of benefits and costs.
UNIVERSAL ACCESS: Everyone must have access to health care services without financial or
other barriers.
Increasingly, Americans, whether insured or uninsured, fear that they will be unable to
obtain needed health care. We must provide a new security that appropriate health care services
4
will be available to all Americans, making health care a right, not a privilege. No one should fear
that a change or loss of a job, part-time or temporary employment, or economic plight will
deprive them of health care coverage. No one should lose access to health insurance or be denied
coverage for needed services due to pre-existing conditions, age, race, genetic background, or
disability. We must remove the barriers to access arising from linguistic and cultural
differences, geographical distance, prejudice, residence in economically deprived or underserved
�Brock and Daniels
DRAFT
page 3
areas, or from excessive out-of-pocket payments. The principle of universal access is the soul of
the reform. Universal access can no longer be a distant ideal; we must offer it to all now.
COMPREHENSIVE BENEFITS: The health care system must meet the full range of our health
care needs.
All health insurance plans should offer a comprehensive package of benefits that will be
acceptable to the vast majority of Americans. Entire categories of health care services should no
longer be excluded from coverage without regard to their benefits in meeting fundamental human
needs. Since meeting needs is what gives health care its special importance, any limitations in
coverage should be of those services that provide the least benefit to patients relative to their
5
costs. Health insurance plans should cover primary, preventive, chronic and long-term care, as
well as acute care; home, as well as hospital care; treatment for mental as well as physical,
illness.
EQUAL
BENEFITS: Health care services should reflect only differences in our health care
needs, not other individual or group differences.
The system must not create two or more tiers among citizens, dividing the nation over
these fundamental services, and leaving the worst-off among us with lower quality and more
restricted services. Ability to pay should not give some people access to important medical
services that others cannot afford. Health care differs even from other important goods like
housing. Modest housing will suffice for shelter, but diminished health care sen/ices can
profoundly limit our opportunities, result in preventable pain and suffering, and even cost us our
lives. Providers should not have to determine patients' insurance coverage before offering needed
care.
FAIR BURDENS: We should spread the uneven costs and burdens of meeting our health care needs
across the entire community; our payments for health care should be based on ability to pay.
The astronomical costs of health care can impoverish the sick and disabled and their
families, compounding the burdens of illness with the prospect of financial ruin. Because
differences in our risks of becoming ill and in the costs of meeting our needs are largely
�Brock and Daniels
DRAFT
page 4
undeserved and beyond our control, and because protecting equality of opportunity is a shared
obligation, fairness requires spreading the costs of insurance across the entire community.
6
Individuals' insurance premiums should be "community rated." In addition, all must belong to
the health care system and share in its support-individuals should not be able to free ride by
receiving needed health care without bearing their fair share of the costs. Even when well, we all
share the risk of becoming sick; the well should share the costs of treating the sick. How likely we
are to be sick or to stay well should not determine how much we pay for our health care.
We pay for health care in various ways-through taxes, insurance premiums, and copayments for services-and these should be based on people's ability to pay. This means that taxes
and other financing mechanisms must be progressive, with high income individuals paying more
and that premiums and co-payments of the poor must be subsidized by the government.
GENERATIONAL SOLIDARITY: The health care system must respond to our needs at each stage
of our lives, and we must share its benefits and burdens fairly across generations.
We commonly perceive that the needs of the old and the young are in conflict. We must
7
renounce this "us" versus "them" mentality that pits generations against each other. We all age
and have a common stake in a health care system that meets our needs as they change through the
course of our lives. By providing for these needs and sharing the burdens fairly, the new health
care system can give us all a new security that our needs, and the needs of our family members
and those we care for, will be met throughout our lives.
MAKING THE SYSTEM WORK
In order to most effectively meet our health care needs without sacrificing other
important goals, the new health care system must allocate wisely, treat effectively, ensure
quality, and manage efficiently. Controlling costs without compromising quality is a moral, not
just an economic, imperative: it is the way we achieve the most good for people with our limited
resources.
�Brock and Daniels
DRAFT
page 5
WISE ALLOCATION : The nation must balance wisely what we spend on health care with other
national priorities, as well as allocate resources within health care to services that meet our
most important needs.
We do not value health care alone. We must also educate our children, provide housing, and
8
defend our nation. A central value of health care is its preservation of our opportunities to
pursue the other things we care about in life, and so resources must be available for these other
activities as well as for health care. In the past, the organization and funding of the health care
system has not enabled us to make clear choices among these priorities. By limiting the growth of
overall health care expenditures, we will be in a better position to meet our other social needs.
Likewise, we do not value all health care services equally and so must give priority to services
that meet our most important needs.
EFFECTIVE TREATMENT: We must deliver effective services, avoid ineffective ones, and
support research that leads to new treatments that work.
Limited data about the effectiveness of many commonly used treatments, as well as a
variety of perverse incentives to over-utilize services, lead to use of unnecessary care that does
9
not benefit patients. We must not waste our health care resources on treatments that do not
work. We must increase substantially our support for "outcomes" research to learn what benefits
10
different treatments provide. We must expand our research on the outcomes of health care to
the broader range of services the system must offer, not just acute care. We must evaluate
whether new technology produces benefits that warrant its additional costs.
QUALITY CARE: We must ensure that high quality services are available and that individuals
receive the information necessary to make informed health care choices.
Our new system must strive to eliminate waste and deliver sen/ices efficiently, but we
must not allow it to compromise the high quality we expect when our health is at stake. New
quality measures must be developed that ensure quality is maintained in individual treatments and
in health care delivery systems, without creating excessive administrative burdens. Effective
grievance systems must be developed for patients who believe the quality of their care has been
�Brock and Daniels
DRAFT
page 6
compromised. Assuring quality requires an environment that fosters the best work of health care
professionals and weeds out unethical or incompetent practitioners.
EFFICIENT MANAGEMENT: The health care system should be simply organized, easy to use for
patients and professionals, and should minimize administrative costs.
The administration of our health care system is now unnecessarily complex and
wasteful.
11
We use a higher proportion of our health care expenditures for administrative costs
than any other country-this interferes with quality care and diverts resources from the
delivery of effective sen/ices. Patients and families must not have the burdens of unnecessary
paperwork added to the burdens of illness. Providers must no longer face the administrative
burdens imposed by insurers whose micro management of clinical decisions often interferes with
appropriate patient care.
CHOICE AND RESPONSIBILITY
The new health care system must respect the choices appropriately left to patients or providers,
encourage personal responsibility and protect professional integrity, while ensuring
accountability through fair procedures.
INDIVIDUAL CHOICE: The health care system should enable all of us to make effective and
informed choices about our providers, health care plans, and the treatments we receive.
Since health care has such profound effects on people's lives, we must respect personal
choice in the health care system. Individuals should be able to maintain important existing
relationships with providers. They should be able to choose the type of health care plan to which
they belong. Within their health care plans, they should be able to choose health care
professionals with whom they can work compatibly and to have their choices about treatment
respected. Consumers and patients should be provided with adequate information and counsel so
that all of their choices will reflect their particular needs and values. Honoring choice in the
health care system not only respects liberty and individual self-determination, but also engages
patients in the success of our own care.
�Brock and Daniels
DRAFT
page 7
PERSONAL RESPONSIBILITY: The health care system should help us take responsibility for
protecting and promoting our health and the health of our families.
Much of what we do affects our health. The health care system should provide information,
education, counseling, and treatment that empower us to make effective choices about how to
protect our health. It is also appropriate for society to create incentives for individuals to reduce
unhealthy behaviors, such as taxes on cigarettes and alcohol, and to ensure treatment programs
are available which help people change such behaviors. But access to needed care should not be
denied because health care needs may be caused by unhealthy behaviors. Making the connection
between individual patient behavior and disease would often be too difficult and too intrusive.
Neither patients nor providers would want the provision of care to have to await determination of
responsibility.
1
2
PROFESSIONAL INTEGRITY: The health care system must respect the clinical judgments of
physicians and other professionals and protect the integrity of the professional-patient
relationship, while ensuring that professionals fulfill their public responsibilities.
All of us have a stake in ensuring that the integrity of the professional-patient
13
relationship is protected and preserved. Efforts to control the growth of health care costs must
not be permitted to undermine either the commitment of professionals to the well-being of their
patients or the trust of patients in that commitment. The health care system must contain
procedures for appeal by either professionals or patients when they believe the integrity of their
professional-patient relationship is threatened.
A huge social investment has helped to form and educate health care professionals. The
health care system should foster ways in which professionals can give back to their community,
for example through national service or work in underserved areas.
FAIR PROCEDURES: To protect these principles and values, fair and open democratic
procedures should exist for making decisions about the operation of the health care system and for
resolving disputes about individual patient care.
�Brock and Daniels
DRAFT
page 8
Even in a just and caring society, reasonable people will disagree about how to translate
our moral ideals, principles and values into a well-functioning health care system.
14
Difficult
and controversial trade-offs and decisions will have to be made. In a democracy that aspires to
respect all people, everyone must have access to the reasons for the decisions that may affect them
so profoundly and must have access to a fair procedure for resolving disputes.
SECTION II: FOUNDATIONS OF THE PRINCIPLES AND VALUES
Because this health care reform is a sweeping change that profoundly affects the lives of
i
all Americans, the principles and values that guide it must rest upon the moral ideals to which
our nation is dedicated. Our long held beliefs and our highest aspirations about justice, equality,
liberty, and community justify this undertaking. These ideals, like the specific health care
principles and values guiding the health care reform, will sometimes come into conflict, and no
one of these ideals must be pursued at the cost of all the others.
EQUALITY
Our nation was founded upon the belief that all individuals deserve equality of opportunity
to pursue their chosen goals in life. By providing health care to all, we move toward the
attainment of that ideal. Pain and suffering, disability and limitation of function, and premature
loss of life all restrict our opportunities. In recognition of the fundamental impact education has
on our opportunities, we long ago made a commitment to a system of public education available
without charge to all members of our society. We thus acknowledge a moral right to fair equality
15
of opportunity. The language of rights expresses the strongest moral claims of individuals
against their fellows and their societies. In different ways, health care is at least as important as
education in securing equality of opportunity. While health care typically does not open up new
opportunities in the way education often does, without needed health care we are often deprived of
opportunities that would otherwise be open to us. Health is not a goal around which we organize
our lives, but a necessary condition for pursuing nearly all of the goals around which people do
organize their lives. In this respect, it is a basic requirement of fair equality of opportunity.
�Brock and Daniels
DRAFT
page 9
Several of the specific health care principles and values are given direct and strong
support by the concern for equality of opportunity. We could not assure equality of opportunity
without fulfilling that the principles of UNIVERSAL ACCESS, COMPREHENSIVE BENEFITS, EQUAL
BENEFITS, and GENERATIONS STANDING TOGETHER. Other concerns about equality and just or fair
treatment, such as the dignity and worth of individuals, and the equal concern and respect each
person is owed, also support these and other of the principles. Ensuring that all our citizens have
equal access to health care is a potent means and symbol of the equal regard our society and our
government should have for all our citizens.
JUSTICE
Our discussion of equality has already introduced some aspects of justice and the fair
treatment of individuals. Fair treatment in the access to benefits requires that the distribution of
basic social goods reflect only morally relevant, non-arbitrary differences between people. Only
differences between people in their health care needs are morally relevant to the distribution of
health care, as the principle of EQUAL BENEFITS requires. Philosophical theories of justice differ
on many matters, including what goods a society should secure for all its citizens as a matter of
right.
16
Nevertheless, nearly all agree that it is a serious injustice when individuals suffer
serious preventable loss of opportunity, preventable pain and suffering, or even preventable loss
of life for want of health care readily available to most members of a country as rich as our own.
And ordinary citizens too recognize the simple injustice of the harms that come to individuals
from want of even basic health care services.
Fair or just treatment of individuals involves the distribution of burdens as well as
benefits. People disagree about how much inequality of income and wealth is fair or just. But here
too there is widespread agreement that justice requires the contributions of individuals to basic
public goods like education and the common defense be based on their ability to pay. Our
progressive federal income tax rates reflect this consensus. For health care too, which has come
to be an increasingly large component of individual and governmental budgets, individuals'
payments for health care, whether direct or indirect, should be based on their ability to pay.
�Brock and Daniels
DRAFT
page 10
Justice, and the principles of FAIR BURDENS and GENERATIONAL SOLIDARITY it supports,
obviously do not provide a precise formula for the financing of health care, but can help guide the
many detailed decisions about how the new system will be financed.
A further aspect of justice involves ensuring that health care does not exhaust resources
needed for other valuable activities, including other requirements of justice such as ensuring
adequate housing, nutrition, and education. This is directly addressed by the principle of WISE
ALLOCATION . The principles of EFFECTIVE TREATMENT, QUALITY CARE, and EFFICIENT
MANAGEMENT indirectly serve justice: they ensure that health care needs are met with high
quality care while minimizing those uses of resources that fail to secure significant benefits to
patients. These four principles do not merely serve prudent allocation and economic efficiency.
They also serve justice by ensuring that other requirements of justice outside health care can be
met and serve the moral value of individual well-being and human flourishing by maximizing the
benefits people receive from limited health care resources.
Finally, justice or fairness also requires FAIR PROCEDURES to resolve the many
reasonable disagreements that will inevitably arise about the design and operation of the health
care system, even among people in agreement about the principles and values that should guide the
system.
LIBERTY
Our revolution began over two centuries ago with a protest against overbearing
governmental authority. Our Constitution enshrines the value of personal choice and tolerance of
diversity. In health care there is a long legal tradition respecting individual liberty going back at
least to the early part of this century when Justice Cardozo, in the case of Schloendorff v. Society
17
of New York Hospital, held that: "Every human being of adult years and sound mind has a right
to determine what shall be done to his body." The requirement that medical care not be rendered
without the free and informed consent of a competent patient is now deeply and firmly embedded in
professional practice and in our legal system.
�Brock and Daniels
DRAFT
page 11
Some liberties are more important to us than others. Choices that affect our lives in farreaching and deeply personal ways, such as whether and whom to marry or what occupation to
pursue, must not be taken from us. Health care too, or the lack of it, affects us in far-reaching
and deeply personal ways. When our lives, goals, and very existence are threatened by illness and
disease, we are particularly concerned to control our fate. Thus, the health care system must be
designed to respect the principle of INDIVIDUAL CHOICE. A proper concern for liberty recognizes
that with liberty comes personal responsibility for our own health. The principle of PERSONAL
RESPONSIBILITY recognizes the health care system's role in enabling and encouraging people to
take responsibility for their own health, without violating the principle of EQUAL BENEFITS by
denying care when health care needs are caused by unhealthy behavtor.
Sometimes it is also necessary to limit people's liberty in order to carry out desirable
social purposes like controlling the growth of health care costs in order to ensure WISE
ALLOCATION. Nevertheless, our commitment to the high value of individual liberty requires that
we do so with minimal limitation of liberty.
18
Specifically, it is not only the liberty of patients
that is important in the health care system, but also the liberty of providers necessary to
maintain PROFESSIONAL INTEGRITY.
COMMUNITY
We began our life as a nation with the proclamation "We the people," declaring our intent
to join together in a single national community. To further bind us together as one community we
must remove the division between those excluded from and included in the health care system. We
are members not only of a national community, but of many diverse, smaller communities that
flourish within our society: religious communities, ethnic communities, as well as the
neighborhoods, towns, and cities in which residents share a common life. Fundamental to all of
these different communities is a shared concern and responsibility for one's fellow members,
especially those suffering misfortune and in need of the help of others.
A health care system that serves the principles and values calls on and strengthens the
shared concern for our fellows that flourishes in the many communities that make up our nation.
�Brock and Daniels
DRAFT
page 12
A common health care system that serves and cares for us all will also bind us together in a
broader national community.
We celebrate our diversity as a nation. Our many religious, ethnic, and cultural traditions
and groups are one of our great strengths: they show us the many ways we can lead a good life. We
also differ amongst ourselves about the full meaning and relative importance of the moral ideals of
equality, justice, liberty, and community that undergird the health care reform. These
differences will sometimes lead us to disagree about the appropriate trade-offs to be made among
the principles and values in designing the health care system. Despite our diverse origins, we
share a broad consensus and commitment as a nation to these ideals and to the principles and
values they support.
19
With good will, tolerance and respect for our diversity, and a willingness
to compromise when we reasonably disagree, we can construct a health care system that is worthy
of our moral ideals as a nation.
SECTION III: ETHICAL CHOICES IN DESIGNING THE NEW SYSTEM
The principles and values we have described, as well as the underlying moral ideals that
support them, will conflict at many places in the design of the new system. In addition, people will
disagree about how the necessary trade-offs among them should be made, weighing their
importance differently. Not only do key choices about the design of the system reflect conflicts of
value, they also reflect different judgments about what it is politically feasible to accomplish.
Successful political reform must avoid two moral errors: aiming too low, thereby missing the
opportunity and need to secure fundamental reform, and aiming too high, rejecting all reform that
falls short of an ideal which is not achievable. Aiming at the best achievable target is notoriously
difficult because judgments about political feasibility are very complex and involve much
uncertainty, and because we also disagree about what is ideal. In what follows, we analyze what is
ethically at stake in ten key choices about the design of the new system, in some cases showing how
the principles and values are embodied, in others emphasizing where they conflict and require
trade-offs, and where judgments of political feasibility enter in.
�Brock and Daniels
DRAFT
page 13
The Phase-in of Universal Access
The failure to provide health care coverage for 37 million persons represents the single
most morally compelling reason to reform the health care system. Providing universal access to
health care services for all Americans without financial or non-financial barriers goes to the
soul of reform. Equality and justice require rapid and certain coverage for the uninsured.
Universal coverage must not depend on political and economic contingencies over an extended
period of time. It cannot await cost savings that the new system will produce.
Political feasibility as well as concern for other principles such as WISE ALLOCATION
might incline us to seek the fiscal and administrative advantages of a lengthy 5 to 7 year phase-in
period during which groups such as children, then employed and self-employed adults, and finally
Medicaid recipients would be folded gradually into the system. However, justice does not permit
the continued exclusion of Americans from our health care system. When we recognized that
guaranteeing equality before the law and due process of law required providing legal
representation for indigent defendants, we did so without an extended phase-in period. When
natural disasters like hurricanes leave people homeless, we provide them with needed aid as
quickly as possible. Though both efforts require new resources, the demands of justice and the
urgency of the needs oblige us to respond. It is the same with health care-the demands of justice
and the urgency of the needs of the uninsured require realizing UNIVERSAL ACCESS without an
extended phase-in to cushion the fiscal impact.
Equality in the System
Together, the principles of UNIVERSAL ACCESS, EQUAL AND COMPREHENSIVE BENEFITS,
QUALITY CARE, and INDIVIDUAL CHOICE require the new health care system to protect low-income
20
and other vulnerable and underserved populations. They must have access to health care plans
whose benefits and quality are acceptable to the broad majority of Americans. We must not
recreate a two-tier system in which the lower quality tier-like Medicaid, despite its promise of
broad benefits-is a dumping ground for the poor. To ensure that competing health plans do not
produce unacceptable inequality, specific steps are necessary at both the federal and state levels.
�Brock and Daniels
DRAFT
page 14
Unacceptable inequality will exist if low-income individuals can only afford low cost plans
whose quality is unacceptable to everyone else. Higher cost health plans could have more or better
quality specialists and reduced waiting time for treatments. They could provide increased benefits
by introducing new technologies and treatments more quickly and visibly.
Some of these differences constitute only amenities that do not significantly affect health
outcomes. People should be able to buy them if they wish, but they do not warrant public subsidy.
Some other differences in quality, however, such as eliminating long delays for important
services, better continuity of care, and more widespread use of beneficial new treatments can lead
to differences in health outcomes, consumer satisfaction, and the quality of the plan. The goal of
offering the same comprehensive benefits to all will then be undermined.
Various measures can reduce unacceptable inequalities: restricting the range of health
plan premiums; offering greater subsidies to low-income groups, or; requiring Health Alliances
and the National Health Board to ensure comparable quality and benefits in all plans. Flexibility at
the state level should tell us which measures work best. Some measures, like restricting the
range of premiums, would restrict the choices available to those with higher incomes in order to
protect the choices of those with lower incomes.
Concerns about equality are raised by other features of the system. The option for very
large companies (over 1,000 or 10,000 employees) to remain outside public Health Alliances
and to form their own instead could threaten community rating of insurance. If their workforces
are generally younger and healthier than the rest of the population, a surcharge on these
employers would be necessary to avoid adverse effects on the premium prices for the general
population: community rating should be preserved.
At another level, individuals might "opt out" of limits that apply to health plans by buying
supplemental insurance. Where supplemental insurance adds only amenities, then serious issues
of equality are not raised. Where supplemental insurance provides people with quicker or better
access to medical services that have a significant effect on health outcomes, or with important
services that are not included in the comprehensive benefit package, then troublesome concerns
�Brock and Daniels
DRAFT
page 15
about inequality again arise. The principles caution against inequalities that significantly affect
health outcomes or that undermine fair sharing of costs.
Comprehensive Benefits and Cost Constraints
Controlling health care costs will always place pressure on the comprehensiveness of
benefits. That pressure must not lead to reintroducing exclusions or reduced coverage of whole
categories of services like mental health, drug and substance abuse, or preventive sen/ices with
little concern for the importance of the needs they meet. Nor must expensive sen/ices be
eliminated in order to achieve cost savings without regard to the importance of the benefits they
provide.
The same standard-that coverage should be based on needs and reflect efficacy-supports
broadening coverage for long term care sen/ices over the lifespan. Some initial steps toward this
goal are taken in the new health care system, but the very great cost of providing comprehensive
long term care remains an obstacle to full compliance with the COMPREHENSIVE BENEFITS
principle. The burdens of many of the costs are already born in one way or another by many
families, unevenly and as needs arise. Properly designed insurance, whether public or private,
need not greatly increase these costs, though it makes them politically visible and spreads the
burden of bearing them more fairly. The conflict here between COMPREHENSIVE BENEFITS and
WISE ALLOCATION is more apparent than real.
One political obstacle to enacting a comprehensive long term care insurance system is the
perception that these services are not needed by "us" but only by "them." The perception is an
illusion: We all age, and as we do we take turns being "us" and "them." This is the point behind the
principle of GENERATIONAL SOLIDARITY. Public insurance solves the problem of long term care
better than private insurance because it both recognizes the social responsibility and makes the
benefit available to all.
The COMPREHENSIVE BENEFITS principle requires providing appropriate services to
people with disabilities and others with special needs. Access to the specialists often necessary to
meet these needs must be available within all health plans.
�Brock and Daniels
DRAFT
page 16
The Fair Sharing of Burdens
A central reform of the new health care system is the insistence on community rating of
insurance and the prohibition against excluding people from coverage because they face higher
risks or have prior medical conditions. This reform reflects the FAIR BURDENS principle. It also
reflects the conviction that the moral function of health insurance is to assure access to services.
For many kinds of insurance, for example automobile insurance, those at low risk should not have
to subsidize those at higher risk. Because of the fundamental impact of health care on our lives,
however, including its effect on equality of opportunity, and because these differences in risk are
largely undeserved, we require the sharing of burdens across all levels of risk. By adjusting
reimbursements to health plans to compensate them for taking high risk individuals, health plans
will have less reason to avoid them. The requirement to share burdens fairly means that the
choices available in the current system to healthier, low-risk individuals-and their
employers-to save money by excluding others from insurance will be restricted in the new one.
Sharing burdens fairly also means that we should pay for our health care in ways that
reflect our ability to pay, that is through more progressive rather than regressive forms of
financing. Considerations of political feasibility may conflict with this ideal. The difficulty of
converting employee benefits into new taxes and fears of expanded public budgets may mean that
some mix of more and less progressive forms of funding must be used.
Budget Caps
Controlling health care costs is required by justice and fairness, not merely by economic
efficiency. A publicly imposed budget cap limiting growth in overall health care expenditures
provides a mechanism for WISE ALLOCATION by which reasonable public choices can be made and
enforced about how to allocate resources between health care and other important goods like
education and housing. To effectively implement a social choice about allocation, the budget must
be broad in scope, including nearly all health care expenditures, and enforceable, thereby
limiting to some extent INDIVIDUAL CHOICE.
�Brock and Daniels
DRAFT
page 17
Staying within a health care budget will force us to eliminate waste and inefficiency within
the system. It will create incentives that force us to comply with the EFFECTIVE TREATMENT
principle, pushing us to develop practice guidelines and other kinds of outcomes research. It will
also create strong incentives for EFFICIENT MANAGEMENT, pushing us to reduce administrative
complexity, which drains health care dollars away from treatment, and to reduce the micro
management of providers, which undermines PROFESSIONAL INTEGRITY.
The Balance Between Individual Choice and Cost Control
In policy design, as in our individual lives, it is not possible to have unlimited choice. To
protect some choices, as well as to pursue other values, it is necessary to limit or forgo other
choices. The moral task is to decide how to secure the choices and values we judge most important.
Most people are principally concerned with three kinds of choice in health care: choice of the type
of health care plan in which they will receive care; choice of physicians and other providers;
choice of treatments they will receive. The new health care system will increase most people's
choices among health care plans. Health Alliances will typically offer managed care plans together
with at least one traditional fee-for-service type plan; individuals will have the choice to change
plans annually. Except in the case of employers who self-insure, people will no longer be limited
to the plan or plans their employer happens to offer, and will not be forced to change plans or
existing relationships with their doctors when they change employment or when their employer
changes the plans offered. Because WISE ALLOCATION and EFFICIENT MANAGEMENT, together with
QUALITY CARE, tend to be achieved at lower costs by managed care than fee-for-service plans,
there will be incentives, but no coercion, to join them. Because all plans must offer a uniform
comprehensive benefits package, along with easily understood quality measures of their services,
people will be able to make more effective comparisons and choices between alternative plans.
Individuals who wish to purchase supplemental insurance, or to pay out-of-pocket, for amenities
or services not covered in the uniform benefits package will be free to use their private funds to
do so; so long as COMPREHENSIVE BENEFITS are provided for all, few people should feel the need
for supplemental insurance. Allowing purchase of limited supplemental insurance is a much less
�Brock and Daniels
DRAFT
page 18
morally troublesome departure from EQUAL BENEFITS than our current system in which the
poorest Americans have access to substantially fewer and lower quality services than most.
Since financial incentives in the new system will lead many people to switch from feefor-service to managed care plans, they may have more limited choice of physicians than at
present. Valuable doctor-patient relationships will sometimes be disrupted. Nevertheless, it
would be possible to retain substantial choice of physicians by requiring health plans to allow
members to choose, and to change, physicians within the plan.
Leaving the present rate of growth in health care expenditures unchecked threatens many
of these relationships as well. Even those people who are now well-covered by health insurance
are at risk of erosion or loss of that coverage and the choices they now have if the system is not
reformed. The new system will provide the security that substantial choice will be protected for
them and their families into the future. Also, those now substantially excluded from the health
care system will have new, effective choices that they are now usually denied. Finally, as we gain
increased knowledge about what treatments work for what conditions, patients will be able to
make more informed choices of treatment alternatives.
The Protection of Professionals Against Excessive Cost Control Pressures
Controlling the growth of health care costs by WISE ALLOCATION, EFFICIENT
MANAGEMENT, and EFFECTIVE TREATMENT may create new and increased pressures on providers
21
to limit care which threaten PROFESSIONAL INTEGRITY. The new health care system will speed
the growth of managed care plans, reducing the opportunities of many fee-for-service
professionals to practice without limits on the treatments and services that they can order and be
reimbursed for. The ability of managed care systems to control costs depends upon the primary
care physician or provider serving as a "gatekeeper" to services.
Professionals can serve with integrity as gatekeepers within well-designed managed care
systems. Even professionals in fee-for-service practice have accepted a commitment to all
patients within their practice, not merely to the patient present at the moment. This broader
commitment includes an obligation to allocate wisely limited resources, including their
�Brock and Daniels
DRAFT
page 18
morally troublesome departure from EQUAL BENEFITS than our current system in which the
poorest Americans have access to substantially fewer and lower quality services than most.
Since financial incentives in the new system will lead many people to switch from feefor-service to managed care plans, they may have more limited choice of physicians than at
present. Valuable doctor-patient relationships will sometimes be disrupted. Nevertheless, it
would be possible to retain substantial choice of physicians by requiring health plans to allow
members to choose, and to change, physicians within the plan.
Leaving the present rate of growth in health care expenditures unchecked threatens many
of these relationships as well. Even those people who are now well-covered by health insurance
are at risk of erosion or loss of that coverage and the choices they now have if the system is not
reformed. The new system will provide the security that substantial choice will be protected for
them and their families into the future. Also, those now substantially excluded from the health
care system will have new, effective choices that they are now usually denied. Finally, as we gain
increased knowledge about what treatments work for what conditions, patients will be able to
make more informed choices of treatment alternatives.
The Protection of Professionals Against Excessive Cost Control Pressures
Controlling the growth of health care costs by WISE ALLOCATION. EFFICIENT
MANAGEMENT, and EFFECTIVE TREATMENT may create new and increased pressures on providers
21
to limit care which threaten PROFESSIONAL INTEGRITY. The new health care system will speed
the growth of managed care plans, reducing the opportunities of many fee-for-service
professionals to practice without limits on the treatments and services that they can order and be
reimbursed for. The ability of managed care systems to control costs depends upon the primary
care physician or provider serving as a "gatekeeper" to services.
Professionals can serve with integrity as gatekeepers within well-designed managed care
systems. Even professionals in fee-for-service practice have accepted a commitment to all
patients within their practice, not merely to the patient present at the moment. This broader
commitment includes an obligation to allocate wisely limited resources, including their
�Brock and Daniels
DRAFT
page 19
professional time. Properly understood, and assuming an adequate pool of resources, the role of
primary care provider as responsible gatekeeper conflicts only minimally and occasionally with
the role of the primary care provider as patient advocate. In general, the advocate role
predominates when the resources will most clearly provide a marked benefit to this particular
patient; the gatekeeper role predominates when the benefit is slight or highly uncertain.
A particular managed care system, however, might violate professional integrity by
sacrificing too many other values to the gatekeeper function. For example, financial incentives to
withhold beneficial treatment may intrude directly into the provider's clinical decision making,
thereby conflicting with QUALITY CARE, or the nature of the gatekeeper system and its financial
incentives may not be disclosed frankly to patients, as required by FAIR PROCEDURES. Whether
the values of patient advocacy and patient choice are being unduly sacrificed to economic efficiency
or the profit motive can be determined only by a detailed inspection of the day-to-day practice
patterns within a health plan. This reinforces the need for ongoing ethics scrutiny within all
health plans, and the need to see decisions about benefit packages, patient appeals, etc. as having
an important ethical component.
The
Provider-Patient
Relationship
For many people, maintaining a close long-standing relationship with a trusted primary
care provider is of fundamental importance.
22
Our trust that appropriate care will be available
is increased when we have a provider who knows our needs and concerns well, and who keeps our
needs paramount in caring for us. For people with disabilities or chronic illness, having a
suitable specialist with whom one has dealt for many years can be essential to securing necessary
and appropriate health care services and to trust that the health care system will consistently
serve one's special needs. These are reasons why the freedom to choose providers is such an
important component of INDIVIDUAL CHOICE.
There will be inevitable strains on this provider-patient relationship in the new health
care system, just as there now are in our current system. With proper attention to its
importance, however, this relationship can be preserved and strengthened. Except in the case of
�Brock and Daniels
DRAFT
page 20
employers who self-insure, the link between employment and health insurance plans will be
broken, thereby reducing the disruption of valued provider-patient relationships that now often
comes with change or loss of employment or employer decisions to offer different plans. Managed
care plans can still provide choice from among large panels of primary care and specialist
physicians. Several other features of the new system that we have discussed in this section can
provide further security to the provider-patient relationship. Proper attention to protecting
PROFESSIONAL INTEGRITY both against unwarranted undertreatment from cost containment
pressures and against unwarranted overtreatment from unethical entrepreneurial conflicts of
interest of providers can together strengthen the commitment of professionals to their patients.
Relying on global budgets to control costs can reduce intrusions into provider-patient
relationships that result from insurers and other third-party payers micro managing the clinical
care of patients. Reduction of administrative complexity can free providers from endless
paperwork, enabling them to focus on patient care. Patients can take a new, more active role in
shared decision making with their providers about their own care with increased information
about treatment outcomes, made available in usable form. The protection of provider-patient
relationships requires continuous vigilance in any health care system, but many features of the
new system should strengthen, not weaken, this relationship.
The Protection of Patients in the New System
Fundamental reforms of the major social and economic institutions that make up the health
care system will inevitably bring uncertainties and conflicts about the new roles,
responsibilities, and legitimate expectations of patients' and professionals' in the new system.
New efforts to control the growth of health care costs will result in pressures throughout the
system to change ineffective and inefficient practices. Ensuring FAIR PROCEDURES will be
especially important in protecting the patients whom the system is designed to serve. Flexible and
effective procedures must be designed and implemented for receiving and handling
misunderstandings, disagreements, and disputes, whether through alternative dispute resolution
�Brock and Daniels
DRAFT
page 21
mechanisms (especially mediation and facilitation) at the Health Alliance and Health Plan levels,
through tort reform, or in the courts.
Fair procedures that are responsive to the interests and viewpoints of the parties
receiving and delivering care are necessary at the local level. These procedures should involve
mechanisms that promote patient involvement in decision making and that address disputes and
conflicts when they arise. Both Health Alliances and Health Plans must identify the procedures and
individuals with authority to make final decisions, as well as appropriate means for appealing to a
higher authority those decisions not accepted. At the national level, health care reform demands
serious review of current malpractice issues and their effect on: patient/provider relationships,
deterring negligent practice, compensating for injuries sustained, and overall costs to the system.
Individuals, health care institutions, and society at large are accustomed to handling
conflicts and disputes in adversarial and polarized ways. An important measure of quality in the
new system at all levels will be its success in preventing unnecessary problems arising from
poor communication, inattention to the needs and interests of patients and providers, and an
insensitive bureaucracy. Training in effective communication and dispute resolution will reduce
the number of misunderstandings that escalate into full-blown disputes. FAIR PROCEDURES and
INDIVIDUAL CHOICE are often best served by a system that emphasizes decisions by the parties
themselves. For example, negotiation and mediation focus on the needs of the people directly
involved, whereas decisions by higher authorities tend to stress rights and fault, undercutting
ongoing relationships between patients and providers.
Federal-State Division of
Responsibilities
Traditionally, our states have been thought of as laboratories for social experiments. They
can adjust for regional differences, are closer than the federal government to the people served,
and so can provide local democratic control of social programs. This social experimentation is a
quite appropriate role for the states who will have considerable flexibility and responsibility in
the new health care system. For example, states will have the option of establishing Health
Alliances offering membership in competing Health Plans to their residents, or establishing a
�Brock and Daniels
DRAFT
page 22
single payer system serving all residents. Perhaps a third of the overall United States population
lives in areas in which the density of population will not support significant competition and in
which a single payer system may thus be especially attractive. If different states exercise the
options of managed competition and single payer systems, this could help in time to resolve the
relative advantages and disadvantages of each system in satisfying the ethical principles and
values.
Single payer systems should satisfy the EQUAL BENEFITS and FAIR BURDENS principles
more fully by bringing all citizens in an area into a single system, could enable more EFFICIENT
MANAGEMENT from greater administrative simplicity, and could maximize INDIVIDUAL CHOICE of
physicians and better protect the PROFESSIONAL INTEGRITY of providers. If there are substantial
benefits in innovation and the efficient delivery of services from competing health plans,
however, the managed competition system would better satisfy the principles of WISE
ALLOCATION, EFFECTIVE TREATMENT, and EFFICIENT MANAGEMENT. It is not obvious that the
remaining principles and values favor one system or the other. Managed competition systems may
also have an advantage in political feasibility if public distrust of expanded government, together
with political opposition to the increased taxes needed to shift from a substantially employerfinanced to a government-financed single payer system, make implementation of a single payer
system difficult or impossible. Alternatively, there is substantial public and professional
resistance to expanding managed care.
Federal flexibility must not, however, be permitted to facilitate erosion of equity and
quality at the state level. The federal government acts for us as a nation and bears the ultimate
responsibility for ensuring that the new system lives up to all of its guiding moral principles and
values. Federal flexibility is morally and politically justified only if the states and all Health
Alliances and Health Plans are strictly accountable for their performance. The federal government
must articulate clear and precise operational criteria of equity, quality, and fair procedures so
that specific failures of states, Health Alliances, or Health Plans, can be identified and rectified.
The challenge is to do so without being bureaucraticaliy rigid, unduly clinically intrusive or
�Brock and Daniels
DRAFT
page 23
adding unnecessary administrative burdens and costs to the system. The federal government must
be responsible for ensuring interstate equity between health plans. And the federal government
has a special responsibility to guard the health interests of the poor, the chronically ill, the
disabled, minorities, and other special populations whose needs have not been adequately met by
our health care system in the past. The general balance that must be maintained is between the
flexibility a dynamic and evolving health care system needs to be creative in managing care and
costs more effectively, and the accountability to ensure that all health plans and health care meet
the standards of equity and quality that best express what we collectively demand in a just and
caring society.
Conclusion
The fourteen principles and values we have described, rooted as they are in fundamental
moral ideals of our nation, provide a tool for the moral assessment of the new health care system
and its performance over time. Key features of the system, such as those we have illustrated in
Section III, embody these principles and values and reflect choices about how to make trade-offs
among them. There may be no one morally best or most just institutional arrangement, and
people-or states-may make different trade-offs among the principles and values. Still, the
principles and values enable us to assess the different moral dimensions of the health care
system, both on a state level and nationwide. They are useful not only as we launch the new
system, but as we assess its performance over time and refine it so that it measures up to the high
ideals they embody.
1
Many other members of the Working Group on Ethical Foundations of the New Health Care
System contributed, directly or indirectly, to this paper. The moral principles and values,
together with the underling moral ideals, were discussed by the Working Group on numerous
occasions and at different stages in their evolution. More specifically, Howard Brody, Leonard
Fleck, and Joan Gibson each contributed material from which we drew for some of the sub-parts
of Section III of the paper, and Joan Gibson helped coordinate material for the paper. We are
grateful for all of these contributions.
This statement of the fundamental moral importance of health care is close to that of the
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and
2
�Brock and Daniels
DRAFT
page 24
Behavioral Research in its report, Securing Access to Health Care (Washington, DC: U.S.
Government Printing Office, 1983).
For development of an account of justice in health care based on health care's role in protecting
fair equality of opportunity, see Norman Daniels, Just Health Care (Cambridge: Cambridge
University Press, 1985).
That health care should be "a basic human right," not a privilege, was acknowledged 40 years
ago by the President's Commission on the Health Needs of the Nation (Washington, DC: U.S.
Government Printing Office, 1953) p. 3, but it has yet to be implemented.
The relevance of costs in prioritizing services is, of course, controversial; see, for example,
David Hadorn, "Setting Health Care Priorities in Oregon: Cost Effectiveness Meets the Rule of
Rescue," JAMA 265 (May 1, 1991) 2218-25, and David Eddy, "Oregon's Methods: Did Costeffectiveness Fail?" JAMA 266 (October 16, 1991) 2135-41.
Norman Daniels, "Insurability and the HIV Epidemic: Ethical Issues in Underwriting," Milbank
Memorial Fund Quarterly: Health and Society 68, 4 (1990) 497-526; Donald W. Ught. "The
Practice and Ethics of Risk-related Health Insurance," JAMA 267 (1992) 2503-8.
Norman Daniels, Am I Mv Parent's Keeper? An Essav on Justice Between the Young and the Old
(Oxford: Oxford University Press, 1988).
This is a major theme in Daniel Callahan's two recent books, Setting Limits: Medical Goals in an
Aging SocietyfNew York: Simon and Schuster, 1987) and What Kind of Life? (New York: Simon
and Schuster, 198 ). See also, Paul Menzel, Strong Medicine: The Ethical Rationing of Health Care
(New York: Oxford University Press, 1990).
See "The Problem of Low Benefit-High Cost Health Care," in Dan W. Brock, Life and Death:
Philosophical Essavs in Biomedical Ethics (Cambridge: Cambridge University Press, 1993).
John E. Wennberg, Jean LFreeman, Roxanne M. Shelton and Thomas A. Bubolz, "Hospital Use
and Mortality Among Medicare Beneficiaries in Boston and New Haven," New England Journal of
Medicine 321 (Oct. 26, 1989) 1168-73.
David U. Himmelstein and Steffie Woolhandler, "Cost Without Benefit: Administrative Waste in
U.S. Health Care," New England Journal of Medicine 314 (1986) 441-5.
Daniel Wikler, "Persuasion and Coercion for Health: The Government's Role in Changing
Lifestyles," The Milbank Memorial Fund Quarterly: Health and Society 56 (1978) 303-38.
Cf. Norman Daniels, "Why Saying No to Patients in the United States is so Hard New England
Journal of Medidne 314 (May 22, 1986) 1381-83. For a systematic examination of providers'
conflicts of interest in health care, see Marc A. Rodwin, Medicine. Money, and Moral: Physicians'
Conflicts of Interest (New York: Oxford University Press, (1993)
One significant example of attempts to involve the public more in health care planning, policy,
and decisions at the state level are the grassroots health decisions programs; cf. Bruce Jennings,
"A Grassroots Movement in Bioethics," Hastings Center Report 18 (June/July 1988) S1-S16.
The need to develop procedures that better protect patients' rights is argued in Susan M. Wolf,
"Toward a Theory of Process " Law. Medicine, and Health Care 20 (1992) 278-90.
For the general account of fair equality of opportunity, see John Rawls A Theory of Justice
(Cambridge, MA: Harvard University Press, 1971).
For a brief survey of main theories of justice, see Allen Buchanan, "Justice: A
Philosophical Review," in Justice and Health Care Dordrecht, Holland: D. Reidel
Publishing Company, 1981) . For a utilitarian treatment of justice, see Richard Brandt,
A Theory of the Good and the Right (Oxford: Oxford University Press, 1979), Ch. 16..
Amartya Sen, Inequality Reexamined fCamhririgfi. MA: Harvard University Press,
1992) contains a broader examination of justified and unjustified inequalities.
Schloendorff v. Society of New York Hospital (1914). 211 NY.... 125, 105 N.E. 92, 95.
3
4
5
6
7
8
9
1 0
1 1
1 2
1 3
1 4
1 5
1 6
1 7
�Brock and Daniels
1 8
DRAFT
page 25
The classic defense of individual liberty is John Stuart Mill, On Liberty. 4th ed. in
Collected Works of John Stuart Mill. Vol. XVIII (Toronto: Toronto University Press,
1977).
John Rawls develops the idea of an overlapping consensus in Political Liberalism
(New York: Columbia University Press, 1993), Ch. 4.
The special claims of the worst-off members of society on grounds of justice is developed by
John Rawls, A Theory of Justice, op. cit.
Haavi Morreim, Balancing Act: The New Medical Ethics of Medicine's New Economics
(Dordrecht, Holland: Kluwer Academic Publishers, 1991).
Dan W. Brock, "The Ideal of Shared Decision Making Between Physicians and Patients,"
Kennedy Institute Journal of Ethics 1 (1991) 28-47, and reprinted in Life and Death op. cit.
1 9
2 0
2 1
2 2
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�WORKING GROUP 17 - BIOETHICS
NAME
DOB
PHONE #
SS #
Nancy Dubler
Director, D i v i s i o n of
Bioethics, (Department of
Epidemiology and S o c i a l
Medicine) Montefiore Med.
Center/ The Albert E i n s t e i n
College of Med.
Co-Leader
Marian Secundy, Ph.D.,
Professor
Howard University
Prog, i n Medical E t h i c s
Co-Leader
00
TJ
Adrienne Asch
Assoc. Prof. Boston Un:
School of S o c i a l Work
5""
Ronald Bayer, Ph.D.,
Columbia U n i v e r s i t y
School of Public Health
Dan Brock Ph.D.
Professor of P h i l , and
Biomedical E t h i c s
Director of Center f o r
Biomedical E t h i c s
Arthur Caplan, Ph. D.
Univ. of Minnesota
Director, Center f o r
Biomedical E t h i c s
•: S .
> r
�Norman Daniels , Ph.D.,
Tufts University,
Prof, of Philosophy
E l l i o t Dorff, Rabbi,Ph.D.,
Provost and Professor of
Philosophy, Univ. of Judaism
Annette Dula Ph.D., / f ^ T ^ N
Visiting Scholar
( .,
" J
Univ. of Colorado V '"
V
Rockefeller Fellow ^
Gary E l l i s , Ph.D,
Office for Protection from
Research Risks
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| Princeton Theolology
H Seminary, Director of
Field Education, Assoc.
Prof, of Prac. Theology
Monsignor Charles J.Fahey
Senior Assoc. Third Age Center
Fordham Univ. N.Y.,N.Y.
Len Fleck
Prof., Michigan State
Norman Fost
Universiy of Wisconsin
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1 Joan Mclver Gibson, Ph.D.,
1 Director, Center f o r Health Law
I and E t h i c s
I Univ. of New Mexico
| School of Law
>v •
Lawrence Gostin J.D.,
Executive Director
Amer. Society of Law,
Medicine, and E t h i c s
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I Pat King, J.D.,
y-
| Professor, Georgetown
\ Univ. School of Law
| Jennifer K l e i n , J.D.
1 Working Group Liason
John Lantos, Assoc. Director,
C l i n i c a l Center, Chief
of Medical S t a f f : LaRabida
Hospital
Carol Levine
Exec. D i r . , The Orphan Project
Fund f o r the C i t y of N.Y.
Bernard Lo, M.D.
Director, Prog, i n Medical
[ E t h i c s , U n i v e r s i t y of C a l i f . ,
San Franciso
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Gary M. Maguire Professor
Southern Methodist U n i v e r s i t y
Professor of E t h i c s
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�Alan Meisel, J.D.,
Professor of Law
D i r e c t o r of Center f o r
Medical E t h i c s
Univ. of Pittsburgh
Mathy Mezey, Ed.D., R.N.,
Independence Professor of
Nursing Education, N.Y.U.
Steven Miles, M.D.,
Associate Professor of
Medicine, Center f o r
Biomedical E t h i c s
Robert Murray, M.D.,
Professor, P e d i a t r i c s and
Medicine, Howard U n i v e r s i t y
School of Medicine
Laurence 0'Connel1, Ph.D.,
S.T.D.
President, CEO the
Park Ridge Center
P i l a r Ossorio, Ph.D.,
Post Doctoral Associate
Yale Univ., School of Med.
Ruth P u r t i l o
Professor, C l i n i c a l E t h i c s ,
Creighton U n i v e r s i t y
Center f o r Health P o l i c y
and E t h i c s
Cheryl Sanders
Associate Professor,
School of Divinty
Howard U n i v e r s i t y
o-
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| OMB
Margery Gehan
Policy Assistant
Theresa P i c i l l o , R.N.
Policy Assistant
•.
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�o
WORKING GROUP 17 -
NAME
—-
ADDRESS
DOB
BIOETHICS
S_Sj8
PHONE #
Nancy Dubler
Adrienne Asch
• •'• r
::
Ronald Bayer
•'
Dan Brock
. J. j _
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Arthur Caplan
.V.i,-
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Norman Daniels
E l l i o t Dorff
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Annette Dula
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Abigail Rian Evans
Charles J . Fahey
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Joan Mclver Gibson
Lawrence Gostin
Pat King
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WM
Carol Levine
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�THE WHITE H O U S E
WASHINGTON
March 9, 1993
Ms. Adrienne Asch
• . , ; P6/(b)(6)
. .
..-l^.vji
00^)
Dear Ms. Asch:
Thank you
Foundations of
Working Group.
from March 15,
for agreeing to participate i n the Ethical
the New System Cluster of the Health Policy
You w i l l serve as a special government employee
1993 to early May 1993.
Please feel free to c a l l Jennifer Klein at (202) 456-2316
with any questions or concerns.
Very truly yours.
J
Ira C. Magaziner
Senior Assistant to the
President for Policy
Development
�SOME ETHICAL ISSUES I N CURRENT PROPOSALS
1. HIPC STRUCTURE
^
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)0<ru^^
1. HIPC S i z e :
By a l l o w i n g d i f f e r e n t s i z e employers t o o p t
o u t , e.g., employers w i t h more than 100 o r more t h a n 1000 o r 10,000
workers, t h e n H I P C s w i l l c a p t u r e d i f f e r e n t p o r t i o n s o f t h e market
share. L e t t i n g any employers o p t o u t , however, can c r e a t e t h e
f o l l o w i n g problems o f access, each o f which r a i s e s q u e s t i o n s o f
justice.
a. E x c l u s i o n : Employers who opt o u t and e i t h e r s e l f - i n s u r e o r
purchase o t h e r i n s u r a n c e p l a n s c o u l d c u r r e n t l y e x c l u d e coverage f o r
workers w i t h p r i o r c o n d i t i o n s , o r t h e y c o u l d r e d e f i n e t h e i r
b e n e f i t s so t h a t t h o s e a t r i s k o r w i t h c e r t a i n c o n d i t i o n s c o u l d
o b t a i n o n l y h i g h l y l i m i t e d b e n e f i t s . W i t h t h e s e d e v i c e s , emloyers
c o u l d t r y t o keep t h e r i s k - r a t i n g o f t h e i r own p l a n s low. Employees
o f companies covered by q u a l i f i e d p l a n s i n H I P C s m i g h t be unable
t o s h i f t j o b s t o companies t h a t o p t o u t and t h a t have p l a n s w i t h
exclusionary
u n d e r w r i t i n g p r a c t i c e s . There a r e s t r o n g moral
arguments t h a t t h e f u n c t i o n o f m e d i c a l i n s u r a n c e i s t o guarantee
access t o needed s e r v i c e s and t h a t i t i s n o t j u s t a d e v i c e f o r
m a r k e t i n g s e r c u r i t y from r i s k s (see D a n i e l s 1991, 1993). A r e f o r m
t h a t l e f t t h e s e e x c l u s i o n a r y u n d e r w r i t i n g p r a c t i c e s i n t a c t w6uld be
morally
objectionable.
These p r a c t i c e s would a l s o
have t o
p r o h i b i t t e d f o r dependents.
S o l u t i o n s : E i t h e r do n o t l e t l a r g e employers t o o p t o u t ,
o r r e v i s e ERISA so t h a t i t r e q u i r e d a l l employers t o o f f e r a b a s i c
package, and/or p r o h i b i t a l l e x c l u s i o n a r y u n d e r w r i t i n g p r a c t i c e s .
b. T r a n s p o r t a b i l i t y : Employees o f companies who o p t o u t may
f i n d themselves l a i d o f f o r f i r e d .
S o l u t i o n : S h i f t i n g coverage i n t o a HIPC p l a n would have
t o be assured; COBRA r u l e s would have t o be adapted. One r e s i d u a l
problem faced here by t h e employee i s t h a t s h i f t i n g i n s u r e r w i l l
p r o b a b l y mean s h i f t i n g p h y s i c i a n s , so t h e r e i s some d i s c o n t i n u i t y
of care.
c. Choice: J u s t as t h e HIPC may s h i f t i n s u r e r s f o r i t s b a s i c
coverage p l a n , which may mean f o r c i n g people t o l e a v e t h e i r d o c t o r s
o r t o pay more t o s t a y i n t h e i r former p l a n , so t o o l a r g e i n s u r e r s
who o p t o u t w i l l c o n t i n u e t o make c h o i c e s on b e h a l f o f t h e i r
employees. These f o r c e d c h o i c e s are v e r y unpopular, and i t does not
seem any d i f f e r e n t i n p r i n c i p l e i f i t i s t h e employer r a t h e r t h a n
t h e HIPC t h a t f o r c e s t h e s e c h o i c e s .
S o l u t i o n : Not obvious t h e r e i s one under managed
competition.
�D r a f t Agenda
ETHICAL FOUNDATIONS OF THE NEW SYSTEM
MONDAY, MARCH 8
MEETING #1
I.
II.
Introductions
Charge t o t h e group
- I d e n t i f y t h e e t h i c a l f o u n d a t i o n s o f medicine and m e d i c a l
practice
- I d e n t i f y t h e e t h i c a l f o u n d a t i o n s o f a h e a l t h c a r e system
- D i s t i n g u i s h t h e fundamental d r i v i n g e t h i c a l q u e s t i o n s o f
h e a l t h care reform
-Create a taxonomy o f t h e n a t i o n a l v a l u e s t h a t must be
r e f l e c t e d i n t h e s t r u c t u r e o f a h e a l t h c a r e system
-Describe t h e v a l u e o p t i o n s r e f l e c t e d i n t h e work o f
v a r i o u s p h i l o s o p h i c a l and r e l i g i o u s communities
-Develop an " e t h i c a l preamble worthy o f a g r e a t n a t i o n "
-Prepare an e x p l i c i t d i s c u s s i o n o f t h e concerns t h a t
s h o u l d guide t h e e f f o r t s o f t h e o t h e r w o r k i n g groups
-Formulate o p t i o n s on e t h i c a l p r i n c i p l e s and approaches
III.
Logistics
- T r a v e l , meeting schedule, workspace
-Procedure f o r n o t i f y i n g home i n s t i t u t i o n o f p o s i t i o n on
H e a l t h Care Working Group
-Review o f government e t h i c s r e q u i r e m e n t s - C h a r l o t t e
Hayes
IV. Review o f t h e " t o l l g a t e " s t r u c t u r e
T o l l Gate 1: workplan, q u e s t i o n s t o be e x p l o r e d ,
c o n s u l t a n t s needed, a d d i t i o n a l data t o be sought,
s t r u c t u r e o f f i n a l document
T o l l Gate 2: statement o f t h e i s s u e s , o u t l i n e o f t h e
o p t i o n s -- o p t i o n s should be b r o a d l y based and t h o r o u g h l y
explored
T o l l Gate 3: s y n t h e s i s o f p o s i t i o n s
V.
Goals o f Meeting
1, Day 1 :
- D e f i n e t h e "macro" i s s u e s t o be e x p l o r e d , i n c l u d i n g moral
i s s u e s and v a l u e i s s u e s
- I d e n t i f y t h e "micro" areas and i s s u e s , i n c l u d i n g moral
i s s u e s and v a l u e i s s u e s
-Decide on a methodology
- D i v i d e i n t o w o r k i n g sub-groups
-Prepare p r e l i m i n a r y d r a f t s o f t h e fundamental moral and
value p r i n c i p l e s
- C r i t i q u e those d r a f t s
�Guide f o r d i s c u s s i o n :
Consider t h e moral bases f o r medicine: autonomy,
b e n e f i c e n c e , j u s t i c e , r e s p e c t f o r persons, r e v e r e n c e
for
l i f e , concern f o r t h e w e l f a r e o f o t h e r s , n o t i o n s
of p u b l i c r e s p o n s i b i l i t y and t h e p u b l i c good and o t h e r s
Consider t h e C u r r e n t Values Framework: p r o f e s s i o n a l
autonomy, p a t i e n t autonomy, consumer s o v e r e i g n t y ,
p a t i e n t advocacy, h i g h q u a l i t y c a r e and access t o c a r e
Consider a proposed v a l u e framework:
Essential values:
F a i r access
Quality
Efficiency
Respect f o r p a t i e n t s
P a t i e n t advocacy
Instrumental values:
Personal r e s p o n s i b i l i t y
Social s o l i d a r i t y
S o c i a l advocacy
P r o v i d e r autonomy
Consumer s o v e r e i g n t y
Personal s e c u r i t y
(Taken from: Reinhard P r i e s t e r , "A Values Framework f o r
H e a l t h System Reform," H e a l t h A f f a i r s . 1, S p r i n g 1992,
p.85-107)
VI.
Goals o f Meeting 1, Day
2:
- I d e n t i f y t h e v a r i o u s areas i n medical and p u b l i c h e a l t h
p r a c t i c e f o r which s p e c i a l moral problems e x i s t
-Create a l i s t i n g o f t h e s p e c i a l problem areas and i s o l a t e
t h o s e e t h i c a l dilemmas o r moral problems t h a t r e l a t e t o
decision-making a u t h o r i t y , patterns o f medical p r a c t i c e ,
myths o r r e a l i t i e s o f t h e l e g a l c l i m a t e , a l l o c a t i o n o f
s c a r c e r e s o u r c e s , access t o c a r e , reimbursement o r
insurance structures, r e l i g i o u s b e l i e f s or doctrines,
s o c i a l o r e t h n i c c o n v e n t i o n s , o r t h a t emerge from o t h e r
considerations
- D i v i d e i n t o sub-working groups and c r e a t e a l i s t o f i s s u e s
and c o n s i d e r a t i o n s r e l a t e d t o each d i f f e r e n t area, t a k i n g
i n t o account a l l o f t h e f a c t o r s i d e n t i f i e d above and o t h e r s
- D e s c r i b e t h e fundamental p r i n c i p l e s t h a t u n d e r g i r d t h e
p a r t i c u l a r areas o f p r a c t i c e
-Reassemble and c r e a t e a document t h a t d e s c r i b e s t h e subcomponents o f a m e d i c a l , mental h e a l t h and p u b l i c h e a l t h
system and d e s c r i b e s t h e fundamental p r i n c i p l e s t h a t
animate each area
VI.
Goals o f Meeting 1, Day
3:
�-Review the work of the f i r s t two days
-Create the short formulations of the values statements, the
moral p r i n c i p l e s and the morally relevant considerations
t h a t must d r i v e any e t h i c a l l y acceptable h e a l t h care reform
- I d e n t i f y the next tasks
�TO:
FROM:
DATE:
RE:
Members o f Working Group #17
E t h i c a l Foundations o f t h e New System
Marian Gray Secundy
Nancy N e v e l o f f Dubler
March 9, 1993
Upcoming Meeting
A f t e r an u n f o r t u n a t e d e l a y , o u r i n i t i a l meeting w i l l be h e l d
on Monday, March 15 a t 8:30 a.m. a t t h e O l d E x e c u t i v e O f f i c e
B u i l d i n g n e x t t o t h e White House. Please e n t e r t h r o u g h t h e door
a t 1 7 t h and G S t r e e t s .
Be sure t o b r i n g a p i c t u r e ID. You w i l l
be c l e a r e d f o r admission and d i r e c t e d t o Room 213. Our meeting
w i l l most l i k e l y be h e l d i n Room 412. Any change w i l l be p o s t e d
on t h e door o f 213.
On Monday, p l e a s e b r i n g a p p r o x i m a t e l y 5 pages on t h e
fundamental p r i n c i p l e s t h a t c o u l d be i d e n t i f i e d as f o u n d a t i o n s o f
a n a t i o n a l h e a l t h c a r e p l a n . Don't be a f r a i d t o t h i n k b i g , broad
and comprehensive.
We w i l l f o l l o w t h e l e a d o f t h e o r i g i n a l " T o l l
Gates" and t r y n o t t o l i m i t b e f o r e we have sketched o u t t h e
universe.
Regarding t r a v e l
arrangements:
1.
B e l i e v e i t o r n o t , we a r e s t i l l t r y i n g t o
d e t e r m i n e i f we have a budget and, a t a minimum, t o a r r a n g e f o r
government t r a v e l vouchers, p e r m i t t i n g i n c r e d i b l e s a v i n g s . For
now, p l e a s e proceed t o book t h i s t r i p on your own. You may want
t o book t h e r e t u r n f o r sometime i n A p r i l (be c e r t a i n t h a t you can
change i t ) . Then, you can book a l l subsequent f l i g h t s Washington
--> home --> Washington i n o r d e r t o t a k e advantage o f supersaver
r a t e s . We w i l l c o n t a c t you i f we have more i n f o r m a t i o n b e f o r e
Monday.
2.
For t h o s e people needing h o t e l rooms, we have
r e s e r v e d a b l o c k o f rooms a t t h e Radisson a t a r a t e o f $88 p e r
n i g h t . Your names a r e on a l i s t o f members o f t h e H e a l t h P o l i c y
Working Group. Simply c a l l t h e Radisson d i r e c t l y a t 202-232-7000
t o r e s e r v e y o u r room.
I f you have n o t a l r e a d y sent your resume, p l e a s e b r i n g i t on
Monday. Please f e e l f r e e t o c o n t a c t J e n n i f e r K l e i n a t (202) 4562316 w i t h any q u e s t i o n s . We l o o k f o r w a r d a g a i n t o Monday!
�S N B : of N
ET YU
=3- 9 9 : 2 2 P :
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M D C L SHOE I A COL
202 456 7739:tf 1/ 1
UNIVERSITY OF MINNESOTA
Twin Citirs Cnmput
CenttrforBiomtMeelItlhlet
Box 33 UMHC
42(JDt:lu>vuie Slicrl S./T.
Minneapolis, MN\im
Office ui 5-/10 Own Hall
612-62.1-4917
Fru:til2-62()-r>liW
March 9,1993
Jennifer Klein
Health Policy Working Staff
The White House
Old Executive Office Building
Washington, DC 20500
Nancy N Dubler, JD, LLB
Div of Legal & Ethical Issues in Health Care
Montefiore Medical Center
111 East 210 Street
Bronx, New York 10467
Dear Jennifer and Nancy,
Since Steve Miles and I will be coming out on Sunday night in order to get Government
rates for hotel and airfare, we will need some sort of documentation. Can you fax us
something? Thanks.
Regards,
\
Arthur L Caplan, PhD
Director
ALOtlk
�TO:
FROM:
DATE:
RE:
Members o f Working Group #17
E t h i c a l Foundations o f t h e New System
Marian Gray Secundy
Nancy N e v e l o f f Dubler
March 4rrT.993
TT)
Upcoming Meeting ^—
f f i w r i n i t i a l meeting w i l l be on Monday, March 8 a t 8:30 a.m.
a t t h e O l d E x e c u t i v e O f f i c e B u i l d i n g n e x t t o t h e White House.
Please e n t e r t h r o u g h t h e door a t 1 7 t h and G S t r e e t s . Be s u r e t o
b r i n g a p i c t u r e ID. W i t h oomc l u o k and t h e h e l p o f v a r i o u s
deities^-' Vou w i l l be c l e a r e d f o r admission and d i r e c t e d t o Room
213. Our meeting w i l l most l i k e l y be h e l d i n Room 412. Any
change w i l l be posted on t h e door o f 213.
We w i l l meet on:
:30
30
30
30
- 12:30
- 6:30
- 10:30
- 4:30
4:00
t o p i c s on which
nd reconvene t o
r i n t h e process, we w i l l be
the members o f t h e o t h e r w o r k i n g
Our p l a n 1
some focused
share p r o d
using t h e
groups.
"r r
•
c- j - •
- •<
On Monday, please^&ome p i u p m u d W i l l i bume i i o L i o n a c j i r t h e
fundamental p r i n c i p l e s t h a t c o u l d be i d e n t i f i e d as f o u n d a t i o n s o f
a n a t i o n a l h e a l t h c a r e p l a n . Don't be a f r a i d t o t h i n k b i g , broad
and comprehensive.
We w i l l f o l l o w t h e l e a d o f t h e o r i g i n a l " T o l l
Gates" and t r y n o t t o l i m i t b e f o r e we have sketched o u t t h a .
universe.
^—•
^
rflZTt'^^l
'f ^
unci 4+0*
mti
•Regarding t r a v e l arrangement^
range f o r government
17"-"^ We have beerf^grying to
i
t r a v e 1 vouchers, permitting i n c r e d i b l e s a v i n g s . However,
l
wfeiie i r l o f you a r c f a b t and f l o w i b l o , — t h o govornmont i s
l o o o oof t h u ^ ^ p l e a s e proceed t o book t h i s t r i p on y o u r own.
Book t h e r e t u r n f o r sometime i n l a t e A p r i l (be c e r t a i n t h a t
you can change i t ) . THEN, book a l l subsequent f l i g h t s
Washington --> home --> Washington.
That g i v e s us t h e
b e n e f i t o f a s u p e r s a v e r ! f a r e , and, when we add t h e
government d i s c o u n t , we w i l l spend v e r y l i t t l e . / , ( T h i c w i l - l
be—explaiiifcid Lu IT a Mogoziner, who must appEP^o o u r budget . P " "
-""
w
W< IVll
I
2. ^We have a l s o attempted t o r e s e r v e a b l o c k o f h o t e l
rooms, b u t a g a i n a r e unable t o do so. We do hope t h a t a l l
p e o p l e who can bunk w i t h f r i e n d s o r r e l a t i v e s w i l l do so.
I f t h a t i s n o t p o s s i b l e , t r y t o f i n d a medium p r i c e h o t e l .
If you have not already sent your resume, please bring it on
CK blttsk
cf
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-iht
Htdmen.
Y^w cun ctcll
let'f}2-lt><
�Monday. Please f e e l f r e e t o contact Jennifer K l e i n a t (202) 4562316 w i t h any questions. We look forward/to Monday/and a groat
bag-inning.^
/
�THE
WHITE HOUSE
WAS
S t u a r t S i l v e r , M.D.
Director
Mental Hygiene A d m i n i s t r a t i o n
209 West P r e s t o n S t r e e t , Room
B a l t i m o r e , MD
21201
HI N GTO
N
416A
February 26,
1993
Dear Dr. S i l v e r :
Thank you f o r your c o n s i d e r a t i o n i n a l l o w i n g Anne S t o l i n e ,
M.D.
t o p a r t i c i p a t e i n t h e Mental H e a l t h C l u s t e r o f t h e H e a l t h
Reform Working Group. She w i l l a s s i s t Dr. Bernard S. Arons i n
c o o r d i n a t i n g between t h e mental h e a l t h subgroups and o t h e r
groups, i n c r e a t i n g and d i s t r i b u t i n g d r a f t documents, i n
r e t u r n i n g phone c a l l s from i n d i v i d u a l s and groups p r o v i d i n g i n p u t
i n t o t h e process, and i n g e n e r a l l y advancing t h e o v e r a l l e f f o r t
toward n a t i o n a l h e a l t h r e f o r m .
Dr. S t o l i n e ' s i n v o l v e m e n t w i t h t h e p r o j e c t began on February
17, 1993.
I u n d e r s t a n d t h a t she w i l l remain a Maryland S t a t e
employee d u r i n g her p a r t i c i p a t i o n here and w i l l r e t u r n t o her
f u l l t i m e work w i t h t h e S t a t e o f Maryland i n e a r l y May.
Thank you f o r your a s s i s t a n c e i n t h i s m a t t e r .
I f you would
l i k e f u r t h e r i n f o r m a t i o n , please c o n t a c t Dr. Arons a t (202) 4566640.
Sincerely
yours.
I r a C. Magaziner
Senior A s s i s t a n t t o the
President f o r Policy
Development
bcc:
C h a r l o t t e Hayes
�TO:
FROM:
DATE:
RE:
I r a Magaziner
Nancy Dubler and J e n n i f e r K l e i n
March 5, 1993
T r a v e l Costs f o r E t h i c s Working Group
Based on t h e government r a t e s p r o v i d e d t o us by t h e White
House t r a v e l o f f i c e , we have prepared a budget f o r t h e E t h i c s
Working Group. The average t r a v e l c o s t , i n c l u d i n g 2 n i g h t s o f
h o t e l comes t o a p p r o x i m a t e l y $720 p e r person.
For t h e
a p p r o x i m a t e l y 23 people i n t h e group, t h a t amounts t o $17,000 p e r
meeting.
Given t h i s s o b e r i n g f i g u r e , we have t h e f o l l o w i n g
options:
1.
Convene t h e e n t i r e group 3 days a week f o r t h e
n e x t 8 weeks a t a c o s t o f $136,000.
2.
Convene t h e e n t i r e group every 2 weeks and a s s i g n
s u b s t a n t i a l w r i t i n g t a s k s i n t h e i n t e r v e n i n g weeks.
This
w i l l c o s t $68,000.
3.
Cut t h e group i n h a l f and meet every week f o r t h e
n e x t 8 weeks a t a c o s t o f $68,000.
4.
Cut t h e group i n h a l f and meet every 4 weeks a t a
c o s t o f $34,000.
5.
Cut t h e group t o those i n t h e D.C. area and o n l y a
few o t h e r f u l l - t i m e p a r t i c i p a n t s .
I n v i t e o t h e r s t o a c t as
c o n s u l t a n t s . We c o u l d b r i n g t h e c o s t down t o $10,000$20,000, b u t we b e g i n t o worry about t h e q u a l i t y o f t h e
group.
6.
Attempt a g a i n t o share t r a v e l c o s t s w i t h t h e
i n d i v i d u a l s and t h e i r i n s t i t u t i o n s . A l l o f t h e p o t e n t i a l
p a r t i c i p a n t s i n s t i t u t i o n s were asked t o s u p p o r t t h e i r
t r a v e l c o s t s . The d e c i s i o n o f a l l o f t h e i n s t i t u t i o n s was
t h a t t h e c o n t r i b u t i o n o f t i m e was a l r e a d y e x t r a o r d i n a r y .
1
The group as p r e s e n t l y c o n s t i t u t e d spans c o n s t i t u e n t s
knowledgeable about r u r a l and urban h e a l t h c a r e . They i n c l u d e a
P r o t e s t a n t m i n i s t e r , a J e s u i t w i t h extensive experience i n longterm c a r e , and a Rabbi who has w r i t t e n w i d e l y on Jewish law and
h e a l t h c a r e d e c i s i o n s . There a r e a l s o p h y s i c i a n s w i t h e x p e r i e n c e
i n broad e t h i c a l i s s u e s and i n c l i n i c a l d e c i s i o n - m a k i n g , and
p h i l o s o p h e r s who have w r i t t e n on m a t t e r s o f e q u i t y and j u s t i c e .
There a r e f o u r A f r i c a n - A m e r i c a n s , one o f whom i s a l s o a woman and
a P r o t e s t a n t m i n i s t e r , a g e n e t i c i s t , one e t h i c i s t and one
p r o f e s o r o f law. We a l s o c o n t a c t e d a woman who teaches m e d i c a l
e t h i c s and i s h e r s e l f u n s i g h t e d .
�TO:
FROM:
DATE:
E t h i c s Working Group Members
Jennifer Klein
March 5, 1993
U n f o r t u n a t e l y , due t o d i f f i c u l t i e s i n a r r a n g i n g t r a v e l , we
have c a n c e l l e d t h e meetings o f t h e E t h i c s Working Group f o r t h e
coming week. We w i l l c o n t a c t you on Monday w i t h more
i n f o r m a t i o n . We a p o l o g i z e f o r any i n c o n v e n i e n c e .
�1
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THE WHITE HOUSE
FAX COVER SHEET
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M-onsaynor
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Phone:
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(202) 456- 23//,
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FROM:
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Phone:
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(202) 456-
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�AGENDA FOR MEETING WITH
CO-CHAIRS OF ETHICS WORKING GROUP
Monday, March 1, 7:00 p.m.
I.
Background
A.
. Description
1.
Structure
a.
Health Policy Task Force v. Working Group
b.
Structure of the Working Group
2.
3.
B.
II.
Goals of the Working Group
Operation of the Working Group
Where we are i n the process
Role of the Ethics Working Group
A.
Goals for the group
B.
Specific tasks
I I I . Ethics Briefing
IV.
Logistics
A.
Confidentiality of process
B.
Additional members
C.
Meetings
1.
Cluster Leader Meetings
2.
Ethics Group Meetings
a.
Plan for f i r s t meeting
b.
Subsequent meeting times
�AGENDA FOR MEETING WITH
CO-CHAIRS OF ETHICS WORKING GROUP
Monday, March 1, 7:00 p.m.
I.
Background
A.
- Description
1.
Structure
a.
Health Policy Task Force v. Working Group
b.
Structure of the Working Group
2.
3.
B.
II.
Goals of the Working Group
Operation of the Working Group
Where we are i n the process
Role of the Ethics Working Group
A.
Goals for the group
B.
Specific tasks
I I I . Ethics Briefing
IV.
Logistics
A.
Confidentiality of process
B.
Additional members
C.
Meetings
1.
Cluster Leader Meetings
2.
Ethics Group Meetings
a.
Plan for f i r s t meeting
b.
Subsequent meeting times
�AGENDA FOR MEETING WITH
CO-CHAIRS OF ETHICS WORKING GROUP
Monday, March 1, 7:00 p.m.
I.
Background
A.
. Description
1.
Structure
a.
b.
Health Policy Task Force v. Working Group
Structure of the Working Group
2.
3.
B.
II.
Goals of the Working Group
Operation of the Working Group
Where we are i n the process
Role of the Ethics Working Group
A.
Goals for the group
B.
Specific tasks
I I I . Ethics Briefing
IV.
Logistics
A.
Confidentiality of process
B.
Additional members
C.
Meetings
1.
Cluster Leader Meetings
2.
Ethics Group Meetings
a.
Plan for f i r s t meeting
b.
Subsequent meeting times
�TO: I r a Magaziner
FROM: J e n n i f e r K l e i n
DATE: March 1 , 1993
RE: Meeting o f Co-Chairs o f E t h i c s Working Group
A t t a c h e d p l e a s e f i n d a proposed agenda f o r o u r meeting t h i s
e v e n i n g w i t h t h e c o - c h a i r s o f t h e E t h i c s Working Group. The coc h a i r s a r e : ( 1 ) Nancy Dubler, t h e c h a i r p e r s o n o f t h e B i o e t h i c s
Team a t M o n t e f i o r e H o s p i t a l i n New York and t h e a u t h o r o f E t h i c s
on C a l l ; and ( 2 ) Marian Gray Secundy, a p h y s i c i a n / e t h i c i s t a t
Howard U n i v e r s i t y H o s p i t a l and t h e a u t h o r o f an a r t i c l e i n t h e
r e c e n t l y p u b l i s h e d A f r i c a n - A m e r i c a n P e r s p e c t i v e s on B i o m e d i c a l
Ethics.
C h a r l o t t e Hayes and I have a l s o asked t h e f o l l o w i n g
t o p a r t i c i p a t e i n t h e group:
people
* A d r i a n Asch, P r o f e s s o r , Boston U n i v e r s i t y School o f
S o c i a l Work (617-739-6467) - e t h i c i s t f o c u s i n g on t h e
disabled
* Dan Brock, Ph.D., Brown U n i v e r s i t y (401-863-2718)
(consultant)
* A r t h u r Caplan, Ph.D., Center f o r B i o m e d i c a l E t h i c s ,
U n i v e r s i t y o f Minnesota ( 6 1 2 - 6 2 5 - 5 0 0 0 ) ( c o n s u l t a n t ) i n v o l v e d i n Minnesota reforms
* L a r r y G o s t i n , J.D., Harvard School o f P u b l i c
Health/American S o c i e t y o f Law and Medicine (617-2624990) - p u b l i c h e a l t h p e r s p e c t i v e ; s i g n i f i c a n t work
i n AIDS
* Mathy Mezey, R.N., P r o f e s s o r o f N u r s i n g E d u c a t i o n ,
New York U n i v e r s i t y D i v i s i o n o f N u r s i n g (212-9985337)(consultant) - nurse/ethicist
* Lawrence 0'Connel1, Park Ridge Center, Chicago, I L
(312-266-2222) - t h e o l o g i a n / e t h i c i s t a t i n t e r f a i t h ,
m u l t i c u l t u r a l r e s e a r c h group
* P a t r i c i a King, J.D., Georgetown U n i v e r s i t y Law Center
( 6 6 2 - 9 0 8 5 ) ( c o n s u l t a n t ) - e t h i c i s t / l a w y e r f o c u s i n g on
c h i l d r e n ' s and m i n o r i t y i s s u e s
I have i d e n t i f i e d a number o f o t h e r p o s s i b l e p a r t i c i p a n t s
and p l a n t o d i s c u s s t h e l i s t w i t h t h e c o - c h a i r s .
J.L.K.
�Working Group #17 (Ethics)
T o l l g a t e #6 March 31, 1993
FOR OFFICIAL USE ONLY
ETHICS GUIDELINES FOR A NEW HEALTH CARE SYSTEM
Table o f Contents
Introduction
1.
2.
3.
4.
5.
6.
7.
8.
9.
Choosing Among Competing AHPs
Choosing Among Limited AHPs or Benefits Sets
Defining and Implementing the Benefits Package
Quality I n d i c a t o r s
Patient/Professional Communication
Informed Consent
Resolving Misunderstandings, Disagreements and Disputes
Ethics Committees
Privacy and C o n f i d e n t i a l i t y
�Working Group #17 ( E t h i c s )
T o l l g a t e #6 March 31, 1993
FOR OFFICIAL USE ONLY
Introduction
The c r e a t i o n o f a system o f managed c o m p e t i t i o n w i l l a f f e c t
i n d i v i d u a l c o n s u m e r / p a t i e n t s and h e a l t h care p r o v i d e r s i n t h e i r
r e l a t i o n s h i p s w i t h each o t h e r and t h e i r i n t e r a c t i o n s w i t h
management s t r u c t u r e s a t t h e AHP, HIPC, and N a t i o n a l Board
l e v e l s . These changes r e q u i r e new e t h i c a l g u i d e l i n e s t o d e a l
w i t h f a m i l i a r issues a r i s i n g i n a new c o n t e x t (e.g., p r i v a c y and
c o n f i d e n t i a l i t y , informed consent and d i s c l o s u r e ) and new i s s u e s
r e l a t e d t o t h e changes themselves (e.g., c o n f l i c t s r e l a t i n g t o
new o v e r s i g h t mechanisms r e g a r d i n g b e n e f i t s ) .
N a t i o n a l g u i d e l i n e s a r e an i m p o r t a n t way t o e s t a b l i s h
broad o u t l i n e s o f c o n s i s t e n c y i n these and o t h e r e t h i c a l
dimensions o f care. Consistency i s i m p o r t a n t n o t o n l y so t h a t
p a t i e n t s moving from one AHP t o another have reasonably s i m i l a r
e x p e c t a t i o n s o f t h e b a s i c approach t o , f o r example, p r i v a c y and
c o n f i d e n t i a l i t y and i n f o r m e d consent. I t i s a l s o i m p o r t a n t so
t h a t p r o v i d e r s w i t h i n AHPs have s i m i l a r approaches t o t h e s e
questions.
These g u i d e l i n e s apply t o a l l h e a l t h care
p r o f e s s i o n a l s and a r e i n t e n d e d t o guide d e c i s i o n making i n
s p e c i f i c s i t u a t i o n s , n o t s u b s t i t u t e f o r such d e c i s i o n making.
The g u i d e l i n e s cover t h e f o l l o w i n g broad i s s u e s :
consumers' r i g h t s t o i n f o r m a t i o n t o make c h o i c e s when s e l e c t i n g
an AHP ( # 1 , # 2 ) ; d e f i n i n g and implementing t h e b e n e f i t s package
(#3); p a t i e n t s ' r i g h t s t o q u a l i t y care and informed c h o i c e s about
t r e a t m e n t (#4, #5 + # 6 ) ; e s t a b l i s h i n g f a i r procedures f o r
m e d i a t i n g d i s p u t e s ( # 7 ) ; e t h i c s committees ( # 8 ) ; and e n s u r i n g
p a t i e n t s ' r i g h t s t o p r i v a c y and c o n f i d e n t i a l i t y ( # 9 ) . Most o f
t h e g u i d e l i n e s concern AHPs; however, where a p p r o p r i a t e , HIPCs
and t h e N a t i o n a l H e a l t h Board a r e i d e n t i f i e d as t h e l o c u s o f
responsibility.
P r e l i m i n a r y S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
FOR OFFICIAL USE ONLY
RECOMMENDATIONS AND GUIDELINES
The following recommendations and guidelines cover indispensable
aspects of e t h i c a l decisions made at the AHP (and HIPC) l e v e l s .
Therefore i t i s recommended that they be national in scope to
insure uniformity in guality and consistency across plans and
apply to a l l health care professionals.
1.
Choosing Among Competing AHPs
When consumers have choices among competing plans, AHPs
should provide information t h a t permits them t o make an
informed decision.
AHPs should:
l.a
l.b
Describe service d e l i v e r y patterns (e.g. evidence o f
e n t i r e range of services t o the f u l l geographic area,
wait times, number of people buying supplemental
insurance);
l.c
2.
Provide information about the f i n a n c i a l s t a b i l i t y o f
the plan (e.g. low c a p i t a l i z a t i o n , low reserves of
operating income, the p o s s i b i l i t y — i f such e x i s t s — o f
bankruptcy);
Provide consumer and a u d i t o r evaluation of plan
performance (as discussed under Section 2 ) .
Choosing Among Limited AHPs or Benefits Sets
When consumers have limited choices among competing plans,
AHPs should encourage greater consumer involvement in the
governance of the AHP.
P r e l i m i n a r y S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
FOR OFFICIAL USE ONLY
3.
Defining and Implementing the Benefits Package
A l l l e v e l s of the health care system share r e s p o n s i b i l i t y
for defining the benefits to be provided.
Discussion
L e g i s l a t i o n w i l l define the p r o v i s i o n of the basic b e n e f i t s
package i n broad terms, such as "medically necessary
services" or "mental h e a l t h services."
The National Health Board w i l l f u r t h e r i n t e r p r e t and s p e c i f y
the p r o v i s i o n s of the basic b e n e f i t s package by c l a r i f y i n g
how broad federal mandates should be i n t e r p r e t e d and
applied.
I n d i v i d u a l AHPs and providers w i l l also have a r o l e i n
determining whether a p a r t i c u l a r medical care service o r set
of services q u a l i f i e s as p a r t of the covered services.
Thus, w h i l e medications, preventive screening, neonatal
i n t e n s i v e care, and chemotherapy w i l l be covered, AHPs w i l l
determine whether Tacrine f o r Alzheimer's disease, genetic
screening f o r c y s t i c f i b r o s i s , treatment of a 450 gram
premature baby, or bone marrow t r a n s p l a n t a t i o n f o r
metastatic breast cancer i s included.
Guidelines
3.a
Empower the National Health Board t o mandate the
i n c l u s i o n of i d e n t i f i e d services, and p r o h i b i t the
i n c l u s i o n of others, and/or the use of c e r t a i n services
f o r s p e c i f i c i n d i c a t i o n s , i n the comprehensive b e n e f i t
set.
The National Health Board should:
•
Develop p r i o r i t i e s f o r i d e n t i f y i n g h e a l t h services
to evaluate. I n c l u s i o n mandates g e n e r a l l y would
apply to services t h a t should be provided t o large
segments o f the p o p u l a t i o n , such as preventive
screening t e s t s , immunizations, prenatal care,
etc.
P r o h i b i t i o n s g e n e r a l l y would apply t o c o s t l y
therapies which o f f e r minimal b e n e f i t .
Preliminary S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
FOR OFFICIAL USE ONLY
Foster the development and use of p r a c t i c e
parameters t o define covered services.
3.b
Although the National Health Board w i l l s p e c i f y some
mandated and p r o h i b i t e d services, i n d i v i d u a l AHPs and
providers w i l l determine whether p a r t i c u l a r services
are provided.
AHPs should:
•
Develop p o l i c i e s t o define c r i t e r i a t h a t are t o be
applied t o decisions about the p r o v i s i o n of drugs,
diagnostic t e s t s , or therapies.
•
Disclose t o consumers procedures or c r i t e r i a t h a t
are used t o make important decisions about
s e l e c t i v e p r o v i s i o n of b e n e f i t s which might be
r e l e v a n t t o a consumer's h e a l t h care or t o t h e i r
s e l e c t i o n of a h e a l t h plan.
Providers
•
3.c
should:
Inform p a t i e n t s when AHP p o l i c i e s d i c t a t e t h a t
services not be provided i n circumstances where
such disclosure i s m a t e r i a l t o the p a t i e n t ' s
h e a l t h or decisions.
Federal p o l i c y should s p e c i f i c a l l y s t a t e t h a t plans may
properly decline t o provide (subject t o approval on
appeal) services t h a t the National Health Board or AHP
deems non-medically necessary.
Federal p o l i c y should:
•
Promulgate l i a b i l i t y reform which c l a r i f i e s t h a t
the non-provision of these s p e c i f i e d services, or
the consequences of the non-provision o f these
services may n o t be taken, by i t s e l f , t o be
evidence of negligence or abandonment.
Preliminary S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Working Group #17 ( E t h i c s )
T o l l g a t e #6 March 31, 1993
FOR OFFICIAL USE ONLY
4.
6
Quality Indicators
AHPs should provide consumers with information about
quality.
AHPs s h o u l d :
4.a
Present i n f o r m a t i o n about q u a l i t y i n a
format;
standardized
4.b
Develop q u a l i t y i n d i c a t o r s t h a t r e p r e s e n t d i v e r s e and
i m p o r t a n t g o a l s f o r h e a l t h c a r e which can be measured
i n v a l i d ways, and t h a t can l e a d t o improved p a t i e n t
outcomes, i n c l u d i n g s a t i s f a c t i o n ;
4.c
Develop q u a l i t y i n d i c a t o r s t h a t i n c l u d e b o t h e a s i l y
u n d e r s t o o d c o r e measures, and more d e t a i l e d i n f o r m a t i o n
about a few s e l e c t e d measures ( p o s s i b l y randomly
s e l e c t e d t o p r e v e n t AHPs from gaming t h e s y s t e m ) ;
4.d
Release i n f o r m a t i o n about q u a l i t y i n a t i m e l y manner
( t o i n c r e a s e consumer t r u s t ) b u t combined w i t h l o n g e r
t e r m averages and a mandatory s e c t i o n d e t a i l i n g
improvements b e i n g implemented by t h e AHP ( t o p r o t e c t
p r o f e s s i o n a l i n t e g r i t y , promote s t a b i l i t y , and
discourage premature p a t i e n t r e j e c t i o n o f t h e p l a n ) ;
4.e
Insure t h a t q u a l i t y i n d i c a t o r s include both g l o b a l
measures and d i s c r e t e i n d i c a t o r s which a r e r e s p o n s i v e
t o t h e i n d i v i d u a l needs among e n r o l l e e s ;
4.f
C o l l e c t q u a l i t y d a t a t h a t i n c l u d e : l e v e l o f r e s p e c t and
r e s p o n s i v e n e s s accorded p a t i e n t s ; presence/absence o f
c u l t u r a l and l i n g u i s t i c b a r r i e r s , an e s p e c i a l l y
i m p o r t a n t i s s u e f o r groups who o f t e n e x p e r i e n c e
d i s e n f r a n c h i s e m e n t (poor p e o p l e , people o f c o l o r ,
members o f s t i g m a t i z e d groups such as those w i t h
c h r o n i c m e n t a l i l l n e s s o r i n j e c t i o n drug u s e ) ;
4.g
A v o i d c r e a t i n g a process o f c o l l e c t i n g i n f o r m a t i o n
about q u a l i t y o f c a r e t h a t i s onerous t o p r o v i d e r s and
AHPs, and do n o t draw a d i s p r o p o r t i o n a t e share o f
r e s o u r c e s away from t h e d i r e c t p r o v i s i o n o f : s e r v i c e s .
4.h
Disseminate a d d i t i o n a l i n f o r m a t i o n about q u a l i t y d u r i n g
t h e t r a n s i t i o n t o p r o t e c t p a t i e n t s from f a i l u r e o f
i n e x p e r i e n c e d AHPs.
P r e l i m i n a r y S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
FOR OFFICIAL USE ONLY
5.
Patient/Professional
Communication
1
Health care professionals i n AHPs should p r o v i d e p a t i e n t s
and f a m i l i e s w i t h i n f o r m a t i o n t h a t permits them t o make
informed decisions among competing diagnostic and treatment
options.
AHPs should:
5.a
5.b
Reimburse health care professionals s p e c i f i c a l l y f o r
discussion time i n the p a t i e n t - p r o v i d e r i n t e r a c t i o n ;
5. c
6.
Foster communication about h e a l t h and h e a l t h options
between providers and p a t i e n t s ;
Have professional s t a f f capable of a s s i s t i n g diverse
p a t i e n t s make informed decisions.
Informed Consent
AHPs must educate p r o f e s s i o n a l s t a f f about the process o f
informed consent.
AHPs should:
6. a
Help p a t i e n t s and f a m i l i e s t o reach personally v a l i d
understandings about the r o l e t h a t medicine and medical
care play i n t h e i r l i v e s ;
6.b
Encourage providers and p a t i e n t s t o work together t o
i d e n t i f y elements of health s t a t u s , r i s k f a c t o r s f o r
disease and s p e c i f i c choices t h a t the p a t i e n t might
face i n the f u t u r e ;
6.c
Apportion the r e s p o n s i b i l i t y f o r health education s t a f f
using i n d i v i d u a l and group discussions and audio v i s u a l
m a t e r i a l as appropriate;
6.d
Encourage conversations w i t h i n d i v i d u a l p a t i e n t s about
the s p e c i f i c s o f care plans whenever possible, against
a background o f p r i o r dialogue on the purposes and
goals of health care, the u n c e r t a i n t y of medical
i n t e r v e n t i o n s and the importance of i n d i v i d u a l choice;
Preliminary S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
POR OFFICIAL USE ONLY
8
6.e
6.f
Offer education about h e a l t h care and t h e process of
choice i n a c u l t u r a l l y , l i n g u i s t i c a l l y and e t h n i c a l l y
accessible manner w i t h m a t e r i a l s t h a t are
comprehensible a t the educational l e v e l s o f p a t i e n t s
and f a m i l i e s .
6.g
A n t i c i p a t e decisions l i k e l y t o a r i s e i n t h e f u t u r e and
help p a t i e n t s decide, w h i l e they are d e c i s i o n a l l y capable, f o r those times when they may no longer be
able t o exercise i n d i v i d u a l choice;
6. h
Develop standard p r a c t i c e s w i t h i n the AHP f o r p a t i e n t s
t o execute advance d i r e c t i v e s as c u r r e n t l y provided by
the P a t i e n t Self Determination Act.
6.i
7.
Explain c l e a r l y t o p a t i e n t s or f a m i l i e s about t h e
p o s s i b l e r i s k s and b e n e f i t s of suggested i n t e r v e n t i o n s ;
Support proxy decision makers ( t h i s i s e s p e c i a l l y t r u e
i n decisions t o permit death. Providers should shoulder
some o f the burden f o r these decisions and s h i e l d the
proxy from the f u l l impact of s i n g u l a r r e s p o n s i b i l i t y ) .
Resolving Misunderstandings, Disagreements and Disputes
F a i r procedures are necessary for the delivery of quality
service. AHPs should develop mechanisms that promote patient
involvement i n decision making and that resolve disputes and
c o n f l i c t s as they a r i s e .
AHPs should:
7. a
Develop procedures f o r making f i n a l decisions about
disputes t h a t occur a t the AHP l e v e l . There should be
a c l e a r statement of who i s authorized t o make t h e
f i n a l d e c i s i o n a t the AHP l e v e l ;
7.b
Give preference t o non-adversarial, interest-based
processes such as f a c i l i t a t i o n and mediation, using
e i t h e r a s i n g l e person/patient r e p r e s e n t a t i v e model, or
a m u l t i d i s c i p l i n a r y committee model, depending on AHP
resources and environment;
7.c
Design an e f f e c t i v e and responsive dispute
resolution/grievance system by:
Preliminary S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Working Group #17 ( E t h i c s )
T o l l g a t e #6 March 3 1 , 1993
FOR OFFICIAL USE ONLY
Thoroughly reviewing t h e o r g a n i z a t i o n f o r t h e
d i f f e r e n t ways i n which c o n f l i c t s a r i s e ;
P l a n n i n g a system t o r e c e i v e and process t h e s e
c o n f l i c t s e f f e c t i v e l y and e f f i c i e n t l y ;
•
Consider t a k i n g t h e f o l l o w i n g s p e c i f i c ' s t e p s :
Create a c o n f l i c t management module as p a r t o f
ongoing o r i e n t a t i o n and t r a i n i n g f o r a l l s t a f f ;
Form an in-house i n t e r d i s c i p l i n a r y mediation team
t o mediate d i s p u t e s ;
Revise employee p e r s o n n e l maual, m e d i c a l bylaws,
and a l l h o s p i t a l c o n t r a c t s w i t h o u t s i d e p a r t i e s t o
i n c l u d e m e d i a t i o n s t e p s and m e d i a t i o n c l a u s e s ;
Create an e v a l u a t i o n system t o t r a c k e v i d e n c e o f
c o n f l i c t s (e.g. a c c o r d i n g t o frequency, number,
type).
7.d
8.
I n s u r e t h a t , f o r t h o s e d e c i s i o n s n o t accepted a t t h e
AHP l e v e l , appeal t o t h e HIPC l e v e l i s p o s s i b l e .
E t h i c s Committees
Each AHP s h a l l a s s u r e t h a t t h e s e r v i c e s o f an e t h i c s
committee p r e p a r e d t o address t h e f u l l range o f AHP e t h i c a l
i s s u e s a r e a v a i l a b l e t o AHP p a t i e n t s , h e a l t h care p r o v i d e r s ,
and a d m i n i s t r a t o r s
The AHP s h o u l d :
8.a
Determine whether i t has access t o a committee t h a t i s
w i l l i n g and a b l e t o address t h e f u l l range o f AHP
e t h i c a l issues;
8.b
I f n o t , e s t a b l i s h a committee o r arrange f o r t h e
s e r v i c e s o f an a p p r o p r i a t e committee;
S.c
Assure t h a t i n f o r m a t i o n about t h e committee's e x i s t e n c e
and f u n c t i o n s i s
and about access procedures i s r e a d i l y
available.
P r e l i m i n a r y S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Working Group #17 ( E t h i c s )
T o l l g a t e #6 March 31, 1993
FOR OFFICIAL USE ONLY
8.d
The
8.e
The
8. f
10
Be a c c o u n t a b l e f o r a d h e r i n g t o broad g u i d e l i n e s o f
a c c e p t a b l e p r a c t i c e t h a t have been d e s c r i b e d i n t h e
e t h i c s l i t e r a t u r e and t h a t are r e f l e c t e d i n t h e c u r r e n t
s t a n d a r d s o f o p e r a t i o n f o r e t h i c s committees. Since
t h i s h e a l t h care mechanism i s i n t h e p r o c e s s o f
e v o l v i n g , AHPs have a s p e c i a l o b l i g a t i o n t o c o n t i n u e t o
r e f i n e t h e i r own processes and t o assure t h a t t h e y
r e f l e c t any s p e c i a l l o c a l needs of p r o v i d e r s and
patients.
HIPC s h o u l d :
Assure t h a t each AHP
e t h i c s committee.
has
access t o t h e s e r v i c e s o f
N a t i o n a l Biomedical E t h i c s Panel
an
should:
Serve p r i m a r i l y as a r e s o u r c e f o r AHPs, c o g n i z a n t t h a t
e t h i c s committees are an e v o l v i n g mechanism f o r t h e
assurance of h i g h q u a l i t y p a t i e n t c a r e .
It may gather
data about t h e success o f v a r i o u s models of: s e r v i c e ,
p r o v i d e t h i s i n f o r m a t i o n t o l o c a l AHPs, and: encourage
t h e i r c o n t i n u e d improvement i n t h i s a r e a .
!
9.
P r i v a c y and
Confidentiality
T r a d i t i o n a l f a i r information p r a c t i c e s should serve as
foundation for privacy law and p r a c t i c e .
the
Emerging e l e c t r o n i c systems must comply with data p r o t e c t i o n
p o l i c i e s that e s t a b l i s h p r i v a c y protection
guidelines
adhering to the Code of F a i r Information P r a c t i c e s .
Guidelines
9. a
E s t a b l i s h l e v e l s of access t o computer-based h e a l t h
r e c o r d systems;
9.b
Establish p o l i c i e s f o r e l e c t r o n i c t r a n s f e r of data;
9.c
E s t a b l i s h c o n f i d e n t i a l i t y p o l i c i e s f o r i n d i v i d u a l s and
o r g a n i z a t i o n s who g a i n l e g i t i m a t e access t o p a t i e n t
records;
9.d
Maintain audit t r a i l s ;
P r e l i m i n a r y S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Working Group #17 (Ethics)
T o l l g a t e #6 March 31, 199 3
FOR OFFICIAL USE ONLY
11
9.e
Routinely review and monitor AHPs and i n s t i t u t i o n s ;
9.f
Guarantee the r i g h t s of the person about whom data i s
collected;
9.g
E s t a b l i s h p o l i c i e s f o r the linkage o f h e a l t h records.
A d d i t i o n a l Recommendations:
Data security systems should be monitored and updated to
protect the privacy of health data.
Many h e a l t h records w i l l need t o be t r e a t e d as though they
are " s p e c i a l l y s e n s i t i v e . "
Development of a "comprehensive longitudinal computer-based
patient record containing c l i n i c a l , f i n a n c i a l and research
data" w i l l require the use of a unique personal i d e n t i f i e r .
Informed consent for the use of data for purposes other than
for which i t was collected must be provided by the
individual about whom data are collected.
A uniform n a t i o n a l standard f o r p r i v a c y and c o n f i d e n t i a l i t y
should be established.
A central managerial structure i s needed for overseeing
privacy policy and confidentiality matters and v i o l a t i o n s .
Special o r i e n t a t i o n and t r a i n i n g programs should be
conducted w i t h a l l personnel.
Individuals should be well informed about the health
information system, t h e i r rights i n r e l a t i o n to the contents
and use of the data i n the system, and the obligations of
the system to protect their privacy and c o n f i d e n t i a l i t y .
Preliminary S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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Health Care Task Force Records
Creator
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White House Health Care Task Force
Is Part Of
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Work Group 17, Ethical Foundations] [1]
Creator
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White House Health Care Task Force
Health Care Task Force
Carolyn Gatz
Identifier
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2006-0885-F Segment 3
Is Part Of
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Box 9
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093616" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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3/16/2015
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42-t-12093616-20060885F-Seg3-009-001-2015
12093616
-
https://clinton.presidentiallibraries.us/files/original/ef966a52f45c3295f06ab1d022ea46ae.pdf
4f52013efdc5217d86bd02036657bf90
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Gatz, Carolyn/Klein, Jennifer
Subseries:
5107
OA/ID Number:
FolderlD:
Folder Title:
[Work Group 17 Ethical Foundations] [2]
Stack:
Row:
Section:
Shelf:
Position:
S
56
5
5
3
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. note
Phone No. (Partial) (1 page)
03/04/1993
P6/b(6)
002. note
Phone No. (Partial) (1 page)
03/05/1993
P6/b(6)
003. note
Phone No. (Partial) (1 page)
n.d.
P6/b(6)
004. note
Phone No. (Partial) (1 page)
03/05/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz; Jennifer Klein
OA/Box Number: 5107
FOLDER TITLE:
[Work Group 17 Ethical Foundations] [2]
2006-0885-F
im862
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. S52(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office [(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(S) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) of the FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
FOR OFFICIAL USE ONLY
ETHICAL GUIDELINES FOR A NEW HEALTH CARE SYSTEM
REPORTS AND SUPPORTING MATERIALS
The attached r e p o r t s provide background and explanatory m a t e r i a l t o
accompany the E t h i c a l Guidelines f o r a New Health Care System.
1.
Introduction
2.
National Guidelines f o r Accountable Health Plans
3.
Fair Procedures f o r Resolving Misunderstandings, Disagreements
and Disputes
4.
Defining and Implementing the B e n e f i t Package
5.
The N a t i o n a l Biomedical Ethics Panel
6.
Privacy and C o n f i d e n t i a l i t y of Health Records Under t h e New
Health Care System
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�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
FOR OFFICIAL USE ONLY
1.
INTRODUCTION
The new health care system w i l l change the way h e a l t h care i s
organized and financed f o r a l l Americans. The c r e a t i o n o f a system
of managed competition w i l l a f f e c t i n d i v i d u a l consumer/patients and
health care providers i n t h e i r r e l a t i o n s h i p s w i t h each other and
t h e i r i n t e r a c t i o n s with management s t r u c t u r e s a t the AHP, HPIC, and
National Board l e v e l s .
These changes r e q u i r e new e t h i c a l
guidelines t o deal w i t h f a m i l i a r issues a r i s i n g i n a new context
(e.g.,
privacy
and c o n f i d e n t i a l i t y ,
informed consent and
disclosure) and new issues r e l a t e d t o the changes themselves (e.g.,
c o n f l i c t s r e l a t i n g t o new oversight mechanisms regarding b e n e f i t s ) .
Several c h a r a c t e r i s t i c s of AHPs w i l l a f f e c t t h e p a t i e n t provider r e l a t i o n s h i p . To f u l f i l l the goals of u n i v e r s a l access
and equitable d i s t r i b u t i o n of b e n e f i t s , AHPs w i l l e n r o l l p r e v i o u s l y
uninsured or underserved populations.
AHPs w i l l t h e r e f o r e serve
a more diverse group o f p a t i e n t s than previous managed care
programs. Depending on l o c a l circumstances, p a t i e n t s may d i f f e r i n
c u l t u r a l background, language, r e l i g i o n , socioeconomic s t a t u s , and
educational l e v e l .
I n a d d i t i o n t o d i f f e r e n t types o f medical
h i s t o r i e s and current needs, they may have d i f f e r e n t c u l t u r a l
understandings of the cause and meaning of disease, the appropriate
roles o f p a t i e n t s and providers, and t h e p o s s i b i l i t i e s and
l i m i t a t i o n s of modern medicine.
Some p a t i e n t s w i l l have experience w i t h a f e e - f o r - s e r v i c e
system.
Others w i l l have had experience w i t h managed care as
members o f HMOs or PPOs. S t i l l others w i l l have had l i m i t e d
experience w i t h the health care system. These groups may have very
d i f f e r e n t expectations o f how a h e a l t h care system should work and
how involved patients should or can be i n decisions about t h e i r
care.
Health care providers w i l l also come t o t h e AHPs w i t h
d i f f e r e n t t r a i n i n g , p r a c t i c e experiences, and a t t i t u d e s about
decision-making. Some may have l i m i t e d experience working i n a
large s t r u c t u r e and w i t h a team approach. Some may have l i m i t e d
experience i n adapting t h e i r p r a c t i c e t o the oversight o f other
bodies.
Both p a t i e n t s and providers w i l l need guidance on i n t e r p r e t i n g
the new f i n a n c i a l a c c o u n t a b i l i t y , i n which some decisions are made
not a t t h e bedside but a t plan or HPIC or even N a t i o n a l Board
l e v e l . C o n f l i c t s may a r i s e between those accustomed t o considering
only the p a t i e n t ' s i n t e r e s t s and preferences i n making treatment
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�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
FOR OFFICIAL USE ONLY
3
decisions and coverage decisions made a t a d i f f e r e n t l e v e l .
Incentives f o r providers w i l l s h i f t from doing more t o doing less.
The p a t i e n t may b e n e f i t from greater p r o t e c t i o n s from i a t r o g e n i c
harm and from i n e f f e c t i v e treatments but may f e e l a loss o f
control.
National g u i d e l i n e s are an important way t o e s t a b l i s h broad
o u t l i n e s o f consistency i n these and other e t h i c a l dimensions o f
care. Consistency i s important not only so t h a t p a t i e n t s moving
from one AHP t o another have reasonably s i m i l a r expectations of the
basic approach t o , f o r example, p r i v a c y and c o n f i d e n t i a l i t y . I t i s
also important so t h a t providers w i t h i n AHPs have s i m i l a r
approaches t o these questions.
These guidelines apply t o a l l
h e a l t h care p r o f e s s i o n a l s , and and are intended t o guide decision
making i n s p e c i f i c s i t u a t i o n s , n o t s u b s t i t u t e f o r such decision
making.
The g u i d e l i n e s cover the f o l l o w i n g broad issues: consumers'
r i g h t s t o i n f o r m a t i o n t o make choices when s e l e c t i n g an AHP;
d e f i n i n g and implementing the b e n e f i t s package; p a t i e n t ' s r i g h t s t o
q u a l i t y care and informed choices about treatment; e s t a b l i s h i n g
f a i r procedures f o r mediating disputes; e t h i c s committees; and
ensuring p a t i e n t s ' r i g h t s t o p r i v a c y and c o n f i d e n t i a l i t y . Most o f
the guidelines concern AHPs; however, where appropriate, t h e
National Board i s i d e n t i f i e d as the locus of r e s p o n s i b i l i t y .
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�Working Group #17 (Ethics)
T o l l g a t e #6 March 31, 1993
FOR OFFICIAL USE ONLY
2.
GUIDELINES FOR ACCOUNTABLE HEALTH PLANS
Because t h e f o l l o w i n g g u i d e l i n e s cover indispensable aspects o f
e t h i c a l decisions made a t t h e AHP (and HIPC) l e v e l s , i t i s
recommended they be n a t i o n a l i n scope t o insure u n i f o r m i t y i n
q u a l i t y and consistency across plans.
Guidelines
RECOMMENDATION 1.
When consumers have choice among competing plans, AHPs should
provide information t h a t permits them t o make an informed
decision.
Guidelines: Information provided should include:
1.
Financial s t a b i l i t y
of t h e plan
(e.g.
low
c a p i t a l i z a t i o n , low reserves o f operating income, t h e
p o s s i b i l i t y — i f such e x i s t s — o f going bankrupt)
2. Service d e l i v e r y patterns (e.g. evidence o f e n t i r e
range of services t o the f u l l geographic area;
3. Consumer and a u d i t o r evaluation o f plan performance
(as discussed under Section 2) .
Discussion. The p r o v i d e r / p a t i e n t r e l a t i o n s h i p i s one b u i l t on
trust.
Because t h i s r e l a t i o n s h i p i s one i n which values
converge ( u n l i k e , f o r example, s t r i c t l y business e n t e r p r i s e s ) ,
consumers should be provided w i t h adequate i n f o r m a t i o n about
the scope and q u a l i t y of services provided — i n f o r m a t i o n t h a t
i s both understandable and s u f f i c i e n t l y comprehensive t o allow
consumers t o make t r u l y informed choices i f they wish t o do
so. Consumers have a r i g h t t o know, AHPs have a duty t o
d i s c l o s e , and openness i n governance i s r e q u i s i t e . AHPs should
provide consumers i n f o r m a t i o n about:
Business p r a c t i c e s .
Information about t h e f i n a n c i a l
s t a b i l i t y of t h e plan (e.g. low c a p i t a l i z a t i o n , low
reserves of operating income, the p o s s i b i l i t y — i f such
e x i s t s — o f going bankrupt)
Service d e l i v e r y p a t t e r n s . Information t o show t h a t the
AHP i s capable of d e l i v e r i n g an e n t i r e range of services
to t h e f u l l geographic area (e.g. i d e n t i f i c a t i o n o f
specialists,
prevention/primary/tertiary services).
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�Working Group #17 (Ethics)
T o l l g a t e #6 March 31, 1993
FOR OFFICIAL USE ONLY
5
I n e v i t a b l y there w i l l be a tension between t h e need t o
c e n t r a l i z e c e r t a i n s p e c i a l t y services (thereby making
access more d i f f i c u l t ) and the desire t o d e l i v e r services
l o c a l l y (thus r e i n f o r c i n g p a t t e r n s o f segregation where
such e x i s t ) .
Consumer and a u d i t o r e v a l u a t i o n o f plan performance (as
discussed under Section 2 ) .
RECOMMENDATION 2.
When consumers have limited choices among competing plans,
AHPs should encourage greater consumer involvement i n the
governance of the AHP.
Guideline:
1. Corporate p r a c t i c e laws should be modified t o allow
consumer involvement i n AHP governance.
Discussion. Because health plans also have a profound impact
on t h e health, finances, and o p p o r t u n i t i e s of i n d i v i d u a l s i n
a community, there should be o p p o r t u n i t i e s f o r consumer
representation i n r e a l decision making a c t i v i t i e s . I t i s a t
the AHP l e v e l t h a t consumer representation should be
strongest. This i s e s p e c i a l l y important i n s i t u a t i o n s where
consumers have l i t t l e choice among plans, and are t h e r e f o r e
unable t o "vote" w i t h t h e i r d o l l a r s or t h e i r f e e t .
U l t i m a t e l y the AHP i s l e g a l l y accountable f o r t h e a c t i o n of
i t s providers. Providers are accountable t o p a t i e n t s i n a l l
ways described by the p r o v i d e r / p a t i e n t r e l a t i o n s h i p , and are
l i k e w i s e bound by t h e i r p r o f e s s i o n a l standards and e t h i c s . A
good health d e l i v e r y system must support professionals and
consumers. This a l l i a n c e i s c e n t r a l t o d e f i n i n g needs and
designing e f f e c t i v e systems t o meet these needs.
RECOMMENDATION 3.
AHPS should provide consumers with information about quality.
Guidelines:
1. Information about q u a l i t y should be presented i n a
standardized format.
2. Quality i n d i c a t o r s should represent diverse and
important goals f o r h e a l t h care which can be measured i n
v a l i d ways, and can lead t o improved p a t i e n t outcomes,
including s a t i s f a c t i o n .
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�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
FOR OFFICIAL USE ONLY
6
3. Quality indicators should include both e a s i l y
understood core measures, and more detailed information
about a few selected measures (possibly randomly selected
to prevent AHPs from gaming the system).
4. Information about q u a l i t y should be released i n a
t i m e l y manner ( t o increase consumer t r u s t ) but should be
combined w i t h longer term averages and a mandatory
s e c t i o n d e t a i l i n g improvements being implemented by t h e
AHP
(to protect
professional
integrity,
promote
s t a b i l i t y , and discourage premature p a t i e n t r e j e c t i o n o f
the p l a n ) .
5. Quality indicators should include both global measures
and discrete indicators which are responsive to the
individual needs among enrollees.
6. Quality data should include: l e v e l of respect and
responsiveness accorded p a t i e n t s ; presence/absence of
c u l t u r a l and l i n g u i s t i c b a r r i e r s , an e s p e c i a l l y important
issue f o r groups who o f t e n experience disenfranchisement
(poor people, people of c o l o r , members of stigmatized
groups such as those w i t h chronic mental i l l n e s s or
i n j e c t i o n drug use).
7. The process of collecting information about quality
of care should not be onerous to providers and AHPs, and
should not draw a disproportionate share of resources
away from the direct provision of services.
8. Additional information about quality should be
disseminated during the transition to protect patients
from f a i l u r e of inexperienced AHPs.
Discussion. High quality health care i s a fundamental concern
to consumers in choosing among AHPs. Because quality i s
complex and measures of quality are potentially used for
different purposes, there are fundamental e t h i c a l issues at
stake in u t i l i z i n g quality measures to a s s i s t people i n
differentiating among AHPs.
Informed choices by consumers/patients. Consumers
need standard i n f o r m a t i o n about t h e q u a l i t y of care
i n AHPs when comparing plans.
Such i n f o r m a t i o n
must be simple enough t o be understandable y e t
comprehensive
enough t o allow t r u l y informed
choice.
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�Working Group #17 (Ethics)
T o l l g a t e #6 March 31, 1993
FOR OFFICIAL USE ONLY
7
i
Prevention of harm t o p a t i e n t s . When p a t i e n t s are s i c k ,
they r e l y on the health care system t o provide
h i g h - q u a l i t y care t h a t w i l l maintain or improve t h e i r
health.
As a p a t i e n t , people are often vulnerable,
dependent, and unable t o protect themselves. I n e f f e c t i v e
or inappropriate care may s e r i o u s l y harm p a t i e n t s .
The
stakes are high f o r p a t i e n t s : t h e i r bodies, well-being,
and l i v e s .
Protecting p a t i e n t s i s p a r t i c u l a r l y
difficult
because health care i s not a standardized product f o r a l l
p a t i e n t s . An AHP may provide high q u a l i t y care f o r some
conditions, but substandard care f o r others.
People
generally do not know what i l l n e s s e s they or members of
t h e i r f a m i l i e s might develop, and thus may
have
d i f f i c u l t y choosing which plan w i l l meet t h e i r p a r t i c u l a r
needs. Yet, w i t h annual enrollment, consumers may be
forbidden t o leave the AHP i f they encounter poor q u a l i t y
care or i f t h e i r needs change.
To p r o t e c t p a t i e n t s from harm, closer monitoring of
quality
w i l l be p a r t i c u l a r l y important during the
t r a n s i t i o n period, when some AHPs may f a i l i n competition
or experience f i n a n c i a l d i f f i c u l t i e s . Otherwise p a t i e n t s
may be harmed because there may be no information about
the performance of a newly formed AHP.
Security and t r u s t i n the health care system. Unless
p a t i e n t s believe they w i l l receive h i g h - q u a l i t y care,
they w i l l not f e e l secure about the new h e a l t h care
system. On the other hand, p a t i e n t s may f e e l anxious and
insecure i f t h e i r plan reports poor outcomes on q u a l i t y
measures. S i m i l a r l y , p a t i e n t s ' confidence i n the system
w i l l be shaken i f many AHPs are closed down and they need
t o change plans f r e q u e n t l y .
Professional i n t e g r i t y . Consumers need information about
outcomes and the degree t o which AHP p r a c t i c e s meet
accepted
standards
of
good
medical
practice.
Professionals need outcome data i n order t o improve the
care they d e l i v e r and make i t more e f f i c i e n t and
responsive t o p a t i e n t s ' needs.
I t i s especially
important t o detect problems e a r l y , when there i s time t o
c o r r e c t them without exposing p a t i e n t s t o undue harm.
Fairness to vulnerable populations and t o h e a l t h care
providers.
Even i f the o v e r a l l q u a l i t y of care i s
acceptable w i t h i n the AHP, i t may be unacceptable f o r
p a r t i c u l a r groups of p a t i e n t s .
Thus i n a d d i t i o n t o
r e p o r t i n g outcomes f o r a l l p a t i e n t s i n the AHP, i t may be
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�Working Group #17 (Ethics)
Tollgate #6 March 31, 1993
FOR OFFICIAL USE ONLY
8
important to report quality of care for vulnerable
populations, such as patients who are poor or have
chronic diseases.
In addition, dissemination of
information on quality of care should be f a i r to health
care providers. Safeguards should be i n place to ensure
that disseminated information i s r e l i a b l e and v a l i d .
Efficiency and simplicity.
The process of collecting
information about quality of care should not be onerous
to providers and AHPs, drawing a disproportionate share
of resources away from the direct provision of services.
As w i t h informed consent i n c l i n i c a l p r a c t i c e , there are
instances i n which these e t h i c a l values may
conflict.
Promoting p a t i e n t choice may c o n f l i c t w i t h p r o t e c t i n g p a t i e n t s
from harm. When they are s i c k , p a t i e n t s may have d i f f e r e n t
p r i o r i t i e s f o r choosing an AHP than when they are healthy
consumers choosing a plan.
When s i c k , p a t i e n t s may be more
concerned about access t o s p e c i a l i s t s or the l o c a t i o n of acute
care h o s p i t a l s , while as healthy consumers they may be more
concerned w i t h access t o primary care appointments and drop-in
visits.
Yet people may be locked i n t o t h e AHP \ they choose
during open enrollment.
Quality i n d i c a t o r s should represent diverse dimensions of
quality:
access, competency of providers, appropriateness,
effectiveness, t i m e l i n e s s , and s a t i s f a c t i o n . The s e l e c t i o n of
quality/outcomes measures t o feed back t o consumers requires
important value choices.
While outcomes selected t o be
reported w i l l present incentives t o AHPs t o improve t h e i r
performance, AHPS should not l i m i t t h e i r q u a l i t y assessment
only t o reported i n d i c a t o r s .
Diversity of indicators. Variables which are reported
should represent diverse and important goals for health
care which can be measured i n valid ways, and can lead to
improved patient outcomes, including s a t i s f a c t i o n .
i
Consumers need both simple, e a s i l y understood core
measures of quality, and more detailed information about
a few selected measures, possibly randomly selected to
prevent AHPs from gaming the system.
Timeliness. Information about quality should be released
in a timely manner to increase consumer t r u s t but should
be combined with longer term averages and a mandatory
PRELIMINARY STAFF WORKING PAPER FOR ILLUSTRATIVE PURPOSES ONLY
�Working Group #17 (Ethics)
Tollgate #6 March 31, 1 . .
993
FOR OFFICIAL USE ONLY
9
section detailing improvements being implemented by the
AHP to protect professional integrity, promote s t a b i l i t y ,
and discourage premature patient r e j e c t i o n of the plan.
Responsiveness. I n a d d i t i o n t o g l o b a l
indicators,
consumers should be provided w i t h more d i s c r e t e
i n d i c a t o r s which are responsive t o the i n d i v i d u a l needs
among enrollees. For example g l o b a l i n d i c a t o r s of
s a t i s f a c t i o n should be supplemented by i n d i c a t o r s such as
l e v e l of s a t i s f a c t i o n w i t h h e a l t h care p r o v i d e r s ; l e v e l
of respect and responsiveness
accorded
patients;
presence/absence of b a r r i e r s , an e s p e c i a l l y important
issue f o r groups who often experience disenfranchisement
(poor people, people of c o l o r , members o f stigmatized
groups such as those with chronic mental i l l n e s s or
i n j e c t i o n drug use) ; and evaluation of the plan's success
i n meeting c u l t u r a l and l i n g u i s t i c consumer needs.
RECOMMENDATION 4.
Health care professionals in AHPs should provide patients and
families with information that permits them to make informed
decisions among competing diagnostic and treatment options.
Guidelines:
1. AHPS must foster communication about health and health
options between providers and patients.
2. AHPS must reimburse h e a l t h care p r o f e s s i o n a l s
s p e c i f i c a l l y f o r discussion time i n the p a t i e n t - p r o v i d e r
interaction.
RECOMMENDATION 5.
AHPS must educate professional s t a f f about the process of
informed consent.
Guidelines:
1. Patients and families must be helped to reach
personally v a l i d understandings about the role that
medicine and medical care play in t h e i r l i v e s .
2. Providers and p a t i e n t s should work together t o
i d e n t i f y elements of health s t a t u s , r i s k f a c t o r s f o r
disease and s p e c i f i c choices t h a t the p a t i e n t might face
i n the f u t u r e .
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10
i
3. The r e s p o n s i b i l i t y f o r h e a l t h education should be
apportioned among s t a f f using i n d i v i d u a l and group
discussions and audio v i s u a l m a t e r i a l as appropriate.
4. Conversations w i t h i n d i v i d u a l p a t i e n t s about t h e
s p e c i f i c s of care plans should take place, whenever
possible, against a background of p r i o r dialogue on t h e
purposes and goals o f h e a l t h care, the u n c e r t a i n t y o f
medical i n t e r v e n t i o n s and t h e importance o f i n d i v i d u a l
choice.
5. Patients or f a m i l i e s should be c l e a r about t h e
possible r i s k s and b e n e f i t s of suggested i n t e r v e n t i o n s .
6. Education about h e a l t h care and the process of choice
should
be o f f e r e d
by providers i n c u l t u r a l l y ,
l i n g u i s t i c a l l y and e t h n i c a l l y accessible manner w i t h
materials t h a t are comprehensible a t t h e educational
l e v e l s of p a t i e n t s and f a m i l i e s .
7. Decisions l i k e l y t o a r i s e i n t h e f u t u r e should be
a n t i c i p a t e d and p a t i e n t s helped t o decide, when they are
decisionally-capable, f o r those times when they may no
longer be able t o exercise i n d i v i d u a l choice.
8. Opportunities t o execute advance d i r e c t i v e s should
form a regular p a r t o f p r a c t i c e i n the AHP.
9. Professionals have an o b l i g a t i o n t o support proxy
decision makers ( t h i s i s e s p e c i a l l y t r u e i n decisions t o
permit death. Providers should shoulder some o f t h e
burden f o r these decisions and s h i e l d the proxy from t h e
f u l l impact of s i n g u l a r r e s p o n s i b i l i t y ) .
Discussions f o r Recommendations 4 & 5. Communication w i t h
p a t i e n t s i s t h e basis f o r t h e p a t i e n t , or the f a m i l y ,
exercising the r i g h t t o informed choice or t h e r i g h t t o refuse
care.
Informed consent i s a process, i t i s n e i t h e r a piece of paper,
nor the s p e c i f i c permission t o proceed w i t h a d i a g n o s t i c or a
treatment i n t e r v e n t i o n . Since decisions whether t o consent t o
or t o refuse diagnostic or treatment i n t e r v e n t i o n s are as much
matters of personal value as matters of science, p a t i e n t s and
f a m i l i e s must be helped
t o reach
personally v a l i d
understandings about the r o l e t h a t medicine and medical care
play i n t h e i r l i v e s .
I
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Providers and p a t i e n t s should be a l l i e s and co-partners i n
" t r u s t " . working together t o i d e n t i f y elements o f h e a l t h
s t a t u s , r i s k f a c t o r s f o r disease and s p e c i f i c choices t h a t the
p a t i e n t might face i n the f u t u r e . I n t h e l a s t two decades
many physicians have come t o see the d o c t r i n e o f "informed
consent" s o l e l y as a defense t o possible l e g a l challenge t o
care.
So viewed, the d o c t r i n e becomes defensive—one more
element separating the doctor and the p a t i e n t — a n d can be
misused t o abandon p a t i e n t s and f a m i l i e s i n the face of r i s k y
and anguished decisions.
Providers should n o t abdicate
r e s p o n s i b i l i t y and make i t appear as i f t h e p a t i e n t alone i s
responsible f o r the decision.
The atmosphere i n the AHP should encourage a " c u l t u r e o f
communication" i n which i t i s not s o l e l y t h e r e s p o n s i b i l i t y of
the physician or primary care provider t o i n s t r u c t p a t i e n t s
and f a m i l i e s .
The r e s p o n s i b i l i t y f o r education should be
apportioned among s t a f f who may choose t o conduct education i n
a v a r i e t y of«ways including i n d i v i d u a l and group discussions.
Conversations w i t h i n d i v i d u a l p a t i e n t s about the s p e c i f i c s of
care plans should take place, whenever p o s s i b l e , against a
background of p r i o r dialogue on the purposes and goals o f
medicine, the u n c e r t a i n t y of medical i n t e r v e n t i o n s and the
importance of i n d i v i d u a l choice.
Communication w i t h p a t i e n t s over time should provide a basis
f o r i n d i v i d u a l decisions about care. P a t i e n t s o r f a m i l i e s
should be c l e a r about the possible r i s k s and b e n e f i t s o f
suggested i n t e r v e n t i o n s . They should be t o l d the diagnosis,
t h e prognosis, t h e a l t e r n a t i v e treatments, t h e r i s k s and
b e n e f i t s of those treatments and the r i s k s and l i k e l y outcomes
of non-treatment. Whereas, a t present, precise i n f o r m a t i o n i s
o f t e n f o i s t e d upon p a t i e n t s and f a m i l i e s who have no context
against which t o measure the q u a l i t y of any p a r t i c u l a r choice,
the goal of t h e AHP should be t o develop an educated
consumer/patient population able t o i n t e g r a t e s p e c i f i c choices
w i t h i n an i n d i v i d u a l philosophy of care.
i
Education about h e a l t h care and the process of choice should
be offered by providers i n c u l t u r a l l y , l i n g u i s t i c a l l y and
e t h n i c a l l y accessible manner w i t h m a t e r i a l s t h a t are
comprehensible a t t h e educational l e v e l s o f p a t i e n t s and
f a m i l i e s . A m a j o r i t y of the American p o p u l a t i o n reads a t or
below the f i f t h grade l e v e l . Presentations, discussions, and
p r i n t e d and v i s u a l materials should recognize and respond t o
the s k i l l l e v e l s of t h e p a r t i c u l a r p a t i e n t population.
D i f f e r e n t communities have various customs and t r a d i t i o n s t h a t
may a l t e r t h e i r perception of h e a l t h messages. I f the goal of
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12
the informed consent process i s t o i n v o l v e p a t i e n t s i n the
process of t h i n k i n g about h e a l t h , before s p e c i f i c decisions
must be made, the c u l t u r a l context o f h e a l t h and i l l n e s s must
be a primary concern o f educators.
Decisions l i k e l y t o a r i s e i n the f u t u r e should be a n t i c i p a t e d
and p a t i e n t s helped t o decide, when they are d e c i s i o n a l l y capable, f o r those times when they may no longer be able t o
exercise i n d i v i d u a l choice. Opportunities t o execute advance
d i r e c t i v e s should form a regular p a r t o f p r a c t i c e i n t h e AHP.
The P a t i e n t Self-Determination Act r e q u i r e s a l l AHPs t o r a i s e
these issues w i t h p a t i e n t s . S p e c i f i c d i r e c t i v e s about f u t u r e
care, i . e . L i v i n g W i l l s , should be discussed w i t h p a t i e n t s and
should be combined w i t h Proxy Appointments f o r those p a t i e n t s
who opt t o choose others t o decide f o r them. Patients should
understand the r u l e s f o r surrogate decision-making i n t h e i r
s t a t e and the p o l i c i e s t h a t guide these choices i n t h e AHP.
I n c o n t r a s t t o many p a t i e n t - p r o v i d e r r e l a t i o n s h i p s today i n
which t h e provider may have l i t t l e knowledge of the p a t i e n t ' s
care philosophy, p a t i e n t s i n the AHPs should be able t o assume
t h a t t h e i r primary provider w i l l be able t o a s s i s t i n
supporting surrogate choice i f the p a t i e n t i s no:longer able
t o decide. Family members and s p e c i f i c a l l y appbinted proxy
deciders should be able t o r e l y on t h e provider i n
i n t e r p r e t i n g the preferences of the p a t i e n t .
Providers should recognize t h a t f o r p a t i e n t s w i t h advance
d i r e c t i v e s , and f o r f a m i l y and loved ones a c t i n g as
surrogates, the provider-proxy r e l a t i o n s h i p i s c r i t i c a l . Many
physicians and h e a l t h care a d m i n i s t r a t o r s see advanced
d i r e c t i v e s as the p r e f e r r e d t o o l s t o disentangle c o n f l i c t i n g
l e g a l and e t h i c a l norms governing surrogate choice.
While
advance d i r e c t i v e s are sometimes h e l p f u l i n t h i s regard t h e
existence of an advance d i r e c t i v e imposes a new set of e t h i c a l
o b l i g a t i o n s on p r o v i d e r s . They must ensure t h a t the i n t e n t of
a l i v i n g w i l l i s c a r r i e d out, or t h a t t h e person appointed as
proxy i s supported i n the process of choice. There i s no more
i s o l a t e d person then an appointed proxy l e f t t o s t r u g g l e alone
w i t h decisions about l i f e - s u s t a i n i n g care.
As p a r t o f t h e
r e l a t i o n s h i p of t r u s t forged w i t h the p a t i e n t the p r o v i d e r has
the o b l i g a t i o n t o communicate w i t h and support t h e proxy
decider.
This i s e s p e c i a l l y t r u e i n decisions t o permit
death. The proxy should be able t o r e l y on t h e p r o v i d e r t o
shoulder some of t h e burden f o r these decisions and t o s h i e l d
the proxy from the f u l l impact of s i n g u l a r r e s p o n s i b i l i t y .
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FAIR PROCEDURES FOR RESOLVING
MISUNDERSTANDINGS, DISAGREEMENTS AND DISPUTES
I n d i v i d u a l s , h e a l t h care i n s t i t u t i o n s and society a t large are
accustomed t o handling c o n f l i c t s and disputes i n adversarial and
p o l a r i z e d ways. An important measure of q u a l i t y f o r AHPs w i l l be
t h e i r success i n preventing unnecessary problems a r i s i n g from poor
communication, i n a t t e n t i o n t o the needs and i n t e r e s t s ; o f p a t i e n t s
and providers, and an i n s e n s i t i v e bureaucracy. Training i n
e f f e c t i v e communication and dispute r e s o l u t i o n s k i l l s w i l l reduce
the number of misunderstandings t h a t escalate i n t o f u l l - b l o w n
disputes. Equally important t o q u a l i t y service, however, i s t h e
design and implementation of f l e x i b l e and e f f e c t i v e procedures f o r
r e c e i v i n g and handling those misunderstandings, disagreements and
disputes t h a t s u r e l y w i l l a r i s e .
This Report contains the f o l l o w i n g :
1.
Dispute
System
Resolution and Grievance
Procedures:
Designing a
•
•
An argument f o r f a v o r i n g a "decision o f t h e p a r t i e s "
system ( n e g o t i a t i o n and mediation) over an " a u t h o r i t y
system ( a r b i t r a t i o n and l i t i g a t i o n ) .
•
A l i s t i n g of the advantages of such a system
•
2.
An i n t r o d u c t i o n t o p r i n c i p l e s and procedures t h a t should
guide the AHP's design o f an e f f e c t i v e dispute system
Basic steps t o f o l l o w
Categories of Complaints: Organized by Involved Parties, with
Vignettes
A taxonomy of p o t e n t i a l sources of c o n f l i c t arranged according
t o the p a r t i e s ' r e l a t i o n s h i p :
•
Patient-Provider
•
Professional-Professional
•
Administrative-Professional
including vignettes i l l u s t r a t i n g l i k e l y c o n f l i c t s .
3.
Consumers/Providers
with a Grievance: Suggested
Procedures
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Introduction
As h e a l t h services are d e l i v e r e d w i t h i n AHPs, i t i s unavoidable
t h a t c o n f l i c t s and disputes w i l l a r i s e among involved p a r t i e s
( p a t i e n t s , h e a l t h care professionals, administrators) i n the course
of p r o v i s i o n of such services. I t i s important t h a t such c o n f l i c t s
be a n t i c i p a t e d , t h a t s t r u c t u r e s and procedures be designed and
implemented t o deal most e f f e c t i v e l y w i t h such disputes, and t h a t
i n d i v i d u a l s be encouraged and (as appropriate) t r a i n e d t o manage
c o n f l i c t l o c a l l y and s u c c e s s f u l l y .
Designing a dispute system t h a t draws from both o r g a n i z a t i o n a l
development and c o n f l i c t r e s o l u t i o n w i l l accomplish t h i s . The
i n e v i t a b i l i t y of c o n f l i c t i n organizations i s widely accepted.
Some estimates of managers' time spent dealing w i t h c o n f l i c t r u n
high as 40%. The causes of c o n f l i c t and tension w i t h i n
organizations of a l l types can be traced t o s i m i l a r society-wide
issues: a rights-conscious society, greater competition, d i v e r s i t y ,
budgetary r e s t r a i n t s t o name but a few. These f a c t o r s t h a t w i l l
continue t o a f f e c t i n d i v i d u a l s and organizations w i t h i n t h e new
Health Reform System.
Negotiation and Mediation
AHPs should be s t r o n g l y encouraged (required?) t o design dispute
systems t h a t emphasize decisions by the p a r t i e s (as d i s t i n c t from
decisions made by higher a u t h o r i t i e s , such as a r b i t r a t i o n or
l i t i g a t i o n , or decisions imposed by f o r c e ) .
Negotiation and
mediation encourage an emphasis on i n t e r e s t s , t h a t i s the needs and
concerns of the people d i r e c t l y involved. Decisions by higher
a u t h o r i t i e s tend t o s t r e s s r i g h t s and f a u l t (e.g. what do t h e
r u l e s . . . p o l i c i e s , manuals, laws, regulations...say about r i g h t and
wrong?) Such r e s o l u t i o n s accentuate r i g h t s and i m p l i c i t l y encourage
power t a c t i c s .
Advantages
Cost c o n t r o l i s often c i t e d as the strongest argument f a v o r i n g
dispute systems design. Increase i n p r o d u c t i v i t y also f o l l o w s due
to improved r e s o l u t i o n of an organization's c o n f l i c t s and t h e
a v a i l a b i l i t y of an organization's human resources f o r other work.
A dispute system design t h a t favors decision by the p a r t i e s avoids
the p i t f a l l s of higher a u t h o r i t y r e s o l u t i o n s t h a t accentuate r i g h t s
and i m p l i c i t l y encourage power t a c t i c s . The emphasis i s on c r e a t i n g
a s t r u c t u r e and climate (both formal and informal) t h a t o f f e r s
interest-based options f o r decisions by the p a r t i e s . Such a system
i s also less l i k e l y t o neglect many disputes t h a t a r i s e among s t a f f
or between managers or professionals who are peers. I n an
authority-based system these c o n f l i c t s tend t o escalate or f e s t e r
and remain unaddressed and unresolved.
Other key q u a l i t i e s of an
e f f e c t i v e system include: open and personal, because i t includes
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meaningful o p p o r t u n i t i e s f o r people t o be heard and responded t o
when they express t h e i r concerns and f e e l i n g s . I t does not take a
large amount o f time and energy f o r an aggrieved jperson or group
t o get the appropriate person(s) t o l i s t e n t o t h e i r complaints. I t
i s " u s e r - f r i e n d l y . " Information about the use o f t h e system i s
r e a d i l y a v a i l a b l e and easy t o understand. I t i s simple t o access
through c l e a r pathways or "pipes" t h a t are i n place. These begin
from p r e d i c t a b l e sources of c o n f l i c t , channelling the problem t o
the system procedures. The system makes sense and seems f a i r . I t i s
also safe t o use because i t p r o t e c t s users from r e t a l i a t i o n and
embarrassment.
I t i s f l e x i b l e , o f f e r i n g m u l t i p l e options and
p r o v i d i n g some degree of choice by the person(s) who have t h e
complaint. Even when ( i f ) a dispute escalates i t can be "looped
back" t o a problem s o l v i n g process i f i t i s appropriate t o do so.
And i t i s p r o f i c i e n t and conclusive. S k i l l e d advisors are a v a i l a b l e
t o educate and help the p a r t i e s . Formal mediation i s an o p t i o n . I t
provides f o r t i m e l y , complete i n v e s t i g a t i o n of complaints. When
necessary, a r b i t r a t i o n , peer review and a d j u d i c a t i o n are a v a i l a b l e
t o give closure w i t h a decision or r u l i n g .
Basic Steps
Design of such a system a t any l e v e l e n t a i l s c e r t a i n common steps:
(1) Thoroughly review the organization f o r the d i f f e r e n t ways i n
which c o n f l i c t s a r i s e (e.g. problems w i t h p a t i e n t s , i n t r a organization issues l i k e departmental t u r f and resource b a t t l e s ,
h i e r a r c h i c a l personnel problems such as
employee-supervisor
r e l a t i o n s h i p s , and i n t e r n a l team problems, e.g. b a t t l e s between coworkers. (2) Plan a system t o receive and process these c o n f l i c t s
e f f e c t i v e l y and e f f i c i e n t l y .
Basic steps t o create a dispute system include:
1.
Gather the team (whether on the i n s t i t u t i o n a l , AHP, o r
HIPC l e v e l ) and provide necessary s t a f f i n g . Include s t a f f
from d i f f e r e n t parts of t h e o r g a n i z a t i o n . An expert i n
the area of organizational dispute r e s o l u t i o n should be
hired/trained.
2.
C o l l e c t i n f o r m a t i o n needed t o understand what works and
what doesn't i n the e x i s t i n g system. Learn t h e
perceptions of the uses of e x i s t i n g dispute r e s o l u t i o n
mechanisms.
i
3.
Assess the information. How and where do disputes arise?
Where do they go? How long do they take and what do they
cost? Diagnose continuing, p r e d i c t a b l e sources o f
c o n f l i c t . Figure out t h e e f f e c t i v e n e s s of e x i s t i n g
dispute r e s o l u t i o n procedures. Analyze how the s t r u c t u r e
of the organization may cause c o n f l i c t . I s o l a t e t h e
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f a c t o r s responsible
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f o r constructive
or
destructive
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4.
Design a more e f f e c t i v e system. Consider ways t o change
the s t r u c t u r e . Include c o n s u l t a t i o n t o help;the p a r t i e s
get disputes t o t h e appropriate place i n the system.
B u i l d i n steps f o r r e s o l v i n g disputes a t low cost.
Emphasize d i r e c t n e g o t i a t i o n and mediated n e g o t i a t i o n .
5.
Implement the design. Prepare t o deal w i t h d i f f i c u l t
people whose power i s t i e d t o high-cost ways of handling
disputes. Schedule t r a i n i n g i n n e g o t i a t i o n and medition
skills
for staff
and i n t e r v e n e r s . Create formal
mechanisms when appropriate w i t h c o n t r a c t clauses and
grievance steps i n personnel p o l i c y manuals. Educate
p o t e n t i a l users about the system. Contract w i t h outside
professionals i f necessary.
6.
Evaluate and improve the system. C o l l e c t data and
p e r i o d i c a l l y conduct an e v a l u a t i o n t o r a t e the system's
effectiveness and e f f i c i e n c y .
Modify a l l or p a r t as
necessary.
An AHP or a h e a l t h care i n s t i t u t i o n (organization) might consider
the f o l l o w i n g steps:
1.
Create a c o n f l i c t management module as p a r t of ongoing
o r i e n t a t i o n and t r a i n i n g f o r a l l s t a f f .
2.
Form an in-house i n t e r d i s c i p l i n a r y mediation team t o
mediate disputes.
3.
Revise employee personnel manual, medical bylaws, and a l l
h o s p i t a l contracts w i t h outside p a r t i e s t o include
mediation steps and mediation clauses.
4.
Create an evaluation system t o t r a c k evidence of
c o n f l i c t s such as (a) complaints r e g i s t e r e d through the
personnel department, (b) number o f claims f i l e d against
the f a c i l i t y , and (c) e x t e r n a l complaints t o agencies
such as the AHP, the HIPC, Board of Medical Examiners,
etc.)
In Getting Disputes Resolved: Designing Systems t o Cut the Costs of
C o n f l i c t , the authors Ury, B r e t t , and Goldberg l i s t s i x p r i n c i p l e s
of dispute system design:
1.
Emphasize processes t h a t w i l l address i n t e r e s t s .
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2.
B u i l d i n "loop-back" procedures t o move people from r i g h t s and
power approaches i n t o n e g o t i a t i o n .
3.
Provide low cost, back-up mechanisms based on r i g h t s and power
approaches when n e g o t i a t i o n and mediation don't work.
4.
Ensure c o n s u l t a t i o n before the dispute moves i n t o t h e system
so i t goes t o the most appropriate place. Get feedback a f t e r
i t has concluded t o improve the system.
5.
Gain maximum cost savings by using a low-cost t o high-cost
sequence of procedures. Cost should be measured i n several
ways: out of pocket expense; the time of the people involved;
and l o s t p r o d u c t i v i t y .
6.
Support the design w i t h the resources, s k i l l s and a t t i t u d e s
necessary f o r i t s success.
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CATEGORIES OF COMPLAINTS:
j
Organized by Involved P a r t i e s , with Vignettes
I.
PATIENT-PROVIDER
•
Denial of Services
Provider says service i s "not p a r t o f t h e p l a n "
( I n vignettes a and b, t h e assumption i s t h a t mandated services
include "reproductive services and prenatal care." Cost per t e s t
i n c l u d i n g counseling i s $200-400. I f every pregnant woman i n t h e
AHP wanted i t , i t might add several hundred thousand d o l l a r s t o t h e
plan. This i s one of many new, expensive technologies t h a t have
r e a l benefits i n a v e r t i n g unwanted b i r t h s . )
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a.
A woman a t no special r i s k wants heterozygote t e s t i n g f o r
c y s t i c f i b r o s i s because she heard about i t on t h e Barbara
Walters show.
b.
A woman, whose cousin has a CF baby, i s a t increased r i s k and
wants the t e s t . She i s very anxious.
c.
A p a t i e n t , Marie, says, "My s i s t e r i n a d i f f e r e n t ' AHP got t h e
t e s t l a s t week. Why can't I have i t ? "
d.
Patient wants a n t i b i o t i c s f o r the common c o l d . Physician says
i t ' s not medically i n d i c a t e d .
i
I n d i r e c t or covert d e n i a l
e.
Patient has eating disorder. I t i s on t h e l i s t o f mandated
services. Primary provider says, "Dr. Murry has an opening i n
August, Thursday morning, a t 8:00." ( I t i s now March. The
appointment i s then cancelled two days ahead o f time,
rescheduled f o r two months hence.)
i
Excessive gatekeeping
f.
A p a t i e n t has s p o t t i n g , c e r v i c i t i s . Primary care physician
says I can take care of t h a t . Patient says, " I want t o see a
specialist."
g.
A p a t i e n t w i t h r e c t a l bleeding, cause unknown, j l h e primary
care physician denies a gastroenterology r e f e r r a l .
h.
Family p r a c t i t i o n e r , caring f o r a woman w i t h a breast lump,
says, " I ' l l
biopsy i t . "
The woman says, " I want an
oncologist.
11
Preliminary S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Group #17,
March 31, 1993
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Disagreement about medically i n d i c a t e d Treatment
i.
P a t i e n t demands a n t i b i o t i c s f o r what i s c l e a r l y a v i r a l
c o n d i t i o n . Physician refuses: not only w i l l i t do no good, i t
also can do harm by c r e a t i n g resistance t o a n t i b i o t i c therapy.
•
Dissatisfaction with provided services
|
Disputes about l e v e l of t r a i n i n g and competence
j.
Spinal taps performed by house s t a f f a t the beginning of J u l y ,
or
i
Sophisticated patient/consumer demands "the most experienced
s p i n a l tapper on s t a f f . "
k.
A possibly c l i n i c a l l y depressed p a t i e n t , who wants a complete
evaluation and diagnostic workup, i s r e f e r r e d t o a s o c i a l
worker f o r " t a l k therapy." The f a m i l y asks f o r p s y c h i a t r i s t .
Interpersonal c o n f l i c t s : provider and p a t i e n t
1.
Home care p a t i e n t : I don't want t h a t black nurse coming i n t o
my home, ( r a c i a l , gender issues of p r o v i d e r / p t r e l a t i o n s h i p )
•
Patient Choice
m.
Mr. Smith i s 80 years o l d . He complains r e g u l a r l y about h i s
primary providers, has been s h i f t e d 5 times t o d i f f e r e n t
physicians. The AHP f i n a l l y says, "No more."
n.
A p a t i e n t who i s i n a r u r a l AHP
choice i s unreasonably l i m i t e d . No
problems and he i n s i s t s t h a t he be
i n another AHP (the closest i s 200
•
Patient satisfaction with provider performance
(excessive)
i n s i s t s t h a t the provider
one understands h i s h e a l t h
allowed t o use a physician
miles away). ;
Cross c u l t u r a l issues: (Note: r u l e s can provide those
w i t h less power access t o sources of power, whereas those already
in
power
often
use
existing informal
structures
more
e f f e c t i v e l y . . . S e e Delgado on t h i s .
Issues of language are also
c r u c i a l here.)
Breaches of confidentiality
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�Group #17, March 31, 199 3
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Disclosure without p a t i e n t consent
o.
"Your f a t h e r has metastatic cancer and I thought you should
know.
Between providers
p.
Social worker sends l e t t e r back t o primary care physician
about p a t i e n t ' s sexual dysfunction, without t h e p a t i e n t ' s
consent.
!
To other
institutions
q.
Social worker discloses HIV status t o the housing a u t h o r i t y ,
i n an e f f o r t t o a s s i s t p a t i e n t i n securing b e t t e r housing.
r.
The school system i s informed about about; a c h i l d ' s
d i s a b i l i t i e s , r e s u l t i n g i n s t i g m a t i z a t i o n , s p e c i a l placement,
etc.
s.
School t r i e s t o get i n f o r m a t i o n about c h i l d r e n
d i s a b i l i t i e s , t o maximize i t s funding sources.
with
Computer information sharing
(The trade o f f here i s the need t o r e s t r i c t access vs.
the need t o know.)
t.
Employee of the AHP i s seen i n the w a i t i n g room of the STD
c l i n i c . A medical student, out of c u r i o s i t y , looks up the
diagnosis i n the c l i n i c .
High r i s k Categories
u.
Newborn screening f o r cocaine.
!
i
•
Access t o medical supplies
v.
AHP has a formulary. Generics drugs are used. Only i f there i s
a good reason t o use something else i s i t done. Which should
be used: beta blockers or calcium channel blockers
given a
100-fold increase i n cost?
Gross negligence (We understand t h a t t h i s k i n d of complaint
f a l l s w i t h i n the ambit of the Malpractice group. Nevertheless,
since i t i s an important source of c o n f l i c t , we would l i k e t o
emphasize two p o i n t s : t r u t h t e l l i n g must be encouraged and
Preliminary S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�TALKING POINTS
OVERVIEW
BRIEFING BOOKS
HRC SPEECHES
POLICY PAPERS / TOPICS
CONGRSSIONAL BRIEFING MATERIAL
TEXT
COMMUNICATIONS
CONCEPT/LAYOUT
CHAPTER ONE
CHAPTER TWO
OUTLINE
CHAPTER FOUR
CHAPTER FIVE
DOC LETTERS
OUTLINES
DRAFTS
REGULATORY RELIEF
LEGAL AUDIT/GENERAL
RURAL
ETHICS
FOIA
SURROGATE DECISION MAKING
PRIVACY
PUBLIC HEALTH
MEDICARE/MEDICAID
MANAGED COMPETITION
PRISON
�FOR OFFICIAL USE ONLY
Working Group #17--Page l
Tollgate #5
THE NATIONAL BIOMEDICAL ETHICS PANEL
( T o l l g a t e Version)
A National Biomedical Ethics Panel should be e s t a b l i s h e d t o
provide a forum f o r t h e t h o u g h t f u l and systematic a n a l y s i s of t h e
e t h i c a l issues t h a t a r i s e from the implementation o f t h e new h e a l t h
care system. The work of t h e National Biomedical E t h i c s Panel w i l l
serve t o i n t e g r a t e c o n s i d e r a t i o n of e t h i c a l issues i n t o p o l i c y and
p o l i t i c a l decision-making processes t h a t a f f e c t h e a l t h care.
I . ETHICAL ISSUES IN THE NEW HEALTH CARE SYSTEM
When the new health care system is established it will face
ethical issues from at least three sources. First, ethical issues
will arise from the creation of new institutional structures: a
National Health Board, many diverse HIPCs, and thousands of AHPs.
For instance, the Board must ensure criteria
are devised
for the
fair distribution
of transplantable
organs.
Second, t h e National Health Board, w i l l have a u t h o r i t y and
responsibility
f o r issuing e x p l i c i t rules,
standards, and
guidelines where none had previously e x i s t e d .
I n this explicit
decision-making process, t h e National Health Board w i l l f r e q u e n t l y
confront fundamental e t h i c a l issues t h a t were n o t p r e v i o u s l y
acknowledged.
Finally, biomedical research and technological
innovation
will
continue raising
additional
ethical
issues for the new health
care
system.
Indeed, as the Human Genome Project
and the Human Brain
Initiative
blossom,
they will raise
issues
of equality
in the
distribution
of
resources.
I I . THE NEED FOR A NATIONAL BIOMEDICAL ETHICS PANEL
A N a t i o n a l Biomedical Ethics Panel w i l l provide an on-going
body which can examine whether implementation o f the new system i s
f a i t h f u l t o t h e e t h i c a l p r i n c i p l e s upon which i t i s founded.
I I I . CHARGE OF THE NATIONAL BIOMEDICAL ETHICS PANEL
The N a t i o n a l Biomedical Ethics Panel i s charged t o study,
advise, and r e p o r t t o t h e National Health Board on t h e e t h i c a l
issues t h a t a r i s e i n developing and operating t h e new h e a l t h care
system, i n i n t r o d u c i n g new technology, and i n p r o v i d i n g access t o
q u a l i t y h e a l t h services. I t i s n o t intended t o consider tiie broad
PRELIMINARY STAFF WORKING PAPER FOR ILLUSTRATIVE PURPOSES ONLY
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array of clinical
issues
that
by the term
"bioethics."
Working Group #17—Page 2
Tollgate #5
have
traditionally
been
encompassed
As i t s f i r s t task, t h e N a t i o n a l Biomedical E t h i c s Panel w i l l
conduct a study t o assess whether access, e q u a l i t y , and q u a l i t y are
being protected i n the new h e a l t h care system.
IV.
FUNCTIONS OF THE NATIONAL BIOMEDICAL ETHICS PANEL
I n c o n s u l t a t i o n w i t h t h e N a t i o n a l Health Board, t h e National
Biomedical Ethics Panel should have d i s c r e t i o n over f o r m u l a t i n g an
on-going agenda of t o p i c s and issues a r i s i n g from implementation o f
the new health care system on which i t studies and r e p o r t s .
A. EXAMINING ETHICAL DECISIONS ARISING FROM THE NEW SYSTEM
The National Biomedical E t h i c s Panel w i l l have t h e f u n c t i o n of
a d v i s i n g the National Health Board on e t h i c a l issues a r i s i n g from
the new system.
There w i l l be fundamental e t h i c a l issues t h a t a r i s e i n t h e
development and operation o f t h e new h e a l t h care system i n c l u d i n g
ensuring f u l l access, e q u a l i t y , q u a l i t y , and d i s t r i b u t i v e j u s t i c e
for a l l patients.
f o r example, the National Biomedical E t h i c s
Board might need a) to devise c r i t e r i a f o r the f a i r d i s t r i b u t i o n o f
s o l i d organs f o r t r a n s p l a n t a t i o n and b) to a r t i c u l a t e a conception
of f u t i l e medical therapies t h a t AHPs should not be r e q u i r e d t o
provide.
B. FACILITATING ETHICS COMMITTEES AND CONSULTATION AT THE AHP
The National Biomedical E t h i c s Panel w i l l create a program t o
f a c i l i t a t e the development o f e t h i c s committees and c o n s u l t a t i o n
w i t h i n each AHP.
The program w i l l respond t o i n q u i r i e s and
disseminate information t o promote q u a l i t y and consistency.
C. EXAMINING ETHICAL ISSUES CREATED BY INNOVATION AND RESEARCH
The National Biomedical Ethics
studying
the ethical
issues raised
potential
for clinical
applications
Panel will have the function
of
by research and innovation
with
in the
future.
Research c u r r e n t l y being conducted w i l l r a i s e fundamental
e t h i c a l issues i n the f u t u r e . The National Biomedical E t h i c s Panel
would s y s t e m a t i c a l l y analyze e t h i c a l issues r e l a t e d t o i n n o v a t i o n .
I t would pay special a t t e n t i o n t o how these new technologies a f f e c t
access and e q u a l i t y to h e a l t h care services.
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Working Group #17—Page 3
Tollgate #5
D. ENCOURAGING ETHICS EDUCATION
The National Biomedical Ethics Panel would have the
of encouraging
biomedical
ethics
education.
function
The National Biomedical
Ethics Panel will issue its
studies
and reports
to the public
to be disseminated
to AHPs,
public
libraries, and educational institutions. The National
Biomedical
Ethics Panel could also encourage AHPs to establish
educational
programs on biomedical
ethical
issues
for their physicians,
other
health care professionals,
and
patients.
V. COMPOSITION AND STRUCTURE OF THE NATIONAL BIOMEDICAL ETHICS
PANEL
The IS-member N a t i o n a l Biomedical Ethics Panel should be
c o n s t i t u t e d under the a u t h o r i t y o f t h e National Health Board and
should r e p o r t t o the N a t i o n a l Health Board.
Nominations w i l l be made by t h e National Health Board and
other i n t e r e s t e d p a r t i e s . The President o r h i s designee w i l l
appoint members t o t h e National Biomedical Ethics Panel.
The
National Biomedical E t h i c s Panel should include a u t h o r i t i e s
knowledgeable i n the f i e l d s of e t h i c s , medicine, nursing, p u b l i c
health, b i o l o g i c a l , s o c i a l and b e h a v i o r a l sciences, law, r e l i g i o n ,
and from t h e general p u b l i c , each o f whom should have s p e c i a l
q u a l i f i c a t i o n s and/or competence t o work e f f e c t i v e l y w i t h e t h i c a l
issues i n h e a l t h care. Members s h a l l be appointed t o staggered,
three-year, non-renewable terms.
VI. IMPLEMENTATION AND POWERS OF THE NATIONAL BIOMEDICAL ETHICS
PANEL
The National Biomedical Ethics Panel s h a l l issue r e p o r t s ,
studies, and recommendations t o t h e National Health Board which
w i l l incorporate them i n t o r u l e s , r e g u l a t i o n s , standards, and
g u i d e l i n e s on e t h i c a l issues f o r t h e HIPCs, AHPs, and other
e n t i t i e s w i t h i n the h e a l t h care system as i t sees f i t . The
National Health
Board s h a l l respond t o the r e p o r t s and
recommendations of the National Biomedical Ethics Panel w i t h i n 180
days o f r e c e i p t .
VII. COORDINATION OF THE NATIONAL BIOMEDICAL ETHICS PANEL WITH
OTHER ETHICS BODIES
The Panel w i l l maintain a l i a i s o n w i t h other r e l e v a n t Federal
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Working Group #17—Page 4
Tollgate #5
bodies and o f f i c e s , i n c l u d i n g t h e Recombinant DNA Advisory
Committee, t h e O f f i c e f o r P r o t e c t i o n from Research Risks, t h e
Advisory Committee of the E t h i c a l , Legal, and S o c i a l Issues Program
of the N a t i o n a l Center f o r Human Genome Research, t h e O f f i c e o f
Science and Technology P o l i c y , and any other e t h i c s advisory boards
c o n s t i t u t e d under the National I n s t i t u t e s o f Health R e v i t a l i z a t i o n
Act of 1993.
A few members o f the Ethics Cluster opposed e s t a b l i s h i n g a National
Biomedical E t h i c s Panel. A few members wanted t h e scope o f t h e
Panel r e s t r i c t e d t o implementation of t h e new h e a l t h care system.
These were t h e claims put forward f o r t h i s .
1. There i s no clear need for a continuing national body.
There i s already a r i c h p u b l i c forum f o r consideration o f
e t h i c a l issues i n health care, i n c l u d i n g academic programs,
n a t i o n a l organizations (ASLM, Hastings Center, SHHV e t c ) ,
e t h i c s committees o f p r o f e s s i o n a l o r g a n i z a t i o n s ) .
In
a d d i t i o n , n a t i o n a l bodies t o address s p e c i f i c issues can and
have been formed when p u b l i c concern i s r a i s e d (e.g. National
Commission, President's Commission, OTA and IOM committees,
NIH consensus conferences and workshops), c o l l a b o r a t i v e
p r o j e c t s by professional s o c i e t i e s w i t h involvement o f
ethicists, etc.
2. There are dangers i n a continuing national body.
F i r s t t h e body may be p o l i c i z i e d as i n t h e case o f t h e
Congressional Bioethics Advisory Board.
Also, a n a t i o n a l
board might over r e s t r i c t t h e n a t i o n a l debate.
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Ethics Issues for a New Health Care System
TOLLGATE VERSION
PRIVACY AND CONFIDENTIALITY OF HEALTH RECORDS UNDER THE
NEW HEALTH CARE SYSTEM
RECOMMENDATIONS
Traditional fair information practices should serve as the foundation for privacy law
and practice.
Emerging electronic systems must comply with data protection policies and
privacy protection guidelines adhering to the Code of Fair Information Practices.
Data security systems should be monitored and updated to protect the privacy of
health data.
Many health records should be treated as though they are "specially sensitive."
Development of "a comprehensive longitudinal computer-based patient record
containing clinical, financial and research data" will require unique personal
identifiers.
Informed consent for the use of data for purposes other than for which it was
collected must be provided by the individual about whom data are collected.
A uniform national standard for privacy and confidentiality should be established.
A central management should be established to oversee privacy policy and
confidentiality matters and violations.
Special orientation and training programs should be conducted for all personnel.
Individuals should be informed about the health information system, their rights
with regard to the contents and use of its data, and the system's obligation to
protect their privacy and confidentiality.
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�Group #17, March 31,1993
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PRIVACY AND CONFIDENTIALITY OF HEALTH RECORDS UNDER THE
NEW HEALTH CARE SYSTEM
BACKGROUND PAPER
CONTENTS
I.
Scope of the Problem
II.
Potential Benefits
ill.
Ethical Framework
IV.
Components of Emerging Health Care Data Systems.
V.
Safeguards/Solutions: A National. Unified Standard of Privacy
Abstract
The new health care system, coming as information technology is rapidly advancing, will
create a new national electronic health care data system that will enable broader and
more rapid access and enhanced use of health records for many patient-centered and
socially desirable goals. These benefits must be balanced with increased protection from
the enhanced risks to privacy and confidentiality of individuals, families, and groups within
communities.
I.
Scope of the Problem—Americans are concerned about threats to their privacy.
In general, American society places a high value on individual rights, autonomous
decision-making, and the protection of the private sphere from governmental or other
intrusion.
Concerns about privacy transcend the health care setting. Americans believe that
their privacy rights as consumers are not adequately protected. A 1991 Harris poll on
consumer privacy conducted for Equifax Inc. found that 79% of respondents indicated
their concern about threats to privacy. Nearly three-quarters (71%) believed that
consumers have lost all control over how personal information about them is circulated
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�Group #17, March 31,1993
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and used by companies. The percentage of people who believe that they have been
victims of invasions of privacy has increased to 25% from 19% in 1978. Between 40%
and 52% of the public is not very willing to have even relevant information about
themselves collected by a credit bureau or consumer reporting agency and used to
determine their eligibility for a home mortgage, a job, an auto loan, a credit card or an
insurance policy.
II.
Potential Benefits—A national electronic health care data system has many
potential benefits to patients, providers, AHPs, HPiCs, and society.
The primary benefits of a longitudinal, easily transferable and accessible
computerized patient record could be:
A.
Improved patient care
-»
-*
B.
C.
D.
Fosters continuity of care;
Consistent format for documentation of services (drugs, therapy);
and
-»
Supports health services research
Improved patient care management
Documents case mix in institutions and practices;
Analyzes severity of illness;
—
Assists in formulation of practice guidelines; and
—
Assists in quality assurance.
Improved patient care support
—
Assessing allocation of resources;
Analyzing trends;
-»
Assessing workloads; and
Interdepartmental communication.
Improved accuracy and efficiency of billing and reimbursement
Secondary benefits might occur in:
E.
Education
-*
-*
F.
Documenting health care professional experience;
Teaching students.
Public health
—
G.
Tracing sources of disease outbreaks (e.g., source of contamination
in series of food poisonings).
Regulation
Fostering post-marketing drug surveillance;
—
Assessing compliance with standards of care; and
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H.
I.
J.
III.
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-»
Accreditation.
Research
-»
Epidemiological;
-»
Clinical; and
Health services outcomes.
Policy development
Strategic planning;
-*
Public health monitoring; and
-*
Resource allocation.
Assessment of Quality in the New System
—
AHPs need for reliable data to assess quality
Ethical Framework.
In health care settings, a balance must be struck between the principle of respect
for persons (which aims to treat individuals as autonomous agents who have the right to
control their own destinies) and the pursuit of the common good (which aims to maximize
possible benefits and minimize possible harms to society and to individuals).
A.
Distinctions between privacy and confidentiality
Privacy, as defined by the Institute of Medicine (IOM), includes "freedom from
intrusion or observation into one's private affairs; therightto maintain control over
certain personal information, and the freedom to act without outside interferences."
Confidentiality, as defined by the (IOM), "is the professional and/or contractual duty
of all [health care workers] with access to patient information to safeguard the
privacy of the patient/client information, regardless of how it is acquired, collected,
stored, processed, generated, retrieved or transmitted."
B.
Ethical principles
Privacy and confidentiality are supported by ethical principles of:
-»
Respect for persons (since information is about patients and only
gathered with the patient's consent, respect for patients and their autonomy
means that they should control who has access to this information and how
it is used;
-»
Beneficence (patients' welfare is promoted, for example, by
preventing discrimination from release of information and by encouraging
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�Group #17, March 31,1993
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patient relationship);
-»
Promise-keeping (the implicit and explicit promises of professional
ethics codes that medical information will be kept confidential unless
otherwise stated in advance of entering a doctor-patient relationship or
unless required by law); and
-»
Truth-telling (providers who breach confidentiality without giving
advance notice of the conditions under which they are morally or legally
compelled to do so are engaging in a type of deceptive practice).
The provider-patient relationship should be built on mutual trust. If the patient
does not trust the provider, there is a greater likelihood that information important
for a diagnosis or treatment will be withheld or disguised and that collective data
about a disease will be inaccurate. Patients who fear disclosure of their identity
are less likely to disclose conditions that present threats to public health, such as
sexually transmitted diseases. The underserved groups who will be brought into
the health care system under the new plan may have serious concerns about the
disclosure of private information to other governmental agencies, such as the
police, welfare agencies, the foster care system, and others.
Privacy and confidentiality of health information is not an absolute value. Breaches
of confidentiality may be justified or even required, for example, when it is in the
best interests of incompetent patients, by some overriding public health threats, by
threats of violence to identifiable other individuals, and, in some instances, by the
likelihood that a crime has been committed. These exceptions are relatively few
and are usually codified by statutes or regulations. The provider has a heavy
burden to justify disclosing confidential information.
C.
Possible harms created by breaches of confidentiality
Individuals whose private medical information is disclosed for purposes other than
their direct medical care face possible harmful consequences:
-»
Loss of insurance or insurability (currently for health insurance; even
under the new system for life, disability, mortgage, or business insurance);
-*
Loss of employment or employability (though prohibited by law,
discrimination based on medical conditions is difficult to prove and requires
legal assistance);
-»
Loss of housing (particularly for conditions like AIDS, mental illness,
substance abuse); and
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-*
Social stigmatization or embarrassment within family, workplace, or
community, leading to loss of status and self-esteem.
Families may also suffer from breaches of confidentiality (e.g. disclosure of genetic
information that affects more than one generation). Ethnic, racial, or community
groups can be harmed by disclosures of information about medical vulnerabilities
that affect groups (e.g. discrimination in employment against African-Americans
because of inappropriate concerns about sickle cell trait).
The existence of a long-term, comprehensive medical record increases the risks
of harm from historical as well as current data. An individual may suffer harms
based on disclosure about a condition that occurred years earlier and that has
been resolved.
D.
Wrongs created by breaches of confidentiality
Even if no measurable consequences or harms occur as a result of breaches of
confidentiality, an individual whose privacy has been invaded for no justifiable
reason has suffered a wrong in that his or her dignity and autonomy has been
compromised.
IV.
Components of Emerging Health Care Data Systems.
The success of health care reform will, in part, depend upon the quality of the data
available for monitoring patient care and assessing system performance as
discussed above. The growing needs for detailed health data are emerging in an
environment in which health information systems have radically changed. Although
automated health records have long existed, they have mainly supported narrow
functions such as the laboratory, pharmacy,financingdepartment. Recently there
has been a dramatic shift toward comprehensive patient records and sustained
efforts toward building national electronic patient-based health information
networks. While specific visions vary, experts on automated health care systems
(e.g. the Computer-based Patient Record Institute, Medical Record Institute, and
American National Standards Institute) ultimately envision:
-»
Comprehensive longitudinal computer-based patient records
containing clinical, financial and research data;
-*
A "national" electronic network for accessing this health record for
several purposes such as primary care, insurance payment, peer review,
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cost containment, public health and research purposes;
Smart cards providing health insurance coverage information, a
conception-to-death health care record and more
—
Unique national or international patient-specific identifiers.
During 1992, several efforts accelerated the wide-spread computerization of health
care records. The federal government and the health insurance industry began
working on an insurance identification and eligibility system that will include
electronic claims transfer, universal claims forms, and automatic payment systems.
Meanwhile, the Computer-based Patient Record Institute formed with the support
of major medical and industry associations. A new American National Standard
Institute Healthcare Informatics Standards Planning Panel formed to coordinate
various voluntary standards activities in the United States and to serve as a liaison
for European standards work. Finally, health care industry groups were proving
that the technology is (almost) ready to implement a paperless computer-based
record systems.
Automation of patient-based health records can strengthen patient privacy and
confidentiality and assure that information is available to improve the quality and
efficiency of health care services. With existing paper systems, requests for
information often lead to releasing data that is not pertinent to the current request
as complete documents are copied and/or faxed to others. Computerized systems
facilitate tailored release of data thereby making it possible to only release
necessary and properly released information.
At the same time, electronic data files can make the anonymous exploring of data
an antiseptic process. Files are easier to access. This increases the range of
uses for data. A single breach of security could result in a very large number of
records being disclosed. Computerization also makes it easier to link information
from many sources, increasing the potential for undue intrusiveness into people's
records and lives. Individuals often do not appreciate where information about
them resides and how that information has been linked or is used.
Those developing electronic health care systems acknowledge the need to protect
access to computer-based record systems. At least fifteen different confidentiality
committees have been formed and are working on this issue. There seems,
however, to be a wide gap in the approach and scope of differing groups efforts
due to a lack of consensus on proper confidentially measures and national goals.
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Many, concerned about the adequacy of existing private and voluntary efforts
argue that the Federal government should play a leadership role in coordinating
efforts to develop standards, including those related to privacy policy, currently
underway in both the public and private sector. A soon to be released GAO
report, "Automated Medical Records: Leadership Needed to Expedite Standards
Development" will recommend that the Federal government assume this role with
standards more generally. Health care reform should address these same issues.
V.
Safeguards/Solutions.
Privacy safeguards have two important goals:
• protecting privacy and confidentiality in order to gain the public's confidence and
trust in emerging, linked health information systems; and,
• providing security for the health data networks to guard against unauthorized use
by individuals and organizations inside and outside the health care system.
Implementing the following safeguards will enhance protection of privacy and
confidentiality.
A.
Traditional fair information practices should serve as the foundation for
privacy law and practice.
Concern for protecting personal privacy is a leading issue in all Western
industrialized societies. Legislators have responded to these concerns by enacting
protective laws. A Code of Fair Information Practices, although stated somewhat
differently from country-to-country, serves as the basis for these laws. In the
United States, traditional fair information practice principles (formulated by an
advisory committee to the Secretary of Health, Education, and Welfare in 1973)
are the foundation for the Privacy Act of 1974 which is applicable to Federal
records. These practices stipulate that individuals about whom data are collected
have the right to know about and approve the uses to which the data are put, that
no secret data systems are permitted to exist, and that individuals have the right
to review and to correct data about themselves. The Privacy Protection Study
Commission in 1977, and other groups, have supported the application of these
principles to paper and electronic health records.
Clear principles for authorized access to health information should be established.
Direct care providers have the clearest justification for unimpeded access to health
records with the patient's consent. Disclosure of identifiable health information to
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the health plan or others outside the plan for utilization review, quality assessment,
or other legitimate purposes requires informed consent by the patient. Disclosure
of unlinked and unlinkable data for research, quality assurance and quality
assessment requires ethical and policy review of the need for and use of
information. When health information is disclosed in these circumstances, it should
only consist of the information that is necessary to accomplish the legitimate
purpose. Such information must only be used for that purpose with strong
protection of the confidentiality of that information.
B.
Electronic systems must comply with data protection policies that establish
privacy protection guidelines adhering to the Code of Fair Information Practices.
Technological advances in electronic systems are proceeding at a rapid pace and
today's systems will soon be replaced with more sophisticated and potentially
intrusive systems. To be effective in this rapidly changing environment, data
protection policies must not be tied to specific systems and system capabilities, but
must establish privacy protection guidelines in relation to the ultimate goals and
linkages of the system. These issues and protection should be addressed at the
outset of developing electronic data systems to be maximally effective.
Fundamentally, they should guarantee that only those with authorized access are
able to access records for authorized purposes. To accomplish this objective,
systems should:
—
Establish levels of access to computer-based health record
systems through passwords; site specific restrictions; limits on
functional access for the entry, review, update, or deletion of records,
and file segregation; and partitioning (limiting access to parts of file
based on "need-to-know");
—
Establish policies to control electronic transfer of data including
encryption and anonymization;
—
Establish confidentiality policiesforindividuals and organizations with
legitimate access to patient records through networking, computer sharing,
and/or outside computer services contracts;
—
Maintain audit trails (e.g. record of access) for tracking access to
health records;
-*
Provide routine institutional review and monitoring to evaluate
appropriateness of access and security measures;
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Guarantee the right of persons about whom data Is collected to
obtain information about the use of their records; and
-*
Establish policies for the linkage of health records with other records
from different sources.
C.
Data security systems should be monitored and updated to protect the
privacy of health data.
The adequacy of data security systems can be evaluated against prior threats to
confidentiality. Threats to confidentiality can emerge from outside an organization
as well from an institution's own personnel. Security systems should be designed
to address each type of threat. The security system should be maintained on an
ongoing basis. Regular security checks should be conducted and recorded. The
system security should be updated as new technology emerges to prevent
unauthorized use of data.
D.
Many health records will need to be treated as though they are "specially
sensitive."
Health records whose disclosure could cause undue stress, affect social standing
in the community, or economic well-being should receive special attention. Some
specially sensitive health records, for example those covering diseases with
attached social stigmas and the records of celebrities, are already special
protected by many providers and plans. Most drug, mental health, and alcohol
abuse records are subject to Federal confidentiality laws. Protection could be
established for all records to obviate the need for special concern about sensitive
records — which will change over time. This would address the concerns of those
who say that what is sensitive will vary from person-to-person or in terms of the
intended use of the data. For example, information on cancer or heart disease
may be specially sensitive to someone seeking credit on a long-term basis, like
a mortgage.
E.
Development of "a comprehensive longitudinal computer-based patient
record containing clinical,financialand research data" will require use of a unique
personal identifier.
While there is agreement that such an identifier is needed, there is not a
consensus about what that number should be. There are concerns about using the
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social security number, which could readily link health and other information about
the individual. In addition, there are technical problems with the number that would
need to be overcome at significant cost (e.g. Social Security Administration
validation of numbers). Many believe that other options, like a new health
insurance number, may not be administratively practical within the time frame
envisioned for implementing a universal health care system.
F.
Informed consent for the use of data for purposes other than for which it
was collected must be provided by the individual about whom data are collected.
Individuals should be given a clear written account of how personal information will
be used when they are asked to supply such information to the health care
system. They should be informed of procedures that the institution collecting the
data will follow before any the data is used for purposes other than those originally
specified.
Information that has no personal identifiers and that cannot be linked to identifiable
persons should be available to legitimate investigators, subject to approval by the
AHP (including consumer representation) and approval by an Institutional Review
Board. These review boards should have explicit guidelines to recognize and
prevent demographic information from unintentionally identifying individuals.
Identifiable information can be released to qualified investigators with informed
consent of patients or their representatives. General consent for such legitimate
use should be solicited, but may not be required, when an individual enrolls in an
AHP. Forms used for this purpose should be limited in time, describe the type of
information to be released, and the purposes for which it is to be released.
Consumers should be given an opportunity, within the privacy of the provider
patient relationship, to define specially sensitive material (e.g. mental illness, HIV,
illicit drug use) for which explicit, specific, additional consent for release of
information is required.
G.
A uniform national standard for privacy and confidentiality should be
established.
A uniform national standard for privacy and confidentiality would simplify
compliance for organizations which operate nationwide, thereby reducing
administrative costs, and provide uniform protection for information that is crossing
state borders and linked or potentially linked to other data systems. Uniform
standards would make it easier for those about whom information is collected to
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have a clear understanding of how their information is protected.
Enforceable legal remedies and sanctions should be developed for the misuse of
data.
H.
A central management structure is needed to oversee privacy policy and
confidentiality matters and violations.
Proposals have been made to establish a Federal board or commission to oversee
and resolve privacy and confidentiality matters and violations. A data protection
board or commission can provide ongoing expertise, counsel, and monitoring on
privacy and confidentiality matters and violations. Such a body would offer
assurances to providers of data that they have recourse when problems arise.
I.
Special orientation and training programs should be conducted with all
personnel.
Threats to privacy often arise within organizations, Violations of privacy and
confidentiality may result from casual or inadvertent disclosure or deliberate
disclosure for financial or personal gain. Training programs can be important
mechanisms for informing employees of their responsibilities and of the penalties
for misconduct. They can help to inculcate respect for individual rights and
address problems that may arise. Manuals of Operations, monitoring of staff
performance, and routine review of audit trails will contribute to controls on
unauthorized release of health information.
J.
Individuals should be well informed about the health information system.
their rights in relation to the contents and use of the data in the system, and the
obligations of the system to protect their privacy and confidentiality.
Prior to implementation of a health information system, there should be public
notice about the contents, uses, and privacy implications of the system.
The health data system should prepare and distribute a patient's rights handbook
which will inform the individual about the contents and uses of the health data
contained in the system. Individuals should have the right to review their records
and inspect what information is to be released. Individuals have the right to
expect, and the system has the obligation to provide assurances that personal
records are as accurate, timely, and complete as the uses to which they are being
put require for protection of individual rights (Westin).
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Ethics Issues for a New Health Care System
TOLLGATE VERSION
POUCY OPTIONS FOR ADDRESSING
POTENTIAL INEQUITIES IN THE NEW HEALTH CARE SYSTEM
An overwhelming moral imperative for the new health care system should be to avoid
creating a two-tiered system the lower tier of which would ultimately degenerate into a
dumping ground for poor people or those with additional needs. Plans may have
financial incentives to dump low income or high risk patients into situations in which
few services are really available or in which the quality is unacceptable. The
inevitable ambiguities in any comprehensive benefits package, will leave room for both
overt and covert discrimination. Principles of
• universal access
• comprehensive benefits
• equal benefits
• quality
• respect for individual choice
would be compromised and eventually the integrity of the entire system would be
undermined. Injustices and inequities that originally are manifest at the margins
eventually may affect a significant percentage of the population.
These four recommendations address inequities that may arise in the new health care
system, in particular, pertaining to persons with low incomes and persons whose
additional needs will be inadequately addressed by the comprehensive benefits
package. (We refer to "additional needs" where others talk about "special needs"
because the needs may not be qualitatively different but only more extensive.)
RECOMMENDATION 1. The price of premiums for all plans offered within a
particular HIPC should be held within a fairly narrow band. The price of the
highest cost plan should not exceed the price of the lowest cost plan by no
more than 20%. Differences in copays should not be allowed to undermine the
premium band.
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RECOMMENDATION 2. Within a banded premium structure, low income and
poor people (for example, up to 200% of federal poverty level) should be
subsidized fully for the benchmark plan. A sliding scale may be necessary to
avoid a "notch" problem for subsidies to the benchmark plan. A sliding scale of
subsidies up to 300% of federal poverty level should exist for plans above the
benchmark so that low and middle income people retain an effective range of
choices among all plans.
Prohibiting all variation in premiums for AHPs, and providing subsidies for lower
income people, would solve the problem of equal access to comprehensive benefits of
comparable quality, but it would do so by imposing the greatest limit on the range of
choices open to those with greater means. The recommendations made here leave
some room for protecting the range of choices of those with higher income, but it
preserves effective choice for lower income groups at the same time. The sliding scale
of subsidies is intended to avoid violating widely held views about "vertical equity"
(those with higher incomes should not end up worse off than those with lower
incomes) as well as to avoid employment disincentives.
RECOMMENDATION 3. The purchase of supplementary Insurance for benefits
should not be permitted to erode the comprehensiveness or quality of the
comprehensive package. Supplementary insurance should only be publicly
subsidized under specific conditions such as those noted In
RECOMMENDATION 4. —draft.
One way around banding and subsidization is to permit a higher tier of
"supplementary" insurance, but this tier can impose a serious risk to the integrity of
the health plan. The central issue is to make sure that services that provide significant
benefits to those with medical needs remain available within the comprehensive
package and are not available solely or more readily to those who can afford to pay
more for supplementary insurance. For example, patients buying "supplementary"
insurance should not be able to preempt patients from regular plans by obtaining
special access to ICU beds or having more rapid access to transplant services. Here
too the ethical tradeoffs are between protecting the choices of low and middle income
groups by restricting the choices open to those who are wealthier.
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RECOMMENDATION 4. AHPs must take steps to minimize non-financial barriers
to access, such as linguistic and cultural barriers, physical and geographical
barriers, and educational and informational barriers that directly interfere with
the delivery of needed services. HIPCs may require coordinated efforts to
address these problems among AHPs. State or Federal financial support may
be necessary to address some barriers, e.g., the training of personnel needed to
address cultural or linguistic barriers.
Though the health care system cannot possibly correct all of the social problems that
may be associated with poor health, certain specific barriers have a direct impact on
vulnerable groups. The principles assuring equal access and establishing a communal
sharing of burdens require that we support eliminating these barriers within reasonable
limits.
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�April 1,1993
Ira Magaziner
Senior Advisor for Policy Development
The White House
Dear Ira:
The Preamble, I take it, has two purposes, relating to two audiences. The first
audience is policy-makers and legislators, who might seek guidance from moral
principles that should shape their work and identify moral parameters for the
design of the system. The second audience is the wider American public which
needs to have some sense, in your words, that this health care reform is a noble
undertaking.
Two versions of the Preamble have emerged from the membership of Group
17, directed to these different purposes. The two versions do not differ much in
substance. They also generally share the first several pages, except for some minor
changes in rhetoric. The first several pages were largely written by those who had in
mind the second purpose. But from that point on, the second version (with the de
Tocqueville quote as a foreword) departs from the format of the policy-oriented list
of fifteen principles to create a document that might prove potentially useful in the
public arena.
I am therefore forwarding to you this alternative draft for your consideration
at the Tollgate. I look forward to the discussion this Sunday.
Sincerely,
larian Secundy
?o-Leader
Working Group #17 - Ethics
�For Official Use Only
Group #17, April 1,1993
Preamble
A New Health Care System
"When an American asks for cooperation from his fellow citizens, it is seldom
refused. 1 have often seen it spontaneously given with great good will. ... If a great
and sudden calamity befalls a family, the purses of a thousand strangers are at once
willingly opened and small but numerous donations pour in to relieve their
distress.
This does not contradict individualism. Equality ... makes people feel their
independence and shows them their own weakness. They are free, but exposed to a
thousand accidents. Experience quickly teaches them that although they do not
routinely require the assistance of others, a time almost always comes when they
cannot do without it. [A] covenant exists ... between all the citizens of a democracy
when they all feel themselves subject to the same weakness and the same dangers;
their interests as well as their compassion makes it a rule with them to lend one
another assistance when required."
Alexis de Tocqueville, 1840
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Our Common Stake
The health of a nation is a measure of its greatness. Preventable diseases, untreated
illness, and neglected disabilities tear at the fabric of a society. Access to health care
by no means guarantees health, but it helps. A nation draws together, its people
more secure, when they know that every member of the community has access,
when needed, to quality health care they can all afford. The time has come for the
richest nation on earth to ensure that all who live within its borders know that they
have ready access to good health care.
A good health care system responds to our most pressing needs. It keeps expectant
mothers healthy, assists in the safe delivery of our babies, prevents polio and
measles, repairs children's broken bones, teaches us about healthy habits, treats
diseased hearts, eases the agony of arthritis, counsels the emotionally disturbed,
provides wheelchairs for those who cannot walk and care for those who cannot
leave their homes, and comforts the dying.
Our lives change and our health care needs shift over time. We move from the
dependence of childhood through the pressures of adolescence and on to the stresses
and responsibilities of adulthood and finally to the aches, pains and wisdom of old
age. Our lives are unpredictable. We change our careers; jobs do not work out as we
had hoped; we move from place to place; we marry and have children, families
break up, accidents and diseases strike unexpectedly. Our well being and sense of
security depend upon a health care system that spans the discontinuities in our
lives.
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Most of us will be caregivers and be cared for. At times we are properly called to
help others who need our aid. At other times we need the support of those who
can help us. Given the complexity and cost of modem health care and the
unpredictability of personal need, we cannot do this alone. Government must help
us help each other in providing health care.
No one may be left out. A fair system must work for those who speak different
languages or follow different cultural traditions. It must reach to those who live on
farms, in towns, in suburbs or cities. It must look with equal favor upon the rich
and the poor. None should be denied the care they need. No one should find their
opportunities limited for want of health care. We must remember that those in
need are our loved ones, our neighbors, our employees, our taxpayers, our future
care-givers and ourselves.
When people are excluded from health care, they suffer a triple deprivation~the
misery of illness, the desperation of no treatment and the cruel proof that they do
not really belong. They become strangers in their own land.
When individuals lack care, the promise of our common life together is
diminished. In relieving private distress the nation also enables its people to
contribute to the common good. A health care system is important not only to each
of us individually but to the collective well-being of the American people.
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4
The Case for Reform
There is much about our health care system that we should be proud of and
conserve. It has enlisted the devotion of millions of health care professionals,
created splendid hospitals, clinics and research institutions, dazzled the world with
its achievements while empowering patients to make choices in their health care.
Any reform of our system must preserve its virtues.
But our health care system is itself unhealthy. It fails to reach many of us and in so
doing fails to provide the security that a comprehensive system would. It does not
offer sufficient primary, preventative, mental health and long-term care. It supplies
too many specialists and not enough generalists; it pays for procedures performed
rather than good outcomes achieved; it often over-treats, yet insurance coverage
sometimes disappears when most needed. It exposes people who have lost their
jobs to financial ruin. It burdens health care practitioners with too many
regulations and forms. It artificially pits generation against generation in the
competition for resources when in fact we are bound by love with those younger
and older than ourselves. We must remove these burdens, fears and divisions
from the people of our nation.
Our system also costs more to operate than any other health care system in the
world; right now it consumes one seventh of everything we make or do. The costs
of the current system continue to spiral out of control. But, these facts, harsh as they
are, do not fully measure the real cost of the current system. The "fringe benefit" of
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health care is anything but a fringe cost of producing cars, computers and
refrigerators. In some industries, health care is the largest source of cost after wages
and salaries. The staggering cost of health care reduces the competitiveness of
American businesses. The draining of our economic resources into the current
health care system imperils the viability of our society. For our own sake, and the
sake of our children, we must be more responsible stewards of our nation's
resources.
THE MORAL IDEALS JUSTIFYING HEALTH CARE REFORM
Because major health care reform profoundly affects the lives of all Americans, it
must rest upon the moral ideals to which we are dedicated as a nation. Our longheld beliefs and our highest aspirations about community, equality, justice, and
liberty justify so grand an undertaking.
COMMUNITY
We began our life as a nation with the proclamation "We the people." Later, we
tested and affirmed that declaration through the bitter ordeal of the Civil War. Our
sense of "we the people" has continued to expand throughout our history to include
people of all nationalities and religions, women, and those with disabilities. The
test continues to this day. We cannot stand divided between the sick and the well,
the protected and the uninsured. Our flourishing as a people rests upon our ability
to create a health care system that binds us together as one community.
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At the time of the American Revolution, a commonly invoked moral ideal was
"public virtue" - the readiness to sacrifice self-interest for the community. When
called upon, we have shown a readiness to make such sacrifices when we are
convinced that they will fall upon us fairly the resources which these sacrifices
make possible will be expended wisely. In our own time, the need for health care
reform calls us to renew our commitment to the good of our community.
EQUALITY
As a nation we began by dedicating ourselves to the proposition that "all men are
created equal." We have slowly come to understand the importance of expanding
the moral reach of that principle to all.
Throughout our history, Americans have sought equality of opportunity. Health
care provides a way to secure equal opportunity, to redress the imbalances of birth,
fate and luck. All deserve a fair chance to succeed, to make something of
themselves; health care provides us with one of the means of living out that ideal.
However, the principle of equality need not apply rigorously to the distribution of
everything, but it must to health care. Defending the nation and housing its people,
along with health care, are fundamental social goods. We would find it absurd to
limit the protection of defense only to those who could afford a private army. We
ought not limit access to doctors and hospitals simply to those who can afford them.
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Health care, like housing, is important. We attempt (imperfectly) to satisfy the basic
need for shelter through public housing and through tax breaks for homeowners.
We think of more lavish housing as an optional commodity. All should be housed,
but not everyone requires a mansion to satisfy the basic need for shelter. However,
an expensive treatment may be a matter of life or death for a patient. It should not
be denied solely on the grounds of inability to pay. Our long-standing reverence for
life and our commitment to equality require that health care depend on need, not
money.
JUSTICE
We believe in the principle of justice for all. Justice requires fair procedures, but it
means much more. Justice also means the fair sharing of benefits and burdens. The
just sharing of benefits requires equality of access to health care on the basis of need.
It also means sharing fairly the burdens of supporting a health care system.
Justice demands that we conserve our resources for valuable activities other than
fighting illness and pain. Our religious and secular traditions recognize the
importance of responsible stewardship of resources. We cannot spend on
everything we might want. Concern about costs, about managing efficiently and
allocating wisely, grow out of our moral convictions, not just economic necessity.
LIBERTY
Our revolution began with a protest against overbearing governmental authority.
And our Constitution enshrines the value of personal choice and tolerance of
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diversity. Health care, or the lack of it, affects individuals and families so fatefully
that we must conserve choice in our health care system. However, liberty for
Americans has meant more than simply freedom from interference and coercion. It
has also meant enabling our people to have the means to make choices. Equality of
access undergirds liberty; if people do not have access, they are not free.
In our generation, as we have widely expanded the liberty of people of both genders
and all ethnic backgrounds to be eligible for jobs, schools, and housing, we also
recognize we must limit our liberty to some extent so that we can enjoy the benefits
of community.
THE MORAL VALUES AND PRINCIPLES SHAPING
THE NEW HEALTH CARE SYSTEM
Our long-held beliefs of community, equality, justice, and liberty cannot directly
determine the details of health reform. However, they can serve as the anchor for
those values and principles we use to take the measure of the current system, guide
reforms, and evaluate future performance.
Community Caring for All
Health care ranks among the necessities of life, not the accessories. It is not an
optional commodity, like a Walkman, a tie, or a scarf. It is a fundamental good.
Because health care is fundamental, it must honor and reflect the following moral
principles.
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Universal in that benefits reach all of us without financial or other barriers. No one
should fear that a change or loss of a job, part-time or temporary employment, or
economic plight will block them off from health care coverage. No one should lose
access to health insurance due to pre-existing conditions, age, race, or genetic
background. The barriers to access arising from linguistic and cultural differences,
geographical distance, and disability must also come down. The principle of
universal access goes to the soul of reform. It can no longer be a distant ideal; we
must offer it with all deliberate speed.
Comprehensive in that benefits meet the full range of health care needs. We
should offer primary, preventive, and long-term care, as well as acute care; home, as
well as hospital care; treatment for mental, as well as physical illness. An observer
saw through our lopsided allocations when he wrote, "Our system's philosophy
might be condensed in the motto, 'Millions for [acute] care and not one cent for
prevention!'" Those lines were written in 1886. When we attend too little to
primary, preventive, and mental health care, the cost of acute care increases: we
mistarget funds; and we fail to empower people to take responsibility for their own
health.
Fair, in that the system does not create two tiers among citizens, dividing the nation
over this fundamental good, and fair in that the uneven costs and burdens of
meeting our health care needs spread across the entire community. Justice requires
that costs and burdens should be based on the ability to pay. The astronomical costs
of some acute and long-term services can impoverish the sick and the disabled and
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their families; and they imperil the sense of security of those of us who have not yet
been stricken. A fair sharing of benefits and burdens draws the community together
and ties the generations to one another.
Of good quality in that health care is too fundamental a good not to be good. Quality
requires providing health care professionals with an environment that fosters their
best work, protects the integrity of professional judgment, delivers effective
treatments, and weeds out the unethical and incompetent practitioner. Health care
is too fundamental a good not to get better. Therefore, the system must also support
research on the full range of health care services, including research on the
outcomes of health care. Without the assurance of quality in the basic health care
package, the well-to-do will buy up and out, returning the country to a two-nation
health care system.
Responsive to choice in that we have a large measure of freedom to choose our
doctors, the treatments we receive, and the health care plans in which we receive
them. Honoring choice in the health care system not only respects liberty; it also
engages the patient in the success of preventive, acute, rehabilitative and long-term
care.
Making the System Work
Because health care is not the only social good, it must also honor and respect the
following principles.
Preliminary Staff Working Paper - For Illustrative Purposes Only
�For Official Use Only
Group #17, April 1,1993
11
Allocating Wisely. In addition to providing for health care, we must also defend the
nation, provide housing, and educate our children. Therefore, the health care
system must enable us wisely to compare and balance what we spend on health care
against other national priorities. In the past, the structure and funding of the health
care system has not permitted us to make clear choices among these priorities. By
limiting national health care expenditures, we will be in a better position to meet all
our other social needs. Our health care system must also enable us to evaluate and
choose among diverse health services.
Managing Efficiently is a moral, not just economic, imperative. The health care
system should be simply organized, easy for patients and professionals to use, and it
should minimize administrative cost. Efficiency, though, must be defined with a
wise heart, not just a calculator. Cost controls require distinctions between needs
and wants, effectiveness and futility, and must establish some priorities among
health needs. Providers should not be bound by medical cookbooks but should be
encouraged to adopt wise treatment guidelines. Efficiency in the service of
universal access is a virtue, not a limit. It can offer choices and opportunities for
health care for all people, instead of denying any choice to millions. We must
allocate our resources wisely so that we can achieve all of the goals of our health
care system.
Under the conditions of limits and scarcity, justice demands wise allocation and
prudent management of resources.
Preliminary Staff Working Paper — For Illustrative Purposes Only
�For Official Use Only
Group #17, April 1,1993
12
Encouraging Responsibility. Givers as well as receivers of care can make or break
the most ingenious of systems. All of us must take responsibility for the success of
our health care system in reaching its goal of improving the nation's health.
Professionals need to be freed to operate responsibly, in party by relieving them of
intrusive administrative burdens. The system must protect the integrity of
professional/patient relationships while ensuring that the profession fulfills its
public responsibilities. A huge social investment has helped to form and educate
professionals - public outlays for research and medical education, foundation gifts,
corporate grants, bonds floated to build hospitals. A good health care system needs
to foster ways in which those who have received much can give back; it must also
provide opportunities for national service or work in underserved areas. The
health care system needs healers who seek to serve the common good through their
art, who see their profession as a calling, not just a career.
The success of the health care system also depends upon the habits of the heart of
our citizenry. Patients are active partners in their health care. Preventing the heart
attack, rehabilitating from the spinal injury, coping with the stroke often require
changes in the patients' habits to succeed. The system cannot gratify all wants, tamp
down all worries, or remove the mark of mortality from our frame. We need some
self control over our wants, composure in the midst of illness, and courage in the
face of dying. No system of itself can bring these virtues to us. We need to bring
them to the system so that its benefits may sustain us more fully.
Preliminary Staff Working Paper - For Illustrative Purposes Only
�For Official Use Only
Group #17, April 1,1993
13
The ancient Romans tended to emphasize the benefits of citizenship, the Athenians
emphasized its responsibilities. For its moral success, our new system of health care
requires both.
Fair Procedures. The moral ideals that shape our tradition have never coexisted in
easy tranquility. They often reinforce one another, but also conflict with one
another.
The values and principles that more immediately characterize our health care
reform will also compete and press against another for priority. These conflicts do
not discredit the principles. They help us identify what is ethically at stake, the
moral trade offs we must make.
To protect these values and principles, fair and democratic procedures should exist
for making decisions about the operation of the health care system and for resolving
disputes about individual patient care.
Even in a caring community, reasonable people will disagree about how to translate
our moral ideals, values, and principles into a well-functioning health care system.
Difficult decisions will have to be made. We are a democracy that respects the value
of all people and everyone must have access to the reasons for the decisions that
affect them so fundamentally and must have a fair procedure for resolving disputes.
Preliminary Staff Working Paper - For Illustrative Purposes Only
�For Official Use Only
Group #17, April 1,1993
14
A Time To Act
We cannot treat health care reform as a partisan or ideological issue. Our founders
assumed that if a nation could create a common good it should make that good
common. We can deliver health care to all our people, and this health care will
secure and enhance life, liberty and welfare that is our nation's promise to its
citizens. Health care reform asks us to declare our nation a community. Americans
see the need for this redefinition and commitment. This commitment must reflect
our national and personal values; it must recognize our interdependence; it must
embody our care for those we love and our willingness to acknowledge and accept
our neighbors help in our own hour of need. We must commit ourselves to
universal and comprehensive health care as a way to fulfill our national promise. It
is time to make that promise to each other. Healthy children, a people's health, is
our nation's covenant with its future.
"[A] covenant exists ... between all the citizens of a democracy when they all feel
themselves subject to the same weakness and the same dangers; their interests as
well as their compassion makes it a rule with them to lend one another assistance
when required."
Preliminary Staff Working Paper - For Illustrative Purposes Only
�President's Health Care Reform Task Force
Privacy and Security
of Health Care Information
Policy Paper
Prepared
by
Working Group 10 - Information Systems
Working Group 17 - E t h i c a l Foundations
D r a f t 12/S
June 2, 1993
Lawrence 0. Gostin, JD
Executive D i r e c t o r , American Society of Law, Medicine & Ethics
V i s i t i n g Professor, Georgetown U n i v e r s i t y Law Center
Joan Turek-Brezina, PhD
D i r e c t o r f o r Technical and Computer Support, O f f i c e o f t h e
A s s i s t a n t Secretary f o r Planning and Evaluation, DHHS
Chair, DHHS Task Force on the Privacy o f P r i v a t e Sector Health
Records
Madison Powers, JD, PhD
Senior Research Scholar, Kennedy I n s t i t u t e o f E t h i c s , Georgetown
University
Rene K o z l o f f , PhD
Vice President, Kunitz and Associates
Ruth Faden, PhD
Professor, Johns Hopkins School of Hygiene and Public Health
Dennis D. Steinauer, PhD
National I n s t i t u t e of Standards and Technology
�Privacy and Security of Health Care Information
A complex health care information i n f r a s t r u c t u r e w i l l e x i s t
under a reformed health care system. The success of the new system
will
depend,
in
trustworthiness
part,
of the
on
the
accuracy,
i n f o r m a t i o n , and
the
correctness
privacy
and
r i g h t s of
i n d i v i d u a l s t o c o n t r o l the disclosure of personal i n f o r m a t i o n .
A l l p a r t i c i p a n t s i n the new system (consumers and p a t i e n t s , health
plans, h e a l t h a l l i a n c e s , and the n a t i o n a l health board) w i l l need
access t o high q u a l i t y information f o r informed decision making. At
the same time, everyone must have confidence t h a t i n f o r m a t i o n of a
p r i v a t e nature i s adequately protected.
American society places a high value on i n d i v i d u a l r i g h t s ,
autonomous decision
making, and
the
p r o t e c t i o n of the
private
sphere from governmental or other i n t r u s i o n . Concerns about privacy
transcend
the
health
1
2
3
care s e t t i n g . ' ' Americans believe
that
t h e i r privacy r i g h t s as consumers are not adequately protected. I n
a 1991 Harris p o l l on consumer privacy conducted f o r Equifax, Inc.,
79% of the respondents i n d i c a t e d t h e i r concern about t h r e a t s t o
privacy. Nearly three-quarters
lost
a l l c o n t r o l over how
(71%) believed t h a t consumers have
personal
information
about them i s
4
c i r c u l a t e d and used. Public fear and d i s t r u s t of both technology
and bureaucracy i s l i k e l y t o increase as c o l l e c t i o n , storage,
dissemination
Health
5
of information becomes even more automated. '
care
information
is
perhaps
the
most
and
6
intimate.
�personal,
and sensitive of any information
maintained about an
individual. As the U.S. health care system grows i n s i z e , scope,
and integration, the vulnerability of that information
w i l l also
increase.
This chapter explains the privacy and security objectives for
the c o l l e c t i o n , storage, and use of health care information i n the
new system and the means to attain those objectives. The goals are
to ensure: (1) the integrity of health data so that information i s
accurate, complete and trustworthy — the integrity of information
is
critical
to quality patient
care,
assessment
of services,
research, and public health; (2) the a v a i l a b i l i t y of health data so
that authorized
persons who need the information
health purposes have ready access
to the data
for legitimate
—
i f clinical
information i s not readily available to health care providers, the
best i n t e r e s t s of patients may be s i g n i f i c a n t l y compromised; and
(3) the privacy of patients so that they can be assured
personal
information
that
remains private and w i l l not be disclosed
without t h e i r knowledge and permission.
The goals of integrity, a v a i l a b i l i t y , and privacy can only be
achieved by establishing a national privacy and security framework.
The terms privacy, confidentiality, and security are used i n the
following ways i n this chapter. Privacy, although a highly complex
concept,
i s defined
accessibility
to
as a condition
some
aspect
of
of limited or r e s t r i c t e d
the
7
8
9
10
person. ' ' ' '
11
This
chapter focuses on informational privacy so that information about
a
person
i s beyond
the range
of
others
without
specific
�authorization.
12
Confidentiality
is
closely
related
to
i n f o r m a t i o n a l privacy. C o n f i d e n t i a l i t y i s defined as an assurance
t h a t personal information obtained i n the course of a h e a l t h care
p r o f e s s i o n a l / p a t i e n t r e l a t i o n s h i p w i l l not be revealed
unless
the
disclosure.
person
is
Security
first
made aware
encompasses
a
and
set
t o others
consents
of
to i t s
technical
and
a d m i n i s t r a t i v e procedures designed t o p r o t e c t data systems against
unwarranted
disclosure,
modification,
or
destruction
and
to
safeguard the system i t s e l f .
This chapter f i r s t
examines the information i n f r a s t r u c t u r e
l i k e l y t o emerge i n the new health care system. This includes
the
continued development of automated systems and the establishment of
a unique i d e n t i f i e r necessary f o r access t o health care. Second, an
examination of
provided
current
law
on
privacy
t o show the wide v a r i a b i l i t y
and
and
confidentiality
is
inadequacy of l e g a l
safeguards. T h i r d , the e t h i c a l foundations f o r safeguarding privacy
are explored so t h a t changes i n law and p o l i c y are consistent w i t h
sound e t h i c a l values. Fourth, a set of f a i r i n f o r m a t i o n p r a c t i c e s
i s presented t h a t w i l l guide a l l p a r t i c i p a n t s i n the new system i n
the c o l l e c t i o n and
use
s e c u r i t y of
information
health
of c o n f i d e n t i a l i n f o r m a t i o n . F i f t h ,
systems, p a r t i c u l a r l y
the
automated
systems, i s examined. F i n a l l y , the chapter sets out a series of
actions necessary f o r ensuring
the i n t e g r i t y , a v a i l a b i l i t y ,
c o n f i d e n t i a l i t y of health records.
The
most important
and
of these
actions are the establishment of a n a t i o n a l privacy p o l i c y through
f e d e r a l l e g i s l a t i o n , and
the c r e a t i o n of a data p r o t e c t i o n
and
�s e c u r i t y panel as p a r t o f the National Health Board t o oversee and
manage privacy and s e c u r i t y i n the new system.
Health Information i n a New Health Care System
The
c o l l e c t i o n and transmission
of vast
amounts o f health
i n f o r m a t i o n i n automated form w i l l occur w i t h or without reform of
the
13
h e a l t h care system. '
14
The new system w i l l
need f o r a d d i t i o n a l information f o r monitoring
also
create
a
p a t i e n t care and
assessing system performance. This w i l l require the sharing of a
large volume of d e t a i l e d health information among system players,
i n c l u d i n g the National Health Board, health a l l i a n c e s , accountable
health plans,
and p u b l i c health departments.
15
The health
care
i n f r a s t r u c t u r e t h a t w i l l e x i s t under the new system w i l l have t h e
f o l l o w i n g features t h a t are c r i t i c a l l y important i n p r o v i d i n g high
q u a l i t y cost e f f e c t i v e health care, but r e q u i r e rigorous
privacy
safeguards.
Automated Health
The
Information
new system w i l l store and transmit more and more health
i n f o r m a t i o n i n e l e c t r o n i c form. Automation w i l l support e f f o r t s t o
provide
higher
quality,
cost
effective
health
care.
16
Data
c o l l e c t e d w i l l provide information needed f o r q u a l i t y assurance,
analysis o f p r a c t i c e patterns and p a t i e n t outcomes, and s c i e n t i f i c
research, a l l of which c o n t r i b u t e t o higher q u a l i t y care. These
data can also b e t t e r inform consumers of t h e i r health care choices.
Automation can reduce health care costs by e l i m i n a t i n g the need f o r
d u p l i c a t e t e s t s , make i t easier t o detect fraud based upon more
d e t a i l e d examination of p r a c t i c e , and e l i m i n a t e enormous paperwork
�burdens from p a t i e n t s , health care professionals and h e a l t h plans.
Automation
coverage.
also
supports
Information
the goal
will
of p o r t a b i l i t y
be r e a d i l y a v a i l a b l e
o f health
i n a mobile
s o c i e t y , as consumers move from provider t o provider, plan t o plan.
The ease of c o l l e c t i o n , storage and transmission o f data over
e l e c t r o n i c networks also creates
s i g n i f i c a n t r i s k s t o privacy.
Health records can contain a vast amount of personal i n f o r m a t i o n
w i t h m u l t i p l e uses:
race,
17
demographic information such as age, sex,
and occupation; f i n a n c i a l
information
such as employment
status and income; information about d i s a b i l i t i e s , s p e c i a l needs
and
other
eligibility
criteria
f o r f e d e r a l or s t a t e
medical i n f o r m a t i o n such as diagnoses, treatments,
subsidies;
and disease
h i s t o r i e s i n c l u d i n g mental i l l n e s s , drug or alcohol dependency,
AIDS and sexually t r a n s m i t t e d diseases; and s o c i a l i n f o r m a t i o n such
as f a m i l y s t a t u s , sexual r e l a t i o n s h i p s , and l i f e s t y l e choices. This
i n f o r m a t i o n i s f r e q u e n t l y s u f f i c i e n t t o provide a d e t a i l e d p r o f i l e
of the i n d i v i d u a l . T r a d i t i o n a l medical records, moreover, are only
a subset o f automated records containing
s u b s t a n t i a l health or
personal i n f o r m a t i o n held by educators, employers, law enforcement,
c r e d i t and banking, and government agencies. (See Figure 1 ) .
Although i t i s not c u r r e n t l y planned, f u t u r e systems may r e l y
on
emerging e l e c t r o n i c card
technologies
t h a t are capable of
s t o r i n g s u b s t a n t i a l health and personal data. The card
technologies
used f o r s t o r i n g information include embossed cards, magnetic s t r i p
cards, i n t e g r a t e d c i r c u i t
cards
(i.e.,
memory chip
cards) and o p t i c a l storage cards. E l e c t r o n i c card
or "smart"
technologies
�could make health data more a v a i l a b l e t o health care p r o f e s s i o n a l s ,
p a r t i c u l a r l y i n emergencies, but pose a d d i t i o n a l r i s k s t o privacy
and system s e c u r i t y .
18
The importance of privacy and s e c u r i t y of automated records i s
widely
acknowledged; numerous governmental and
19
committees are working on
General
Accounting
20
the i s s u e . ' '
Office
(GAO)
report
21
nongovernmental
A recently
recommends
released
a
federal
leadership r o l e i n the development of n a t i o n a l standards f o r the
p r o t e c t i o n of automated records.
22
Health Security Cards and Unique I d e n t i f i e r s
Under the new system, health s e c u r i t y cards w i l l be issued t o
a l l c i t i z e n s and l a w f u l residents of the United States
them t o r e g i s t e r i n an accountable health plan and
services
under
Identifiers
health
are
care
a
f e d e r a l l y defined
benefits
be
used
to
package.
needed f o r the e f f i c i e n t operation
system. They w i l l
entitling
receive
Unique
of the
f o r purposes
such
new
as
p r o v i d i n g access t o care; e s t a b l i s h i n g l o n g i t u d i n a l and geographic
l i n k s among health care records i n order t o improve p a t i e n t care;
analyzing
activities;
patterns
and
of
health
providing
a
care;
more
evaluation of the health care system.
identifying
detailed
fraudulent
examination
and
23
Perhaps the most c r i t i c a l s i n g l e decision regarding
privacy
and s e c u r i t y i n the reformed health care system i s whether t o use
the s o c i a l s e c u r i t y number (SSN)
as the i n d i v i d u a l
identifier.
2 4
Almost a l l of the recent health care i n i t i a t i v e s have proposed
using the SSN as the unique personal i d e n t i f i e r because i t provides
�the
most cost e f f e c t i v e
individual
and
25
26
information. ' '
completely
and t i m e l y method of i d e n t i f y i n g the
reliably
27
collecting
However,
reliable
the SSN
identifier:
and
at
sharing
present
personal
i s not a
i t i s not unique, there are
m u l t i p l e users of a s i n g l e number, and i t i s d i f f i c u l t t o determine
28
whether a random n i n e - d i g i t number i s a v a l i d SSN. The p r i n c i p a l
reason f o r the lack of r e l i a b i l i t y i s t h a t u n t i l t h e l a t e 1970s
stringent
documentation
requirements
f o r the SSN
were not
implemented. I t could cost i n the range of $1.0 t o 2.5 b i l l i o n t o
v e r i f y t h e i d e n t i t i e s of a l l holders and t o issue a new, more
secure card. Supporters argue t h a t , i n s p i t e of current problems,
the
SSN can be cleaned up f a s t e r and cheaper than c r e a t i n g a new
29
system. '
30
Objections t o the use of the SSN have been raised on c i v i l
l i b e r t i e s grounds. The SSN i s used extensively f o r a large v a r i e t y
of non-health r e l a t e d purposes. Among the users of the SSN are debt
collectors,
department
stores,
utilities,
check
validation
services, super markets, cable t e l e v i s i o n , c r e d i t card issuers,
banks, major o i l
companies, the I n t e r n a l Revenue Service, other
Federal agencies ( m i l i t a r y , Parent Locator Service, Food Stamps,
Selective Service System), m a i l i n g l i s t companies, c r e d i t bureaus,
law
enforcement
agencies,
insurance
companies,
the Medical
Information Bureau, motor vehicles departments, employers, schools
and
universities,
capacity
3 3
3 4
to link
3 5
life. ' ' '
3 6
and s t a t e
databases
31
agencies. '
on many
32
The SSN provides a
aspects
of a
person's
�Many people fear t h a t the SSN has become a de f a c t o n a t i o n a l
identifier.
3 7
Evan Hendricks noted:
Not only does the SSN make i t easier f o r large
i n s t i t u t i o n s t o compare t h e i r databases, i t allows
curious
individuals (including private detectives,
computer hackers or other strangers you might not want
snooping i n your p r i v a t e l i f e ) t o "hop" from database t o
database and draw out a p r o f i l e of your buying habits and
personal l i f e s t y l e . "
An a l t e r n a t i v e t o the SSN as a unique i d e n t i f i e r would be a number
with
no use other
than f o r the new health
care system. Each
person's h e a l t h s e c u r i t y number, then, would become j u s t as p r i v a t e
as his orher health record.
Whatever unique i d e n t i f i e r i s chosen, i t w i l l be necessary t o
m i t i g a t e t h e fears expressed by many c i t i z e n s by e s t a b l i s h i n g a
n a t i o n a l privacy p o l i c y t h a t e x p l i c i t l y f o r b i d s the l i n k i n g of
health care and other
number.
38
information using
the SSN or any other
Exceptions f o r l i m i t e d , c l e a r l y defined purposes such as
health care research or s t a t i s t i c a l information i n n o n - i d e n t i f i a b l e
form should be permitted. Further discussion of a l t e r n a t i v e s f o r a
unique i d e n t i f i e r w i l l begin immediately, and an i d e n t i f i e r w i l l be
established very e a r l y i n the reform process.
Patient Based L o n g i t u d i n a l Health Records
The
growing
needs
f o r detailed
micro-level
health
data
generated by health care reform are emerging i n an environment i n
which t h e f u t u r e v i s i o n of health information systems i s already
undergoing r a d i c a l change. Although many health records have long
existed
i n automated
form, they
have t r a d i t i o n a l l y
tended t o
support s p e c i f i c functions such as the l a b o r a t o r y , pharmacy, or
8
�finance department. A fundamental s h i f t t o patient-based records i s
now o c c u r r i n g as p a r t of longer-term
national
electronic
39
40
networks. ' '
patient-based
efforts
toward b u i l d i n g
health
information
41
The development of e l e c t r o n i c health care networks p e r m i t t i n g
standardized
patient-based
i n f o r m a t i o n t o flow nationwide, and
perhaps even worldwide, means t h a t the current privacy p r o t e c t i o n
focus on r e q u i r i n g the i n s t i t u t i o n t o p r o t e c t i t s records must be
reconsidered. Our past t h i n k i n g assumed a paper or automated record
created
and protected by the provider. We may now envision a
patient-based
record t h a t anyone i n the system can c a l l up on a
screen. Because l o c a t i o n has less meaning i n an e l e c t r o n i c world,
p r o t e c t i n g privacy requires a t t a c h i n g privacy p r o t e c t i o n s t o the
health record i t s e l f , r a t h e r than t o the i n s t i t u t i o n t h a t generates
it.
4 2
Dual Systems of Health Records
While many health care services w i l l be provided w i t h i n the
framework of the new health care system, some w i l l be provided
outside o f i t . As a r e s u l t , a n a t i o n a l privacy p o l i c y must apply t o
a l l h e a l t h care records whether or not they were generated i n the
new system.
Health records outside of the new system may be generated from
many d i f f e r e n t sources: services not covered i n the comprehensive
b e n e f i t s package under the new system may be purchased
supplemental insurance;
through
large employers may choose t o opt out o f
the system; Medicare may remain outside of t h e new system;
43
and
�some epidemiological, behavioral, and health services research may
be conducted outside o f the new system.
Breaches o f privacy
outside
accountable health
plans may
create unintended and undesirable consequences f o r the operation o f
the new health care system.
44
Because the same records may be used
f o r both system and non-system purposes, a r e a l danger e x i s t s t h a t
abuses occurring outside the new health care system w i l l be f a l s e l y
attributed
t o i t thereby c r e a t i n g
negative impressions o f how
i n f o r m a t i o n i s handled.
Current Legal Protection of Privacy and Confidentiality
Legal p r o t e c t i o n of privacy and c o n f i d e n t i a l i t y i n the current
health care system i s h i g h l y v a r i a b l e and usually w e l l below the
standards proposed i n privacy commission r e p o r t s .
45
A recent U.S.
Department o f Health & Human Services r e p o r t concludes t h a t s t a t e
rules superimposed on a f e d e r a l regulatory framework r e s u l t s i n "a
4 6
morass o f e r r a t i c law, both s t a t u t o r y and j u d i c i a l . " '
4 7
Current privacy and c o n f i d e n t i a l i t y protections are a product
of
federal
and s t a t e
c o n s t i t u t i o n a l law, f e d e r a l
and s t a t e
s t a t u t e s , and s t a t e common law. The Supreme Court held i n Whalen v.
Roe
the
48
t h a t when states e s t a b l i s h mandatory r e p o r t i n g requirements
public
health
department must have minimal
p r o t e c t i n g t h e privacy
standards f o r
o f h i g h l y personal or s e n s i t i v e medical
i n f o r m a t i o n . The d o c t r i n e of Whalen v. Roe, however, applies
to
only
governmental agencies, not t o p r i v a t e p a r t i e s ; i t has been
r a r e l y , and i n c o n s i s t e n t l y , applied outside o f the s p e c i f i c f a c t s
10
�of t h a t case ( i . e . , drug abuse r e p o r t i n g
Since t h e 1970s, more than
49
50
requirements). ' '
a dozen states
51
have adopted
c o n s t i t u t i o n a l amendments designed t o p r o t e c t a v a r i e t y of privacy
i n t e r e s t s , and most include provisions l i m i t i n g access t o personal
or
highly
sensitive
information.
52
Although most o f t h e s t a t e
c o n s t i t u t i o n a l provisions only p r o t e c t against breaches o f privacy
by governmental agencies, some courts have applied t h e i r guarantees
5 3
t o p r i v a t e p a r t i e s as w e l l . '
The
together
uncertain
with
provisions,
5 4
status of f e d e r a l c o n s t i t u t i o n a l safeguards,
the l i m i t e d
means t h a t
number
the main
of
state
protection
constitutional
f o r informational
privacy resides i n l e g i s l a t i o n and the common law. Even here, the
value o f privacy protections i s h i g h l y v a r i a b l e depending upon the
j u r i s d i c t i o n and the kind of health information c o l l e c t e d .
The
landmark Federal Privacy
Act of 1974 protects c i t i z e n s
from government disclosure of c o n f i d e n t i a l i n f o r m a t i o n .
55
Hospitals
operated by the f e d e r a l government and p r i v a t e health
research
institutions
maintaining
medical
records
care or
pursuant t o
government contract are subject t o i t s p r o v i s i o n s . The f a c t t h a t i t
does not apply t o many other i n s t i t u t i o n s means t h a t i t does not
f i l l many o f the most s i g n i f i c a n t gaps i n privacy p r o t e c t i o n .
Federal
legislation
5 6
and r e g u l a t i o n
57
create
strict
rules
f o r maintaining the c o n f i d e n t i a l i t y of records of p a t i e n t s who are
treated
f o r drug
facilities.
5 8
A
or alcohol
dependency
significant
limitation
at federally
of
these
funded
federal
r e s t r i c t i o n s i s t h a t information about drug and alcohol use, as
11
�well
as information
about
prior
treatment
f o r addiction, i s
r e g u l a r l y entered i n t o v i r t u a l l y a l l other r o u t i n e medical records
and i s thus made more r e a d i l y a v a i l a b l e t o wider audiences than the
f e d e r a l s t a t u t e contemplates.
Many states have privacy p r o t e c t i o n contained
i n medical and
other p r o f e s s i o n a l p r a c t i c e acts, h o s p i t a l and other i n s t i t u t i o n a l
licensure
laws
and, i n some
cases,
comprehensive
medical
i n f o r m a t i o n s t a t u t e s . These s t a t u t o r y schemes also contain many
important gaps i n coverage. Many s t a t e medical records s t a t u t e s ,
f o r example, contemplate or require maintenance o f manual p a t i e n t
records
so t h e p r o t e c t i o n
59
uncertain. '
regulation
60
afforded
t o automated
records i s
I n a d d i t i o n , i n most states there i s l i t t l e or no
o f the i n f o r m a t i o n a l practices
of insurers;
61
only
fourteen states have adopted model privacy l e g i s l a t i o n d r a f t e d by
the National Association of Insurance Commissioners (NAIC).
Other s t a t e laws o f f e r a patchwork o f privacy p r o t e c t i o n t h a t
is
often
disease-specific.
For example, most
states
protect
i n f o r m a t i o n regarding HIV i n f e c t i o n or AIDS. However, some o f these
states allow disclosure
only t o avert a s i g n i f i c a n t r i s k t o a
sexual or needle sharing
r e q u i r e disclosures
itself
becomes
transmitted
while
others
allow
or even
i n so many s i t u a t i o n s t h a t the privacy
virtually
disease
partner,
meaningless.
statutes
62
contain
Many
strong
state
rule
sexually
protections
of
c o n f i d e n t i a l i t y , but communicable disease or t u b e r c u l o s i s s t a t u t e s
6 3
contain weak p r o t e c t i o n s or none a t a l l . '
6 4
Most states recognize a common law duty o f c o n f i d e n t i a l i t y
12
�applying t o c e r t a i n health care professionals. Thus, i f a p a t i e n t
discloses
personal
information
t o a health
care
professional
b e l i e v i n g t h a t i t i s p r i v a t e and c o n f i d e n t i a l , the p r o f e s s i o n a l may
be
l i a b l e f o r disclosure without the p a t i e n t ' s consent.
65
While
common law p r o t e c t i o n s o f c o n f i d e n t i a l i t y probably provide the most
consistent safeguards, s i g n i f i c a n t gaps e x i s t i n l e g a l d u t i e s . For
example,
i n many
states,
the l e g a l
duties
o f physicians
to
safeguard p a t i e n t confidences do not extend t o other h e a l t h care
professionals,
clinical,
epidemiological
and
behavioral
researchers, or health care i n s t i t u t i o n s , even though the r i s k o f
66
harm from disclosure may be as great or g r e a t e r . '
67
There are several important reasons t o believe t h a t continued
r e l i a n c e upon state-by-state privacy laws, supplemented by l i m i t e d
f e d e r a l l e g i s l a t i o n , i s incompatible w i t h the p o l i c y o b j e c t i v e s o f
an
integrated
national
health
care
system.
68
A
state-by-state
approach t o r e g u l a t i o n o f medical information does not r e f l e c t the
r e a l i t i e s o f modern health care finance and d e l i v e r y . The flow o f
medical i n f o r m a t i o n i s r a r e l y r e s t r i c t e d t o the s t a t e i n which i t
i s generated. Such information i s r o u t i n e l y t r a n s m i t t e d t o other
states,
subject
to differing
legal
requirements
and
privacy
p r o t e c t i o n s , f o r a wide v a r i e t y o f purposes ranging from medical
c o n s u l t a t i o n and research c o l l a b o r a t i o n t o governmental monitoring
f o r q u a l i t y and f o r d e t e c t i n g fraud and abuse.
Further, t h e physical l o c a t i o n o f health i n f o r m a t i o n i s no
longer
a
relevant
consideration
f o r development
of
privacy
p r o t e c t i o n p o l i c i e s . Databases containing huge q u a n t i t i e s o f health
13
�and personal information provide the basis f o r immediate access by
a v a r i e t y o f e l i g i b l e users i n remote l o c a t i o n s . Thus, s t a t e laws
which attempt t o regulate information p h y s i c a l l y contained
p a r t i c u l a r s t a t e are anachronistic
vestiges
ina
of a p r e - e l e c t r o n i c
era.
The prospects
f o r r e s o l v i n g privacy
problems through the
enactment o f model or uniform laws i n every s t a t e i s exceedingly
small. The National Conference of Commissioners on Uniform State
Laws adopted the Uniform Health Care Information Act i n 1985, but
only two s t a t e s , Montana and Washington, have enacted i t .
6 9
The
l i m i t e d response t o the NAIC Model Act i s f u r t h e r evidence o f the
p o l i t i c a l i m p r a c t i c a b i l i t y of the uniform s t a t e law approach.
The absence of uniform privacy and c o n f i d e n t i a l i t y p r o t e c t i o n
applicable throughout the country imposes hardships on v i r t u a l l y
a l l involved. Health care i n s t i t u t i o n s , insurance companies, and
self-insured
employers who transmit
health
information
i n t e r s t a t e commerce o f t e n do so without c l e a r guidance
which state's
jurisdiction
ability
laws govern or which state's courts
t o resolve
disputes
through
regarding
have proper
t h a t may a r i s e . Without the
t o know and t o r e l y upon uniform
privacy
regulations,
p a t i e n t s may lack the basis f o r meaningful consent t o disclosure of
information.
adversely
Lack
of u n i f o r m i t y
of privacy
protections
may
a f f e c t the q u a l i t y of health data, and the q u a l i t y of
care i t s e l f ,
by undermining e f f o r t s t o automate health
records.
These detriments of state-by-state privacy p r o t e c t i o n s w i l l only be
magnified
i n a new health care system where p a t i e n t s w i l l
14
be
�e n t i t l e d t o coverage anywhere they l i v e i n the country and where
i n f o r m a t i o n f o r monitoring q u a l i t y and cost effectiveness w i l l be
c o l l e c t e d n a t i o n a l l y under the auspices o f a National Health Board.
Consequently, many persuasive reasons e x i s t t o adopt a uniform
f e d e r a l privacy p o l i c y t h a t transcends s t a t e borders.
The E t h i c a l Framework for Privacy
The nature and degree o f p r o t e c t i o n which should be accorded
t o t h e i n d i v i d u a l ' s i n t e r e s t s i n privacy and c o n f i d e n t i a l i t y are
among the most s i g n i f i c a n t questions t o be addressed i n the process
of h e a l t h care reform. The task i s t o secure an adequate measure o f
respect f o r the privacy and autonomy o f the i n d i v i d u a l consistent
w i t h s o c i e t a l needs f o r an e f f i c i e n t system o f health care finance
and
d e l i v e r y , an adequate and r e l i a b l e i n f o r m a t i o n a l basis f o r
health care planning, and an enhanced c a p a b i l i t y f o r promoting and
p r o t e c t i n g the public's h e a l t h . The p o t e n t i a l harm t o i n d i v i d u a l
i n t e r e s t s from disclosure of personal health i n f o r m a t i o n , as w e l l
as a strong presumption i n our society i n favor o f respecting
autonomy (or t h e r i g h t o f the i n d i v i d u a l t o r e t a i n c o n t r o l over
aspects o f h i s or her own person) provide powerful
favor
of restricting
the access
others
may
arguments i n
have
t o such
i n f o r m a t i o n . However, the i n f o r m a t i o n a l requirements f o r r e a l i z i n g
l e g i t i m a t e s o c i e t a l goals of health care reform may necessitate
t h a t more r a t h e r than
less personal
i n f o r m a t i o n i s generated,
c o l l e c t e d , and made a v a i l a b l e t o designated others f o r a v a r i e t y o f
treatment, research, and p o l i c y planning purposes.
15
�The l i t e r a t u r e on privacy abounds w i t h accounts o f t h e moral
foundations
or j u s t i f i c a t i o n s
f o r r u l e s of privacy. A primary
j u s t i f i c a t i o n f o r respecting privacy resides i n the p r i n c i p l e o f
respect
f o r autonomy. To respect the privacy o f others i s t o
respect t h e i r autonomous wishes not t o be accessed i n some respect- not t o be observed or have i n f o r m a t i o n about themselves made
a v a i l a b l e t o others. Respecting
privacy i s an important means of
f o s t e r i n g and developing a sense of s e l f , of personhood, and of
70
personal
autonomy. '
individuals
cannot
71
In
the
formulate
absence
autonomous
of
some
privacy,
preferences
o r , more
b a s i c a l l y , develop the capacity t o be s e l f governing.
Privacy
also enhances the development and maintenance of
i n t i m a t e human r e l a t i o n s h i p s — r e l a t i o n s of t r u s t , f r i e n d s h i p and
respect.
72
I t i s arguably one of the d e f i n i n g c h a r a c t e r i s t i c s of
i n t i m a t e r e l a t i o n s h i p s t h a t they involve the s h a r i n g — f r e e l y given-of
private
i n f o r m a t i o n , spaces,
r e l a t i o n s h i p , we allow another
and acts.
I n an i n t i m a t e
t o enter the otherwise
private
sphere o f our l i v e s . I f privacy i s not cherished and respected,
both the capacity f o r , and meaning o f , i n t i m a t e d i s c l o s u r e i n human
r e l a t i o n s h i p s are c l e a r l y diminished.
F i n a l l y , i n f o r m a t i o n f r e q u e n t l y i s viewed as a resource, the
possession of which by others enables them t o exercise power over
i n d i v i d u a l s . This raises the p o s s i b i l i t y of e x p l o i t a t i o n and the
consequent
73
being. '
74
loss
of psychological, s o c i a l ,
and economic
I t i s not necessary t o resolve which
foundational
moral
justification
16
f o r respecting
well-
i s t h e more
privacy—the
�formation of i n t i m a t e r e l a t i o n s h i p s , respect f o r autonomy, or the
development
expression.
of
personhood
and
the
capacity
for
autonomous
The c e n t r a l p o i n t i s t h a t privacy's moral value i s i n
the main d e r i v a t i v e , and based on a complex of moral commitments
and concerns.
Several moral arguments have been used t o j u s t i f y r u l e s of
confidentiality
intrinsic
i n the health care context:
to
the
professional/patient
very
nature
of
confidentiality is
the
r e l a t i o n s h i p , characterized
health
as
care
i t is
(or
should be) by t r u s t and intimacy; c o n f i d e n t i a l i t y i s at l e a s t an
i m p l i c i t and sometimes e x p l i c i t promise embedded i n the i n s t i t u t i o n
of h e a l t h care and i t i s wrong t o break a promise; c o n f i d e n t i a l i t y
i s necessary t o b r i n g about good t o p a t i e n t s and t o society
without t h i s assurance, people would not share medically
and,
relevant
i n f o r m a t i o n ; and c o n f i d e n t i a l i t y i s necessary t o prevent p a t i e n t s
from the harm t h a t could
collected
i n the
reasonably b e f a l l them i f i n f o r m a t i o n
course of
treatment
a v a i l a b l e . C o n f i d e n t i a l i t y i s important
were t o become p u b l i c l y
i n health care not
only
because i t i s a s i g n i f i c a n t component of i n f o r m a t i o n a l privacy, but
also because i t advances these other moral values, i n a d d i t i o n t o
respecting
privacy.
75
The e t h i c a l j u s t i f i c a t i o n s f o r privacy p r o t e c t i o n s and rules
of c o n f i d e n t i a l i t y p o i n t t o a v a r i e t y of underlying harms t h a t may
r e s u l t from unwanted disclosures
of personal medical or
health
status i n f o r m a t i o n . I n t r i n s i c moral harms are those t h a t r e s u l t
from the mere f a c t of an unwanted or u n j u s t i f i e d d i s c l o s u r e
17
of
�personal
i n f o r m a t i o n . Many moral views a t l e a s t recognize t h e
d e s i r a b i l i t y o f p r o t e c t i n g i n d i v i d u a l s against i n s u l t t o d i g n i t y
and
t h e lack
o f respect
f o r the person
evidenced
by such
disclosures.
Consequential harms are those which are a r e s u l t o f a loss o f
p r i v a c y , and they matter morally regardless o f whether the loss o f
privacy i s a consequence o f an i n t e n t i o n a l , n e g l i g e n t , or p e r f e c t l y
innocent a c t i o n o f another. The morally s i g n i f i c a n t feature o f such
losses o f privacy l i e i n the actual harm t h a t i s caused. A breach
of privacy can r e s u l t i n economic harms such as loss o f employment
or e m p l o y a b i l i t y , insurance or i n s u r a b i l i t y , or housing. I t can
also r e s u l t i n s o c i a l or psychological harms. Disclosure o f some
conditions can be s t i g m a t i z i n g , and can cause embarrassment, s o c i a l
i s o l a t i o n , and the loss o f self-esteem. These r i s k s are e s p e c i a l l y
great when the perceived causes o f the medical c o n d i t i o n or i l l n e s s
include t h e use o f i l l e g a l drugs, s o c i a l l y disfavored
forms o f
sexual expression, or other behavior not widely s o c i a l l y approved.
Moreover, s t i g m a t i z a t i o n may be a consequence o f such disclosures
i n some instances even when the p o t e n t i a l causes do not involve any
despised
choices
individual.
withdraw
on the p a r t
o f the a f f e c t e d
Family members, neighbors, and work associates
s o c i a l support
conditions
mental
or behavior
from
those
revealed
t o have c e r t a i n
or diseases, e s p e c i a l l y i f such conditions
o r emotional
instability
or physical
may
or
involve
behavioral
a t t r i b u t e s t h a t some i n d i v i d u a l s f i n d uncomfortable t o observe.
Although privacy i s important, i t i s not always unambiguously
18
�a p o s i t i v e value.
Nor
i s i t always paramount i n c o n f l i c t s w i t h
other cherished values. For example, there may be a need t o access
an i n d i v i d u a l ' s personal health information i n order t o prevent
harm t o an i d e n t i f i a b l e person, or t o b e n e f i t the person who i s the
subject
of
the
information,
or
to
benefit
another
person.
A l t e r n a t i v e l y , access t o the information may be needed i n order t o
f u r t h e r the l e g i t i m a t e and valued s o c i a l i n t e r e s t s of a l l c i t i z e n s
i n such matters as p u b l i c a c c o u n t a b i l i t y , monitoring and evaluation
of the h e a l t h care system, e f f i c i e n c y i n the d e l i v e r y of
care,
s c i e n t i f i c advance and medical knowledge, and the public's h e a l t h .
Any
infringement
of
privacy
must
be
done
in
the
least
i n t r u s i v e manner possible. The information accessed must be no more
than i s necessary t o accomplish the end j u s t i f y i n g the
and
must be
r e s t r i c t e d t o only those persons who
l e g i t i m a t e need t o know. I n general,
infringement
have a
the more comprehensive
i d e n t i f i a b l e the i n f o r m a t i o n , the more l i k e l y i t i s t o
e r r o r or be
misleading,
and
truly
the more s e n s i t i v e or
and
contain
potentially
damaging i f disclosed, the greater the moral burden on those
who
have such i n f o r m a t i o n i n t h e i r possession.
F a i r Information Practices
A major p o l i c y e f f o r t on privacy and c o n f i d e n t i a l i t y emerged
i n the e a r l y 1970s t h a t has
development of a uniform
enduring importance today f o r the
f e d e r a l privacy
p o l i c y . The
Advisory
Committee on Automated Personal Data Systems developed p r i n c i p l e s
of
"fair
76
information practices." '
77
Fair i n f o r m a t i o n
practices
r e q u i r e the informed consent of persons f o r the use of personal
19
�data, grant persons the r i g h t t o review and c o r r e c t personal data,
and l i m i t the use o f data t o t h e i r l e g i t i m a t e intended purposes.
Informed Consent
If
a c e n t r a l e t h i c a l value behind
privacy i s respect f o r
personal autonomy, then i n d i v i d u a l s about whom data are c o l l e c t e d
must be a f f o r d e d t h e r i g h t t o know about and approve t h e uses t o
which
data
are t o be put. Informed
consent requires adequate
i n f o r m a t i o n t o enable a person t o make a genuinely informed choice.
The
person,
t h e r e f o r e , needs i n f o r m a t i o n about t h e purpose o f
d i s c l o s u r e , t o whom i t w i l l be made, during what period o f time,
and t h e safeguards
against unauthorized d i s c l o s u r e . I n d i v i d u a l s
cannot provide informed consent unless they have the capacity t o
understand
t h e i n f o r m a t i o n and are l e g a l l y
competent.
The
i n d i v i d u a l must be presented w i t h a t r u l y v o l u n t a r y choice and must
78
consent t o the s p e c i f i c d i s c l o s u r e . '
79
Persons cannot make an informed choice about d i s c l o s u r e i f
they are unaware t h a t personal data i s being c o l l e c t e d , stored, o r
released t o t h i r d p a r t i e s . Consequently, f a i r i n f o r m a t i o n p r a c t i c e s
would not permit secret data systems t o e x i s t .
Informed
consent,
i n i t s best
sense,
i s founded
on an
i n t e r a c t i v e , meaningful dialogue between a h e a l t h care p r o f e s s i o n a l
and p a t i e n t . Creative and responsive informed consent
procedures
can r e a d i l y be b u i l t i n t o automated systems t o supplement t h i s
personal dialogue. This includes automatic reminders o f the need t o
o b t a i n consent before d i s c l o s u r e and t o renew an informed consent
statement a f t e r the lapse of an agreed upon time.
20
�I n d i v i d u a l s have the strongest
claim t o c o n t r o l access of
others t o t h e i r health records when they are i n i d e n t i f i a b l e form.
A strong
justification
f o r the release
of these data
without
consent i s required, such as a s i g n i f i c a n t r i s k t o the health or
safety o f others, or urgent care f o r the i n d i v i d u a l him or her
s e l f . Where disclosure of information without consent i s authorized
or
required
by law (e.g.,
mandatory
reporting
requirements),
persons have the r i g h t t o be informed i n advance.
Disclosure
o f unlinked
and unlinkable
data
for quality
assurance, assessment of system performance, or research may not
r e q u i r e informed consent. Where information i s n o n - i d e n t i f i a b l e ,
the
i n d i v i d u a l usually
does not have a personal stake i n the
intended use of the data.
the
80
However, e t h i c a l and p o l i c y review of
need f o r and use of data i s s t i l l
important.
Under
fair
i n f o r m a t i o n p r a c t i c e s , when n o n - i d e n t i f i a b l e health i n f o r m a t i o n i s
disclosed,
i t should consist
only
of the i n f o r m a t i o n
that i s
necessary t o accomplish the l e g i t i m a t e purpose; the information
should be used f o r t h a t purpose or a compatible purpose; and strong
c o n f i d e n t i a l i t y p r o t e c t i o n s should be i n place.
Right t o Review and Correct Personal Data
A c e n t r a l element of f a i r
information
practices
i s that
i n d i v i d u a l s have the r i g h t t o review and t o c o r r e c t data about
themselves. At present, p a t i e n t s have a s t a t u t o r y r i g h t of access
t o t h e i r own health records i n approximately eleven s t a t e s .
right
81
The
t o review and t o c o r r e c t personal data i s founded upon
respect f o r autonomy and the i n t e g r i t y of data. I n d i v i d u a l s cannot
21
�meaningfully c o n t r o l the use of personal data unless they are f u l l y
aware of t h e i r contents. I n d i v i d u a l s are also i n the best p o s i t i o n
t o assess the i n t e g r i t y of information about themselves. They can
help determine i f the information c o l l e c t e d i s accurate, complete,
and t r u s t w o r t h y . Consumers are most l i k e l y t o have confidence i n
personal
data
contents,
systems i f they
are
well
informed
about
have the opportunity t o c o r r e c t inaccuracies,
control their
their
and
can
use.
Use of Data f o r Intended Purposes
To some, c o l l e c t i o n of ever greater q u a n t i t i e s of health data
are important/ without the need t o j u s t i f y the intended purposes.
Under f a i r i n f o r m a t i o n p r a c t i c e s , however, data are not regarded as
inherently
good,
but
need
careful
justification
for
their
c o l l e c t i o n or d i s c l o s u r e . F a i r information practices would l i m i t
the c o l l e c t i o n of health information t o c e r t a i n l e g i t i m a t e purposes
i n c l u d i n g d i r e c t care, u t i l i z a t i o n review, q u a l i t y assessment, and
research.
82
Data could be c o l l e c t e d only t o the extent necessary
t o achieve a l e g i t i m a t e purpose. Further, health data could be used
only
for
the
purposes
for
which
they
were
collected.
If
i d e n t i f i a b l e data were t o be used f o r another v a l i d purpose, i t
would r e q u i r e the person's informed consent. F i n a l l y , data would be
disposed of when no longer necessary t o carry out the purposes f o r
which they were c o l l e c t e d .
Self
83
Regulation
Privacy
protection
i s enhanced
i f a l l health
plans
and
providers produce t h e i r own information codes w i t h i n the framework
22
�of f a i r i n f o r m a t i o n p r a c t i c e s and
guidelines established by
the
National Health Board. Preparation of a privacy p r o t e c t i o n p o l i c y
i s an e x c e l l e n t method of r e q u i r i n g specialized groups t o consult
t h e i r own s e l f - i n t e r e s t , t o r e p o r t on t h e i r own good p r a c t i c e s , and
to
formulate
efforts
reasonable solutions t o outstanding
at s e l f - r e g u l a t i o n can
result
problems. Such
i n pamphlets and
public
notices t h a t can be used t o b e t t e r inform the general p u b l i c about
the privacy code i n place and assuage consumer concerns. I d e a l l y ,
adherence t o a sound information code should be reviewed on
ongoing basis by a Privacy
P r o t e c t i o n Committee at the plan
an
and
provider l e v e l .
In
order t o develop sound privacy
practices,
accountable
health plans and providers must t r a i n and r e t r a i n s t a f f ; develop
d e t a i l e d manuals of appropriate procedures; and monitor and a u d i t
compliance w i t h s t i p u l a t e d norms.
Security of Health Information Systems
The
National
Research Council recommends t h a t "The
needs computer technology t h a t supports s u b s t a n t i a l l y
safety, r e l i a b i l i t y ,
and,
in particular, security."
84
nation
increased
They define
s e c u r i t y as:
. . . p r o t e c t i o n against unwanted d i s c l o s u r e , m o d i f i c a t i o n
or d e s t r u c t i o n of data i n a system, and also ... the
safeguarding of systems themselves. Security, s a f e t y , and
reliability
together
are
elements
of
system
t r u s t w o r t h i n e s s — w h i c h i n s p i r e s the confidence t h a t a
system w i l l do what i t i s expected t o do.
85
As automated systems i n c r e a s i n g l y contain standardized
health care
i n f o r m a t i o n capable of being t r a n s m i t t e d widely over e l e c t r o n i c
23
�networks, "society becomes more vulnerable t o poor systems design,
accidents t h a t disable systems, and attacks on computer systems."
96
Opportunities f o r using e l e c t r o n i c h e a l t h care networks may also be
l o s t i f there i s serious m i s t r u s t o f t h e i r s a f e t y .
E s t a b l i s h i n g appropriate s e c u r i t y standards w i l l , w i t h i n the
proper l e g i s l a t i v e framework, both strengthen p a t i e n t privacy and
c o n f i d e n t i a l i t y and assure t h a t i n f o r m a t i o n i s a v a i l a b l e t o improve
the q u a l i t y and e f f i c i e n c y of health care s e r v i c e s .
87
With e x i s t i n g
paper systems, requests f o r i n f o r m a t i o n o f t e n r e s u l t i n the release
of data t h a t are not p e r t i n e n t t o the c u r r e n t request
as t o t a l
documents are photocopied and/or faxed t o users. With computerized
systems, t a i l o r e d s e l e c t i o n of data items from an i n d i v i d u a l health
record
i s easy, thereby
making i t possible t o share only the
i n f o r m a t i o n t h a t i s necessary t o the i n q u i r y a t hand. With the
establishment
o f appropriate access requirements,
more accurate,
r e l i a b l e , and c o s t - e f f i c i e n t p r o t e c t i o n of h e a l t h care i n f o r m a t i o n
can
be
achieved
than
with
non-automated
systems.
Moreover,
technology o f f e r s a means of c r e a t i n g a u d i t t r a i l s f o r monitoring
all
instances
o f access t o and disclosure of automated h e a l t h
records on i n d i v i d u a l s . This involves computers producing logs t h a t
can
be
consulted
complaints
record
by
supervisors
are received
occurs.
from
Thus, patterns
and
security officers
i n d i v i d u a l s or when a
of s t a f f
records might be i d e n t i f i e d and questioned
8 8
8 9
9 0
protection o f f i c e r s . ' ' '
browsing
when
suspicious
i n patients'
by s e c u r i t y and data
9 1
At the same time, computers make the anonymous e x p l o r a t i o n o f
24
�data an a n t i s e p t i c process. Computerization makes f i l e s t h a t were
d i f f i c u l t t o use easier t o access, and thus increases t h e range of
secondary uses made of the data. A s i n g l e breach o f s e c u r i t y can
r e s u l t i n a very large amount of information about a l o t o f persons
being disclosed.
Computerization also
makes i t easier
to link
information from many sources together increasing the p o t e n t i a l f o r
undue intrusiveness
i n t o people's records and l i v e s .
Individuals
find
t o understand where information
about them
i tdifficult
resides
and how
that
information
has been
linked
or used.
Computerization can make i t extremely d i f f i c u l t t o c o n t r o l the r e disclosure
of information
e f f e c t i v e l y . Records
can be e a s i l y
t r a n s m i t t e d across s t a t e l i n e s , making i t d i f f i c u l t f o r any s t a t e
92
93
t o o f f e r reasonable p r o t e c t i o n s . ' '
94
Although making a computer system one-hundred percent secure
i s not f e a s i b l e , there i s much t h a t can be done t o p r o t e c t records
with
careful
planning
and use of technology.
95
Technological
advances i n e l e c t r o n i c systems are proceeding a t an
accelerated
pace and today's s t a t e of the a r t systems w i l l soon be replaced
w i t h more s o p h i s t i c a t e d systems. Data p r o t e c t i o n p o l i c i e s , i f they
are t o be e f f e c t i v e i n t h i s r a p i d l y changing environment, must not
be t i e d t o s p e c i f i c systems and system c a p a b i l i t i e s , but rather
must e s t a b l i s h privacy
p r o t e c t i o n guidelines
t h a t define
system
goals but do not specify how these goals w i l l be reached. These
protections w i l l be most e f f e c t i v e i f privacy i s addressed d i r e c t l y
at
t h e outset
i n developing
guarantee t h a t only authorized
electronic
systems.
They
should
persons are able t o access records
25
�for authorized purposes at authorized
times.
Because computer technology i s r a p i d l y evolving i t w i l l
also
be necessary t o fund an ongoing research program t o ensure t h a t
these advances do not erode s e c u r i t y p r a c t i c e s . There w i l l also be
a
need f o r oversight
and
development and proper use
management s t r u c t u r e s
promoting
the
of system s e c u r i t y p r i n c i p l e s i n the
development and implementation of health care data systems.
E f f e c t i v e s e c u r i t y p r o t e c t i o n f o r health care i n f o r m a t i o n w i l l
r e q u i r e use
of technology t h a t i s not
r e g u l a r l y used i n most
computer systems and networks today. While t h i s technology e x i s t s
and has been shown t o be e f f e c t i v e and a f f o r d a b l e , i t i s not widely
used because i t would have t o be r e t r o f i t t e d t o e x i s t i n g systems or
because of perceived
has
been
the
costs or inconvenience. A continuing concern
a c c e p t a b i l i t y of
computer
security
to
health
professionals i f s e c u r i t y i s perceived as slowing down the flow of
i n f o r m a t i o n needed f o r providing health care. These concerns are
v a l i d p a r t i c u l a r l y i n emergency s i t u a t i o n s when seconds count or
when the p a t i e n t i s unable t o supply the necessary i n f o r m a t i o n .
The
necessary
steps i d e n t i f i e d
for
by
achieving
the
National
greater
Research Council
computer
security
as
and
trustworthiness are as applicable t o health computer systems as t o
those serving other purposes. These steps include: promulgating a
comprehensive
set
of
"Generally
P r i n c i p l e s " which would provide
security
features,
Accepted
System
Security
a c l e a r statement of e s s e n t i a l
assurances and
practices.
96
Among the
major
elements of these p r i n c i p l e s are q u a l i t y c o n t r o l , access c o n t r o l on
26
�code as w e l l as data, user i d e n t i f i c a t i o n and a u t h e n t i c a t i o n ,
protection
of executable
code,
security
logging,
a
security
a d m i n i s t r a t o r , data encryption, operational support t o o l s t o a s s i s t
i n v e r i f y i n g the s e c u r i t y s t a t e of the system, independent audits
of the system and hazard analysis. Levels of access can also be
established
recognizing
the varying degrees of s e c u r i t y
required
f o r d i f f e r i n g kinds of information.
The
against
adequacy o f data s e c u r i t y systems can also be evaluated
prior
threats
to
confidentiality.
Threats
to
c o n f i d e n t i a l i t y can emerge from outside an organization as w e l l as
among an i n s t i t u t i o n ' s own personnel and the s e c u r i t y system should
be designed t o address each type of t h r e a t . Regular s e c u r i t y checks
should be conducted and recorded.
Needed Actions
This chapter began w i t h the observation t h a t the goals o f
i n t e g r i t y , a v a i l a b i l i t y and privacy i n the new health care system
can
be achieved
only
by e s t a b l i s h i n g
a national
privacy
and
s e c u r i t y framework. This f i n a l section describes the actions needed
t o e s t a b l i s h a coherent n a t i o n a l framework.
(1)
Establish,
privacy
the
safeguards
Code of Fair
through
preemptive
covering
all
Information
federal
health
records
legislation,
that
national
are based
upon
Practices.
Federal l e g i s l a t i o n w i l l e s t a b l i s h uniform and comprehensive
privacy
and
confidentiality
protection
27
for
individually
�i d e n t i f i a b l e health care i n f o r m a t i o n . Through f e d e r a l preemption,
the n a t i o n a l p o l i c y w i l l replace the current patch work o f s t a t e
laws, and provide the framework f o r sharing i n f o r m a t i o n generated
w i t h i n and outside
o f t h e new health care system. Some health
a l l i a n c e s , employers, and providers
persons w i l l move —
will
cross s t a t e l i n e s and
only a n a t i o n a l p o l i c y can cover i n f o r m a t i o n
i n i n t e r s t a t e commerce. A uniform n a t i o n a l standard f o r privacy and
confidentiality w i l l
s i m p l i f y compliance f o r organizations
that
operate nationwide; provide p r o t e c t i o n f o r data t h a t are l i n k e d or
p o t e n t i a l l y l i n k e d t o other data systems; and make i t easier f o r
those
about
whom
information
i s collected
t o have
a
clear
understanding o f how personal information i s protected.
Federal law w i l l p r o t e c t a l l types o f health care i n f o r m a t i o n ,
regardless o f whether i t i s part o f the new health care system or
e x i s t s outside o f i t . Privacy p r o t e c t i o n w i l l be afforded t o a l l
identifiable
health
care information
equally,
with
no s p e c i a l
p r o t e c t i o n f o r p a r t i c u l a r diseases such as mental i l l n e s s , drug
dependency, sexually t r a n s m i t t e d diseases, or AIDS. The absence o f
separate standards f o r d i f f e r e n t diseases i s j u s t i f i e d
because
i n d i v i d u a l s have d i f f e r e n t perceptions o f the s e n s i t i v i t y of health
care i n f o r m a t i o n ; no r a t i o n a l d i s t i n c t i o n could be made between,
say, cancer, heart disease or Huntingtons, and mental i l l n e s s or
s y p h i l i s . Federal privacy p r o t e c t i o n w i l l also cover a l l types o f
health care i n f o r m a t i o n , regardless
o f form (paper, m i c r o f i l m or
e l e c t r o n i c ) , l o c a t i o n (storage, t r a n s i t , archive) or user/holder
(government, provider, p r i v a t e o r g a n i z a t i o n ) .
28
�I n order t o ensure t h a t the privacy of health care data i s
taken s e r i o u s l y ,
i twill
be necessary
t o establish
effective
mechanisms f o r enforcement. This includes s i g n i f i c a n t p e n a l t i e s f o r
breach o f l e g a l requirements.
A n a t i o n a l privacy framework w i l l be founded on a code o f f a i r
i n f o r m a t i o n p r a c t i c e s . The code w i l l s t i p u l a t e , i n t e r a l i a , t h a t
i n d i v i d u a l s about whom data are c o l l e c t e d have the r i g h t t o know
about and t o approve the uses t o which the data are put, t h a t no
secret data systems are permitted t o e x i s t , t h a t i n d i v i d u a l s have
the
r i g h t t o review and t o c o r r e c t data about themselves, and t h a t
data may be c o l l e c t e d and used only f o r l e g i t i m a t e purposes.
(2)
care
Establish
a system
of
universal
identifiers
for
the
health
system.
Unique i d e n t i f i e r s are needed t o help ensure the accuracy of
i n f o r m a t i o n and e f f i c i e n t operation of the health care
system.
However, such i d e n t i f i e r s should not become a r i s k t o the p r i v a c y
of the i n d i v i d u a l . Although the Social Security Number (SSN) i s the
most obvious candidate f o r a health care i d e n t i f i e r , there are
serious concerns about the privacy i m p l i c a t i o n s of i t s use. Further
discussion and examination of a l t e r n a t i v e s w i l l begin immediately
and an i d e n t i f i e r scheme w i l l be established very e a r l y i n the
reform process.
(3) Issue
effective
security
standards
information.
29
and guidance
for
health
care
�The
current
voluntary
process
has not r e s u l t e d
i n the
development o f a comprehensive set of standards needed f o r ensuring
the s e c u r i t y of automated systems. The promulgation o f n a t i o n a l
s e c u r i t y standards and guidance i s necessary t o ensure t h a t the
i n t e n t of n a t i o n a l privacy p r o t e c t i o n l e g i s l a t i o n covering
health
care i n f o r m a t i o n systems w i l l be met.
The f e d e r a l
government
will
assume a leadership
role i n
developing and p e r i o d i c a l l y r e v i s i n g s e c u r i t y standards. A u t h o r i t y
f o r developing health care information s e c u r i t y standards and t h e i r
f u r t h e r development w i l l be vested i n the National
Health Board
w i t h a c t i v e p a r t i c i p a t i o n by other relevant Federal agencies (e.g.
Department of Health and Human Services, Department of Defense,
Department of Veterans A f f a i r s , National
Highway T r a f f i c
Safety
A d m i n i s t r a t i o n , Consumer Product Safety Commission, and National
Institute
of Standards
and Technology
i n the Department o f
Commerce).
(4)
Establish
the
National
a Data
Health
Protection
Board
for
and Security
overseeing
Panel(s)
and managing
as part
privacy
of
and
security.
E s t a b l i s h i n g a Data Protection and Security Panel(s) as p a r t
of the National Health Board w i l l f i l l
a major gap i n America's
privacy
and s e c u r i t y framework. The proposal f o r c r e a t i o n o f a
privacy
protection
entity
has been recommended by persons i n
experts
98
19 7 4 . ' '
99
and by privacy
National
Health Board w i l l play the major p o l i c y s e t t i n g r o l e ,
30
since
97
Congress
While the
�s t a t e s , health a l l i a n c e s , accountable health plans, and providers
w i l l also be a c t i v e partners i n t h i s process.
The
Data P r o t e c t i o n and Security Panel(s) w i l l
responsibilities
that
are e s s e n t i a l
have several
f o r the development and
implementation o f e f f e c t i v e privacy and s e c u r i t y i n the health care
system. The panel w i l l :
( i ) set privacy and s e c u r i t y standards
through i n t e r p r e t i v e r u l e s and/or guidelines t h a t must be followed
by
p a r t i c i p a n t s i n the health
evaluate
the
implementation
care
of
system;
( i i ) monitor and
standards
set by
statute,
r e g u l a t i o n s , and/or guidelines; ( i i i ) sponsor or conduct research,
studies, and i n v e s t i g a t i o n s ; ( i v ) supplement other mechanisms i n
the
health
care
system
through
which
citizens
question
the
p r o p r i e t y of information c o l l e c t e d and used by various p a r t i c i p a n t s
i n the system; (v) advise the President, the Congress, government
agencies, s t a t e s , and other p a r t i c i p a n t s i n the health care system;
(vi)
support the development of f a i r and comprehensible consent
forms governing the disclosure and re-disclosure of i n f o r m a t i o n t o
authorized persons, f o r authorized purposes, a t authorized
times;
( v i i ) fund p i l o t p r o j e c t s demonstrating the technology required f o r
implementing s e c u r i t y standards and sharing
h e a l t h care s e t t i n g ; and ( v i i i )
information
work w i t h the health
i n the
provider
community t o f o s t e r development of s e c u r i t y practices responsive t o
t h e i r goals o f p r o v i d i n g e f f e c t i v e health care.
(5)
Establish
security
education
a
comprehensive
program
and awareness
among all
31
fostering
members
privacy
of
the
and
health
�care
system
including
consumers.
Unless those involved i n the health care system are aware o f
t h e i r r i g h t s and r e s p o n s i b i l i t i e s , established
have
limited
impact.
The National
Health
protections
Board w i l l
will
play
a
leadership r o l e i n f o s t e r i n g the development and implementation o f
o r i e n t a t i o n and t r a i n i n g programs f o r personnel w i t h access t o
health
care
information.
The Board
will
also
support t h e
development o f programs f o r f o s t e r i n g consumer awareness about
t h e i r r i g h t s w i t h respect
t o the c o l l e c t i o n and disclosure o f
personal i n f o r m a t i o n .
Handbooks describing p a t i e n t s ' r i g h t s w i t h respect t o records
maintained about them w i l l
be d i s t r i b u t e d by health
and/or accountable health plans.
alliances
I n d i v i d u a l s have the r i g h t t o
expect, and the system has the o b l i g a t i o n t o provide, assurances
t h a t personal records are accurate, t i m e l y and complete, and t h a t
records w i l l be c o n f i d e n t i a l and maintained i n a secure system.
The
success o f the new health care system depends i n large
p a r t on t h e i n t e g r i t y o f information and the confidence o f the
p u b l i c t h a t p r i v a t e information w i l l be vigorously
A:\PRIV-11S.TRY...CS\WTDOCS\HCPOLICY\FRIV-118.TRY
32
protected.
�Notes
1. Privacy P r o t e c t i o n Study Commission. Personal
Information Society:
Commission.
1977.
The Report
Privacy i n an
o f the Privacy P r o t e c t i o n
Washington D.C.: U.S. Government P r i n t i n g
Study
Office,
2. Westin AF. "How the American Public Views Consumer Privacy
Issues i n the Early 90's — And Why." Testimony t o t h e U.S.
Congress, House Subcommittee on Government I n f o r m a t i o n , J u s t i c e ,
and A g r i c u l t u r e , Committee on Government Operations.
Washington
D.C., A p r i l 10, 1991.
3. Louis Harris and Associates, Westin AF. The Equifax Report on
Consumers i n the Information Age. A t l a n t a : Equifax, 1990.
4. Louis Harris and Associates, Westin AF.
The Equifax Report on
Consumers i n t h e I n f o r m a t i o n Age, Second Annual Update. A t l a n t a :
Equifax, 1992.
5. Goldberg J. Who's Reading Your Medical Records? Lear's. November
1992:40-41.
6. Medical Records I n s t i t u t e . The Challenge o f t h e Next Two
Decades. Towards an E l e c t r o n i c Patient Record. 1992;1(5):1-7.
7. For a survey of l i m i t e d access or r e s t r i c t e d access d e f i n i t i o n s
see: A l l e n A. Uneasy Access: P r i v a c y f o r Women i n A Free S o c i e t y .
New Jersey: Rowman and A l l a n h e l d ; 1987:11, 29-39.
8. Warren S, Brandeis L. The Right t o Privacy, and Gavison R.
Privacy and the L i m i t s o f Law. Reprinted i n Philosophical
Dimensions o f P r i v a c y : An A n t h o l o g y e d i t e d by F Schoeman. New York:
Cambridge U n i v e r s i t y Press, 1984.
9. Parent WA. Privacy, M o r a l i t y and the Law. Philosophy and Public
A f f a i r s , 1983;12:271-2.
10. Thomson JJ. The Right t o Privacy. I n Philosophical
o f Privacy, Op. c i t . , p.117.
Dimensions
11. Brannigan VM. P a t i e n t Privacy: A Consumer P r o t e c t i o n Approach.
Journal o f Medical Systems. 1984;8(6):501-505 . Attachment D.
12. Brannigan V, B e i e r B. Standards f o r P r i v a c y i n Medical
Information Systems: A Technico-Legal Revolution. Washington,
D. C: National Bureau o f Standards; 1977. P u b l i c a t i o n 46.
13. A dramatic s h i f t t o patient-based records i s now o c c u r r i n g as
p a r t o f longer-term e f f o r t s toward b u i l d i n g n a t i o n a l e l e c t r o n i c
patient-based h e a l t h i n f o r m a t i o n networks. While p a r t i c u l a r groups
vary i n t h e s p e c i f i c s o f t h e i r v i s i o n , those focusing on
33
�development of automated h e a l t h care systems, such as the Computerbased P a t i e n t Record I n s t i t u t e , the Medical Records I n s t i t u t e , and
the American National Standards I n s t i t u t e , see a system of several
parts emerging i n t h e long run: a comprehensive l o n g i t u d i n a l
computer-based p a t i e n t record containing a l l c l i n i c a l , f i n a n c i a l
and research data; a " n a t i o n a l " e l e c t r o n i c network f o r accessing
t h i s h e a l t h record f o r a v a r i e t y of purposes such as primary care,
insurance payment, peer review, cost containment, p u b l i c h e a l t h and
research purposes; use of a smart card f o r purposes ranging from
p r o v i d i n g h e a l t h insurance coverage i n f o r m a t i o n t o p r o v i d i n g a
conception-to-death record o f a l l h e a l t h care; and use o f unique
p a t i e n t - s p e c i f i c i d e n t i f i e r s n a t i o n wide, and perhaps, world wide.
14. Medical Records I n s t i t u t e . The process o f c r e a t i n g e l e c t r o n i c
p a t i e n t records. Toward an E l e c t r o n i c Patient Record. 1992;1(3):17.
15. Epstein MH. Guest A l l i a n c e : Uses o f S t a t e - l e v e l H o s p i t a l
Discharge Databases: How and Why States C o l l e c t Secondary Data
Varies Widely. Journal o f AHIMA. 1992;63(4):32-37.
16. Yenney SL. Solving the Health Data Management Puzzle. Business
and Health. September 1990:41-49.
17. D i c k RS, Steen EB, eds. The Computer-Based P a t i e n t Record: an
E s s e n t i a l Technology f o r H e a l t h Care. Washington D.C.: I n s t i t u t e o f
Medicine Committee on Improving the P a t i e n t Record, 1991:31-35.
18.
Wright
T. H e a l t h
Care
Technology:
A Privacy
Perspective.
Ontario: I n f o r m a t i o n and Privacy Commissioner/Ontario (IPC), 1992.
19. Several governmental groups are already considering privacy
and s e c u r i t y issues w i t h respect t o h e a l t h records. The National
Academy o f Sciences, I n s t i t u t e of Medicine i s examining issues
regarding t h e privacy o f r e g i o n a l h e a l t h data networks. The
Department o f Health and Human Services, Task Force on the Privacy
of P r i v a t e Sector Health Records, established i n 1990, was
i n i t i a l l y charged w i t h examining issues surrounding t h e use and
p r o t e c t i o n o f personally i d e n t i f i a b l e medical and other h e a l t h r e l a t e d i n f o r m a t i o n i n t h e p r i v a t e sector. Emerging events have
refocused the Task Force's mission t o focus on e f f o r t s t o develop
e l e c t r o n i c h e a l t h care i n f o r m a t i o n systems i n the context of h e a l t h
care reform. I n a d d i t i o n , the Congressional O f f i c e o f Technology
Assessment, Telecommunications and Computing Technologies Program,
has completed a study examining privacy issues r e l a t e d t o h e a l t h
care i n f o r m a t i o n .
20. For a d e t a i l e d discussion o f p r i v a t e sector e f f o r t s see:
Medical Records I n s t i t u t e . Computerization and C o n f i d e n t i a l i t y .
Toward an E l e c t r o n i c P a t i e n t Record, 1993 ; 1 ( 6 ) : 1 - 8 .
34
�21. I n November o f 1991, then Secretary of Health and Human
Services, Dr. Louis S u l l i v a n , established three workgroups
c o n s i s t i n g o f h e a l t h care leaders from the p r i v a t e sector — The
Workgroup f o r E l e c t r o n i c Data Interchange; The Taskforce on P a t i e n t
Information, and t h e Workgroup on A d m i n i s t r a t i v e Costs and
B e n e f i t s . See: Brophy JT, Tresnowsli BR, co-chairs. Workgroup f o r
E l e c t r o n i c Data I n t e r c h a n g e : Report t o t h e S e c r e t a r y o f t h e U.S.
Department o f H e a l t h and Human S e r v i c e s . Washington, D.C.: U.S.
Government P r i n t i n g O f f i c e , July 1992.
22.
Automated
Medical
Records:
Leadership
Needed
to
Expedite
Standards Development. Report t o t h e Chairman, Committee on
Governmental A f f a i r s , U.S. Senate. Washington, D.C.: General
Accounting O f f i c e , 1993.
23. Unique i d e n t i f i e r s or ,Personal I d e n t i f i c a t i o n Numbers (PINs)
remain e s s e n t i a l f o r the successful matching o f diverse items o f
i n f o r m a t i o n about a p a r t i c u l a r person. Most i n d i v i d u a l s have a
s i g n i f i c a n t s e l f i n t e r e s t i n ensuring t h a t the i n f o r m a t i o n i n t h e i r
health and medical f i l e s i s accurate. See: Council o f Europe. The
Committee o f Experts on Data P r o t e c t i o n . The I n t r o d u c t i o n and Use
of
Personal
I d e n t i f i c a t i o n Numbers: The Data P r o t e c t i o n I s s u e s .
Strasbourg: Council of Europe; 1991:19-20.
24. U.S. O f f i c e o f the Inspector General. The Extent and Use o f
Social S e c u r i t y Numbers.
Washington, D.C.: U. S. Government
P r i n t i n g O f f i c e , August 1988. OAI-06-88-00800.
25.
Sullivan
LW.
The
Medical
and
Health
Insurance
Reform
I n f o r m a t i o n Act o f 1992. L e g i s l a t i o n proposed by the Secretary o f
the Department o f Health and Human Services, June 16, 1992.
26. S t a r k P. H. R. 200: H e a l t h Care Cost Containment and Reform A c t
of
1993.
103rd
Congress, F i r s t
Representatives, January 5, 1993.
Session.
U.S.
House
of
27. The Computer-based P a t i e n t Record I n s t i t u t e supports immediate
adoption o f t h e SSN as t h e u n i v e r s a l p a t i e n t i d e n t i f i e r .
They
f u r t h e r s t a t e : "The o v e r r i d i n g advantages o f t h e SSN, and t h e
reason f o r CPRI's support i s economy. Minimal investment w i l l be
required t o use an e x i s t i n g number, which many h e a l t h care
providers already c o l l e c t and which has demonstrated success i n one
of the l a r g e s t h e a l t h care systems i n the United States (Veterans
A d m i n i s t r a t i o n ) " . See t h e i r p o s i t i o n paper, Computer-based Patient
Records Standards,
p. 2.
28. L e t t e r from E Roberts, J Golman, E Hendricks,
H i l l a r y Rodham C l i n t o n , A p r i l 26, 1993.
et a l . to
29. Statement by the Commissioner of Social S e c u r i t y , Gwendolyn S.
King, before the House Subcommittee on Social S e c u r i t y , Committee
on Ways and Means, February 27, 1991.
35
�30. The Computer-based Patient Record I n s t i t u t e believes t h a t the
cost w i l l be somewhat lower. They estimate t h a t i s s u i n g health
care cards w i l l cost about $2.50 per person, or one b i l l i o n
dollars.
31. Smith RE. Report on the C o l l e c t i o n and Use o f Social S e c u r i t y
Numbers. Providence: Privacy Journal, 1985.
32. Hendricks, E. Testimony before the House Subcommittee on Social
S e c u r i t y , Committee on Ways and Means. February 27, 1991.
33. F l a h e r t y DH. P r o t e c t i n g P r i v a c y i n S u r v e i l l a n c e S o c i e t i e s : The
F e d e r a l R e p u b l i c o f Germany, Sweden, France, Canada, and t h e U n i t e d
States. Chapel H i l l : U n i v e r s i t y o f North Carolina Press; 1989:ISIS , 406.
34. Unique i d e n t i f i e r s should be used provided t h a t s t r i c t c o n t r o l s
are put i n place t o c o n t r o l t h e i r use f o r unrelated purposes. See:
Flaherty DH. Privacy, C o n f i d e n t i a l i t y , and t h e Use o f Canadian
Health Information f o r Research and S t a t i s t i c s . Canadian Public
A d m i n i s t r a t i o n . 1992;35(1):75-93.
35. At l e a s t one author recommends t h a t i f s o c i a l s e c u r i t y numbers
"are used i n r e p o r t s , they should be scrambled upon i n p u t , w i t h the
output key being s t r i c t l y regulated." See: Bruce JAC. Privacy and
Confidentiality
of
Health
Care
American Hospital Publishing;
I n f o r m a t i o n . 2nd
ed. Chicago:
1988:63.
36. Smith RE, S i e g e l E. War S t o r i e s : Accounts o f Persons V i c t i m i z e d
by Invasions o f Privacy. Providence: Privacy Journal, 1990.
37. Hendricks, Op.cit.
38. Marx, GT. The I r o n F i s t and t h e Velvet Glove: T o t a l i t a r i a n
P o t e n t i a l s w i t h i n Democratic Structures. I n The Social F a b r i c :
Dimensions and Issues edited by JE Short J r . Beverly H i l l s , CA:
Sage P u b l i c a t i o n s , 1986.
39. U. S. General Accounting O f f i c e . Medical ADP Systems: Automated
M e d i c a l Records Hold Promise t o Improve P a t i e n t
Care.
Washington,
D.C.: U.S. General Accounting O f f i c e , 1991. (GAO/IMTEC-91-5).
40. Gabriele ER, Murphy G. Computerized Medical Records. Journal o f
AMRA. 1990;61(1):26-37.
41. Medical Records I n s t i t u t e . Concepts o f Computer-based Patient
Record systems. Towards an E l e c t r o n i c Patient Record. Analysis
Number 1, 1992:1-7.
42. Gabriele ER. Data Security. ASTM: Committee
Computerized Systems. November 1, 1992. D r a f t .
36
E-31 on
�43. Medicare records are covered by the Privacy P r o t e c t i o n Act o f
1974. Medicaid records are covered by s t a t e law but are required
t o comply w i t h T i t l e 19 o f the Social Security Act when used by
s t a t e agencies t o administer t h a t program.
44. The
records
patient
Patient
lack o f adequate, uniform, n a t i o n a l p r o t e c t i o n o f p a t i e n t
may, i n f a c t , hinder the f u l l development and release o f
i n f o r m a t i o n . Waller, AA. Legal Aspects o f Computer-based
Records and Record Systems. I n The Computer-based Patient
Record: An E s s e n t i a l
Technology f o r H e a l t h Care, by t h e I n s t i t u t e
of Medicine. Washington D.C.: National Academy o f Sciences, 1991.
(Appendix B)
45. P l e s s e r RL, and Cividanes EW. P r i v a c y P r o t e c t i o n i n t h e U n i t e d
S t a t e s : AS 1991 Survey o f Laws and R e g u l a t i o n s A f f e c t i n g P r i v a c y i n
t h e P u b l i c and P r i v a t e S e c t o r I n c l u d i n g a L i s t o f A l l Relevant
O f f i c i a l s . Washington, DC: Piper and Marbury; May 1991.
46.
Workshop for Electronic Data Interchange [WEDI]. Report to the
S e c r e t a r y of Health and Human S e r v i c e s , Appendix 4. J u l y 1992.
47. Powers M. Legal
Protections o f C o n f i d e n t i a l Medical
Information and the Need f o r A n t i - D i s c r i m i n a t i o n Laws, i n AIDS,
Women and the Next Generation (Faden R, G e l l e r G, Powers M, eds.)
New York: Oxford U n i v e r s i t y Press; 1991, 221-255.
48.
Whalen v. Roe, 429 U.S. 589 (1977).
49.
See, e.g.. U n i t e d S t a t e s v . Westinghouse E l e c t r i c C o r p . , 638
F.2d 570 (3rd C i r . 1980) (adopts a very s p e c i f i c set o f c r i t e r i a
f o r applying c o n s t i t u t i o n a l p r i n c i p l e s o f i n f o r m a t i o n a l p r i v a c y ) .
50. J.P. v. DeSanti, 653 F.2d 1080 (1981) ( c o n s t i t u t i o n a l privacy
r i g h t s do not extend t o disclosures o f personal i n f o r m a t i o n ) .
51.
Note. The Constitutional Protection of Informational
Privacy.
Boston Univ. L . Rev. 1991;133.
52. Compilation o f State and Federal
J o u r n a l . Providence, RI; 1992.
53.
Privacy
Laws.
Privacy
Rasmussen v . South F l o r i d a B l o o d S e r v i c e s , I n c . , 500 S.2d 533,
536 ( F l a . 1987).
54.
Soroka v . Dayton Hudson C o r p . , 1 C a l . R p t r . 2d 77 (1991).
55.
5 U.S.C. Section 552 a (1988).
56.
42 U.S.C. sections 290dd-3 and 290ee-3 (1988).
57.
42 C.F.R. Sections 2.1 e t seq (1990).
37
�58. National I n s t i t u t e on Drug Abuse. Legal Opinions on t h e
C o n f i d e n t i a l i t y o f Alcohol and Drug Abuse Patient Records 19751978. U.S. Government P r i n t i n g O f f i c e , Washington D.C.
59. The c u r r e n t patchwork o f s t a t e law and r e g u l a t i o n creates
problems f o r the development o f computerized systems t h a t must be
resolved. E l e c t r o n i c records and signatures are c u r r e n t l y not
accepted w i t h i n t h e l e g a l framework o f many states and a r e ,
consequently, not admissible evidence i n s t a t e c o u r t s . See: Fulton
DK. Legal Problems A r i s i n g i n t h e Automation o f Health Records:
L e g a l Review. Topics i n H e a l t h Record Management. 1987:8(2):73-79.
60.
Waller A. Appendix B. Legal aspects o f Computer-Based Patient
Records and Record Systems i n The Computer-Based P a t i e n t Record: An
E s s e n t i a l Technology f o r H e a l t h Care, ( D i c k RS, Steen EB, eds.)
Washington, DC: National Academy Press; 1991.
61.
Privacy Law and P r a c t i c e , Section 801.
62. Rowe M, Bridgham B. Volume 1 : E x e c u t i v e Summary and a n a l y s i s
and
Volume 2 :
Individual
State
Summaries:
Laws
Governing
C o n f i d e n t i a l i t y o f H I V - r e l a t e d I n f o r m a t i o n -1983
to
1988-.
Washington, DC: The AIDS Policy Center, Intergovernmental Health
P o l i c y P r o j e c t , The George Washington U n i v e r s i t y ; June 1989.
63. Gostin L. The f u t u r e o f p u b l i c health law. Amer. J . Law & Med.
1987;12:461-490.
64. Gostin L. C o n t r o l l i n g the resurgent t u b e r c u l o s i s epidemic: a
50-state survey o f TB s t a t u t e s and proposals f o r reform. JAMA.
1993;269:255-261.
65. Humphers v. F i r s t I n t e r s t a t e Bank o f Oregon, 298 Or. 706, 696
P.2d 527 (Supreme Court o f Oregon, I n Banc, 1985).
66.
Note, Public Health Protection and the Privacy of Medical
Records. Harvard C i v i l R i g h t s - C i v i l L i b e r t i e s Review. 1981;265.
67. Quarles v. S u l l i v a n , 389 S W 2d 249 (Tenn. 1964) (no implied
..
c o n t r a c t o f c o n f i d e n t i a l i t y between "company doctor" and an
employee examined by him).
68. Report t o t h e S e c r e t a r y o f t h e Department o f H e a l t h and Human
S e r v i c e s , Toward a N a t i o n a l H e a l t h I n f o r m a t i o n I n f r a s t r u c t u r e .
Report o f the Work group on Computerization of the Patient Record,
Appendix D; 1993.
69. Mon. Code Ann. Section 50-16-501; and Washington W C Section
RA
70.02.005.
70. Reiman J. Privacy, Intimacy, and Personhood. Philosophy and
Public A f f a i r s . 1976;6;38
38
�71. Benn S. Privacy, Freedom, and Respect f o r Persons. I n : Nomos
X I I I : Privacy. N.Y.: A t h e r t Press, 1971:1-26.
72. F r i e d C. An Anatomy o f Values: Problems o f Personal and Social
Choice. Cambridge: Harvard U n i v e r s i t y Press, 1970:142.
73. Parent, Op. c i t . , 271-272.
74. Gavison, Op. c i t .
75. Gellman RM. Prescribing Privacy: The Uncertain Role o f the
Physician i n the P r o t e c t i o n o f Patient Privacy. North Carolina Law
Review. 1984;62(2):255-294.
76. Westin AF. Computers, Health Records, and C i t i z e n s '
New York: P e t r o c e l l i Books, 1977.
Rights.
77. U. S. Department o f Health and Human Services, Secretary's
Advisory Committee on Automated Personal Data Systems. Records,
Computers, and the Rights o f C i t i z e n s .
Washington, D.C: U. S.
Government P r i n t i n g O f f i c e , 1973.
78. Faden R., Beauchamp T. A History and Theory o f Informed
Consent. New York, Oxford U n i v e r s i t y Press, 1986.
79. Rozovsky FA. Consent t o Treatment; A P r a c t i c a l Guide. 2nd ed.
Boston: L i t t l e Brown. 1989.
80. U.S. Department o f Health and Human Services, Public Health
Service, Agency f o r Health Care Policy and Research. Report t o
Congress: The F e a s i b i l i t y o f L i n k i n g Research-related Data Bases t o
Federal and Non-Federal Medical A d m i n i s t r a t i v e Data Bases, A p r i l
1991.
81.
82.
Frawley
KA.
The Computerized
Patient
C o n f i d e n t i a l i t y . I n Confidence, 1993;1(2):1-3.
Record
and
83. Organization f o r Economic Cooperation and Development.
Guidelines on the P r o t e c t i o n o f Privacy and Transborder Flows o f
Personal Data. Paris: Organization f o r Economic Cooperation and
Development; 1981:10.
84. System Security Study Committee, National Research Council.
Computers a t Risk: Safe Computing i n the I n f o r m a t i o n Age.
Washington D.C: National Research Council; 1990: 2.
85. I b i d .
86. I b i d : l .
39
�87. C u r r e n t l y , the m a j o r i t y of standards i n the U.S. are developed
through a voluntary consensus process w i t h p a r t i c i p a t i o n from both
the p u b l i c and p r i v a t e sectors. Within the Federal government, the
Omnibus Budget R e c o n c i l i a t i o n Act o f 1989 assigned the Agency f o r
Health Care P o l i c y and Research (AHCPR) o f the Department o f Health
and Human Services r e s p o n s i b i l i t y f o r developing automated medical
record standards. AHCPR has pursued t h i s o b j e c t i v e by a c t i v e l y
supporting ANSI's Health Informatics Standards Planning Panel and
other a c t i v i t i e s encouraging standards developments.
88.
Bruce
JAC.
Privacy
and C o n f i d e n t i a l i t y
of
Health
Care
I n f o r m a t i o n . 2nd ed. Chicago: American Hospital Publishing, 1988.
Defending
89. U. S. Congress, O f f i c e o f Technology Assessment.
Secrets,
Sharing
Data:
New
Locks
and
Keys
for
Electronic
Information.
Washington. D.C. U.S. Government P r i n t i n g
October 1987. OTA-CIT-310.
Office,
90. Minimum Requirements f o r the S e c u r i t y o f Computerized Records
o f H e a l t h and S o c i a l S e r v i c e s Network C l i e n t s . Quebec: Commission
d'acces a 1'information, A p r i l 1992.
91.
U.S.
Government
Congress,
Office
o f Technology
Assessment.
Federal
I n f o r m a t i o n Technology: E l e c t r o n i c Record Systems and
I n d i v i d u a l Privacy. Washington
O f f i c e , June 1986. OTA-CIT-296.
D.C:
U.S. Government
Printing
92. R o t h f e d e r J . P r i v a c y f o r S a l e : How C o m p u t e r i z a t i o n Has Made
E v e r y o n e ' s P r i v a t e L i f e an Open S e c r e t . New York: Simon and
Schuster, 1992.
93. Rosenberg
R. Privacy i n the Computer Age. Computer
Professionals f o r Social R e s p o n s i b i l i t y . Boston, January 1989. No.
CL-100-3.
94. U. S. Congress,
Government
Office
o f Technology Assessment.
Federal
I n f o r m a t i o n Technology: E l e c t r o n i c Record Systems and
I n d i v i d u a l Privacy. Washington, D.C:
O f f i c e , 1986.
U. S. Government P r i n t i n g
95. Bennett CJ. Computers, Personal Data, and Theories o f
Technology: Comparative Approaches t o Privacy P r o t e c t i o n i n the
1990s. S c i e n c e , Technology & Human Values. W i n t e r 1991;16(1):51-69.
96. Systems Security Study Committee, Op. c i t . , p.4-6, 28-29.
97. Wise B. H.R. 685: A B i l l
t o E s t a b l i s h a Data P r o t e c t i o n Board
and f o r other purposes. 102nd Congress, F i r s t Session, House o f
Representatives, January 29, 1991.
40
�98. Rotenberg M, Culnan MJ, Rosenberg R. "Computer Privacy and
H.R.3669, The Data P r o t e c t i o n Act of 1990". Prepared Testimony and
Statement f o r t h e Record, The House Subcommittee on Government
I n f o r m a t i o n , J u s t i c e and A g r i c u l t u r e , Committee on Government
Operations. Washington, D.C, May 16, 1990.
99. Rotenberg M. I n Support of a Data P r o t e c t i o n Board i n the
United States. Government Information Q u a r t e r l y . 1991;8(1):79-93.
41
�Figure 1:
SPHERE OF ACCESS TO HEALTH RECORDS
Source: U.S. Department of Health and Human Services Task Force on Privacy
�Group #17, March 31, 1993
-21-
POR O F F I C I A L USE ONLY
supported — assuring p a t i e n t s they w i l l be informed i f
mistakes have occurred w i l l go a great distance i n r e p a i r i n g
the loss o f t r u s t between provider and p a t i e n t — ) and j u s t i c e
and equity served — the way t h e c u r r e n t system|compensates
f o r i n j u r y i s p a t e n t l y u n f a i r . The new system w i l l reverse
this.)
•
Non-compliance/Abuse
w.
Non compliant TB p a t i e n t .
x.
Abusive p a t i e n t : gun-toting d i a l y s i s p a t i e n t .
II.
j
PROFESSIONAL-PROFESSIONAL
•
Limited n o t i o n o f c o n s u l t i n g r e s p o n s i b i l i t i e s
y.
P s y c h i a t r i s t refuses t o consult on depressed, middle aged
p a t i e n t s ; refuses t o assess whether depression i s masquerading
as d e c i s i o n a l incapacity.
•
Scope of a u t h o r i t y
z.
P e d i a t r i c i a n r e g u l a r l y deals w i t h asthma p a t i e n t s . The asthma
consultant complains the c h i l d should be r e f e r r e d t o her.
(Many of these problems would disappear i f many professional
s t a f f are s a l a r i e d . )
•
I n t e r p r o f e s s i o n a l (We assume AHPs w i l l have incentives t o r e l y
h e a v i l y by nurse=practitioner/physician a s s i s t a n t s . C o n f l i c t s are
inevitable.)
I I I . ADMINISTRATIVE-PROFESSIONAL
(No matter how s p e c i f i c the b e n e f i t plan, i t w i l l need t o be
i n t e r p r e t e d by people who are a c t u a l l y seeing p a t i e n t s , e.g.
B e n e f i t plan may say reproductive services and p r e n a t a l care are
included i n the package...see p t - p r o v i d e r disagreement above over
whether t e s t i n g f o r CF i s covered.)
Preliminary S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
�Group #17, March 31, 1993
-22-
FOR OFFICIAL USE ONLY
•
Disagreement over what the plan covers
aa.
" I n f e r t i l i t y services are covered," i s l i k e l y t o be as
s p e c i f i c as language w i l l get. A couple asks,"Does t h i s cover
IVF?" (which has 15-20% success r a t e )
•
Overly r i g i d adherence to practice guidelines
bb.
Cataract surgery i s r o u t i n e l y done on a day-surgery, outp a t i e n t basis.
j
An e l d e r l y p a t i e n t needs t o come i n t h e night ibefore. She
can't get up a t 5:00 i n the morning and come t o the h o s p i t a l .
AHP g u i d e l i n e s don't bend.
•
Personnel a l l o c a t i o n
cc.
No s o c i a l worker w i l l be assigned t o adult p r o t e c t i o n cases.
i
Pressures from administration for services with high marketing
value, though of l i t t l e or no use to patients
Preliminary S t a f f Working Paper f o r I l l u s t r a t i v e Purposes Only
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Clinton Presidential Records
Health Care Task Force
Carolyn Gatz; Jennifer Klein
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2006-0885-F
jm862
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b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA|
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells ((b)(9) of the FOIA]
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C. Closed in accordance with restrictions contained in donor's deed
of gift.
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2201(3).
RR. Document will be reviewed upon request.
�To.
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DATE
Phone No. (Partial) (I page)
03/05/1993
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P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz; Jennifer Klein
OA/Box Number:
5107
FOLDER TITLE:
[Work Group 17 Ethical Foundations] [2]
2006-0885-F
im862
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
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P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute ((a)(3) of the PRA]
P4 Release would disclose trade secrets or confidential commercial or
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P5 Release would disclose confidential advice between the President
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P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency |(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�MEMORANDUM
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COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz; Jennifer Klein
OA/Box Number:
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FOLDER TITLE:
[Work Group 17 Ethical Foundations] [2]
2006-0885-F
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b(2) Release would disclose internal personnel rules and practices of
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b(3) Release would violate a Federal statute |(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
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C. Closed in accordance with restrictions contained in donor's deed
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PRM. Personal record misfile defined in accordance with 44 U.S.C.
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RR. Document will be reviewed upon request.
�MEMORANDUM
OF C A L L
Previous editions usable
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RECEIVED BY
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Clinton Library
DOCUMENT NO.
AND TYPE
004. note
DATE
SUBJECT/TITLE
03/05/1993
Phone No. (Partial) (1 page)
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz; Jennifer Klein
OA/Box Number:
5107
FOLDER TITLE:
[Work Group 17 Ethical Foundations] [2]
2006-0885-F
jm862
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
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P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
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P4 Release would disclose trade secrets or confidential commercial or
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P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
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RR. Document will be reviewed upon request.
�^^^^^^^^^^^^^
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�Public Health
P u b l i c h e a l t h issues are e x t r e m e l y i m p o r t a n t t o h e a l t h care
r e f o r m . T r a d i t i o n a l l y , p u b l i c h e a l t h agencies have been
r e s p o n s i b l e f o r disease assessment, c o n t r o l , and p r e v e n t i o n ,
through both p a t i e n t - s p e c i f i c and p o p u l a t i o n - w i d e s e r v i c e s .
H e a l t h care reform w i l l place the a p p r o p r i a t e and necessary
emphasis on these f u n c t i o n s at the l o c a l , s t a t e , and n a t i o n a l
l e v e l s through the new s t r u c t u r e s c r e a t e d by r e f o r m , as w e l l as
through maintenance of e f f o r t from e x i s t i n g s t r u c t u r e s .
P u b l i c h e a l t h concerns w i l l be a major focus of the N a t i o n a l
H e a l t h Board. P u b l i c h e a l t h e x p e r t i s e w i l l be r e p r e s e n t e d i n i t s
membership, and p u b l i c h e a l t h p e r s p e c t i v e s w i l l be a c t i v e l y
sought by the Board b e f o r e i t takes a c t i o n or makes
recommendations.
The U.S. P u b l i c H e a l t h Service w i l l m a i n t a i n i t s c u r r e n t
r e s p o n s i b i l i t i e s and e f f o r t s i n p u b l i c h e a l t h . H e a l t h s t a t u s
m o n i t o r i n g of the p o p u l a t i o n w i l l h e l p the N a t i o n a l H e a l t h Board
assess the progress and impact of r e f o r m , and i d e n t i f y areas
r e q u i r i n g increased a t t e n t i o n .
States and l o c a l i t i e s have t r a d i t i o n a l l y e x e r c i s e d wide
powers t o promote h e a l t h and s a n i t a t i o n and t o c o n t r o l epidemic
disease and e n v i r o n m e n t a l bayards.
flany of these f u n c t i o n s , even
though designed t o promote p o p u l a t i o n - w i d e h e a l t h , are
implemented i n p a t i e n t - s p e c i f i c ways. These i n c l u d e :
school-based n u r s i n g programs p r o v i d i n g immunizations
p r i m a r y care t o c h i l d r e n i n p u b l i c s c h o o l s ;
child
h e a l t h c e n t e r s p r o v i d i n g basic p e d i a t r i c
neighborhood
care;
health centers;
s e x u a l l y - t r a n s m i t t e d disease
tuberculosis
and
(STD)
clinics;
clinics;
p r e - n a t a l care c e n t e r s ;
case management s e r v i c e s ;
l a b o r a t o r y s c r e e n i n g programs, such as f o r lead l e v e l s i n
children;
i s o l a t i o n or q u a r a n t i n e of persons w i t h c e r t a i n
c o n d i t i o n s i n h o s p i t a l s and other f a c i l i t i e s ;
infectious
e n v i r o n m e n t a l i n s p e c t i o n s of homes or businesses, as
i n d i c a t e d by suspicion, of e n v i r o n m e n t a l pathogens.
�Although c e r t a i n p a t i e n t - s p e c i f i c public health
i n t e r v e n t i o n s are i n c l u d e d i n t h e comprehensive b e n e f i t package,
t r a d i t i o n a l p u b l i c h e a l t h f u n c t i o n s and mandates are n o t
preempted. P u b l i c h e a l t h departments r e t a i n a u t h o r i t y t o order
h e a l t h p r o f e s s i o n a l s and h e a l t h f a c i l i t i e s t o implement p u b l i c
h e a l t h measures i n t h e i r p r a c t i c e s . P u b l i c h e a l t h a u t h o r i t i e s
r e t a i n t h e a b i l i t y t o enforce l e g a l d u t i e s o f p r o v i d e r s t o r e p o r t
diseases, t o i s o l a t e i n f e c t i o u s p a t i e n t s , t o r e f e r p a t i e n t s w i t h
STDs t o c o n t a c t t r a c i n g programs, t o screen c h i l d r e n f o r l e a d , t o
g i v e s p e c i f i c immunizations, and t o i n t e g r a t e s p e c i f i c p r e v e n t i o n
messages i n t o h e a l t h care d e l i v e r y .
P u b l i c h e a l t h agencies and other e s s e n t i a l community
p r o v i d e r s (ECPs) should m a i n t a i n these and o t h e r v i t a l s e r v i c e s
which are proven l i n k s t o disease p r e v e n t i o n and h e a l t h
p r o m o t i o n . ECPs have d i s e a s e - s p e c i f i c e x p e r t i s e n o t r e a d i l y
a v a i l a b l e i n p r i m a r y - c a r e s e t t i n g s , and can p r o v i d e t h e economies
of scale and p o p u l a t i o n - w i d e p u b l i c h e a l t h p e r s p e c t i v e t h a t
i n d i v i d u a l h e a l t h plans cannot o f f e r . H e a l t h plans are r e q u i r e d
to reimburse ECPs on a c a p i t a t e d or c o n t r a c t e d b a s i s f o r s e r v i c e s
p r o v i d e d t o h e a l t h plan members from the comprehensive b e n e f i t
package.
Such reimbursement i s n o t meant t o b o l s t e r i n e f f i c i e n t or
poor q u a l i t y community p r o v i d e r s . The N a t i o n a l H e a l t h Board w i l l
a s s i s t i n d e v e l o p i n g q u a l i t y and outcomes measures a p p r o p r i a t e t o
public health providers.
I n order t o q u a l i f y f o r l o c a l , s t a t e or
n a t i o n a l f u n d i n g , ECPs w i l l be expected t o m o n i t o r q u a l i t y and
meet q u a l i t y s t a n d a r d s .
P u b l i c h e a l t h s e r v i c e s cannot f u n c t i o n e f f e c t i v e l y under
reform u n l e s s they are w e l l i n t e g r a t e d i n t o t h e o v e r a l l h e a l t h
care network. Health plans should e v a l u a t e t h e i r i n t e r a c t i o n s
w i t h p u b l i c h e a l t h agencies as p a r t o f t h e i r o v e r a l l q u a l i t y
improvement process. These assessments should be r e a d i l y
a v a i l a b l e t o consumers and governmental p u b l i c h e a l t h
departments, along w i t h other measures o f p l a n q u a l i t y .
Many p u b l i c h e a l t h i n t e r v e n t i o n s are n o t conducive t o
outcomes measures, e i t h e r because i n p u b l i c h e a l t h emergencies
outcomes measures are n o t immediate enough t o measure h e a l t h p l a n
compliance or because p a t i e n t p e r c e p t i o n s o f s a t i s f a c t i o n may n o t
measure success o f t h e i n t e r v e n t i o n s . The above mentioned
outcomes measures would n o t apply i n these cases.
However, d e s p i t e t h e l a c k o f outcomes measures, p u b l i c
h e a l t h departments must be a b l e , through p r o v i d e r i n v e s t i g a t i o n s ,
surveys and c h a r t reviews, t o a c t q u i c k l y t o enforce these
mandates. T h e r e f o r e , the A c t a l l o w s s t a t e s and l o c a l i t i e s t o
continue t o enforce p u b l i c h e a l t h standards through these survey
mechanisms, w i t h p e n a l t y and f a c i l i t y l i c e n s i n g powers.
The U n i t e d States has developed, o u t s t a n d i n g p u b l i c h e a l t h
s e r v i c e s and i s a w o r l d leader i n the s c i e n t i f i c m o n i t o r i n g and
�c o n t r o l of d i s e a s e . Health care reform w i l l m a i n t a i n these and
o t h e r s t r e n g t h s of the p u b l i c h e a l t h system, and w i l l h e l p
c o o r d i n a t e e x i s t i n g agencies w i t h h e a l t h plans and p r o v i d e r s t o
improve the o v e r a l l e f f i c i e n c y of the h e a l t h care system.
The
N a t i o n a l H e a l t h Board w i l l oversee t h i s c o o r d i n a t i o n , and w i l l
m a i n t a i n a s t r o n g emphasis on p u b l i c h e a l t h . The u l t i m a t e
success of h e a l t h care reform w i l l be measured not o n l y by
c o n t r o l l e d cost and improved access, but a l s o by the improved
h e a l t h of the p o p u l a t i o n ; p u b l i c h e a l t h methodology and e x p e r t i s e
w i l l be e s s e n t i a l i n e n s u r i n g t h i s g o a l .
�Public Health
States and l o c a l i t i e s have t r a d i t i o n a l l y exercised wide
powers to promote health and sanitation and to control epidemic
disease and environmental hazards. Many of these functions, even
though designed to promote population-wide health, are
implemented i n patient—specific ways. These include: (1) schoolbased nursing programs providing immunizations and primary care
to children i n public schools; (2) c h i l d health centers providing
basic pediatric care; (3) neighborhood health centers; (4)
sexually-transmitted disease (STD) c l i n i c s ; (5) tuberculosis
c l i n i c s ; (6) pre-natal care centers; (7) case management
services; (8) laboratory screening programs, such as for lead
l e v e l s i n children; (9) i s o l a t i o n or quarantine i n hospitals and
other f a c i l i t i e s of persons with infectious conditions; and (10)
environmental inspections of homes or businesses, as indicated by
suspicion of environmental pathogens.
Although certain patient-specific public health
interventions are included i n the comprehensive benefit package,
t r a d i t i o n a l public health functions and mandates are not
preempted. Public health departments retain authority to order
health professionals and health f a c i l i t i e s to implement public
health measures i n their practices. Public health authorities
retain the a b i l i t y to enforce legal duties of providers to report
diseases, to i s o l a t e infectious patients, to refer patients with
STDs to contact tracing programs, to screen children for lead, to
give s p e c i f i c immunizations, and to integrate s p e c i f i c prevention
messages into health care delivery.
Many of these public health interventions are not conducive
to outcomes measures, either because i n public health emergencies
outcomes measures are not immediate enough to measure health plan
compliance or because patient perceptions of s a t i s f a c t i o n may not
measure success of the interventions. Instead, public health
departments must be able, through provider investigations,
surveys and chart reviews, to act quickly to enforce these
mandates. Therefore, the Act allows states and l o c a l i t i e s to
continue to enforce public health standards through these survey
mechanisms, with penalty and f a c i l i t y licensing powers.
Remaining Issues:
•
Plan reimbursement for patient-specific interventions
provided\fe^_public health agencies?
•
Exclude cost of public health interventions from
budgets?
�MICHAEL A. ANDREWS
303 CANNON HOUSE OFFICE BUILDING
WASHINGTON, DC 206 15-4325
(202] 225-7508
25TH DISTRICT, TEXAS
COMMITTEE ON
WAYS AND MEANS
COMMITTEE ON THE
Congress oftfje©mteti States
BUDGET
JOINT ECONOMIC COMMITTEE
tousle of Eepretfentattoe*
a^asinnaton,
20515-4325
FEDERAL BUILDING
515 RUSK
HOUSTON. I X 77002
(7 13) 229-2244
1001 E. SOUTHMORE
SUITE 810
PASADENA, TX 77502
(7 13) 473-4334
M a r c h 2 5 , 1993
Mr. I r a Magaziner
H e a l t h Care Reform Task Force
Old E x e c u t i v e O f f i c e B u i l d i n g
Washington, DC
Dear I r a :
Per your r e q u e s t a t t h e Medicare w o r k i n g group's t o l l g a t e on
Monday, March 22, I am f o r w a r d i n g a d i s c u s s i o n paper on r i s k
a d j u s t m e n t ( E n c l o s u r e 1) . The concepts c o n t a i n e d i n t h e paper
have been developed by Drs. Bryan Dowd and Roger Feldman, b o t h
p r o f e s s o r s a t t h e U n i v e r s i t y o f Minnesota.
(Brief bios are
i n c l u d e d as E n c l o s u r e 2.) Because Dr. Dowd i s o u t o f town t h i s
week. Dr. Feldman prepared t h i s f i n a l d r a f t o f t h e paper. They
have done e x t e n s i v e a n a l y t i c a l s t u d i e s i n these areas and, based
on t h e i r e x p e r i e n c e , a r e a b l e t o p r o v i d e an a d d i t i o n a l
p e r s p e c t i v e on t h e need f o r r i s k a d j u s t e r s .
Drs. Dowd and Feldman have i n d i c a t e d t h a t t h e y would be a v a i l a b l e
t o p a r t i c i p a t e i n f u t u r e d i s c u s s i o n s on t h e s u b j e c t . Dr. Dowd
can be reached a t (612) 624-5468, and Dr. Feldman can be reached
a t (612) 624-5669.
I f I can be o f f u r t h e r a s s i s t a n c e , p l e a s e do n o t h e s i t a t e t o
c o n t a c t me a t 225-7508.
Sincerely,
Melanie A. M i l l e r
Medicare Working Group
cc:
Judy Feder
Gary C l a x t o n
Steve Bandeian
Josh Wiener
Barbara Cooper
Bryan Dowd
Roger Feldman
�Enclosure 1
RISKY BUSINESS:
RISK POOLING, RISK-ADJUSTMENT A D REINSURANCE IN H A T CARE
N
ELH
Roger Feldman and Bryan D w
od
University of Minnesota
March 25, 1993
1. Risk Pooling in Health Care
Health care is inherently risky. In one large H O in Minneapolis, pre-term
M
and low birthweight (LBW) babies were born in the ratio of 1 7 to normal
:
deliveries. The hospital cost for each L W baby was almost $21,000, compared
B
with $1,292 for a normal delivery.
Risks such as this are unacceptable for a normal person to bear. However,
by pooling risk, large groups of people can share the expected cost of having a
baby, which was $3,629 per delivery in this H O Using the laws of probability,
M.
actuaries can determine h w m n people must be pooled to reduce risk. In the
o ay
H O in our example, which has 260,000 members, the average cost of deliveries has
M
a 95% chance of b^tng within $25 (plus or minus) of the expected cost of $3,629.
Therefore, even though risk is unacceptable for an individual, i t can be reduced
to acceptable levels by pooling large groups.
S m of our fellow researchers have proposed developing systems of riskoe
based transfer payments, or "risk adjustments," to transfer money a o g health
mn
plans. These systems would reward health plans that experience high numbers of
adverse events such as L W babies. W part company with these proposals.
B
e
Instead, w propose two guiding principles for analyzing health care risk:
e
• Health plans are insurance companies; and
• Health plans should be responsible for promoting and
maintaining the health of their enrollees.
The first principle implies that the health plan should cover the cost of
insurable\yents without seeking additional reimbursement. The second principle
rules out any payment adjustment based on events that happen post-enrollment.
Post-enrollment data is not an accurate measure of risk because i t includes s m
oe
insured events that the health plan might have prevented.
In Section 2 of this memorandum, w detail some problems with riske
adjustment proposals, starting with the lack of demonstrated evidence of the need
for such adjustments, and the lack of risk adjustment in large employment-based
health insurance groups. This is followed by a discussion of s m practical
oe
problems in implementing a risk-adjustment program. Section 3 explains how
health plans can eliminate excess risk by reinsurance. Efficient reinsurance
markets allow small H O , that haven't reached the size of the plan in our
Ms
example, to operate without fear of financial losses due to unexpected high-cost
incidents.
12-39
PM
par
�2. Systematic Risk and Risk-Adjustment Payments
Systematic risk exists i f s m plans are more likely than others to enroll
oe
individuals who are chronically i l l (or who have a high probability of developing
catastrophic short-term illness). Systematic risk cannot be eliminated by
pooling large numbers of people: the larger the plan gets, the more high-spending
people i t will enroll.
S m of our colleagues have proposed making extra
oe
payments to health plans that enroll more than their share of high risks. Before
agreeing with these proposals, policy makers need to answer the following
questions.
a. What is the Evidence on Systematic Risk Selection?
We have reviewed the published literature on systematic risk selection.
Our conclusion is similar to Hellinger's earlier opinion: "Review of the
available literature leads one to conclude that prepaid group practice H O s do
M'
experience favorable selection.
A recent study of systematic risk selection
in the Medicare H O program found favorable selection in 13 H O , unfavorable
M
Ms
selection in one case, and inconclusive selection in three others. Enrollees
in IPA and mixed-model H O were more similar to non-enrollees in their prior
Ms
reimbursement patterns than were group and staff model H O enrollees. No
M
published study indicated significant systematic selection on any basis other
than a preference by low-spending people to join coordinated-care plans.
3
In a previous paper, we suggested that the importance of the positive
association between coordinated care and favorable risk selection may not be
fully appreciated by health policy analysts.* W would like to emphasize this
e
point once again. Since the only proven way to attract good risks is to provide
careful management of care, H O may benefit by not risk adjusting. I f they
Ms
receive extra payments for attracting high risks, their incentive to manage care
will be reduced.
There is only one exception to this rule -- when a health plan becomes very
large relative to the total market, i t literally may "run out of bad risks."
Short of this point, however, pooling will not cure the problem of systematic
risk.
Bellinger, Fred J., "Selection Bias in Health Maintenance Organizations:
Analysis of Recent Evidence," Health Care Financing Review. 9:2 (Winter, 1987),
pp. 55-63.
3
Langwen, Kathryn M. and James P. Hadley, "Evaluation of the Medicare
Competition Demonstrations," Health Care Financing Review. 11:2 (Winter, 1989),
pp. 65-80.
Zeldman, Roger and Bryan Dowd, "Must Adverse Selection Cause Premium
Spirals?" Journal of Health Economics, 10:3 (October, 1991), pp. 350-357.
�b. Why Aren't Large Employers Using Risk Adjustments?
In addition to reviewing the published studies on systematic risk
selection, i t is worthwhile to consider the experience of large employers that
offer multiple health plans. Although some large employers have expressed an
interest in risk adjustment, we are not aware of any employer that has
implemented a risk-adjustment scheme.
The State of Minnesota is a large employer that does not adjust its premium
contribution for systematic risk.
Minnesota's situation is especially
interesting because the State offers several health plans, makes a level-dollar
premium contribution based on the low-cost health plan, and does not require that
the plans offer a standardized benefit package. This program would seem to be
the most likely design for creating systematic risk selection.
However, systematic risk selection does not seem to be a problem for the
Minnesota State program. Table 1 presents data on two standard actuarial risk
factors -- age and sex -- for approximately 12,000 employees at the University
of Minnesota who participate in the State program. Using a scoring system where
higher numbers reflect greater risk, Table 1 shows almost no systematic risk
selection among the 4 H O that serve the University.
Ms
Group Health, a network-model HMO, has the lowest single-coverage risk
score of 1.28, but its family-coverage risk is higher than MedCenters or Medica
Primary, two other network H O . The data indicate a limited amount of adverse
Ms
selection into the State Health Plan, a preferred provider organization (PPO)
offered by Blue Cross and Blue Shield of Minnesota for State employees. Even so,
the risk level in the State Health Plan is only slightly higher than the average
risk of the H O sector. These data cannot rule out the existence of "hidden
M
risk" factors, but they show that risk based on age and sex is not a problem for
this large-employer group.
W postulate that this occurs because all health plans in the Minnesota
e
system recognize that careful management of medical costs is the best way to
attract good risks. At one time the State of Minnesota offered a fee-for-service
(FFS) plan with generous benefits and very l i t t l e management of medical costs.
This plan experienced spiralling premiums and had to be withdrawn from the
market.
c. What Are the Technical Issues in Risk Adjustment?
Designing a workable risk-adjustment program for systematic risk is certain
to be complex. Numerous issues must be addressed including the tradeoff between
costs and completeness, types of conditions to be covered, what to do about
moderately-severe conditions, how to deal with multiple simultaneous diagnoses,
and a host of other questions. Our discussion of these issues is not meant to
be all-inclusive; time and the need for conciseness did not permit more extensive
development.
The main contribution we can make is to emphasize that health plans must
be responsible for maintaining the health of their enrollees. This principle
rules out any adjustment based on events that happen post-enrollment. In order
�to design a risk-adjustment program, i t would therefore be necessary to collect
data at the time a person enrolls in the health plan. All post-enrollment data
are subject to possible influence by the health plan.
To illustrate the seriousness of this problem, we presented a list of 18
chronic health conditions to a nurse and an internist on the staff of our
research institute. Our two experts immediately identified 12 of these
conditions as being under the health plan's influence. The other six items
were questionable. An H O with more low birthweight babies definitely should not
M
receive extra reimbursement. Numerous scientific studies indicate that low
birthweight can be prevented by prenatal medical care and healthy lifestyles
(e.g., not smoking during pregnancy.)
5
Table 2 presents data which illustrate the practical problems with making
payment adjustments for systematic risk. These data pertain to the s m large
ae
H O that was mentioned in Section 1. The most costly single hospital admission
M
for this plan is pre-term and L W babies, which accounted for $1,692,145 in total
B
hospital costs over a recent 9-month period. The average cost per case was
$20,891. But we have argued that L W births can be prevented so we do not
B
recommend using this diagnosis for risk adjustment.
Also note that other complications of childbirth appear frequently in this
these complications were given additional payments.
Finally, we note that most of the diagnoses on this list do not have
extraordinarily high average costs. This happens because high-cost cases are
averaged together with others in the s m diagnosis that are not as costly. This
ae
means that a risk-adjustment system, in order to be sensitive to very high-cost
cases, might have to implemented at the sub-diagnosis level. This would require
extremely complex systems for tracking individual cases within a diagnosis.
The 12 conditions are high blood pressure, anemia, heart trouble or angina,
circulation problems, paralysis or the effects of a stroke, Alzheimer's disease,
arthritis, cancer other than skin cancer, digestive problems, liver problems,
kidney-bladder problems, and mental health conditions. Alzheimer's disease was
on this list because i t is sensitive to screening and labeling. The six
conditions less likely to be influenced by the health plan are asthma, diabetes,
nerve or muscle problems, chronic skin problems, and speech and hearing problems
�3. Random Risk and Reinsurance
a. An Example of Random Risk
Although we do not recommend adjusting premiums for systemic risk, we
nevertheless recognize that random risk poses a real problem for small health
plans. However, a reinsurance market exists to deal with this problem.
Random risk can be illustrated with a simple numerical example. Suppose
that 999 individuals in a population of 1,000 spend $900 on health care each
year, but 1 individual has a chronic illness that costs $100,900 per year to
treat. Also suppose that every health plan in the market area enrolls 1,000
people like those in this example. Therefore, risk is randomly distributed among
the health plans.
6
Using the laws of probability, we can calculate the probability that the
health plan will enroll "X" chronically i l l people, where X is any number. The
following table shows the probability that X equals 0, 1, 2, 3, or 4:
Number of Cases
0
1
2
3
4
5
Probability
.368
.368
.184
.0613
.0153
almost 0
W can also calculate the probability that the plan will enroll "fewer than X
e
"
chronically i l l people. The same table shows that the probability of enrolling
fewer than four chronically i l l people is .368 + .368 + .184 + .0613 = .9813.
In other words, i t is very likely that the plan will enroll fewer than four
chronically i l l people.
Even so, the health plan would experience severe financial loses i f the
number of chronic cases is higher than expected. Therefore, i t will want to
"sell off" the risk of excess cases to a reinsurance company. By pooling the
excess risks from many small insurers, the reinsurer can be very confident that
its premium will be adequate to cover any payout to its policy-holding plans.
The health plan must decide at what point i t wants the reinsurer to take
over the job of paying for excess risk. W calculated the fair reinsurance
e
premium for different levels of excess risk (the fair premium is just high enough
to cover the reinsurer's expected payout).
S e also could assume that each person has a .999 chance of spending $900
/
in a given year and a .001 chance of contracting an acute illness that costs
$100,9000 to treat.
�Fair Premium
Per Enrollee
$ 2.40
$ 10.40
$ 36,80
$100.00
Reinsurer Pays All Costs
Exceeding X Cases
3
2
1
0
This table indicates that a very modest premium of $2.40 per member per
year will cover the risk that the plan will enroll more than 3 high-spending
chronic cases. However, the plan s t i l l faces the risk 1 or 2 cases of chronic
illness. Which level of coverage will the plan select? The answer is obvious:
i f reinsurance can be bought at a fair premium, the plan will sell a?7 of its
risk to the reinsurer for a premium of $100. This premium will just cover $100
of expected health care spending, leaving the plan no worse off than i f i t paid
for all health care spending. Since the plan gains by avoiding risk and i t does
not lose any profits by reinsuring, i t will buy complete reinsurance.
b. Reinsurance in the Real World
W don't observe complete reinsurance in the real world because reinsurance
e
policies are not sold at a fair price. Reinsurers always add a margin for profit
and administrative expense into their premiums. They m y even add a "pure risk
a
premium" i f they are not confident that their pool is large enough to eliminate
risks, or i f they are unsure about the potential exposure to high-cost cases.
In addition, reinsurers add a margin to the premium to protect against the
possibility of "opportunistic" behavior by the health plan. In other words, once
the plan has sold its excess risk to a reinsurer, i t m y take less care to
a
prevent high-cost cases. Reinsurers increase their prices as coverage becomes
more generous to protect themselves against this kind of behavior.
Nevertheless, in the real world reinsurance is very important to health
plans. Since a few high-cost cases can virtually wipe out a small plan's
operating margin, small H O uniformly reinsure. Typically, this is done on a
Ms
per-case basis, with a deductible of $30,000 and cost-sharing of 20% to
discourage opportunistic behavior by the H O Examples of complaints concerning
M.
these reinsurance policies are rare. As the plan gets larger, i t can reduce
random risk by pooling of its own enrollees, and therefore i t needs less
reinsurance. The deductible m y increase to $100,000 per case, for example. F w
a
e
H O with more than 100,000 enrollees need reinsurance.
Ms
Health plans can also buy "all-risks" insurance policies which protect them
against all types of risks, not just those arising from high-cost cases. These
policies are very expensive, however, so they are not very common.
In a recent report funded by the Health Care Financing Administration, we
interviewed the 8 H O that serve State employees in Wisconsin and Minnesota.
Ms
None of these health plans expressed dissatisfaction with existing reinsurance
arrangements. (Bryan Dowd, Roger Feldman, Jon Christiansen, and Janet Shapiro,
Development of the Competitive Pricing Proposal for Medicare. Final Report, H F
CA
Cooperative Agreement No. 99-C-99169/5-04, February , 1993.)
�Real-world reinsurance policies are folded into the health plan's own risksharing arrangements with its physician groups. For example, many health plans
capitate their physician groups partially or completely for health care costs.
This arrangement gives physicians -- who are in the best position to manage highcost cases - a strong incentive to do so. Plans that capitate their physician
groups will need to buy less reinsurance, but the physicians m y reinsure.
a
Because a private reinsurance market exists to pool random risks, and
because this market operates reasonably well, there is no justification for a
government program to pay health plans for random risks.
4. Summary
The only type of risk selection for which i t is necessary to consider risk
adjustment is systematic risk and then only that systematic risk attributed to
the plan based on what i t is doing right. I t would be counterproductive to
adjust for systematic risk which the plan attracts due to poor practices.
However, determining the distinction m y be difficult because a fine line exists
a
between managing care effectively and rewarding inefficient plans. Experience
in the large group market, resembling purchasing cooperatives, does not support
strong need for risk adjustment.
Random risk is just that: i t cannot be predicted in advance of occurrence.
As such, i t represents just those conditions which health plans should be
responsible for insuring without additional reimbursement. Random risk is
typically eliminated by pooling over a large enrollment base, and reinsurance is
a demonstrated remedy for protecting health plans against low-probability
occurrences of very high-cost diagnoses.
Last, before risk adjustment can be applied to systematic risk selection,
extensive further research must be done to demonstrate an appropriate level of
accuracy with any certainty.
PM
P0'
�TABLE 1
W A ARE THE AGE/SEX RISK F C O S IN A LARGE
HT
ATR
E P O M N - A E H A T PLAN?
MLYETBSD ELH
UNIVERSITY OF MINNESOTA^ 1990
(ABOUT 12,000 CONTRACTS)
HAT PA
ELH LN
GROUP HEALTH
MEDCENTERS
MEDICA PRIMARY
MEDICA CHOICE
M D L SINGLE RISK
OE
TYPE
FCO
ATR
N
N
N
IPA
PO
P
1.28
1.38
1.32
1,40
3.29
3.27
3.18
3.40
1.32
T T L HO
OA M
STATE HEALTH
PLAN
FAMILY RISK
FCO
ATR
3.30
1.42
3.55
CONCLUSIONS:
• THERE I S ALMOST NO SELECTION WITHIN H O TYPES
M
• THERE IS LIMITED ADVERSE SELECTION INTO THE P O
P
SOURCE: TPF&C, FOR THE UNIVERSITY OF MINNESOTA
HEALTH PLAN TASK FORCE
! I : ? 'j P M
�1
i •.i— •—
r u L . i ••.
TABLE 2
MHP INPATIENT HOSPITAL CLAIMS BY PRIMARY DIAGNOSIS
ADMITS FROM 04/01 /90-12/31 /90
DIAGNOSIS
765
410
414
715
574
296
V57
V30
656
250
650
486
664
428
996
654
427
518
820
411
644
540
661
786
436
-
-
-
-
-
663
441
722
780
218
660
560
424
303
658
153
652
276
493
642
174
•
-
Pre-term & Low Birth Weight
Acute Myocardial Infarction
Other Chronic Ischemic Heart Disease
Osteoarthrosis
Cholelithasis
Affective Psychosis
Rehab Care & Procedures (PT, etc.) Speech
Newborn
Fetal & Placental Problems
Diabetes Mellitus w/o Mention of Complication
Normal Delivery
Pneumonia (organism unspecified)
Trauma to Perineum & Vulva During Delivery
Heart Failure
Complications from Implants, Grafts & Devices
Abnormality of Pelvic Organs
Cardiac Dysrhythmias
Lung Collapse, Emphysema, etc.
Fracture of Femur
Other Acute and Subacute Ischemic Heart Disease
(Occlusions with Myocardial Infarction)
Early or Threatened Labor
Acute Appendicitis
Abnormal Labor (stow)
Chest Pain/Respiratory Pain
Acute, but ill-defined Cerebrovascular Disease
Umbilical Cord Complications
Aortic Aneurysm
Lumbar Disc Displacement/Cervical Disc Displacement
Syncope/Convulsions
Uterine Leiomyoma
Obstetrical Labor
Intestinal Obstruction, Adhesions, etc.
Mitral Valve Disorder (also aortic)
Alcohol Dependence Treatment
Amnionic Membrane Problem
Malignant Neoplasm Colon & Rectum
Malposition
Electrolyte Imbalance & Dehydration
Asthma
Hypertension Complications of Child Birth
Breast Cancer
PAID AMOUNT
ADMITS
$1,692,145
1,281,468
1,115,763
1,034,899
953,520
952,068
875,330
837,833
799,090
796,887
788,434
745,867
735,554
719,614
682,932
638,622
589,563
557,236
552,682
529,985
81
256
121
169
303
316
143
607
491
164
610
211
554
205
117
280
158
61
131
140
521,462
516,180
507,315
505,747
480,585
473,917
448,668
440,918
420,148
396,775
375,611
358,594
357,954
341.441
338,526
337,642
337,518
313,822
309,550
307,643
297,338
290
157
251
242
113
344
24
166
204
112
165
92
22
187
200
56
145
155
137
150
124
�i IHK—iiCi— i
i i • •4Z'
rr.un
1
ui i L i v ni_ i n otr: r-tzz- r u u i L
IU
DIAGNOSIS
745
430
345
197
V58
440
617
038
998
434
600
785
-
-
Heart Valve Repair (& Other)
Subarachnoid Hemorrhage
Epilepsy/Grand Mal, etc.
Cancer of Respiratory & Digestive System (Secondary)
Radiotherapy or Chemotherapy
Atherosclerosis
Endometriosis
Septicemia
Post OP Complications (Infection, Persist Fistula, etc.)
Occlusion of Cerebral Arteries
Hyperplasia of Prostate
CV. System Symptoms, Tachycardia, Palpatations, etc.
B1 i k J i i i . - J i i U
PAID AMOUNT
293,402
289,920
286,274
273,920
272,424
272.057
271,436
268,149
266,662
263,676
262,358
260,004
r . iu
ADMITS
18
10
37
47
101
50
77
47
72
62
98
14
?O pM
�Enclosure 2
Roger Feldman i s P r o f e s s o r o f H e a l t h S e r v i c e s Research and
Economics a t t h e U n i v e r s i t y o f Minnesota. H i s major f i e l d i s
h e a l t h economics. R e c e n t l y , he has completed s t u d i e s o f
c o m p e t i t i o n among p r i v a t e h e a l t h i n s u r e r s , h o s p i t a l s , and h e a l t h
maintenance o r g a n i z a t i o n s i n c l u d i n g a s t u d y o f HMO mergers. From
1988 t o 1992, he d i r e c t e d one o f t h e f o u r n a t i o n a l r e s e a r c h
c e n t e r s sponsored by t h e H e a l t h Care F i n a n c i n g A d m i n i s t r a t i o n .
Dr. Feldman was a M a r s h a l l Scholar a t t h e London School o f
Economics, where he r e c e i v e d an M.Sc. degree. H i s Ph.D. i n
economics i s form t h e U n i v e r s i t y o f Rochester. B e f o r e coming t o
Minnesota, he h e l d an appointment i n t h e Economics Department a t
the U n i v e r s i t y of North Carolina.
Dr Feldman i s a r e g u l a r
c o n t r i b u t o r t o p r o f e s s i o n a l j o u r n a l s i n health services research
and economics, and i s on t h e e d i t o r i a l boards o f s e v e r a l
j o u r n a l s , i n c l u d i n g H e a l t h S e r v i c e s Research and I n q u i r y .
Bryan Dowd i s a h e a l t h p o l i c y a n a l y s t s p e c i a l i z i n g i n r e s e a r c h
r e l a t i n g t o t h e s t r u c t u r e and performance o f h e a l t h care markets.
He has p u b l i s h e d e x t e n s i v e l y on t h e e f f e c t s o f HMOs on t h e c o s t
and u t i l i z a t i o n o f h e a l t h care s e r v i c e s and t h e e f f e c t o f
government r e g u l a t i o n on h e a l t h care markets. I n 1987, Dr. Dowd
i n i t i a t e d a HCFA-funded study o f b i a s e d s e l e c t i o n i n Twin C i t i e s '
Medicare h e a l t h p l a n s , w i t h t h e g o a l o f d e v e l o p i n g a c o r r e c t i o n
f o r s e l e c t i o n b i a s i n t h e AAPCC-based c a p i t a t i o n f o r m u l a . I n
1990, he d i r e c t e d a y e a r - l o n g study o f HCFA's approach t o
r e i m b u r s i n g Medicare HMOs. The r e s u l t o f t h i s s t u d y was a
recommendation t o r e p l a c e t h e c u r r e n t system w i t h an approach
based on c o m p e t i t i v e c o n t r a c t i n g p r i n c i p l e s . HCFA i s now
supporting research t o f u r t h e r r e f i n e t h i s proposal.
Dr. Dowd's
Ph.D. degree i s i n P u b l i c P o l i c y A n a l y s i s from t h e U n i v e r s i t y o f
Pennsylvania.
�04.'06.'93
001
10:35
DEPARTMENT OF H E A L T H AND HUMAN S E R V I C E S
ASSISTANT SECRETARY FOR HJVNNINU AND EVALUATION
PHONE: (202)690-8794
FAX: (202)690-6518
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ror o f f i c i a l use Only
ATTACHMENT
BENEFIT OPTIONS
I t i s l i X e l y t h a t the new standard benefita package w i l l be mora
generous than the current Medicare benefits package. Decisions
w i l l need t o be made about the degree t o which, i f any. Medicare
b e n e f i t s should be testiuutui-eU i g briny them more i n l i n e w i t h
the standard benefits package.
Medicare has two parts: Part A, HuapiLal Insurance (HI) helps
pay f o r i n p a t i e n t h o s p i t a l care (time l i m i t e d , w i t h a $676
deductible and a f t e r 60 days coinsurance of $169 per day);
HXilltid nursiny care (Lime-limited and coinsurance o f $04.50
a f t e r 20 daye); home health care; and hospice care.
Part B, Supplementary Medical Insurance (SMI), pays f o r 80
percent o f the approved amount f o r covered services i n excess o f
an annual deductible ($100). covered services include:
physlviau's services; home health services; and other medical and
health services: and Supplies.
Other b e n e f i t s include; comprehensive outpatient r e h a b i l i t a t i o n
f a c i l i t y services; p a r t i a l h o s p i t a l i z a t i o n f o r mental health
treatment; c e r t a i n preventive services such as screening
mauunography, screening pap smears; diagnostic t e s t s ; c l i n i c a l
laboratory serviices; kidney d i a l y s i s and supplies; amhulance
services; durable medical equipment; prosthetic and o r t h o t i c
devices; and l i m i t e d coverage of drugs and b i o l o g i c a l s .
The primary areas i n which the new standard b e n e f i t package i s
l i X e l y t o o f f e r more generous coverage than Medicare include
p r e s c r i p t i o n drugs and a l i m i t on catastrophic costs. I n
a d d i t i o n , the hew standard pacXage l i X e l y w i l l contain more
favorable cost sharing (e.g., smaller deductible and coinsurance
amounts) f o r the beneficiary.
I f the new standard b e n e f i t package i s immediately adopted f o r
Medicare, i t w i l l cost b i l l i o n s of Federal d o l l a r s . I t may be
possible t o phase i n coverage, s t a r t i n g w i t h p r e s c r i p t i o n drugs,
l o r example, arid gradually adding other benefits as health reform
savings accelerate.
The cost of a l t e r n a t i v e b e n e f i t packages i s s t i l l under
development.
Preliminary S t a f f working Paper - For i l l u s t r a t i v e Purposes Only
�04.'06.'93
10:36
003
ror gftlclfll VIM only
ATTACHMENT
ELIGIBILITY—DISABILITY
BENEFICIARIES
Under current liw, Medicare e l i g i b i l i t y for the disabled begins
only after an individual has been entitled to social security
d i s a b i l i t y benefits for 24 months. This 24-month waiting period
was established to hold down program costs. I f the new health
care system i s going to subsidize the premiums for health care
for many of the; disabled, should this waiting period be
maintained?
in 1991, approximately 3.4 million d i s a b i l i t y beneficiaries were
entitled to Medicare (projected to increase to 3.8 million by
1993). Medicare outlays for the disabled i n 1991 were $12.7
b i l l i o n (projected to increase to $15.4 b i l l i o n by 1993).
i t i s estimated that the 10-year cost to Medicare of a cohort of
10,702 d i s a b i l i t y beneficiaries would have increased by about 45
percent i f the waiting period had been eliminated and Medicare
were the primary payer during that period. Thirty percent of
that increase would have been for persons who died within two
years of entitlement to d i s a b i l i t y benefits.
Previous studies showed that approximately 3/4 of the disabled
individuals entitled to Social Security benefits had some type of
health insurancie coverage other than Medicare during the two-year
waiting period.; Approximately 16% of the individuals were
covered by Medicaid and/or State plans, and over half had private
health Insurancie.
The principal issues are: How many of these individuals would be
covered by private health insurance under the new health care
system, and how many would require a subsidy? would Medicare be
the most appropriate and cost-effective source of subsidy for
disabled individuals during the f i r s t two years of their
e l i g i b i l i t y for Social Security benefits? Moreover, i f Medicare
became the sole; insurer of these disabled .Individuals, rather
than Federally subsidizing private health care for them through
the HIPC, would this result in a large portion of these
individuals being shifted from the standard benefit package to a
less' generous Medicare benefit pacXage?
Preliminary Staff working Paper - For IlluBtrative Pmrposes Only
�0/|/0g./93
10:37
001
For O f f i c i a l uaa only
ATTACHMENT
SLOBMi BUDGET \
The major issue i s whether Medicare i s subject to a global
budoet. I f a global budget applies to Medicare, there are a
series of policy issues that must be addressed including:
o
Whether the global budget i s separate from the managed
competition structure or whether i t i s part of the HIPC?
o
Who sets the global budget?
o
o
What i s included i n the global budget?
How i s the! budget net and adjusted from year to year?
Should increaueB i n the Medicare budget, differ from those of
other public or private programs?
How i s the budget enforced and how can cosL-ehifting onto
Medicare from other programs be prevented?
o
These issues w i l l be addrestted by the work group on global
budgets.
PruHmlnary staff working Paper - For IUttfitrBtlYC PWgpPffgg 9n*Y
�March 11, 1993
SUBJECT:
Medicare and other options for fee-for-service
under the HIPCs
FROM:
Paul Starr
One of the great "sleeper" issues we are facing i s the
treatment of fee-for-service under the HIPCs. The o r i g i n a l
managed-competition models did not foresee any conventional
insurance being offered; a l l plans would consist of networks of
providers competing on quality as well as cost.
But structuring a national program on these l i n e s has never
been r e a l i s t i c . For one thing, i n many parts of the country
network-based managed care plans are undeveloped; i t i s
inconceivable that the entire marketplace could be transformed
immediately or even over several years. Moreover, i t would be
impossible to get the program passed by Congress i f the only
choices offered were network-based managed care plans. The
opposition would be overwhelming.
The question, therefore, i s not whether there w i l l be
conventional insurance under the HIPCs, but how i t w i l l be
treated. (By conventional insurance I mean a health insurance
plan that pays providers by fee-for-service and has no separate
or preferred network, although i t may have some kind of
u t i l i z a t i o n management). Should there be one or more FFS plans?
Should Medicare be one of multiple FFS options, or the one and
only FFS option? Should the system be set up so that FFS costs
w i l l go sky high and FFS w i l l disappear, or should the system be
set up to keep FFS costs down?
I do not see how we can be indifferent to FFS costs--there
are j u s t too many people who are going to be enrolled i n FFS
plans. I f there i s no control on FFS, there i s no way to enforce
a budget. To be sure, i f we hold down FFS costs, we reduce the
incentive for people to enroll i n more e f f i c i e n t plans. Moreover,
i f we a r t i f i c i a l l y depress FFS costs by holding down payment,
there may be cost-shifting to managed care plans--at l e a s t ,
that's what the managed-care industry w i l l say (I'm not sure i t ' s
true).
We know from experience that multiple FFS plans w i l l r a i s e
administrative costs. At Tollgate 2, Kurt Smith of the federal
employees plan estimated that FEHB could save $200 m i l l i o n i f i t
could consolidate and competitively bid FFS. Consolidating FFS
under the HIPCs w i l l not only mean consolidated claims processing
and hence l e s s duplication of administrative systems; i t w i l l
w i l l also reduce the likelihood of r i s k selection problems. And
i f there i s j u s t one FFS plan, i t ' s going to have a l o t of market
�-2power i n relation to the providers. That could make i t much
easier for the FFS to stay within a budget.
So the case for one and only one FFS plan i s very strong.
But should that one plan be Medicare or a private insurer that
bids competitively to get the HIPCs contract to run i t s one FFS
plan?
There are some key differences between having a
competitively bid, privately run FFS plan i n each region and
using Medicare as that plan:
(1) The private FFS plans i n each regional
HIPC would presumably have different
premiums, depending on regional differences
in practice patterns and costs. On the other
hand, most Americans would expect a Medicare
plan to have a single, national premium. To
be sure, you could use Medicare as a payment
system but have varying regional rates
depending on costs i n those regions. But i t
would be very confusing to have Medicare
operating on a national basis for the elderly
and a regional basis for the under-65
population.
(2) We have generally assumed that the HIPCs
would pay benchmark premiums i n each region
and that consumers would pay more for plans
that were more costly than the benchmark.
This would lead to an additional feature that
the public would find confusing: the cheaper
the benchmark plan i n a region, the more
costly to the consumer the Medicare option
would be. People would say that was "unfair."
(3) I f Medicare were the FFS option, there i s
no way that HIPCs could bargain with i t . Nor
could there be any competitive bidding.
Indeed, because Medicare's intermediaries
enjoy a protected franchise, administrative
costs would be significantly higher than i f
the HIPCs were free to seek alternative
bidders.
The most serious problem i s one of expectations. I f the
benefit package for the under 65 population i s i n any way more
generous than Medicare (and most of us assume i t w i l l be), the
use of Medicare as the FFS option w i l l make i t impossible to
withhold the same benefits from the elderly population. This w i l l
greatly increase the costs of the program we are proposing.
�-3On the other hand, there are some t e r r i f i c advantages t o
using Medicare as the FFS option. I t would make possible a more
r a p i d s t a r t u p of the e n t i r e program—whatever happened w i t h
development o f managed care plans. Medicare would be a v a i l a b l e as
the d e f a u l t o p t i o n .
Second, i f Medicare rates were used f o r a l l FFS under the
HIPCs, i t would b r i n g about a sharp reduction i n payments t o
h o s p i t a l s and d o c t o r s — s o large t h a t i t could finance the
extension o f coverage t o the uninsured. (Of course, i t would also
arouse f i e r c e opposition from the providers, not t o mention the
insurers!)
T h i r d , i t would c e r t a i n l y provide a l o t of s e c u r i t y t o
people about the new program. They might not know what a HIPC
w i l l be, but they would be much r e l i e v e d t o know t h a t Medicare
would always be a v a i l a b l e as an option. (That may not, however,
be enough f o r many people w i t h b e t t e r coverage from Blue Cross
and other plans; they would be concerned t h a t Medicare's low
payment r a t e s might cut them o f f from t h e i r doctors, who would be
saying, "We won't be able t o take you any more," even though
they'd r e a l l y have l i t t l e choice.)
F i n a l l y , many people w i l l see t h i s as a back door t o a
s i n g l e payer system--Medicare f o r a l l , a t l e a s t f o r a l l who want
i t . Pete Stark should be delighted. Those who have opposed s i n g l e
payer w i l l see i t as an i n s i d i o u s device t o get everybody i n t o a
government plan.
I t ' s a hard decision. I n the end, I t h i n k we would be b e t t e r
o f f t o have a s i n g l e FFS plan using a modified Medicare payment
system r a t h e r than Medicare i t s e l f . This plan can be explained as
being " l i k e Medicare" but i t should d e f i n i t e l y not be confused
w i t h Medicare i t s e l f .
�04-06-93 04:06 P FO O P
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FACSfMIU TRANSMISSION RIQUIST
AOOUSUn PAX MACHINI PHOfU NUMIIKi
IP PAX MACMMI UTIAMIMISMON IINKUIAIT PUAM CAUl
IMUUTOVf INtnUOlONf lO IKIIWb
Pl
O
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4 0 - 3 4 0 M RM L
For Official Use Only
P2
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19
Alternate Option; Phflgq^i" Inteq^jl9n
of Medicare Beneficiaries into the HIPC
Enrollment
Newly-eligible Medicare beneficiaries would be phased into the
HIPC structure starting three years after implemontation of
managed competition for the under-65 population. Delaying
initiation of phase-in minimizes any potential strain on the new
system early in i t s implementation/ but ultimate integration
achieves a common health care delivery system across a l l segments
of society and facilitates global budgeting. Integration of the
Medicare population into the HIPC allows the risk inherent to an
open-ended payment structure to be transierred from the
government to the AHPs which would provide health care to this
population within a capitated rate
significant from a costcontainment standpoint and especially important in a non-means
tested entitlement program.
The phase-in, starting three years after managed competition i s
initiated, would occur month by month. Each month approximately
200/000 people turn 65 and are eligible for government
subsidization of their health care costs. Prior to an
individual's 65th birthday/ enrollment and comparison information
on plana would be provided. Individuals would make a selection
through the HIPC similar to what they did under managed
competition prior to turning 65. Individuals would be locked-in
to their health plan selection until the next open enrollment
period. Nearly complete Integration of the Medicare population
into the HIPC structure would be accomplished in approximately 20
years, at which time the Medicare program would no longer exist.
By the time this phased-in integration of Medicare into the HIPC
begins, the under-65 population will be functioning in the HTPC
structure. This should lessen any transition problems for
beneficiaries who will be familiar with managed care and managed
competition.
FFS Mgdlcar?
The current FFS Medicare program would continue to exist for
current beneficiaries who would remain grandfathered to the old
system. The current beneficiaries grandfathered to the FFS
Medicare system could voluntarily choose to obtain their benefits
through plans in the HIPC. Medicare beneficiaries choosing to
receive their health care through an AHP could do so as soon as
managed competition i s implemented and would not have to wait for
the phase-in of newly-eligible beneficiaries to begin. For these
individuals/ Medicare would contribute an amount equivalent to
Preliminary Staff Working Paper - For IllttBtratlve PurpoBes Only
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4 0 - 3 4 0 M RM L
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the coat of the benchmark plan similar to the approach i n the
under-65 segment. The FFS Medicare market would be reduced each
month as newly-eligible beneficiaries would be maintained i n the
HIPC. Medicare FFS would continue to be administered by HCFA
including cost control mechanisms such as the DRGs and the RBRVS
methodology.
Premium Charged
Each AHP would be required to accept Medicare beneficiaries.
Each AHP would offer two premium bids: one for the under-65
population and one for the 65 and over population. Two bids are
able t o account for health care cost differences between the two
populations and for any cost differences due to two different
benefits packages to the extent that the basic Medicare benefit
package d i f f e r s from the standard benefit package for the rest of
the population. An AHP's premium for the 65 and over population
would be tied t o i t s premium bid for the under-65 population
( i . e . , r e f l e c t i n g the average difference i n health care costs
between the populations) to ensure that plans are not overbidding
for the 65 and over group to avoid serving them.
ggvernment Contribution
The 65 and over individuals/ who as part of the phase-in would
continue t o obtain their health care by selecting an AHP i n the
HIPC/ would have a portion of the AHP's premium paid by the
federal government. That contribution would be the cost of the
benchmark plan less the Part B premium paid by the beneficiary
which could be adjusted based on the beneficiary's income. For
those retirees with high incomes, the individual contribution t o
the Part B premium could be gradually increased above the current
25%, culminating i n a 100% Part B contribution at a certain
income level. As i n the under-65 market, the beneficiary would
bear any additional costs greater than the cost of the benchmark
plan encouraging cost- and quality-conscious choices and
ultimately resulting i n cost savings for tho government and the
beneficiary. The HIPC would dispense funds to the AHPs based on
the number of beneficiaries 65 and over (and any other included
groups, i . e . , disabled and ESRD). The government would not be
involved i n payment to providers, and the Medicare H O programs
M
would be eliminated.
Benefit Package
For implementation of this option, the content of the benefit
package does not play a large role. I f the standard benefit
Prellwinarv Staff Workino Paper - For I l l u s t r a t i v e Purposes only
�04-06-93 04:06 P FO O P
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21
package and the basic Medicare benefit package are the same (the
best option for the 65 and over population because presumably the
standard benefit package w i l l be more generous than the current
basic Medicare benefit package), transition into the 65 and over,
government-subsidized system would be seamless for beneficiaries.
The contrasting scenario of the basic Medicare benefit package
being less generous than the standard benefit package does not
present an untenable alternative. The separate bids f o r the
over- and under-65 populations create a convenient means to offer
separate benefit packages. Cost for the government also becomes
an issue with increasingly extensive Medicare benefit packages.
Also, the presumed inclusion of prescription drug coverage as
part of health care reform w i l l provide the Medicare population
with significant additional benefits which may render less
significant other unobtained benefits.
Assuming that AHPs emphasizing managed care replace deductibles
and coinsurance with actuarily-equivalent copayments, the need
for Medlgap policies would be reduced as more and more of the
newly-eligible Medicare population stay i n the HIPC structure
rather than FFS Medicare. A supplemental insurance market,
similar to today's Medigap market, may exist for those
beneficiaries who choose the "free choice" AHP (essentially FFS)
in the HIPC.
Methodology for implementing risk adjustment adequately i s not
currently available, and the need for i t appears to have been
overstated.
Two kinds of r i s k exist: random and systematic. Random r i s k i s
that r i s k which occurs post-enrollment and for which the plan, as
an insurer, i s supposed to be covering. A viable reinsurance
market exists for pooling higher-than-expected random risks.
Risk adjusters should not be applied to incidents of random
(post-enrollment) risk.
Systematic r i s k i s that risk which i s attributed to the plan
based on pre-enrollment conditions. A plan can obtain this r i s k
because of what i t does well or because of what i t does poorly.
Risk adjustment, i f needed at a l l , should only be provided to
plans which receive a higher-than-normal incidence of preenrollment high cost cases because of what they do well as far as
managing care. The type of high-cost cases which apply should be
not more than ten or twelve to ensure that plans have an interest
in managing care well rather that relying on an increased payment
scheme.
PrffUnlMTY Staff Working Paper - For I l l u s t r a t i v e Purposes only
�04-06-93 04:06 P FO OP
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ror Qttlcial una only
Further, the distinction between good and bad practices and t h e i r
impact on systematic r i s k is extremely d i f f i c u l t to measure. I n
fact, i t has not been demonstrated that systematic risk w i l l not
be equitably distributed among plans thereby negating the need
for what i s sure to be a complicated risk adjustment system,
assuming one can be developed. Large employers who offer a
choice of plans to employees have not u t i l i z e d risk adjusters,
and the states of Hawaii and Minnesota have not found a need for
them either because of the natural risk distribution between
plans.
Pgtllmlnarv Staff Working Paper - For I l l u s t r a t i v e Purpose Only
P5
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21
�The ancient law looked upon fraud as a greater crime than theft,
and, therefore, seldom failed to punish it with death, for with
care and vigilance and a very common understanding might a man
preserve his goods from thieves, but honesty has no defense
against superior wit and cunning.
-Anonymous (1726)
Health Care Provider Fraud: The Medicaid Fraud Control Unit Experience
State Medicaid Fraud Control Units (MFCUs)
Medicaid Fraud Control Units are federally funded state law enforcement entities which
investigate and prosecute Medicaid provider fraud and violations of state laws pertaining to fraud
in the administration of the Medicaid program. In addition, the Units are required to review
complaints of patient abuse and neglect in all residential health care facilities that receive
Medicaid funds. The Units are staffed by attorneys, investigators and auditors trained in the
complex litigation aspects of health care fraud. The Units are required to be separate and
distinct from their state Medicaid programs and are usually located in the state Attorney
General's office.
There are 41 federally certified Medicaid Fraud Control Units. Since the inception of
the Medicaid Fraud program in 1978, the Units have successfully prosecuted over 6,000 cases
and have been responsible for identifying and returning hundreds of millions of program dollars.
It is important to note that every criminal conviction excludes the provider from participation
in both the Medicaid and Medicare program as well as other federal health care programs. The
Units are also responsible for protecting the frail elderly who reside in nursing homes, some of
the most vulnerable of our population.
The National Association of Medicaid Fraud Control Units represents the 41 federally
certified units and is staffed by a Medicaid Fraud Counsel who conducts its daily work at the
office of the of the National Association of Attorneys General, in Washington, D.C.
The Association was founded in 1978 to provide a forum for a nationwide sharing of
information concerning the problems of Medicaid fraud; to foster interstate cooperation on legal
and law enforcement issues affecting the Units; to improve the quality of Medicaid fraud
investigations and prosecutions by conducting training programs and providing technical
assistance to Association members; and to provide the public with information about the
Medicaid Fraud Control Unit Program.
�The Association conducts several training conferences yearly and publishes a newsletter,
the Medicaid Fraud Report, 10 times a year.
History of the Program
As a preface, it is worth noting the historical context of the MFCU program. Medicaid
was created by Congress in 1965 as a national attempt to provide uniform health care benefits
for the financially indigent. Initially, no fraud and abuse provisions were contemplated nor
enacted. Congress, in the mid-1970's, became aware of widespread fraud and abuse by health
care providers in the Medicaid Program when it conducted hearings which documented evidence
of provider fraud. These hearings revealed that fraud and abuse were taking a toll on the
beneficiaries as well as on the ability of the states to deliver these federally mandated health care
services.
The Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977 (P.L. 95-142),
signed by President Jimmy Carter on October 25, 1977, were designed to strengthen the
capability of the government to detect, prosecute and punish health care fraud. The key to the
success of the MFCUs are the following statutory requirements: the Units must be separate and
distinct from the Medicaid agency; are generally located in the state Attorney General's office;
must be solely dedicated to investigating and prosecuting provider fraud and patient abuse; must
be staffed by trained specialists, i.e. attorneys, investigators, and auditors who are trained in the
prosecution of complex white-collar crime cases; and must have state-wide prosecutorial
authority or the ability to establish formal procedures with the appropriate state prosecuting
authority.
Many believe that the gap between the establishment of the Medicaid Program in 1965
and the establishment of the MFCUs in 1977 forced law enforcement into a nearly impossible
catch-up mode. New health care fraud schemes and new twists to old schemes are documented
every day. Health care providers are no exception to those who would cheat a system where
a large amount of money is administered. Criminal health care fraud not only diverts scarce
resources but also deprives those who are in need of health care. In addition, fraudulent health
care providers are sometimes found to be incompetent.
As Professor Pamela Bucy so accurately points out in her exhaustive law review article
on health care fraud', the growing commercialization of health care encourages fraudulent
behavior. Furthermore, Professor Bucy states, as the number of providers increase, and the
efforts to control health expenditures increase, there will be fewer dollars to be divided among
the provider community. "As providers seek to maintain what they perceive as appropriate
'Pamela H. Bucy, Fraud By Fright: White Collar Crime by Health Care Providers, 67 N.C.
L.Rev. 855, 856 (1989).
�2
target incomes, the unscrupulous provider is more likely to succumb to fraud ." Some health
care professionals and non-professionals literally scheme and plot ways to get around any new
rules, regulations, or controls and continue to divert large amounts of program dollars for their
own benefit. While the vast majority of health care providers are honest, health care is a big
business and big business without regulatory and legal controls sets the stage for fraud. Health
care provider fraud undeniably exists and affects both government and private insurance payers.
We urge you to not repeat what should be a lesson of history. When a new health care delivery
system is chosen, a program for the detection and prosecution of those who will defraud it,
should also be created.
Current Fraud Schemes
1.
Billing for Services Not Provided
This is one of the most common types of abuse. Examples include, a provider who bills
Medicaid for a treatment or procedure which was not actually performed, such as blood tests
when no samples were drawn, x-rays which were not taken, or, in the case of a dentist, billing
for a full denture plate when only a partial was supplied. It is improper for a Medicaid provider
to bill Medicaid for any service not performed.
2.
Double Billing
A provider will bill both the Medicaid Program and a private insurance company (or the
recipient) for the treatment. Another example is two providers requesting payment for services
rendered to one recipient for the same procedure on the same date.
3.
Misrepresenting the Nature of Services Provided
A pharmacy may bill the program for the cost of a prescription drug charging the name
brand prescription drug price, when, in fact, a generic substitute was supplied to the recipient
at a substantially lower cost to the pharmacy. Less expensive goods are often supplied to a
patient but a higher priced item is billed for.
4.
Providing Unnecessary Services
A provider may misrepresent the diagnosis and symptoms on recipient records and billing
invoices to obtain payment for unnecessary tests and procedures.
:
Id. at 936.
�5.
Illegal Remunerations
A provider, for example, a nursing home operator conspires with another health care
provider, i.e. physical therapist, pharmacy, laboratory, ambulance company or physician, to pay
a certain portion of the monetary reimbursement the health care provider receives for services
rendered to patients in the nursing home. Payments include, vacation trips, leased vehicles or
other remuneration. This practice usually results in unnecessary tests and services being
performed for the purpose of generating additional income.
6.
False Cost Reports
A nursing home owner or hospital administrator may include inappropriate expenses in
claims to Medicaid. These expenses often include the costs of items for personal consumption
and use.
Fraud In Other Government Programs/Private Payers
The fraud units have found that a provider who submits false claims to Medicaid very
often submits false claims to other government programs and to private insurance payers.
Increasingly, the cases of many fraud units include a component of private insurance fraud as
well as other government program fraud (i.e. Medicare and CHAMPUS prosecuted in
conjunction with Medicaid fraud cases).
In order to successfully investigate and prosecute providers of any health care program,
one must understand the program's rules and regulations. As a result of this increasing
experience with a variety of health care reimbursement systems, the Units have gained a wealth
of experience that would be difficult to duplicate or replace.
Fraud In Managed Care Programs
Both the Medicaid and Medicare programs have experimented with managed care. In
some states, managed care has been in existence since the early 1980's. Recently, more states
are requiring greater numbers of their Medicaid population to participate in their managed care
programs.
Proponents of the managed care system believe that it is the best method for providing
low cost high quality health care to more people. Managed care is not only supposed to save
money but it is also designed to cut down on the amount of paperwork. While many observers
point out that the very nature of managed care prevents fraud, the experience of the fraud units,
the Arizona Unit in particular, the Medicare program and the private insurance industry, reveal
that no health care plan is immune from fraud and indeed fraud does occur in managed care
plans. Rather, fraud simply takes different forms, in response to the way the program is
structured.
�While the traditional Medicaid provider fraud investigation focuses on overutilization of
services and fraudulent billing and seeks as the ultimate aim accountability for claimed services,
in managed care investigations, the evil more likely lies in the underutilization of services .
Unlike the typical Medicaid provider fraud case, the human cost in terms of reduced access to
quality care may be tremendous .
3
4
The Arizona Experience
The Arizona Health Care Cost Containment System (AHCCCS), a statewide prepaid
capitated program, that is designed to provide the same quality health care to the poor that is
provided to private pay patients, began on October 1, 1982. Each recipient is enrolled in a
health maintenance organization (HMO or AHCCCS Plan), which in turn contracts with the state
to provide all benefits for a fixed fee per enrolle. Plans bid competitively by county. The
AHCCCS Fraud Unit was established on November 5, 1984, and has 8 1/2 years of experience
in investigating and prosecuting fraud in the AHCCCS Program.
AHCCCS is operated by private plans, which may be for-profit, rather than administered
directly by the state. Federal and state monies are the payment source for these for-profit plans
that actually provide care to the beneficiaries. Each of these private plans represent
opportunities for entrepreneurial fraud.
/. False Claims
Because AHCCCS has a limited fee-for-service component of its system, the AHCCCS
Fraud Unit has found numerous examples of a traditional type of fraud, that is, the submission
of false claims. The AHCCCS program is a two-tier system, the state agency pays certain types
of claims directly, and the subcontracted plans pay other types of claims. The AHCCCS Fraud
Unit has found that false claims have been submitted at both levels.
At the state level, the submission of false claims involves mainly upcoding and doublebilling. While there are many types of upcoding, the primary type that the AHCCCS Fraud Unit
has discovered is billing for a higher level of service than actually provided. For example,
physicians have billed for a Level II ultrasound when they have really performed a Level I, have
submitted claims for a comprehensive consultation when they have only performed an
examination or merely admitted a patient, and have submitted claims for a more complex
surgical procedure than actually performed.
'Cathy Pilkington, Health Maintenance Organizations: Investigating Industry-Wide Practices,
Medicaid Fraud Rep., Feb. 1988, at 1.
J
Id.
�The AHCCCS system enables providers to double-bill that is, they can bill for the same
service at the state level as well as at various subcontracted levels because the system which has
different payers or beneficiaries, is so complex.
At the plans' subcontractor level, the AHCCCS Fraud Unit has found that false claims
have been submitted by virtually every provider type; physicians, osteopaths, medical
transportation companies, hospitals, pharmacies, physical therapists, registered nurses, etc.
These false claims involve the following schemes:
Upcoding; billing for services or supplies not provided; several types of
unbundling (split billing, breaking services down into steps and stages, billing for
services included in the single fee, etc, etc.); billing for unnecessary services,
duplicate billing; hospital bill padding; pharmacy fraud (generic substitution, short
filling; false refilling; forged RX); billing for services provided by others; and
false time claims by health care workers.
No one health care entity can effectively cover all services that will be needed by a plan's
beneficiaries. Therefore, some fee-for service component will continue to exist as part of any
managed health care plan and the types of fraud that are inherent to the traditional delivery
system will continue to exist.
//. White-Co liar Crime
"Fraud by health care providers is one of the most deleterious of all white-collar
crimes ."
5
The AHCCCS Fraud Unit has learned that any managed care system that allows profitminded entrepreneurs to be involved will be subject to traditional white-collar crimes. In fact,
the government is often victimized twice, first by failing to receive performance on its prepaid
capitation contracts, and then again by having to pay for services to the beneficiaries when the
vendors fail to provide them. In some cases, the subcontracting provider may actually be the
victim, by providing the care and then not getting paid for that care by the contracted plan.
Specifically, Arizona has documented the following types of criminal cases:
Embezzlement of funds paid by the state to plans for client services; theft of
funds, equipment and services; fraudulent subcontracts (for example, no services
provided, or phony management contracts); fraudulent related party transactions;
excessive salaries and fees to the entrepreneurs involved; extortion; conspiracy;
mail and wire fraud; bribery; tax evasion; and, pure and simple bustouts (money
5
Bucy, supra at 855.
�goes in, no money goes out to the vendors, then the entrepreneur claims
bankruptcy).
In general, the white-collar crime aspect of the AHCCCS program has been exacerbated
by inadequate investigation and supervision of the subcontractors, poor monitoring of plan
activities and providers by the subcontracted plan, and inadequate operation and financial
reviews.
///.
Kickbacks/Rebates and Other Illegal Economic Arrangements
Arizona is becoming increasingly aware of a rising occurrence of kickbacks. Examples
of kickback cases include: money from one provider to another provider (for example, for
referral of patients); from a subcontracting plan to a provider (or employee of a provider); from
one subcontractor to another subcontractor, and from an unlicensed provider to a licensed
provider for the use of his license. Also, Arizona has found providers sharing capitation
payments with each other subsequent to an "arranged" assignment of patients. Due to the
complex structure of the AHCCCS managed care program, and the many types and levels of
providers, there are opportunities for kickbacks among providers. Thus far, Arizona has found
physicians, osteopaths, home health care facilities, durable medical equipment companies, and
physical therapists involved in kickbacks. In general, kickbacks are a very difficult type of fraud
to detect and prosecute.
IV. Fraud in Government Administration/Lack of Internal Controls
Arizona has recently begun to take more of an interest in the actual administration of the
AHCCCS managed care program and is discovering reason for concern at the state
administrative level. Among the kinds of fraud that have been, or are being, reviewed are bid
rigging by state personnel (collusion with the bidders); self-dealing by state and county
employees; and numerous types of conflicts-of-interests by state employees in their dealings with
the plans.
This type of problem is inherent in any business organization or governmental program and
should be addressed by a strong regulatory effort to vigorously educate and monitor staff with
respect to conflicts-of-interests, and to regulate and enforce laws dedicated to exposing and
discouraging these relationships. The agencies that regulate the health care plans must be
required to cooperate with the investigative agency or law enforcement entity that is charged
with ferreting out fraud. Under current Medicaid regulations, the state Medicaid agency is
required to refer suspected cases of fraud and abuse to the MFCU.
V. Miscellaneous Frauds/Collateral Criminal Activity
There are other kinds of fraudulent activity that Arizona has discovered which may not
fit into any convenient category and include:
�1.
Providing Medicare and Medicaid services when the provider has been previously
excluded from the programs. This could occur as a result of providers who have
been excluded based on a criminal conviction or license proceedings.
2.
Forging professional credentials to gain employment in an AHCCCS contracted
facility.
3.
Exploiting the Medicaid funds of incapacitated adults. Arizona has numerous
examples of the embezzlement of patients' trust funds or assets by nursing staff
or family members, by false powers of attorney and forgeries; by impersonating
licensed health care professionals in order to exploit an AHCCCS client; and by
diverting the Social Security checks of AHCCCS clients for unauthorized uses.
4.
Providing false information on applications to qualify for AHCCCS. This
includes financial and other information used to make contractual decisions.
The Experience of Other States
As previously described, more states are requiring Medicaid beneficiaries to participate
in managed care programs. For example, while managed care in Michigan has existed in
various forms since 1982, the state Medicaid agency has been aggressively pursuing the managed
care option during the past two years and anticipates that by December, 1994, 60% of the
Medicaid population in Michigan will become part of the managed care system.
The Michigan program consists of three types of managed care; physician sponsored
plans, clinic plans and HMOs. The MFCU has had experience in dealing with fraud in both the
physician sponsored plans as well as the clinic plans. The physician sponsored plans run the
gamut of fraudulent activity from kickbacks to billing for services not rendered. This plan is
very similar to the traditional fee for services payment system with Medicaid providers.
Although a limited number of clinics operate under the managed care system in
Michigan, the MFCU is currently investigating a clinic in Detroit that it anticipates charging
with Medicaid fraud and other crimes in the near future. This is an enrolled Medicaid clinic that
utilizes unlicensed doctors and physicians' assistants. Although the Michigan MFCU has less
experience with HMOs, it does note that they are subject to kickbacks. Typically, the HMOs
have no internal mechanism to monitor fraud.
Illinois has also had prepaid, preventive health care for Medicaid recipients since 1982.
The Illinois MFCU began an investigation into prepaid health plans in 1987 and found fraudulent
marketing techniques, reduced access to quality of care and improper disenrollment practice. The
Unit learned that misleading or downright fraudulent marketing practices are a common
complaint in the Medicaid HMO population. At the time the investigation began, the Unit
learned that many HMO salesmen worked on a "quota system." Under the quota system
salesmen were required to enroll a certain number of recipients per week. The Unit learned of
8
�instances in which salesmen not meeting quotas lost their jobs or were threatened with
termination. The incentive to enroll recipients at any cost, coupled with recipient
misunderstanding of the consequences of HMO enrollment seems to have caused tremendous
problems in Medicaid HMO enrollments.
A further category of complaints pertained to HMO disenrollment practices. Recipients
complained that upon becoming dissatisfied with HMO health care, disenrollment was made very
difficult. Recipients who desired to disenroll were advised to take a bus trip to downtown
Chicago. Some recipients described hours long waits in HMO reception rooms before obtaining
appropriate forms. Even after travelling downtown and filling out forms, changing health care
providers allegedly took several months.
In California, the state has enrolled 1.1 million Medi-Cal beneficiaries in 1993 and
expects to enroll 2.5 million beneficiaries by the end of 1994. Fifty percent of the Medi-Cal
population (Medi-Cal is the Medicaid program in California) will be enrolled by the end of
1994. The program expects to spend $15 billion in the upcoming year. Existing HMOs will
participate by accepting Medi-Cal beneficiaries.
In California's managed care system, the single state agency (Medicaid agency) contracts
for some or all of its Medicaid covered services and supplies. The services are provided by
employees of the contractors or by subcontractors. The victim of fraud may be the program,
the contractor, the subcontractor or the individual provider. The perpetrator of fraud may be
an individual within the single state agency, an individual employed by the contractor or
subcontractor, or individual provider, agent, employee or an entity that controls the service
provider.
Huge dollar amounts are at stake in California's managed care program unlike the
average individual provider. While Medicaid and/or Medicare providers who have been
convicted of health care fraud are subject to civil fines, sanctions and exclusion from the
programs, managed care plans would suffer a far greater financial loss if sanctioned or excluded
from participation in the health care delivery system. The system would suffer the loss of a
major provider and therefore the ability to deliver health care to large numbers of beneficiaries.
Some potential areas of fraud that the California Unit has found include the following:
a contractor arbitrarily excludes identifiable groups of beneficiaries (people with
mental/emotional problems, children, infants, elderly) from service even though
these people were assigned to one plan; a contractor denies treatment requests
regularly or by policy without regard to legitimate medical evaluation; a
contractor has policies that require an appeal prior to providing the treatment; a
contractor relies strictly on the language of the contract and only measures
performance by breach of contract concepts; a contractor fails to notify assigned
beneficiaries of theirrightto services yet keeps a capitated sum; a contractor fails
to obtain health practitioners thus no service is supplied; a contractor retains an
�exorbitant "administrative fee" releasing too little to the subcontractor or
individual provider to cover their costs; a contractor keeps an administrative fee
but fails to monitor shortcomings of the subcontractor; and a contractor attempts
to assign too many beneficiaries to providers of service thus making adequate
service impossible.
Maryland recently initiated a managed care approach for a large percentage of its
Medicaid enrollees. It has already become apparent that a problem will occur with respect to
the quality of patient care being afforded by some of the more unscrupulous providers
participating in the program. This "quality of care" issue is directly attributable to the desire
of providers to increase their reimbursement from the Medicaid program and other insurers.
Specifically, the Maryland MFCU is now investigating an internist who, although a solo
practitioner, is attempting to treat up to ninety Medicaid patients during hisfive-hourwork day.
Needless to say, the actual medical care rendered is minimal (at best) and the cost to the state
Medicaid Program is exorbitant~up to $42.50 per patient. The Unit has learned that his "private
pay" patients receive a more complete routine examination while the typical Medicaid recipient
on managed care receives what one would generously call an abbreviated service, regardless of
the symptoms with which they present.
The Unit recently learned of another managed care provider who went on vacation and
left a message on his answering machine telling his patients that if they had a medical problem,
they should seek assistance at a hospital emergency room.
In addition, the Unit has received an allegation concerning a Baltimore HMO which paid
cash incentives to its sales staff, the amounts of which were determined by the number of new
enrollees they were able to attract. This practice is alleged to have led to falsification of new
enrollee registrations, leading to increased and false charges to third-party insurers, including
Medicaid.
Medicare/HMO Fraud
In the early 1980s, concerned with the skyrocketing costs of health care, Congress
evaluated the efficiencies of HMOs as a way to save dollars for Medicare while providing high
quality, coordinated benefits. Given appropriate safeguards on access and quality, it was
assumed that Medicare could save billions of dollars by giving older Americans the option to
participate in a system of health care delivery that had already attracted increasing numbers of
younger individuals.
Under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), Congress
authorized the Medicare program to contract with HMOs for covering beneficiaries on a "risk"
basis. Under ariskcontract, the HMO would provide the full range of Medicare benefits for
afixedcost for each enrollee. If the actual costs of services were higher than the payment, the
HMO would absorb the loss. Thus, the concept of risk.
10
�Thefirstrisk contracts were signed in April 1985. As of March 1,1987, about 3 percent
of the Medicare population - 867,087 individuals - were enrolled in 151 HMOs under risk
contracts.
In addition to traditional HMOs Congress authorized "competitive market plans" (CMPs)
which were groups of providers who came together for the purpose of contracting with Medicare
to supply flat fee paid health care services to defined Medicare populations. In 1987, the late
Senator John Heinz, then ranking member of the U.S. Senate Special Committee on Aging,
conducted an investigation of the Medicare HMO and CMPs alternative program. The following
results were documented in the Committee's report, Medicare and HMOs: A First Look with
Disturbing Findings, and may be relevant to determine where fraud and abuse may occur in
these non-traditional delivery programs.
Providers were found to manipulate the beneficiary pool in an attempt to remove higher
risk (more expensive) participants. Reducing health care costs of any participant increases
profits. Marketing practices of the plans were found to be misleading in some cases and even
false. Quality of care was found to be inadequate because medical judgments became the basis
for profits. In at least one instance the provider, International Medical Centers (IMC), a Florida
HMO, falsified it's financial background, denied access to beneficiaries, and went bankrupt after
diverting pre-paid sums causing Medicare to have to intercede and pay twice for the care of the
IMC's beneficiaries.
The illegal schemes used by these plans included: pre-enrollment health screening of
potential enrollees; selective marketing practices; denying access to high cost beneficiaries in an
attempt to have them withdraw from the plan; and geographically terminating the plans coverage
to remove high cost beneficiaries.
Subsequent legislation banned the use of physician incentives by hospital and Medicare
HMOs. The incentives were designed to put undue and clinically inappropriate pressures on
physicians to limit care.
The Lesson of International Medical Centers
In 1981, the Miami-based International Medical Centers received federal government
approval to provide comprehensive medical care to Medicare patients. For a flat payment of
95 percent of Medicare's normal per-patient costs, all the health care needs of the enrollees
would be taken care of. Even free prescriptions, eyeglasses and hospital care without
Medicare's deductibles were promised. The Regan administration believed that IMC would be
the national model for low cost, high quality health care for the elderly. IMC ultimately became
This discussion of IMC is excerpted from an article by Michael Abramowitz, Collapse of
a Health Plan: How Did Such a Good Idea Turn Out So Bad?, Wash. Post, June 23, 1987 at
Al.
11
�the country's largest Medicare HMO, enrolling more than 130,000 elderly Florida residents and
costing the government approximately $360 million annually.
IMC enrolled such a large number of beneficiaries because of a large television
advertising campaign as well as aggressive and high-pressure door-to-door sales techniques.
However, as a result of the rapid and unexpected enrollment of so many beneficiaries, IMC
became overburdened and unable to pay its bills or provide adequate care. There were
allegations that IMC officials paid themselves unusually large salaries for an HMO.
IMC finally collapsed only five years after it began because of alleged mismanagement
and failure to maintain adequate capital. Furthermore, both the Inspector General of HHS and
the FBI investigated allegations of fraud. The founder of IMC, Miguel Recarey, Jr., was
indicted by a federal grand jury in Miami for conspiring to bribe union officials to send patients
to the health plan and charges of fraud, racketeering, wiretapping and bail-jumping.
As of July 1992, the FBI was still pursuing Recarey who had fled the country in 1988
supposedly to Venezuela .
7
Fraud in Private Insurance/Managed Care
In addition to the government's attempts to reduce costs by encouraging the establishment
of managed care systems, the private insurance industry has also steered more of its beneficiaries
into managed care plans. And private insurers have also found fraud in these plans. Some
industry observers believe that preferred provider arrangements (PPAs) are more susceptible to
fraud because there are fewer controls, therefore there's more incentive to increase or fabricate
charges.
Quality of Care
Quality of care problems occur more frequently in managed care systems than in the
traditional fee-for-service. While the success of the MFCUs in discovering and prosecuting
Medicaid provider fraud is widely recognized, it is less well known that they have jurisdiction
over complaints of patient mistreatment in residential health facilities that receive Medicaid
funds. When Congress held numerous hearings on Medicaid fraud in the 1970's, egregious
cases of patient abuse and neglect in nursing homes were described and Congress soon realized
that in the institutional setting poor quality of care was often the result of fraud by nursing home
owners and operators. For example, in its investigation of the state's nursing home industry,
in the mid 1970s, the New York Office of the Special Prosecutor for Medicaid Fraud Control
found that patients suffered dramatically because the Medicaid money that was to be used for
the care of patients was diverted into the hands of greedy nursing home operators. The result
'Michael Isikoff, As Race Heats Up, So Does Scrutiny of Bush's Family, Relatives' Business
Affairs Become Target, Wash. Post, July 4, 1992, at A l .
12
�of this greed was patients who were horribly neglected, many of whom developed decubitus
ulcers and were literally left to rot in their own waste. Because of these scandals, Congress
authorized the MFCUs not only to investigate and prosecute Medicaid provider fraud but also
to investigate allegations of patient abuse and neglect in nursing homes. After more than a
decade of investigating patient and resident abuse, neglect, mistreatment and economic
exploitation, the state MFCUs have established that patient abuse crimes pose a significant threat
to the safety and well-being of the elderly and sick residing in health care institutions.
In managed care plans, the types of quality of care fraud issues that occur include the
denial of medically necessary care and the delivery of substandard and generally inappropriate
health care. The Illinois MFCU, for example, found that a significant number of the complaints
made to the Unit alleged that recipients seeking medical treatment had been turned away or told
to make appointments several weeks in the future. In some instances, recipient ignorance or
misinformation regarding HMO health care precipitated the problems. Recipients were unaware
that upon HMO enrollment, they would be essentially restricted to one location. Certain
recipients alleged that upon enrolling in an HMO, they were assigned to clinic locations miles
away from their homes. No longer could they merely walk to the neighborhood clinic to seek
medical treatment. Admission to a hospital or even an emergency room visit now required the
consent of the HMO. As the investigation progressed, Unit personnel learned that physician
incentive payments were a common practice in HMOs. Essentially, this means that physicians
on contract to the HMO receive monies leftover for hospital days not used or for surgery not
performed, etc. A fair amount of physicians called to complain that their medical judgments
were, at times, being replaced by what they felt were improper cost containment considerations.
Therefore, in some instances, it appeared that underutilization of services and the potential for
interference with medical judgments was a problem*.
The underutilization of services, the falsification or misrepresentation of professional
credentials by providers and the use of unlicensed professionals all of which have been seen in
managed care plans, will surely affect the quality of care and could indeed lead to patient abuse.
Furthermore, although the health care delivery system may change, a large portion of health care
services will continue to be delivered in hospitals and nursing homes and just as fraud will
continue to exist, so will patient and resident abuse.
Underutilization
Crimes involving "overutilization" result in providers ordering tests, medical equipment,
and other services which are not medically necessary but do result in a greater profit to the
provider. In a program which attempts to cap costs or establish contractual flat fee payments
to supply a beneficiaries' health care, a motive is created to accept payment and supply as few
services as possible thus maximizing profits. The same provider who currently lies about the
necessity of a test for profit, will also lie about the need for a necessary test in order to reduce
'Pilkington, supra at 3.
13
�costs and retain a higher level of profits. "Underutilization" takes a number of forms to include
falsifying medical records which would support the need for treatment or altering medical
decisions (for example, a patient needs a complex and expensive battery of tests) to avoid the
expense. If the duty that is contractually established is to supply a certain level of health care
benefits, a knowing and willful refusal to supply agreed and necessary services should be a
crime.
U.S. v. National Health Laboratories
A Case Study in the Manipulation of Medical Judgment for Profit
National Health Laboratories (NHL), a publicly traded corporation, is one of the largest
medical laboratory chains in the country. In 1987, NHL instituted a marketing and billing
scheme which ultimately cost the Medicaid and Medicare programs millions of dollars. One of
the most disturbing aspects of NHL's scheme involved a small, greedy group of business
executives who devised a method to circumvent the medical judgement of thousands of medical
doctors for the corporation's gain. NHL's scheme involved adding an expensive blood test to
a standard panel test. Through aggressive and deceptive marketing techniques, the corporation
managed to double and then triple its profits using the scheme over a three year period. In the
end, NHL used the thousands of tests ordered by physicians to imply that the doctors medical
judgment extended to the tests added by the company. An important lesson of U.S. v. NHL case
is that the government should be careful in trusting a for-profit business entity in making medical
judgments.
This case also illustrates the scope of health care fraud and its national implications. In
December of 1992, NHL and its president/chief executive officer entered guilty pleas in United
State District Court for the Southern District of California in San Diego. The defendants agreed
to repay $110.5 million dollars to Medicare and 33 state Medicaid programs. This case is the
largest health care prosecution ever and represents a high point in the cooperation of 33 state
Medicaid Fraud Control Units and with federal prosecutors. It is of note that this prosecution
involved: ancillary services not physician care; tests actually performed and not fictitious
billing; the manipulation of the concept of medical judgement and necessity for a profit; a large
national corporation and not a primary provider or clinic; and a group of profit minded
unscrupulous businessmen in search of a way to maximize their company's profits at the expense
of government and health care beneficiaries. NHL also exemplifies the ability of the states to
coordinate and cooperate both with each other and with the federal government on health care
fraud cases. If the new health care delivery system establishes entities that cross state lines, the
state MFCUs can be looked to as a model of state law enforcement agencies that are capable of
handling multi-jurisdictional health care fraud cases.
Conclusion
Health care fraud occurs and will continue to occur in the future no matter what type of
delivery system is created. Our experience has shown that unscrupulous providers have always
14
�found new and innovative ways to criminally profit at the expense of patients and health care
payers. If there is a larger amount of health care fraud than in the past, it may be attributable
to the growing size of the industry and the diversity of the services that are considered to be a
part of "health care." All payment programs have relied heavily on the integrity of those with
whom they have contracted and too often the expectation that the provider is honest and believes
that the patient's health is of paramount concern has not been realized.
Unfortunately as James Pinkerton predicted in his article in New York Newsday, March
18, 1993 "About 10 minutes after the President signs a bill, Americans will figure out how to
'game' the new system. The cleverest doctors and lawyers in the country will match wits with
bureaucrats. Guess who will win."
A program for the detection and prosecution of those who will prey on any health care
delivery system that is selected should be a part of the Task's force report.
15
�
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Health Care Task Force Records
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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2006-0885-F
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[Work Group 17, Ethical Foundations] [2]
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White House Health Care Task Force
Health Care Task Force
Carolyn Gatz
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2006-0885-F Segment 3
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Box 9
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093616" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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3/16/2015
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42-t-12093616-20060885F-Seg3-009-002-2015
12093616
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https://clinton.presidentiallibraries.us/files/original/f22ce58dfead67e2f7f71f7eed72edc7.pdf
882043cbcf6ced754a625c393f41df56
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Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Gatz, Carolyn/Klein, Jennifer
Subseries:
5107
OA/ID Number:
FolderlD:
Folder Title:
[WorkGroup 17 Ethical Foundations] [3]
Stack:
Row:
S
56
Section:
Shelf:
Position:
5
3
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
DATE
SUBJECT/TITLE
RESTRICTION
001. note
Phone No.'s (Partial) (1 page)
n.d.
P6/b(6)
002. note
Phone No. (Partial); Personal (Partial) (1 page)
n.d.
P6/b(6)
003. note
Phone No. (Partial) (1 page)
n.d.
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Carolyn Gatz; Jennifer Klein
OA/Box Number: 5107
FOLDER TITLE:
[Work Group 17, Ethical Foundations] [3]
2006-0885-F
im863
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information [(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the I O I A |
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA)
National Security Classified Information |(a)(l) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PR A]
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�05/30/1993
22:34
99999
G A AND ENTENZA
UM
To; Jennifer Klein
From: Lois Quam
Re; Rural Audit
Date: May 27. 1993
AS we discussed last week, below are m suggestions on the rural audit:
y
Objective:
^Conduct a technical review to Identify any unintended
harmful consequences for rural areas and propose an alternative
approach.
^Identify any gaps related to rural health care and propose a remedy.
*Review for inclusion of the workgroup's rural health initiatives.
Timing:
Step One: Review draft specifications and plan June 3-4
Step Two. Review revised specifications and plan June 10-11.
I think that the audit will work best by focusing on the written materials
available at each stage rather than meetings with workgroup leaders.
I agree with vou that Dena Puskln. Peter Reinecke and the other
Congressional staff members recommended by Chris Jennings are the right
list.
PAGE 06
�FOR OFFICIAL USE ONLY
HEALTH CARE REFORM ACTION PLAN
FOR RURAL AMERICA
Recommendations of the
RURAL CROSS-CUTTING WORK GROUP
MAY 7, 1993
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TABLE OF CONTENTS
HEALTH ALLIANCES
Size and Market Share
Benchmark Premium
Risk Adjusters
1
2
5
6
BUILDING CAPACITY IN RURAL AMERICA
Access to Plans Throughout the Health Alliance Area
Solvency Concerns
Community Plan Development Grant Program
Rural Practice Development Grant Program
7
8
9
10
11
LEGAL ISSUES
Alternatives to Federal Anti-trust Laws
Technical Assistance on Anti-trust
Safe Harbors for Rural Providers
Federal Preemption of Corporate Practice of Medicine Restrictions
12
12
13
13
14
WORKFORCE DEVELOPMENT AND MAINTENANCE
1
4
Immediate Measures
Long-term solutions
EMS/TRAUMA DELIVERY SYSTEMS
MENTAL HEALTH AND SUBSTANCE ABUSE
15
18
20
21
GOVERNANCE
22
Rural representation on the National Board and Health Alliance Boards . . . . 22
FUNDING FOR STATE INFRASTRUCTURE DEVELOPMENT AND ONGOING STATE
ACTIVITIES
22
INTERIM COST CONTAINMENT
Discussion of other interim cost containment options
23
24
BUDGET
Adoption of Medicare Cost Indices for Input Prices in the Budget
26
27
ADMINISTRATIVE SIMPLIFICATION AND INFORMATION SYSTEMS
QUALITY AND ACCOUNTABILITY
Practice Guidelines
CLIA
28
29
29
30
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Page 1
HEALTH CARE REFORM ACTION PLAN
FOR RURAL AMERICA
One quarter of the U.S. population lives in rural areas. These areas differfromeach
other in many ways. Some rural areas are more densely populated and are located adjacent
to urbanized areas. Others arefrontierareas with a sparse population spread over large
geographic areas. Although this paper refers to rural America as a general term, there is an
underlying recognition that frontier areas will need special consideration to facilitate the
successful implementation of national health reform.
The challenge of implementing health reform in rural America is to create a system
that meets the unique needs and circumstances of all rural communities no matter where they
fall on the continuum of population density. For health care reform to succeed, it must
provide acceptable and appropriate strategies for health care delivery andfinancingin rural
areas.
The President's plan offers much promise for improving the health of rural
Americans. First and foremost, this plan promises to remove many of the barriers to health
care posed by a lack of health insurance coverage. Rural residents experience higher
uninsurance and poverty rates than their urban counterparts. The President's plan would
provide these residents with universal coverage, a provision that would benefit both
consumers and the health care providers who serve them.
In rural communities, resolvingfinancialaccess issues addresses only half of the
problem. Universal coverage alone will not address many of the non-financial barriers that
severely limit access to health care in rural areas. The most severe of these barriers include
inadequate numbers of providers, lack of primary and preventive health services and
fragmentation of those services that do exist in much of rural America. Building stable
systems of health care in these areas is a key to overcoming these barriers.
This paper suggests several actions, which if included, would strengthen the
President's plan in meeting the needs of rural communities. The budget specifications in this
paper provide a more detailed description of the budget figures prepared by Work Group 22.
HEALTH ALLIANCES
Underservice in rural areas is in large part due to the declining economic vitality of
increasingly smaller rural communities. The fragilefinancialstability of the health care
marketplace in most rural communities is the result of a reduced employment base, primarily
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Page 2
dependent on small and individual business ownership; more people insured by Medicare and
Medicaid; and higher rates of non-insurable individuals with chronic illness and disability due
to their employment in high risk industries such as mining, logging, and farming. Large
employers in these communities are often government organizations (e.g., local school
district, county hospitals, state or federal correctional institutions) or a single fabricating
plant located to take advantage of the low wage employment available. If these employers
go out of business or relocate, the local marketplace for health care in rural communities is
often devastated.
Although national reform resolves the problem of insurance for many rural residents,
it does not directly address many of the underlying economic deficiencies of rural areas that
limit access to health services in rural communities. Therefore, health alliances must have
sufficient flexibility and powers to ensure that rural communities have an equal opportunity
to participate in health care reform and benefit from its goal of providing comprehensive
health care services to all citizens. In some rural areas, where the market does not respond
adequately, the health alliances may need to take specific actions to assure that rural residents
have access to health care services. If necessary, health alliances may have to develop their
own health plans to provide rural access.
The question of who is included and who is excluded from the health alliance is of
vital importance to rural communities and predominantly rural states. Health alliances need
to be sufficiently large, in terms of membership, to provide strong purchasing power for
negotiation with plans and providers. This is particularly true if rural residents are going to
have significant choices among competing plans. Large size is also necessary for equitable
risk pooling and community rating.
The effectiveness of health alliances in negotiating with providers also will depend on
the share of the market they control. This is especially relevant in communities with only a
few providers who are able to maintain their income simply by treating Medicare patients
and employees of a large plant that is excluded from the health alliance.
Size and Market Share
Action: Health alliances should have large numbers of enrollees to support adequate
purchasing power, risk pooling, and community rating. Federal guidelines should be
developed to help states assess the effective population for health alliances.
Rationale: Large populations are necessary for adequate purchasing power and equitable risk
pooling. It has been suggested that health alliances have a population of greater than one
million. For rural populations, the community rating area should be as large as possible.
Large health alliances will be better for redistributing risk and negotiating with the health
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Page 3
plans. Alternatively, small health alliances could result in certain populations being
segregated based on income or geography, and have little power to negotiate with health
plans.
Measurement of the size of the health alliance should be based on enrollment, rather
than total population, because it best assures the size and strength of the health alliance. For
example, if Medicare beneficiaries and employees of large businesses are not part of the
health alliance, their absence could reduce the number of individuals in theriskpool
significantly. Consequently, the health alliance would control a much smaller share of the
health care market and would have limited effectiveness in negotiating with health plans and
providers and developing health care delivery systems. This is especially of concern to rural
areas that need a large health alliance to leverage purchasing power in order to effectively
negotiate affordable premium prices for health coverage.
Federal guidelines should be made available to assist states with assessing the
effective population base for the health alliance and communityratingarea. These guidelines
would also assist in assessing the market share of the health alliance that is adequate to
effectively control the market and develop delivery systems.
States may be tempted to develop rural-only health alliances. However, such
alliances may unintentionally disadvantage rural residents. Rural-only alliances are likely to
have fewer resources, and be more dependent on federal subsidies due to higher proportions
of poor, unemployed, and elderly residents. Moreover, such alliances will have more
difficulty garnering market share and distributing risk than would occur in mixed urban and
rural health alliances. Although states should have the flexibility to configure alliances in a
manner that best meets their needs, it may be desirable for federal guidelines to recommend
against rural-only alliances.
Action: All government employees should be included in the health alliance.
Rationale: Work Group 16 has recommended options for the Federal Employees Health Plan
that could exclude federal employees from the health alliance. For rural communities,
government employees are often the largest employers. Because federal government actions
set standards for state governments, exempting federal employees from the health alliance
could encourage state governments, as large employers, to follow suit. Aside from the
negative public perception of a health care system that mandates private employer
participation while exempting government employees, the exclusion of government
employees could significantly reduce a health alliance's market share in rural areas and, thus,
their capacity to negotiate effectively with health plans or local providers.
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Action: States should have the option to require that all employers in the state, including the
establishments of large nationalfirms,participate in the health alliance.
Action: States should be able to seek waiver authorityfromthe federal government to enroll
Medicare beneficiaries (and the payment for their care) in the health alliance.
Rationale: In many rural communities, where the employment base is likely to be made up
primarily of small employers and the self-insured, there may be a single large enterprise,
such as a processing plant or a mine, that comprises a large share of the workforce,
Excluding them could limit the bargaining power of the health alliance and impede the
development of managed care networks in these rural communities.
In addition, rural communities sometimes have larger elderly populations that
dominate the health care marketplace. Though the population may be less than a majority,
health care purchasing by this population may be as much as 60 percent of hospital and 50
percent of physician revenues.
Following the logic related to health alliance size, states should be able to assure a
sufficient health alliance population to negotiate equitable service and service networks in its
rural areas. Including all employers operating within the state or those individuals on
Medicare may often be key to achieving this sufficiency.
Action: States will be able to seek waiversfromstructural requirements (including Medicare)
that decrease the capacity of the health alliance to serve rural residents or discourage
competing health plans. The process will be administratively simple and have built-in federal
response requirements, including the following:
o
Coordinated federal agency waiver and plan approval responsibilities so states have
access to a single request process.
o
Stricter rules on the amount of time the federal government can take to act on state
waiver requests.
o
Rules governing Medicare waivers that allow states to demonstrate budget neutrality
periodically rather than year by year.
o
Federal waiver reviews on a periodic basis with mandatory continuation approval i f ,
and for so long as, the project meets minimum federal requirements.
o
Medicare waiver authority for states that intend to establish uniform rates among all
payers.
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Page 5
Rationale: Flexibility is an important principle if states are to succeed in implementing
health care reform. This includes the capacity to use a wide range of innovative strategies to
meet the diverse local needs and circumstances of the nation's rural areas.
In the past, the processes for applying and granting federal waivers have been
cumbersome and time-consuming, often creating insurmountable barriers to state innovation.
If states are to have the responsibility for achieving the cost containment and access goals of
national reform, the system must have procedures that provide states with the tools necessary
to achieve these goals.
Benchmark Premium
The benchmark premium determines the employer and employee payment shares, the
low income subsidy, and any tax limitations that may be recommended for national reform.
The selection of the benchmark premium could have a significant effect on rural residents.
Work Group 1 is currently recommending that a benchmark premium be set for each county
within a state. It also recommends that the benchmark level be set at the lowest premium of
any plan that can enroll all area residents who want to join. These recommendations were
made to assure that those with low incomes would have geographic access to an affordable
set of comprehensive health care services.
It is important to consider the impact of benchmark premium options on rural
residents and their communities. Plans may be unwilling to serve the smaller populations of
geographically isolated communities. Managed competition may result in fewer, more
expensive choices for these areas than at present, and fewer than found in urban areas.
Using the county to define the benchmark premium area could create wide differences
in the benchmark premiums across county boundaries. This could affect the decisions
companies make on where to locate new plants. Individuals, as well, may gravitate toward
areas with more reasonable health care costs. The result might be a diminished economic
future for already fragile rural economies.
In addition, some counties are very large, with both urban and rural areas. A
benchmark premium based on a plan that serves the entire county could have a fairly high
premium, even though lower cost plans are readily available in the urban parts of the county.
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Action: The benchmark premium area should be defined by rational service areas to ensure
that low-income residents of the area have access to an affordable, available health plan.
Rationale: It is essential that low-income residents of rural areas have an affordable health
plan that they can easily access. For purposes of the low-income subsidy, it makes sense to
use a small area to define the benchmark premium. This way, the subsidies will reflect
premiums that are affordable and available to low-income individuals. Otherwise, the
universal access goal of national reform may not be achieved.
Action: When more than one plan serves a rural area, the benchmark premium should be set
to allow choice between the two lowest cost plans.
Rationale: The benchmark premium should not be set by the lowest priced premium in the
area if there is a choice of plans in the area. Individuals receiving low-income subsidies
should have a choice of plans, rather than all being directed to the lowest cost plan. At a
minimum, the benchmark premium should be at or above the premiums of at least two plans
in areas where more than one plan is available. Fee-for-service plans should be excluded
from the benchmark calculation in areas with at least one managed care plan because of the
poorer cost containment practices and higher premium costs of indemnity plans.
Risk Adjusters
In the background papers for Cluster I , it is suggested that locadonal adjustments
might be used to adjust community rated premiums for plans that enroll higher percentages
of individuals from certain areas. The locational adjustments would serve as proxy measures
for plans enrolling a greater proportion of individuals with higher health care costs who may
be sicker or have higher medically related needs related to poverty.
The details of the risk adjustment process have not been outlined in any of the papers
to date. Moreover, it is unclear how the risk adjustment process would account for plans
that enroll a high proportions of individuals in high risk occupations, such as mining or
agriculture. At this point in time, we do not have sufficient information upon which to base
an equitable risk adjustment or risk adjustment process. However, we can make
recommendations regarding some of the parameters that should be considered in the risk
adjustment process.
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Action: We support the recommendation of Work Group 22 that the risk adjustment system
be designed to ensure that there is no financial disincentive for plans to offer service in low
income or underserved areas. The use of an income-based adjustor as a proxy for the
potential higher costs associated with providing service in traditionally underserved areas
should be evaluated and reviewed annually, at least until low income people have been fully
integrated into the health plans.
Rationale: The literature appears to document that low income populations have inherently
greater need for health care services and thus, higher costs. At a minimum, during the
period of transition, as uninsured and underinsured low income individuals are brought into
the system, an adjuster based on income should be reviewed and considered annually to make
sure that there is no financial disincentive for plans serving low income communities. When
low income individuals and families have been fully integrated into health plans, such an
adjustment may no longer be necessary.
Action: If the risk adjustment system includes locational adjusters, they should not be based
solely on historical costs.
Rationale: Rural residents in many communities are underserved and, therefore, often have
had significantly lower historic costs that do not reflect the true costs of providing adequate
access to health care in those communities. Health plans are likely to experience higher
developmental and other ongoing per capita costs as they expand services to these areas.
Thus, any locational risk adjustment should take into consideration the higher costs of
serving historically underserved rural communities.
BUILDING CAPACITY IN RURAL AMERICA
In general, rural communities have limited capacity tofinanciallydevelop health plans
and the provider networks necessary to support those plans. The federal and state
governments, and health alliances will have a variety of tools to ensure that such capacity is
developed.
First, health alliances will be required to ensure that all areas within the health
alliance area are served by plans. The federal government could jump-start the development
of networks in rural communities through direct technical assistance to those developing
networks. The health alliance could selectively contract with qualified health plans,
negotiating the service area to ensure that underserved areas receive service. It could also
provide technical assistance and other assistance to foster plan development in communities.
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To ensure that rural residents have a choice of plans in areas where organized plans
do not develop, the health alliance could operate or contract with others to operate a non-feefor-service plan. In the following section, several approaches are suggested for fostering
plan development in rural communities where it may not otherwise occur.
Moreover, rural providers generally have not developed the integrated networks of
care that will be the backbone of community-based health plans. Network development is
impeded by many factors including the instability of rural practices and rural hospitals,
inadequate billing and data systems, and concerns over anti-trust and other legal issues.
Rural communities will require technical and financial assistance to recruit practitioners and
develop efficient and stable health care networks. Two grant programs (described below)
will assist rural communities and practitioners with developing rural health plans and
establishing new rural practices.
Steps must be taken both to train practitioners for rural practice and make rural
practice more attractive. A third grant program (described on page 17 of the workforce
section) is designed to develop existing rural practice sites as training sites for health care
professionals. Rural training sites reduce the isolation felt by rural practitioners while
providing more appropriate experiences for rural practitioners than are found in urban
tertiary settings. At their best, rural training programs become an integral part of a
comprehensive strategy for building rural networks.
The following actions will help build the health care capacity necessary to assure
access to care in rural areas.
Access to Plans Throughout the Health Alliance Area
Action: At the point that it begins coverage of individuals, a health alliance should be
required to make their best efforts to ensure that residents of its area have the option to
enroll in at least one non-fee-for-service plan that provides accessible services within their
area. Wherever feasible and desirable, rural community-based plans should be encouraged.
Rationale: Health alliances will play a critical role in ensuring that the goal of universal
access to health care is achieved in underserved urban and rural communities. Network and
plan development is unlikely to spontaneously occur in some rural areas without technical
and financial assistance. This is especially true in sparsely populated rural areas where there
are few health care providers and no capacity for competing health plans. Even if assistance
is provided, network and plan development takes time. It is estimated that there will be
many areas in which fee-for-service (FFS) will be the only real system available to rural
residents. More specifically, given current HMO penetration in this country, perhaps as
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many as 70-90 percent of rural residents may only have FFS providers available to them
unless steps are taken to make it otherwise.
FFS plans tend to be more costly than non-FFS plans for the same set of benefits.
Moreover, the 25 percent cost sharing provision for fee-for-service plans, proposed as a
disincentive to select these plans, will ftirther disadvantage many rural residents.
Thus, in many parts of rural America, rural consumers will continue to pay higher
premiums and be forced to bear higher co-pays because an alternative to fee-for-service is
not available to them. Rural residents should not be penalized by these higher costs when
they have no choice.
Health alliances should be provided the authority to require plans to expand their
service areas, to provide technical assistance, and if necessary, to contract for or sponsor
their own non-FFS plan (such as a preferred provider organization (PPO)) to ensure that all
communities in their area are served by at least one non-FFS plan. States would bear the
risk for non-FFS plan development under a state reinsurance pool.
Action: Health alliances responsible for rural areas should make adjustments in their
payments to plans serving rural areas for (1) incentives that encourage health professionals
to practice in rural communities and (2) "enabling services" such as transportation, child
care, outreach or social services case management.
Rationale: The capacity of health alliances to reverse historic patterns of underservice in
rural areas will require more than passive implementation of managed care or competitive
strategies. In addition to technical expertise, infrastructure building and negotiating leverage,
the development of plans in rural areas will require the expenditure of additional sums to
specifically address the causes of underservice, i.e., low provider reimbursement patterns and
low income geographic and other barriers to access. By placing these dollars within the plan
premium payments, they will be part of the competitive forces which will eventually come
into play to contain these additional costs.
Solvency Concerns
Action: States should ensure that development of community-based plans is not deterred by
fears of insolvency.
Rationale: Fear of insolvency is a major deterrent to the development of rural communitybased plans. On the other hand, smaller plans often find it impossible to meet the solvency
standards required of larger plans. Cluster 1 has recommended that the solvency
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requirements be tailored to a plan's enrollment. As such, smaller plans would have lower
solvency requirements. For example, to facilitate development of community based plans in
smaller communities, background papers suggest that the smallest plans would need only a
net worth of $500,000 to meet solvency requirements. The Cluster I papers also recommend
that special trust funds be established to ensure that providers are paid and to assist
individuals in obtaining affordable coverage in the event that a plan goes out of business.
These are important steps in promoting community based plans.
States could create state-wide reinsurance pools that protect against catastrophic
expenses of individual enrolled members. Reinsurance could be provided for claims
exceeding a large deductible for any individual, with larger plans having larger deductibles
per individual. Small community-based plans are likely to be small and be at greater risk of
financial instability caused by unexpected large claims. While this could be a problem in
urban areas, it is far more likely to be a problem for rural community-based plans that
generally will be based on much smaller population and provider bases. A state-wide
reinsurance plan would help allay the fear of insolvency in smaller plans and assist in
overcoming disincentives by both larger and smaller plans to serve highriskindividuals,
especially low income individuals.
Community Plan Development Grant Program
Action: The Department of Health and Human Services should provide technical assistance
and grant funding to consortia for the planning and development of community-based rural
health plans. The federal government would provide ongoing technical assistance on the
development of plans, including legal and financial management advice. The grant program
would be an interim measure to provide immediate funding for front-end development of
networks and garnering expertise in network development, including legal and financial
expertise. Monies would also be used to develop the information systems necessary to
operate an information network in rural areas (including telecommunications).
Rationale: In the 1970s, many HMOs moved into rural communities to market their plans,
only to abandon these communities several years later. In the meantime, patients were
channeled away from local providers to the detriment of the communities' health care
systems.
Advocates of community-based plans argue that locally developed systems are more
likely to succeed in providing appropriate, cost-effective services to rural communities.
Development of these plans will require establishment of networks among providers in the
community and with providers outside the community. It is important for communities to
have the opportunity to develop their own plans to generate a sense of ownership and
participation among local residents and providers and to create plans that best meet
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community needs. However, communities often do not have the capital or technical
expertise to develop health plans.
Another important component of network development for rural communities is
linking providers in these communities to specialty back-up services in larger urban and rural
facilities. Electronic information systems will be critical to the efficient management of plans
in rural communities. Expanded telecommunications access can facilitate the development of
information networks. Funding under this program can be used to establish
telecommunications linkages, if such linkages are coordinated with other telecommunications
users in the community to avoid unnecessary duplication.
Consortia would be composed of three or more entities. The prime applicant would
be located in a rural area. Other members of the consortium could be based elsewhere, but
the locus of control should be in the rural community. This configuration would ensure that
the resulting grantee was responsible to the community. At the same time, the community
could seek and utilize expertise of other consortia members that are not rural-based.
Applicants would be directed to work with their states in the development of their
applications.
The program would be modeled after the Rural Outreach grant program administered
by the Office of Rural Health Policy. This program uses rural-based consortia to promote
innovative health care delivery systems in rural areas.
Total funding for this program would be approximately $60 million, wherein $25
million would comefroma redirection of the Rural Health Care Transition grant program.
The Office of Rural Health Policy would be directed to arrange and provide technical
assistance to the communities as they develop plans. The Office is well accepted as an
ombudsman in the Department for rural issues, and has had a long-standing focus on capacity
development in rural communities.
Rural Practice Development Grant Program
Action: The Department of Health and Human Services would fund a grant program to
health care practitioners, in conjunction with their health alliances, for the development of
rural health care practices. The funding could support initial start-up costs for the new
practice, including purchases of equipment, recruitment costs and initial salaries of
appropriate staff, telecommunications linkages, and other costs of establishing a rural
practice site. Eligible practitioners include physicians, nurse practitioners, physician
assistants, mental health professionals, dentists, etc. A service obligation would be
associated with this grant program.
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Rationale: In many rural areas, health care services do not exist because there are no
practitioners and no practice sites. To assure adequate access to health care in these areas, it
will be necessary to establish new or expand existing health care practices. Grant funding
would be available to health care practitioners, who would apply in conjunction with their
health alliance, to support development of rural practices.
Applicants would be required to coordinate with their health alliance and demonstrate
the need for the services to be provided at the new practice. Applicants also would have to
demonstrate that the new practice will participate in a health care network that has a contract
with, or is part of, the health alliance. Funding could be used to support initial start-up
costs, equipment purchases, recruitment costs, initial salaries, etc.
As a part of their practice development, applicants could request funds for
telecommunications linkages, but the request for any equipment or any information system
development should be coordinated with other telecommunications users in the community to
avoid unnecessary duplication of equipment.
Preference will be given to practices that provide a broad range of primary care
services, especially those that include mental health services. Research has demonstrated that
systems that integrate primary care and mental health services are more effective than a
system of referral to stand-alone mental health services.
Grants would be for one year. Total funding for the grant program would be $40
million.
LEGAL ISSUES
Alternatives to Federal Anti-trust Laws
Action: The Department of Health and Human Services, in conjunction with the Department
of Justice and the Federal Trade Commission, will develop model legislation that can be used
by the states to protect developing networks from federal anti-trust laws. States that adopt
laws meeting the specifications of the model legislation will receive federal assurance that
developing networks meeting state requirements will be protected from federal anti-trust laws.
The model legislation will specify the situations under which networks could develop and the
criteria by which they would be reviewed. A mechanism by which networks could apply to
the state for anti-trust law protection would be required.
Rationale: Federal anti-trust laws have had a chilling effect on the development of health
care networks. In rural areas, in particular, establishment of networks may preclude future
competition. Despite its anticompetitive nature, rural network development may promote
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more cost-effective and higher quality health care than would otherwise occur. Several states
(Maine and Minnesota) have already developed legislation to protect cooperative agreements
among health care providers from federal anti-trust laws. These states approve proposed
arrangements that might be considered violations of federal or state anti-trust laws if they are
found to be more likely to result in lower costs, provide greater access, or assure higher
quality to health care than would otherwise occur in the marketplace. Adverse impacts on
payers and other providers are considered in granting the protection. These state laws should
be considered in developing model legislation.
Technical Assistance on Anti-trust
Action: The Secretary of Health and Human Services should provide, in cooperation with the
Department of Justice and the Federal Trade Commission, technical assistance to health care
providers on anti-trust concerns that emerge during the development of health care plans.
Rationale: Development of health care plans in rural areas, where competition does not
occur, will require development of new relationships that may be viewed as anticompetitive.
Rural health care providers are nervous about establishing these relationships because they
fear legal action that istime-consumingand costly. Network development would be
facilitated if these providers could receive guidance before committing to these new ventures.
Safe Harbors for Rural Providers
Action: The Secretary should develop safe harbor regulations that clarify the situations
under which rural providers can safely finance other health care entities.
Rationale: Rural areas may have limited capability to develop competitive health care
systems. In some rural areas, it is incumbent upon local providers to finance the
establishment of auxiliary health care services, such as laboratory and x-ray services. As
rural areas develop networks and managed care systems, rural hospitals and health care
practitioners may cultivate relationships that could be in conflict with the Department's fraud
and abuse regulations. Possible areas for safe harbor regulations include:
o
the situations under which rural hospitals can purchase physician practices;
o
the extent to which rural hospitals can offer special financial inducements to
recruit and retain health care practitioners;
o
when rural practitioners are permitted to have afinancialinterest in auxiliary
health care services, such as laboratory and imaging services; and
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the types of referral relationships that can be developed between rural primary
care practitioners and specialists.
Action: The Secretary should develop a process by which rural providers, health alliances,
and states can seek advice on proposedfinancialrelationships to assure that these
relationships will not be in conflict withfraudand abuse regulations.
Rationale: The use of capitated payment systems will eliminate some of the potential fraud
and abuse problems that are inherent in fee-for-service payment systems, such as problems
associated with referral relationships between general practitioners and specialists. However,
it is likely that fee-for-service arrangements will remain in many rural areas, at least initially.
Efforts to curb fraud and abuse in these areas will have to be carefully evaluated for their
effects on access and the development of new systems of care.
Federal Preemption of Corporate Practice of Medicine Restrictions
Action: We support the recommendation of workgroup 1A that the federal government should
preempt state laws that restrict corporate practice of medicine.
Rationale: These restrictions inhibit network development by limiting the employment of
physicians and other providers by general business and/or nonprofit corporations. They also
may limit the ability of providers to form corporations as vehicles for providing services and
sharing risk in integrated care delivery arrangements. In rural areas with shortages of health
care providers, it may be particularly important to permit arrangements whereby hospitals
employ physicians or physicians have afinancialinterest in the hospital or other health care
facilities. These types of arrangements may be critical to developing and maintaining access
adequate health care services in rural communities.
WORKFORCE DEVELOPMENT AND MAINTENANCE
The new health care system will rely extensively on primary care practitioners to
provide basic health care services and to serve as gatekeepers to more specialized care. The
competition between urban and rural health plans for already scarce primary care
practitioners will only intensify. One possible outcome is that rural communities will have
increasing difficulty recruiting and retaining primary care practitioners. As recognized by
Work Group 12 (Workforce Development), it will be necessary, but not sufficient, to train
more primary care practitioners. It also will be necessary to train practitioners (primary care
and specialists) in rural practices and make rural settings more attractive to these
practitioners.
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Four recommendationsfromWork Group 12 offer the greatest potential help, if they
are coupled with the national workforce plan outlined below: 1) pooling all Federal health
professions training dollars, including GME dollars, into a workforce investment fund; 2)
utilizing the transferred GME funding for training in ambulatory settings; 3) achieving a
more equitable physician specialty distribution; and 4) increasing the number of physician
assistants and advanced practice nurses trained (using GME funding) and practicing within
their full scope. However, these recommendations must be part of a coordinated plan that
integrates the different types of providers and considers rural workforce development as it
relates to the reformed health care system, if the anticipated positive impact on rural areas is
to be realized.
In addition, adequate payment systems for rural practitioners are essential for
establishing and maintaining personnel in rural areas. Lower payments to rural practitioners,
based on historical charges, are a deterrent to establishing practices in rural communities.
Payments to rural practitioners should be adequate to attract and retain physicians in rural
areas.
Below are recommendations to accompany and support the recommendations of Work
Group 12. The recommendations are for immediate and long-term measures that, if adopted,
would help assure that rural communities have adequate numbers of practitioners.
Immediate Measures
Action: Medicare Graduate Medical Education (GME) funding should be restructured to
support training of residents in ambulatory care settings and rural areas, and to support
training of mid-level providers. Until a national -workforce plan is developed, funding of
residency positions would be directed toward the goal of a 50-50 ratio between primary care
and specialty residents.
Rationale: Medicare funding contributes the largest portion of federal funding for physician
training ($5.2 billion in 1992). GME dollars carry inherent incentives to train specialists,
primarily because the money is only available for training provided in a hospital setting and
specialty care receives higher payments. Because much of a primary care residency program
takes place in ambulatory settings, where Medicare payment is not available, there is little
financial incentive to develop primary care residencies. Making Medicare GME payments
available for training in ambulatory and rural settings will be an incentive to develop primary
care residencies.
When teaching hospitals reduce the number of specialty residency positions, they are
unlikely to reduce the amount of services they provide. Rather, they will use clinical nurse
specialists (CNSs), physician assistants (PAs), nurse practitioners (NPs), and nurse-midwives
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in place of the residents. This will increase the demand for these mid-level practitioners. At
the same time, the new health care system will be looking to these same mid-level
practitioners to provide primary care services in rural and underserved areas. Therefore,
there will be an urgent need to train significantly more mid-level practitioners. Medicare
GME funding should be directed to support the training of mid-level practitioners.
The 50-50 ratio of generalists to specialists could be adopted as a goal for the short
term. It will take time to redirect residency training toward primary care and away from
specialty care. Adoption of this goal for the short term would provide a clear indication of
the direction desired for shifting the focus of residency training. However, long-term goals
should be established as part of the national health care personnel workforce plan described
below.
Action: Increase overall funding for the National Health Service Corps (NHSC) and other
federal health professional training programs, and expand the National Health Service Corps
Community Scholarship Program. Refund the NHSC Private Practice Option Loan Program.
Rationale: The NHSC provides scholarship or loan repayment to new physicians and midlevel practitioners who practice in underserved areas. The National Health Service Corps
Community Scholarship Program (CSP) is a scholarship program that provides scholarships
that are jointly funded by the federal government, the state government, and the student's
own community. CSP is based on the idea that students are more likely to stay and serve
underserved communities if they are chosen and financially supported by those communities.
Although CSP is only 3 years old and active in only 12 states, early results suggest that the
program holds much promise for recruiting health professionals to underserved rural
communities.
Through the mid-1980s, the NHSC Private Practice Option Loan Program provided
assistance to NHSC physicians and dentists to establish their practices, primarily for the
purchase of equipment. As funding for the NHSC declined overall, funding for this program
was discontinued. The rural cross-cutting work group believes that this is a useful program
for promoting rural practice, especially infrontierrural communities.
Overall, the NHSC has been effective in getting practitioners to serve in underserved
areas. However, it is too small in scope to eliminate current underserved areas.
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Action: Medicare payments to physicians and non-physician practitioners should be
restructured to provide incentives to practice in rural and underserved areas.
Rationale: One of the disincentives to practice in rural areas is that Medicare pays less to
rural practitioners. The difference in payments stems from the adjustment for the
Geographic Practice Cost Index. Although the difference in payments is supposedly quite
small, it creates a huge perception problem for practitioners that is a deterrent to rural
practice. If the difference from the health alliance is small, it would make more sense to
eliminate the health alliance adjustment entirely and pay rural and urban practitioners that
same amount for providing the same services.
Alternatively, one could argue that it costs more to recruit practitioners to rural areas,
so payments to rural practitioners should be based on the economic price of getting them to
practice in rural areas. This is particularly true in underserved areas. There are several
ways Medicare payments could be restructured to make practice in underserved areas more
attractive.
1.
Medicare must raise payments to physicians in shortage areas, beyond the current 10
percent bonus already added to reimbursement, relative to payments to physicians
practicing in urban and non-underserved areas. The current 10 percent bonus
payments, which are added to lower reimbursement levels, have proved inadequate to
attract physicians to rural underserved areas. Medicare payments must reflect true
practice costs in rural areas and the amount necessary to attract and retain physicians
in these underserved communities.
2.
All non-physician practitioners should be directly reimbursed for the services covered
under Medicare for which they are licensed and trained to provide under state practice
acts. Medicare payments to these non-physician practitioners should reflect the
amount necessary to attract and retain these providers in underserved communities.
Action: Establish a grant program for the development of rural practices as training sites for
health care practitioners, including sites for rural interdisciplinary training programs. The
grant program would also support the operations of the training programs. The grant
program would expire when other Junding mechanisms for rural training programs are made
available, such as through the workforce investment fund proposed by Work Group 12.
Rationale: Using rural practice sites as training sites will have several benefits. Rural
primary care practitioners may be called upon to provide a wider range of services than their
urban counterparts. Specialists are further away and patients cannot be as quickly referred to
them from a rural practice. Practitioners trained in rural areas will be better prepared for the
unique aspects of rural practice and therefore, more likely to practice in a rural area.
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Linking rural practice sites to training institutions will stabilize the practice in that
community. The practitioners and their patients will benefitfromthe association with the
educational entity because of the improved access to consultations. The collegiality the
association provides would facilitate continuing education and reduce the isolation rural
practitioners often experience.
Grants would be available to local providers and teaching institutions, who would
apply together for the grant. The money would be used for development of existing rural
practice sites as training sites, including establishing telecommunications linkages between
the rural practice and the teaching institution, and paying for rural faculty salaries. The
grants would be available for training physicians, mid-level practitioners, mental health
professionals, dentists, allied health professionals, and others based on community need.
Development of sites and training programs for interdisciplinary training would be
encouraged. In rural health care, it is particularly important for multiple levels of providers
to be able to work together to assure continuity of care. A total of $25 million per year
could be awarded.
Long-term solutions
Action: A national health professions workforce plan should be developed during the first
two years following enactment of health care reform. The plan should be based on an
assessment of the health care needs across the United States. It should integrate the needs
for all types of health care practitioners ~ including dental and mental health professionals for both primary care and specialties. The plan should specify goals for the numbers,
professional mix, ethnic and racial distribution, and geographic distribution of primary care
practitioners and specialists required to meet national health care needs.
Because health professional shortage area (HPSA) designations are likely to play a
critical role in the allocation of resources and the implementation of policy incentives, plan
development should include a reexamination of the designation criteria and the designation
process.
National and state goals for workforce development should be specified and include
priorities for federal funding. The national health professions workforce plan should be used
to coordinate and direct federal funding toward the achievement of national workforce goals.
The Departments of Labor, HHS, and Education should work cooperatively to meet the
national workforce goals.
Rationale: Without a national plan, federal funding for health care professionals has lacked
coordination and direction. Rural workforce development, in particular, has been neglected.
Moreover, current policies have contributed to both an undersupply of primary care
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physicians and an oversupply of specialists. Without a plan, we will be unable to see beyond
today's crisis to a better vision for tomorrow.
National and state goals for workforce development that include goals for the
geographic distribution of practitioners will be important for rural areas. The goals should
take into account the effect of health alliances and health plans on recruitment and retention
of practitioners to rural areas. The goals will be used to direct federal and state funding for
health professional training. By including geographic distribution in the goals, rural
workforce concerns are more likely to be addressed in federal funding policies.
Primary care HPSA designations are used to target federal funding and policy
incentives to underserved areas. However, there is debate over the adequacy of the
definition of HPSAs. The current definition is based solely on the number of primary care
physicians in an area, and does not include physician assistants, nurse practitioners, or nursemidwives. The current ratio of one physician per 3500 individuals is considered to be an
extreme measure of shortage. In addition, reduced federal support and varying state capacity
has resulted in long delays in the designation process. These issues should be considered in
reexamining the designation criteria and the designation process.
Development of the national workforce plan could be accomplished in a number of
ways. The Council on Graduate Medical Education and the Advisory Council on Nurses
Education could be combined into a single advisory board that would develop the plan and
consider other workforce issues. Alternatively, a sub-board of the National Health Board or
a federal agency could be charged with developing the plan.
Currently, federal funding for health professions education is spread across a variety
of different agencies. This decentralization makes it difficult to direct spending toward
meeting national workforce goals. Rural workforce development has often received short
shrift in this system. Directing federal funding toward the achievement of national goals that
include goals for geographic distribution will better ensure that rural communities have
access to providers.
Many of the recommendations from Work Group 12 could be adopted as measures to
achieve national goals. Examples include: expanding the National Health Service Corps;
redirecting Medicare dollars to foster training of primary care physicians; and increasing
support for training non-physician practitioners. In addition, Medicare GME dollars could be
used to train mid-level practitioners. Federal funding also should be used to support ruraloriented health professions training and rural training site development, including
telecommunications networks that link the rural sites with training institutions. Regardless of
the mechanisms used, federal funding should not be spent on training programs that do not
contribute to the achievement of national goals.
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EMS/TRAUMA DELIVERY SYSTEMS
Action: Under health care reform states will develop plans for regional EMS/Trauma care
systems and be accountable for their implementation. The States will submit their plans to
the Department of Health and Human Services (DHHS) where federal support for
EMS/Trauma care system care systems will be consolidated. The DHHS will approve states
plans and make funds available to states to support the infrastructure for emergency care.
Rationale: Since the end of the 1970s, the federal government has not played a major role in
the funding or development of emergency care systems. These responsibilities have been
relegated to the states. Only a few states have developed statewide or regional systems for
the delivery of EMS/Trauma care services. In rural areas, the organization and delivery of
emergency care is largely determined by local providers and their communities. Much of the
rural EMS system is dependent upon committed community volunteers who serve their
communities despite the difficulties inherent to a volunteer system. Too often, emergency
services are poorly coordinated among communities and providers are increasingly dependent
on scarce local resources for their survival. Federal EMS support for states and local
communities has declined and isfragmentedacross several different agencies. In general,
the states are not accountable for the limited federal dollars that are available.
Under health care reform, states would be responsible for strengthening existing
systems of emergency care in rural areas and developing new systems. Experience has
shown that organized regional networks of providers in rural areas can facilitate appropriate
access to emergency care within the limits imposed by distance and terrain. Regional
networks that make the most sense for rural areas will not always correspond with the
jurisdictions for health alliances and/or plans. Thus, the states must continue to exercise
their lead responsibilities for the organization and delivery of emergency care. They will
also need to work closely with each other when EMS systems cut across state boundaries.
The federal government would assist states by making resources available to support
the infrastructure for rural emergency care. This includes training programs for Emergency
Medical Technicians, Paramedics, Physicians, emergency nurses and other EMS personnel;
emergency transportation vehicles; emergency communications systems; etc. The
administrative responsibility and funds for federal support would be centralized in the
Department of Health and Human Services. A consolidation of existing programs could
make available approximately $25 to $50 million dollars for more coordinated effort in
emergency care.
Regional organizations designated by the states would be eligible for federal support.
These regional entities would be responsible for developing and implementing EMS systems
of care in their designated areas. States would assure that the regional organizations
represent both consumers and providers of emergency care. Regional EMS organizations
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would apply for federal support directly or through their states. In either case, the states
would be responsible for ensuring that applications for federal support are consistent with
state plans and the needs of rural communities. Federal support would include matching
grants, direct loans, insured loans, and other appropriate mechanisms to support these
organizations. States could apply for funds on their own if there is a statewide system of
emergency care.
This program would be compatible with the goals of health care reform and the need
to create better systems of care in rural communities. It would be superior to the haphazard
support of EMS that typifies current federal activities related to EMS/trauma care. It would
maintain the central role of states in developing the infrastructure for emergency care. It
would not supplant local support for emergency services or detract from the role of health
alliances and plans in making emergency care a standard, accessible benefit under health care
reform.
MENTAL HEALTH AND SUBSTANCE ABUSE
Rural residents experience the same rate of mental illness as urban residents. The
rate of substance abuse in rural areas is approaching that of urban areas. However, many
rural areas have severe shortages of mental health and substance abuse professionals and
therefore have limited access to these services. In addition, rural communities provide
unique challenges to maintaining patient confidentiality.
Providing mental health and substance abuse services to rural residents may be more
costly than for urban residents. It may cost more to recruit and retain mental health
professionals in rural areas. Social services, vocational rehabilitation, and supportive
housing systems for the mentally ill and recovering substance abusers are often
underdeveloped or non-existent in rural communities. Additional support must be provided
to develop adequate mental health and substance abuse services in rural communities. Until
these services are developed, plans may need to account for the additional costs of
transportation to mental health professionals.
It is especially important in rural areas to integrate primary services with mental
health and substance abuse services. Integrated systems of care have been shown to be more
effective than systems of stand alone mental health services. Primary care practitioners are
the entry point for health care in most rural communities. They must be able to recognize
mental illness and substance abuse and make referrals for appropriate treatments. Prevention
programs for substance abuse also are important for rural residents.
The rural cross-cutting work group has integrated the development of adequate
mental health and substance abuse services with several other actions in this paper. Funding
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preference under the Rural Practice Development Grant program would be made to practice
that integrate mental health and primary care services. Actions for workforce development
incorporate education and training of mental health and substance abuse professionals. The
work group also supports inclusion of mental health and substance abuse benefits as an
integrated part of the benefits package.
GOVERNANCE
Rural representation on the National Board and Health Alliance Boards
Action: The National Health Board should include members with direct experience and
expertise in the unique aspects of health care access, delivery, andfinancingin rural areas.
The number of members with rural expertise should be two or more, up to 25 percent of the
total board membership.
Rationale: About one quarter of the U.S. population resides in rural areas. This population
experiences unique problems with health care access, delivery, andfinancingthat will be
addressed by the National Health Board. However, without special designation, rural
populations are often unrepresented on national advisory boards. Therefore, it should be
specified that at least two members of the board have experience and expertise with issues of
vital concern to rural populations.
Action: The health alliance boards, which are composed of consumers, should include rural
residents in direct proportion to the percentage of the rural population within the health
alliance area.
Rationale: The health alliances have responsibility for assuring that everyone enrolled in the
health alliance has access to a health care plan. This responsibility includes development of
appropriate health care delivery systems, as necessary. Health alliance boards should reflect
the populations they serve. To assure that the health care plans and delivery systems are
responsive to rural needs, the board should include rural residents in direct proportion to the
rural population of the health alliance.
FUNDING FOR STATE INFRASTRUCTURE DEVELOPMENT AND ONGOING
STATE ACTIVITIES
There are a number of issues related to the development of state infrastructure that
will need to be addressed to assure the successful implementation of national health reform in
rural states. These issues build on the recommendations of Work Group 18, which relate to
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the implementation of the new system. This Work group has addressed a number of issues
related to state readiness for health reform and is recommending a direct appropriation to
each state to assist them in the expedited transition to national health reform without having
to go through a procurement procedure. Group 18 is recommending that all states receive a
base amount of funding with some adjustment factor for total population of the state.
Action: States will be required to assure that the needs of rural communities are specifically
addressed in the development of the state plan, infrastructure development, and ongoing state
activities to implement national health reform, including facilitating the development of health
care delivery systems in rural areas.
Rationale: While some states are ready and able to implement sophisticated health reform
systems, many are not. Under health care reform, states will be asked to perform a variety
of functions for which many have limited resources and technical expertise. These states will
require technical assistance and front-end dollars to allow them to develop the necessary
capacity to implement health care reform (e.g., information systems, plan evaluation
expertise). Work Group 18 has recommended a direct appropriation to each state for these
purposes. States also should be required to assure that rural concerns are specifically
addressed in their implementation of health care reform. This is especially critical if the
states are to provide ongoing assistance to rural communities and if they will be called upon
to make judgements about when and how exceptions should be made to accommodate the
needs of rural communities (e.g., exemptions from competition to allow franchises).
INTERIM COST CONTAINMENT
Several options have been proposed to place immediate controls on national health
care cost increases. They are:
A.
B.
C.
D.
E.
F.
pricefreezeon providers
surtax on increases in provider revenue
all payer rate setting
regulation of health insurance premiums
increased use of managed care
a cap on health insurance premiums (similar to D)
The rural cross-cutting group recognizes the importance of short-term cost
containment if national health care reform is to be successful over the long term.
Nevertheless, there is concern that the method chosen should not create additional
disincentives to rural practice. In anticipation of national health care reform, health care
insurers and other health care plans are beginning to develop new products that incorporate
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Page 24
primary care. Interim cost containment initiatives should not exacerbate the already
inequitable payments to rural primary care practitioners. In fact, the need for short term cost
containment could be used as an opportunity to reduce the payment differentials between
urban and rural health care professionals.
The following actions outline rural concerns with the interim cost containment options
and discuss modifications that must be made under each option to protect the already fragile
status of health care delivery in rural areas.
Action: Options D and F would have similar effects on rural areas. They are the preferred
interim cost containment options for rural areas. These options would regulate or cap health
insurance premiums by freezing or limiting premium growth to some percent of the Gross
Domestic Product (GDP). They also would prohibit benefit reductions, allow insurers to set
fees, and require assignment. Current policy holders would be protected by insurance
reforms such as guaranteed renewability and solvency adjustments. To ensure that payments
to rural providers are not diminished by this initiative, insurers should not be allowed to
reduce existing rural provider payment rates.
Rationale: Although health insurance premiums in rural areas are generally higher for the
same benefits than in urban areas, these options would at least limit the rates of increase for
rural policy holders. These options would also serve to "jump-start" health care reform by
implementing insurance reforms and incentives to develop cost effective, provider
contracting. These benefits would be negated in rural areas if insurers chose instead to
discount payments to already low-paid providers.
Discussion of other interim cost containment options:
Options A and B
Option A wouldfreezeprices immediately and then implement a more flexible system
of limits within 3 to 9 months. The flexible system would limit price growth, establish
volume offsets, and allow exemptions for defined special circumstances. The initial freeze
would include percentage rollback provisions to offset anticipated increases.
Option B would impose a surtax on increases in provider income.
Action: If option A is chosen, (1) any price freeze rollback must exempt primary care and
other rural providers, and (2) the growth limits and volume offsets established for the flexible
system must be designed to encourage practice in undeserved areas.
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Option B, if based on historic revenues, could have negative effects on health care
delivery in rural underserved areas if applied across the board. Adjustments in the surtax
rate should recognize the inadequacy of existing incomes for most health care professionals
in rural areas.
Rationale: These options are based on historic costs. One of the reasons for underservice in
rural areas is the historic inadequacy of provider payments. To further exaggerate this
inadequacy, even temporarily, would have a deteriorating effect on the numbers of providers
who choose to practice in rural areas.
Over the longer interim period, the system should be designed to help underserved
rural areas compete more successfully for providers.
Option C
Option C would put an all payer rate-setting system in place, requiring all payers to
use the current Medicare payment methodologies (i.e. DRGs for hospitals and RBRVS for
physicians services). This option includes making necessary modifications to the existing
payment schedules, calculating new conversion factors, and using Medicare data as a proxy
to establish volume controls.
Action: Because short-term cost containment methods may continue for several years, if
option C is selected, any recalculation of the DRG and RBRVS payments must provide
incentives to encourage primary care providers to serve rural and other undeserved
populations. At the least, states should be allowed to modify the national payment rates to
include incentives for improving access and quality.
Rationale: Medicare payment methodologies have consistently paid rural providers less than
urban providers. The new RBRVS system for physician payments has made only marginal
improvements in payments to rural primary care physicians. Continuation of these
disincentives to rural practice will further disadvantage rural populations and require even
greater long-term investments of resources to overcome the disparity in access between rural
and urban areas.
Option E
Option E would increase the use of managed care by: providing large employer tax
incentives to offer plan choices; creating incentives for employees to choose the lowest cost
plans; and allowing small employers to join federal and state employee pools. It also
encourages managed care in Medicare and Medicaid.
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Action: This option would not control costs in rural areas because few rural communities
have managed care plans available. In addition, increases in managed care in urban areas
may place even greater demands on the scarce supply of primary care practitioners.
Nevertheless, if this option is chosen, funding of rural infrastructure development must begin
immediately to allow rural communities to participate in the development of rural primary
care networks and to compete effectively for rural health professionals.
Rationale: The group is concerned that increases in managed care in urban areas may well
place even greater demands on the scarce supply of primary care practitioners, leaving rural
communities at a competitive disadvantage for these professionals. Moreover, few rural
communities have managed care plans. For this option to be even remotely effective in rural
areas, the developmental resources required for health care reform must be made available
immediately to give rural areas an equal opportunity for participation.
BUDGET
Action: Legislation must specify that the budget will be based on an average national per
capita premium within 4 to 7 years. The transition towards a budget based on a national
per capita average should start when the budget is imposed. The national per capita average
will be adjusted for the input costs of providing health care and adjusted upward for the
extra costs and payments required for recruitment and retention of health care practitioners
to rural areas within a state. The National Board will be directed to develop both the input
cost index and the rural adjustment. The formula for the state allocation should not be
specified in law.
Rationale: Historical spending rewards those who have charged more and had higher costs
in the past. These providers have not necessarily been the most efficient. In addition,
payments based on historical costs have contributed to the shortage of health care providers
in rural areas. We should move away from historical per capita spending and towards an
adjusted national per capita average. Any national per capita average must be adjusted to
include the extra costs of maintaining adequate health care resources in rural areas. The time
frame for moving toward the national per capita average should be clearly specified in the
law, and be complete within 4 to 7 years.
The change to a national per capita average will result in a redistribution of funds that
could be disruptive if implemented immediately. On the other hand, unless we begin to
move toward a national measure immediately, we will continue to perpetuate the inequities of
past policies. A blended rate of historical spending/national per capita average should come
into use when the budget comes into effect. A consensus on the definition of "rural area" is
under development.
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The National Board should develop the formula for state allocations, rather than
specifying the formula in the law. At present, there is no basis upon which to develop a
formula. Once a formula is specified in law, it is difficult to change, even if it has obvious
flaws. In addition, specifying the formula in law brings a level of micromanagement to the
system that is not warranted. It is appropriate for the National Board to develop the formula
during the transition period, when there istimeto develop it correctly, and the flexibility to
change it later if necessary.
Adoption of Medicare Cost Indices for Input Prices in the Budget
Action: The law should not specify that the Medicare hospital wage index and the
Geographic Practice Cost Index (GPCI) for physician payments will be adopted as the input
prices in the budget. The National Board should consider the adequacy of these indices as
measures of the input prices for providing health care services in rural areas. The Board
should determine whether these indices can be modified or if better input price measures can
be developed.
Rationale: The budget will need to account for geographic differences in the costs of
providing health care services in different areas. Because input price indices have already
been developed for Medicare payments to hospitals and physicians, it has been suggested that
these indices could be applied directly to the budget. However, these indices rely heavily on
historic costs and do not adequately measure the economic costs of providing health care
services in rural areas.
Currently, the hospital wage index for rural hospitals is based on the wages paid by
all rural hospitals in a state. Even in large states, all rural hospitals are paid based on the
same wage index. Many alternative definitions of the labor market area for hospitals have
been proposed. The most promising recommendation came from the Prospective Payment
Assessment Commission (ProPAC) this March. They recommend using hospital-specific
labor market areas based on geographic proximity measured by the air-mile distances
between nearby hospitals. This proposal has not been adopted, but HCFA is considering its
use and soliciting public comment on it. ProPAC's definition should result in more equitable
adjustments for labor costs among rural hospitals than the current definition.
The data used to develop the hospital wage index is always about four years old, even
though it is now updated annually. In addition, the wage index is based exclusively on
wages paid, and does not include any additional costs rural hospitals incur to recruit
professional staff. Additional costs may include sign-on bonuses, fees to recruitment
agencies, moving costs, and scholarship programs offered to local residents who promise to
return and work in the local hospital.
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Similarly, the GPCI adjusts for the historical costs (professional and employee wages,
rent, medical supplies and equipment, malpractice premiums) incurred by a physician
practice, but does not adjust for the price that must be paid to get practitioners to work in
underserved, rural areas. Unless these costs are recognized, rural areas will continue to
struggle to recruit and retain an adequate health care workforce.
ADMINISTRATIVE SIMPLIFICATION AND INFORMATION SYSTEMS
The President's plan contains a comprehensive series of recommendations to simplify
administrative procedures and develop a national health care information system. They range
from standardizing data sets and formats to consolidating facility licensing programs.
These recommendations will use electronic technology for the collection,
transmission, maintenance, and analysis of data. Although the initial investment in such
technology is costly, the long term simplification for providers, plans, alliances, and
governments will substantially reduce administrative costs. In addition, the accuracy,
timeliness, and relevancy of the information will improve the quality and outcomes of health
care. More reliable data will enhance health policy and program decisions.
Rural providers - practitioners, clinics, hospitals - have small budgets and low
operating margins. Their record-keeping staff often have multiple responsibilities, and may
not be familiar with state-of-the-art computerized billing and data systems. Consequently,
rural providers have been slow to adopt electronic data systems. Development of the
national information system must consider the additional support rural providers will need for
purchasing and learning to use electronic data systems. State funding for infrastructure
development (see page 22) should target funds for development of information systems in
rural areas.
Action: If electronic billing and data transmission is required, time frames for the conversion
to these systems must accommodate rural facilities that have not yet adopted electronic
information systems.
Rationale: If rural providers are to switch to electronic technology, they will need time and
assistance to procure the equipment and develop the skills of existing staff.
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Action: Immediate development of a single, standardized billing form for each class of health
care service is essential for reducing administrative costs of rural providers.
Rationale: Because rural providers, in general, handle patient encounter records, billing, and
payment accounting with fewer personnel, the proliferation of forms for multiple insurance
programs adds a substantial administrative burden. Standardization of the forms and the data
required would immediately improve this situation.
QUALITY AND ACCOUNTABILITY
Action: The accountability system outlined in the tollgate paper should be adopted as a pan
of the health care reform package.
Rationale: Health plans need to be accountable for ensuring that the quality of services
available are accessible, affordable, and of acceptable quality. The accountability system
outlined in the tollgate paper goes a long way toward achieving these objectives without
bogging down plans in unnecessary regulatory requirements.
Practice Guidelines
Action: National practice guidelines should be outcomes oriented, prevention focused, and
community based.
Rationale: Practice guidelines direct health care practitioners to the most effective services
for a specified medical diagnosis. Primary care practice guidelines that include referral
criteria and general guidelines can be used to assess malpractice or risk of malpractice.
Current guidelines focus on high technology interventions that may not be available or
appropriate for rural andfrontierareas. Efficient and effective care does not necessarily
require the use of the latest technology. Outcome oriented guidelines will identify the
effective low technology services and will appropriately value the preventive, public health,
nutritional, and social services that are as much a part of the total illness as the medical
condition.
Practice guidelines also will recognize that for some medical conditions, the use of
high technology is appropriate. In those conditions, referrals to facilities or services that can
provide the necessary level of care are appropriate and expected.
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CLIA
The Clinical Laboratory Improvement Amendments of 1988 (CLIA) were passed to
assure the quality of laboratory testing wherever such testing takes place. In particular,
Congress was concerned about the quality of cytology testing and testing in physician office
laboratories. CLIA regulates laboratories based on the tests they perform, not on the
location or size of the laboratory. New personnel standards, quality assurance controls, and
proficiency testing requirements were established. The cost of implementing CLIA is bome
completely by the regulated laboratories through registration fees. The CLIA regulations
were implemented last September.
Action: The regulations implementing CLIA should be reexamined to consider the effects of
CLIA on access to laboratory testing (particularly screening tests) in rural areas and to
reduce the burden on rural providers. An exceptions process should be developed that
exempts practitioners from CLIA regulations for certain tests — exceptions would be granted
only for tests that are necessary for immediate diagnosis or treatment when there is no
alternative testing site available that can produce results within 12 hours. The rural crosscutting work group does not support the complete, broad-based exemption of small physician
practices and small clinics after two years, as proposed by Work Group 9.
Rationale: Rural providers, in particular, have been burdened by the new CLIA
requirements implemented last September. The CLIA regulations were developed without
consideration of the effect they would have on access in rural areas. Some rural practitioners
have chosen to stop providing on-site testing that is essential to making informed decisions
about diagnoses and treatments. In these situations, patients must wait 24 hours or more for
test results that are sent to another laboratory, or travel to another site for testing. In
addition, the personnel requirements exacerbate the difficulty rural hospitals and other
providers already have recruiting laboratory personnel. CLIA also has added costs that are
difficult for rural providers to absorb or pass on to their patients.
An exceptions process should be implemented that makes it possible for practitioners
to receive an exemptionfromCLIA for certain laboratory tests that are essential for
immediate diagnosis and treatment. The exemption would be granted only when there are no
reasonable, alternative sites for laboratory testing that can produce the test result within 12
hours.
Under Work Group 9's proposal, small physician offices and clinics would be
completely exemptedfromCLIA regulation if no significant quality problems are discovered
during the first two years of laboratory inspections under CLIA. However, testing in
physician office laboratories was one of the concerns that led to the passage of CLIA. Even
small physician offices are able to purchase laboratory equipment that can perform a number
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of laboratory tests with just a push of a button. Until CLIA, this testing was unregulated,
with no assurances that the equipment was maintained correctly or that quality controls were
performed regularly. Without these actions, there is no assurance that the test results are
accurate.
Exempting small physician offices and clinics, which predominate in rural areas,
suggests that a lower standard of quality is acceptable for rural residents. We agree that the
burden of the CLIA regulations should be reduced for rural providers. Reasonable
requirements should be adopted that assure quality and access to laboratory testing in rural
areas. An exceptions process should be developed for those tests that are essential for
immediate diagnosis and treatment decisions. However, the regulatory burden should not be
reduced to the point that rural practitioners are completely relieved from reasonable measures
that assure accurate laboratory testing for their patients.
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�M0NTEF10RE MEDICAL CENTER
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MEMORANDUM
NANCY NEVELOFF DUBLER, LL.B.
Director
Division of Bioethics
Professor of Bioethics
Albert Einstein College of Medicine
MQNTEFIQRE
PPi
TO:
Prison Health Care Planning Persons
FROM:
Nancy Neveloff Dubler
DATE:
May 13, 1993
RE:
Amending previous memorandum
The last memorandum described some of the problems and some possible solutions
for folding prisoners into the new system. However, a conversation with Mark Barnes, a
member of the Legal Audit Group, produced some new ideas for consideration.
Rather than focusing on the role of the AHPs directly, Mark suggested that the system
require much more extensive activity by the HA and more extensive funding by the state.
Combining new concepts with points in the last memorandum would lead to a plan that
disassociated issues of funding from issues of service delivery and required that the HA play
a role in both. The state, or local county or city government, would remain the primary
funder for prison and jail health care. The HA would, however, have extensive
responsibilities for contracting with care providers and assuring quality.
FUNDING PRISON AND JAIL HEALTH CARE
For prison health care, the state would be responsible for paying the HA covering the
territory of any prison for the average daily census of the prison, times the price of the
benchmark premium in that area.
For jail health care, the county or the city government responsible for the jail would
pay the relevant HA an amount equal to the average daily census of the jail, times a
percentage of the benchmark premium equal to the average length of stay for inmates in that
jail.
�FUNDING FOR PRISON AND JAIL HEALTH CARE SERVICES
The Health Alliance would compute the amount that the legally responsible
governments had paid for prison and jail health care services and compute the relative risk
adjustments necessary to adequately treat the level of medical acuity in the population.
Given the fact that between 15 and 20 percent of the prison and jail populations of some
states are HIV positive, the adjustments might need to be substantial. One further suggestion
would be that the HA, once it had computed the amount necessary for fair risk adjustment,
would charge the state or local government for that amount. The decision should rest on
whether the health budget or the correctional budget as established by the legislature should
bear the burden of risk adjustment.
ARRANGEMENT OF PRISON AND JAIL HEALTH CARE SERVICES
Once the funding for the contract had been established, the HA would be responsible
for finding an AHP, in the locality of the correctional facility, or a provider, not in the area
but willing to serve, with whom to contract. In the last decade increasing amounts of
correctional health care services have been provided to county and state facilities by "for
profit" correctional health care corporations. These providers were able to gain these
lucrative contracts because they: were able to produce a range of care-giving staff by being
able to pay more than the civil service rate; and, were able to manage their budgets and
supervision more capably than the government officials who had been responsible previously.
This experience indicates that the HA might want to offer bids for an AHP specially
constituted to provide correctional health care that might be incorporated either within or
without the territory of the HA.
The HA would be responsible for negotiating the contract and for supervising the
quality of care. The quality would be reviewed according to the measures established for
community providers in the free-world and might, therefore, help to ensure that correctional
health care be of the same quality as other health care services financed and overseen by the
HA.
RESERVATIONS ABOUT THIS PLAN
As the prior memorandum argued, the status of health care in a prison or jail is as a
second class citizen after the concerns of security and punishment. Whether the HAs are
going to be able to master the environment and insist on quality despite the difficulties of
access and monitoring is not clear. We do know, however, that the best correctional health
care is provided by outside health care organizations committed to quality care according to a
community standard. Perhaps this is, indeed, the route to follow.
�PLEASE NOTE THAT NUMBERS CAN BE PROVIDED ABOUT THE SPECIFIC
POPULATIONS OF VARIOUS PRISONS AND JAILS AND THE BUDGETS PROVIDED
FOR THEIR HEALTH CARE-ON REQUEST.
A:\PRISON2
�maintenance o f s t a t e e f f o r t i n p r e s e n t l y funded s t a t e r u n
programs and systems.
Responsible c o r r e c t i o n a l h e a l t h a d m i n i s t r a t o r s would l i k e
the new system t o encompass inmates f o r two reasons:
f i r s t , so
t h a t i t m i g h t p r o v i d e e x t r a resources f o r t h e c a r e o f inmates;
and, second, so t h a t i t might i m p o r t community q u a l i t y assurance
and performance measurement standards i n t o t h e u n i v e r s e o f
c o r r e c t i o n a l h e a l t h s e r v i c e s . Since h e a l t h c a r e budgets have n o t
r i s e n n e a r l y as q u i c k l y as p o p u l a t i o n i n t h e l a s t decade, even
t h o s e h e a l t h s e r v i c e s t h a t were r e l a t i v e l y adequate some y e a r s
ago a r e now s t r u g g l i n g t o meet t h e c o n s t i t u t i o n a l s t a n d a r d o f
c a r e w i t h f a r fewer resources p e r inmate.
For t h i s same s e t o f reasons i t i s l i k e l y t h a t s t a t e
governments might o b j e c t t o t h e p a r t i c i p a t i o n o f t h e new system.
I f q u a l i t y assessment i s t a k e n s e r i o u s l y a new v o i c e m i g h t emerge
c a l l i n g f o r i n c r e a s e d c o r r e c t i o n a l - - i . e . s t a t e — s p e n d i n g on
health care.
N a t u r a l l y , t h i s a n a l y s i s does n o t p r e c l u d e t h e s t a t e s from
t r y i n g t o d e v i s e c r e a t i v e and i n n o v a t i v e p l a n s t o i n v o l v e t h e HAs
or t h e AHPs i n t h e process o f i m p r o v i n g t h e q u a l i t y o f c a r e i n
s t a t e p r i s o n s o r i n j a i l s , f o r which county governments a r e
r e s p o n s i b l e . S t a t e s might, f o r example, r e q u i r e a l l c o r r e c t i o n a l
f a c i l i t i e s t o have an independent b i d d e r on t h e h e a l t h c a r e
s e r v i c e s and t h e n ask t h e HA t o s u p e r v i s e t h a t process. Given t h e
f a c t t h a t t h e HA should have t h e b e s t data on what c a r e s h o u l d
c o s t i n t h e area, and t h e most r e l e v a n t e x p e r i e n c e i n managing
the c o s t - n e g o t i a t i o n process, t h i s assignment might improve t h e
value f o r t h e d o l l a r t h a t c o r r e c t i o n a l services could expect.
the
IV.
The r e a l i s s u e i s : should t h i s new p l a n mandate a r o l e f o r
HAs and t h e AHPs over s t a t e o b j e c t i o n ?
THE ROLE OF THE NEW SYSTEM
I would argue that c e r t a i n o b l i g a t i o n s regarding
c o r r e c t i o n a l h e a l t h s e r v i c e s should be mandated by s t a t u t e i n the
new system.
The HA could play an important r o l e i n s t r u c t u r i n g s e r v i c e
c a p a c i t y . One of the major problems i n c o r r e c t i o n a l h e a l t h care
i s the problem of f i n d i n g consultant and s p e c i a l t y c a r e providers
w i l l i n g t o serve inmates, and finding h o s p i t a l s w i l l i n g t o
provide s e r v i c e s . Inmates may not be paid f o r by the new system
and might not be t o t a l l y integrated i n t o the normal c a r e plans,
yet,
a s p a r t of t h e i r management of care a v a i l a b l e i n i t s area,
the HA should have the o b l i g a t i o n of ensuring that s p e c i a l t y
s e r v i c e s and h o s p i t a l i z a t i o n a r e a v a i l a b l e t o the p r i s o n and j a i l
�h e a l t h s e r v i c e s . Most providers do not want to serve inmates.
Yet, inmates are a disadvantaged and underserved population to
whom the system owes the e t h i c a l o b l i g a t i o n of attempting to
improve c a r e .
The s t a t e might a l s o involve the HA i n the process of
a u d i t i n g the q u a l i t y of care according to the e s t a b l i s h e d
standards i n the f r e e community.
There a r e two f i n a l reasons why t h e care o f inmates s h o u l d
be as i n t e g r a t e d as p o s s i b l e i n t o t h e community s t a n d a r d o f c a r e .
Most inmates s t a y i n p r i s o n f o r s l i g h t l y l e s s t h a n t h r e e y e a r s .
At t h e end o f t h a t t i m e t h e y r e e n t e r t h e community and w i l l be
e n r o l l e d i n an AHP.
I f t h e care i n p r i s o n o r j a i l i s inadequate
the subsequent c o s t s t o t h e system w i l l be g r e a t e r . U n t r e a t e d
and n e g l e c t e d h e a l t h problems t e n d t o c o s t more i n t h e l o n g - r u n .
I n a d d i t i o n , u n t r e a t e d h e a l t h problems t h a t p r e s e n t p u b l i c
h e a l t h c h a l l e n g e s w i l l f o l l o w t h e inmate i n t o t h e community and
s u b j e c t o t h e r s t o t h e r i s k o f i n f e c t i o n and d i s e a s e .
This l a s t
phenomenon i s most obvious now i n d i s c u s s i o n s o f HIV Disease and
M u l t i p l e d r u g - r e s i s t a n t T u b e r c u l o s i s . I n New York, f o r example,
a p p r o x i m a t e l y 25% o f inmates e n t e r i n g t h e system from New York
C i t y a r e HIV p o s i t i v e ; f u l l y 25% o f t h e TB i n New York C i t y i s
r e s i s t a n t t o t h e f i r s t two s t a n d a r d drugs; persons w i t h HIV and
TB a r e t e n t i m e s more l i k e l y t o progress t o TB d i s e a s e t h a n those
not d u a l l y i n f e c t e d .
I t i s not hard t o f o r e s e e t h e p u b l i c h e a l t h
c a t a s t r o p h e t h a t would r e s u l t i f t h e p r i s o n s and j a i l s were n o t
d e a l i n g a d e q u a t e l y w i t h t h e d u a l epidemic.
V.
EQUITY IN THE
NEW
SYSTEM
The most b a s i c d e f i n i t i o n o f j u s t i c e i s t r e a t i n g l i k e cases
a l i k e . M a i n t a i n i n g s t a t e programs and s t a t e f i s c a l
r e s p o n s i b i l i t y f o r persons i n t h e c r i m i n a l j u s t i c e system i s
c o n s i s t e n t w i t h d e c i s i o n s made p r e v i o u s l y i n r e g a r d t o person i n
the f o r e n s i c mental h e a l t h system, and persons
d e i n s t i t u t i o n a l i z e d from l o n g - t e r m mental i n s t i t u t i o n s .
Person i n t h e f o r e n s i c system, ( t h a t i s i n a mental h e a l t h
f a c i l i t y t o assess a b i l i t y t o stand t r i a l o r t o c o n f i n e as an
a l t e r n a t i v e t o p r i s o n — b a s e d on t h e judgment o f n o t g u i l t y by
reason o f i n s a n i t y ) w i l l be cared f o r and p a i d f o r by t h e s t a t e s .
The f o r e n s i c system and t h e g e n e r a l c r i m i n a l j u s t i c e system share
c e r t a i n c h a r a c t e r i s t i c s t h a t argue f o r u n i f o r m t r e a t m e n t . I n
b o t h systems i t i s t h e j u d i c i a l system and t h e c r i m i n a l j u s t i c e
system t h a t makes t h e d e c i s i o n s about where and how a person w i l l
be t r e a t e d .
I n b o t h cases i t would be i m p o s s i b l e f o r an AHP t o
"manage" c a r e . The key d e c i s i o n s r e g a r d i n g care are o u t s i d e o f
�the a u t h o r i t y o f the plan.
burden.
Thus t h e s t a t e s must bear t h e e n t i r e
I n c o n t r a s t , consider the treatment o f t h e
d e i n s t i t u t i o n a l i z e d mentally i l l .
These people w i l l , upon
placement i n t h e community, be e n r o l l e d i n an AHP. Whereas t h e
AHP might be e l i g i b l e f o r a r i s k adjustment, g i v e n t h e d i f f i c u l t y
o f p a t i e n t management, i f t h e AHP subsequently decides t o
r e i n s t i t u t i o n a l i z e t h e p a t i e n t , i t w i l l be r e s p o n s i b l e f o r t h e
costs o f t h a t i n s t i t u t i o n a l i z a t i o n ;
i t manages t h e c a r e ; i t
decides t o r e i n s t i t u t i o n a l i z e ;
i t i s l i a b l e f o r payment.
C o n t r a s t t h i s w i t h t h e course o f an inmates c a r e e r d u r i n g
w h i c h t h e c r i m i n a l j u s t i c e system decides when t o i n c a r c e r a t e and
when t o r e l e a s e , when t o t r a n s f e r t o a new f a c i l i t y , when t o send
f o r s p e c i a l t y c a r e , o r when t o r e l e a s e f o r h o s p i t a l o r hospice
care.
Imposing burdens on t h e AHP under these c i r c u m s t a n c e s
would s e r v e no u s e f u l purpose.
VI.
POSSIBLE QUALITY IMPROVEMENT FOR INMATES IN THE NEW SYSTEM
Inmates may y e t b e n e f i t i n o t h e r ways under arrangements i n
t h e new system. They may be e n t i t l e d t o more s e r v i c e s i f t h e
b e n e f i t package comes t o be seen as t h e p r e s c r i p t i o n f o r
m i n i m a l l y adequate c a r e . On t h e o t h e r hand, g i v e n t h e f a c t t h a t
f e d e r a l cases have r e q u i r e d d e n t a l care, mental h e a l t h c a r e and
r e h a b i l i t a t i o n under t h e r u b r i c o f " s e r i o u s medical needs" t h i s
might n o t p r o v i d e t h e b a s i s f o r an expansion o f c a r e .
There w i l l be t h e need t o c o o r d i n a t e e x i t from t h e c r i m i n a l
j u s t i c e system w i t h e n r o l l m e n t i n a AHP. I t i s p r e s e n t l y t h e
case t h a t inmates d i s c h a r g e d from a p r i s o n o r j a i l have no sure
way o f l i n k i n g up t o s e r v i c e s , even i f t h e y a r e e l i g i b l e f o r
Medicaid.
The chaos and c o n f u s i o n o f t h e systems, and t h e f e a r
o f e x - p r i s o n e r s as a danger t o p r o v i d e r s and p a t i e n t s , tends t o
d i s c o u r a g e c o n t a c t and e n r o l l m e n t . S t a t e s s h o u l d be r e q u i r e d t o
develop p l a n s t o e n r o l l inmates i n AHPs a t t h e p o i n t o f r e l e a s e .
Given t h e p r e v a l e n c e o f AIDS, mental i l l n e s s and substance abuse,
t h e e x i s t e n c e o f p o s t i n c a r c e r a t i o n care o p p o r t u n i t i e s w i l l
p r o v i d e a r e a l , new b e n e f i t t o inmates.
High r a t e s o f r e c i d i v i s m
might a l s o d e c l i n e i f these s e r v i c e s were p r o v i d e d .
S t a t e s s h o u l d be r e q u i r e d t o i n v o l v e t h e HA i n t h e b i d d i n g
o u t and m o n i t o r i n g o f care i n t h e p r i s o n s and, perhaps i n t h e
j a i l s a l s o . Any developments t h a t encourage t h e g e n e r a l m e d i c a l
community t o m o n i t o r and assess q u a l i t y w i l l h e l p those p r o v i d e r s
g e n u i n e l y concerned w i t h q u a l i t y t o improve t h e system o f c a r e .
Thus, even though inmates should n o t be e n r o l l e d i n t h e new
system, t h e y w i l l l i k e l y b e n e f i t from t h e o r g a n i z a t i o n and
management o f a u n i v e r s a l coverage sustem and from enhanced
�q u a l i t y assessment i n the
future.
�DRAFT
PRISON AND JAIL HEALTH CARE
IN THE NEW SYSTEM
I.
INTRODUCTION
One m i l l i o n 300,000 persons are i n c a r c e r a t e d e v e r y day i n
our n a t i o n s p r i s o n s , j a i l s and d e t e n t i o n c e n t e r s .
These persons
range i n age from young c h i l d r e n , age 7 o r 8, t o t h o s e i n t h e i r
eighties.
Indeed, i n t h i s area, as i n many o t h e r s , t h e " g r a y i n g "
of the p r i s o n population i s noticeable.
T h i s p o p u l a t i o n o f i s composed o f t h r e e major groups: t h o s e
i n p r i s o n s s e r v i n g sentences o f year o r more; those i n j a i l s who
are a w a i t i n g t r i a l and have been denied o r are unable t o r a i s e
b a i l ; and t h o s e i n j a i l who are s e r v i n g s h o r t - t e r m sentences o f a
y e a r o r l e s s . P r i s o n s c o n f i n e a p p r o x i m a t e l y ~9cw,' thousand
inmates, w h i l e j a i l s c o n f i n e &'ot<<^. A j a i l p o p u l a t i o n census,
however, may be m i s l e a d i n g .
For example, R i k e r s I s l a n d , t h e
major New York C i t y j a i l c o n f i n e s about Ij^OOO inmates;
this
number may r e p r e s e n t ,.^86,000 separate admissions a y e a r , some o f
which may be r e a d m i s s i o n s .
^
„ ,
l 0
V
e
?jJ
a C
D
The correctional institutions of the nation are
^cw . u /
d i s p r o p o r t i o n a t e l y i n h a b i t e d by t h e poor and people o f c o l o r . I n
/
many s t a t e s upward o f 90% o f i n c a r c e r a t e d persons are poor and i n
some more t h a t 80% are people o f c o l o r , A f r i c a n - A m e r i c a n and
Hispanic.
Data produced by "The Sentencing P r o j e c t " i n 1990
showed t h a t 25% o f Black men between t h e ages o f 19 and 29 are
under t h e j u r i s d i c t i o n o f t h e c r i m i n a l j u s t i c e system. ( I n t h e
D i s t r i c t o f Columbia, t h e number i s 42%)
w
Since 1976, when t h e Supreme Court decided t h e case o f
E s t e l l e v. Gamble, t h e s t a t e s have been r e s p o n s i b l e f o r p r o v i d i n g
h e a l t h c a r e f o r those i n c a r c e r a t e d i n p r i s o n s o r j a i l s .
The
F e d e r a l government i s a l s o r e s p o n s i b l e f o r p r o v i d i n g h e a l t h c a r e
i n i t s d e t e n t i o n c e n t e r s and Federal C o r r e c t i o n a l F a c i l i t i e s .
The c o n s t i t u t i o n a l standard f a s h i o n e d by t h e c o u r t f o r
j u d g i n g t h e adequacy o f care i s : " D e l i b e r a t e i n d i f f e r e n c e t o t h e
s e r i o u s m e d i c a l needs o f inmates" c o n s t i t u t e s t h e w i l l f u l and
wanton i n f l i c t i o n o f p a i n t h a t t h e E i g h t h Amendment i s designed
t o p r o h i b i t . That i n d i f f e r e n c e may be demonstrated by d e n y i n g
access t o t h e c a r e system, by f a i l i n g t o p r o v i d e access t o t h e
a p p r o p r i a t e l e v e l o f h e a l t h p r o f e s s i o n a l necessary t o diagnose o r
t r e a t t h e a i l m e n t , o r by f a i l i n g t o f o l l o w t h e p r o v i d e r ' s o r d e r s .
�The c o u r t reasoned t h a t t o p u t someone i n a c o r r e c t i o n a l
f a c i l i t y , where t h e y cannot secure t h e i r own c a r e , and t h e n n o t
t o p r o v i d e t h a t c a r e , i s t o produce p r e c i s e l y t h e k i n d o f p a i n
and s u f f e r i n g t h a t t h e E i g h t h Amendment i s designed t o p r o h i b i t .
D e s p i t e t h e f a c t t h a t inmates a r e t h e o n l y persons i n t h e
n a t i o n w i t h a C o n s t i t u t i o n a l l y guaranteed r i g h t t o h e a l t h c a r e ,
t h e q u a l i t y o f c a r e p r o v i d e d - - m e d i c a l c a r e , mental h e a l t h c a r e ,
c h r o n i c c a r e and r e h a b i l i t a t i v e c a r e - - ( a l l o f which a r e r e q u i r e d
by v a r i o u s F e d e r a l Court cases) v a r i e s w i d e l y among t h e
j u r i s d i c t i o n s and i s o f t e n found inadequate.
Since 1976 every s t a t e has been faced w i t h c h a l l e n g e s t o t h e
adequacy o f systems developed t o p r o v i d e c o r r e c t i o n a l h e a l t h c a r e
s e r v i c e s . Some s t a t e s , Alabama and Texas among them have had
t h e i r c o r r e c t i o n a l medical s e r v i c e s i n v i r t u a l , o r a c t u a l ,
r e c e i v e r s h i p f o r a decade o r more. A s s u r i n g q u a l i t y , always a
problem i n segregated s e r v i c e s t h a t serve powerless p o p u l a t i o n s ,
i s f u r t h e r c o m p l i c a t e d by t h e e x p l o s i o n o f inmates over t h e l a s t
decade.
Since 1980 t h e p r i s o n and j a i l p o p u l a t i o n o f t h e c o u n t r y has
more t h a n doubled. T h i s has r e s u l t e d i n huge c a p i t a l
e x p e n d i t u r e s f o r new c e l l s i n some s t a t e s and i n h e a v i l y
overcrowded f a c i l i t i e s i n o t h e r s . The reasons f o r t h i s g r o w t h
include: the increasing fear of c i t i z e n s a t the increase i n
v i o l e n t c r i m e s and crimes a g a i n s t persons; t h e r e s u l t a n t " l o c k them-up" p h i l o s o p h y o f p o l i t i c i a n s and judges; t h e "war on
drugs" t h a t may n o t have done much t o stem t h e f l o w o f p r o h i b i t e d
substances b u t has l e d t o t h e i n c a r c e r a t i o n o f ever l a r g e r
numbers o f d r u g users and d e a l e r s ; and t h e i n c r e a s e i n "mandatory
s e n t e n c i n g g u i d e l i n e s " t h a t has produced l o n g e r sentences f o r a
v a s t number o f r e p e a t o f f e n d e r s . I n a d d i t i o n , women a r e e n t e r i n g
c o r r e c t i o n a l systems i n e s c a l a t i n g numbers, and many c h i l d r e n ,
who used t o be t r i e d and c o n f i n e d i n j u v e n i l e f a c i l i t i e s a r e now
t r i e d and sentenced w i t h i n t h e a d u l t system.
The huge numbers o f inmates, t h e budgets r e q u i r e d f o r
confinement and c a r e , t h e problems i n h e r e n t i n p r o v i d i n g decent
m e d i c a l c a r e i n c o r r e c t i o n a l s e t t i n g s , and t h e c o n s t a n t p r e s s u r e
of t h e advocate groups i n t h e Federal Courts have made t h e
p r o v i s i o n o f c o r r e c t i o n a l h e a l t h c a r e a major concern o f t h e
states.
II.
CORRECTIONAL HEALTH CARE: THE DILEMMAS
P r o v i d i n g h e a l t h c a r e i n a p r i s o n o r j a i l i s an a l i e n
e x p e r i e n c e f o r most h e a l t h care p r o v i d e r s , one t h a t i s
u n c o m f o r t a b l e and s c a r y . The g o a l o f a c o r r e c t i o n a l f a c i l i t y i s
t o c o n f i n e and p u n i s h . The g o a l o f medicine i s t o diagnose,
c o m f o r t and c u r e . These g o a l s must c o - e x i s t i f inmates a r e t o
�r e c e i v e decent and a p p r o p r i a t e care; medicine must u l t i m a t e l y be
i n charge o f t h e c a r e d e l i v e r y system, t h e p r o t o c o l s used, and
t h e c o n s u l t a n t arrangements made, i f t h e c a r e i s t o meet t h e r e a l
needs o f inmates.
The c o n s t i t u t i o n a l standard r e q u i r e s t h a t t h e inmates be
a b l e t o g a i n access t o t h e h e a l t h s t a f f , be examined by an
a p p r o p r i a t e h e a l t h p r o v i d e r , be a b l e t o g a i n access t o t h e c a r e
o r d e r e d and be p r o v i d e d w i t h c o n s u l t a n t c a r e o r h o s p i t a l i z a t i o n
when necessary. Whereas a l l o f these elements a r e r e l a t i v e l y
easy o u t s i d e o f p r i s o n , t h e y present major management c h a l l e n g e s
f o r c o r r e c t i o n a l h e a l t h a d m i n i s t r a t o r s . Many o f t h e o b s t a c l e s
stem from t h e u n w i l l i n g n e s s o f those n o t d i r e c t l y i n v o l v e d i n
c o r r e c t i o n a l h e a l t h care t o provide services. Often t h i s
r e l u c t a n c e extends t o i n d i v i d u a l s p e c i a l i s t s , t o t h e l o c a l
ambulance c o r p , and t o t h e area h o s p i t a l .
Given t h e a d v e r s a r y r e l a t i o n s h i p between c o r r e c t i o n a l
a d m i n i s t r a t o r s , c o r r e c t i o n o f f i c e r s and inmates, gaming t h e
system i s p a r t o f inmate c u l t u r e . Conversely, d e n i a l o f access
and d e n i a l o f t r e a t m e n t i s a c o n s t a n t t h r e a t o f t h e o f f i c e r s .
Because o f f i c e r s c o n t r o l t h e space, i t i s i m p o s s i b l e , i n t h e
f i r s t i n s t a n c e , t o d i s t i n g u i s h a r e f u s a l o f c a r e from a d e n i a l o f
c a r e i n any c o r r e c t i o n a l s e t t i n g .
I n a d d i t i o n , data i n d i c a t e t h a t many persons e n t e r i n g t h e
c o r r e c t i o n a l system have f a r more acute m e d i c a l problems t h a n one
m i g h t assume from age alone.
Prevalence o f h y p e r t e n s i o n , c a r d i a c
problems, u n t r e a t e d o r t h o p e d i c c o n d i t i o n s , e p i l e p s y and major
mental i l l n e s s e x i s t i n t h i s p o p u l a t i o n t o a f a r g r e a t e r degree
t h a n found i n a matched n o n - i n c a r c e r a t e d c o h o r t . T h i s a d d i t i o n a l
burden o f unaddressed d i s a b i l i t y , i l l n e s s and d i s e a s e e x i s t e d
even b e f o r e t h e advent o f AIDS, t h e reemergence o f T u b e r c u l o s i s
and t h e development o f d r u g - r e s i s t a n t s t r a i n s o f t h e b a c t e r i u m .
III.
POSSIBLE SOLUTIONS
There a r e t h r e e p o s s i b l e o p t i o n s f o r c o n s i d e r i n g t h e
r e l a t i o n s h i p o f t h e new system t o c o r r e c t i o n a l h e a l t h c a r e .
Each
must c o n s i d e r t h e problems o f p r o v i d i n g s e r v i c e and p a y i n g f o r
the service
separately:
1. F o l d a l l s t a t e p r i s o n and j a i l inmates and a l l F e d e r a l
inmates i n t o t h e new system;
2.
Phase i n a system t h a t w i l l g r a d u a l l y charge AHPs f o r
tfce some p a r t s o f t h e care p r o v i d e d d u r i n g s t a y s i n t h e j a i l
system, e s p e c i a l l y t h a t p a r t o f care t h a t c o n t i n u e s
t r e a t m e n t f o r p r e v i o u s l y i d e n t i f i e d m e d i c a l problems.
3.
Continue t h e p r e s e n t system o f s e p a r a t e s t a t e o r f e d e r a l
f u n d i n g f o r h e a l t h programs i n c o r r e c t i o n a l f a c i l i t i e s w h i l e
u s i n g t h e HA5to ensure t h a t c o n s u l t a n t c a r e , s p e c i a l t y c a r e
and h o s p i t a l i z a t i o n a r e a v a i l a b l e t o inmates.
�Under none o f t h e o p t i o n s , would t h e AHP a c t u a l l y be i n a
p o s i t i o n t o p r o v i d e p r i m a r y c a r e s e r v i c e s ( a l t h o u g h t h e AHP might
be c r i t i c a l f o r t h e e f f o r t t o p r o v i d e c o n s u l t a n t c a r e , s p e c i a l t y
c a r e and h o s p i t a l i z a t i o n ) .
Given t h e g e n e r a l s e c u r i t y problems, t h e l e g a l mandate o f
t h e c o r r e c t i o n a l s e r v i c e s , a d m i n i s t r a t i v e management, c o u r t
appearances, f a m i l y and a t t o r n e y v i s i t s , t h e f r e q u e n t " l o c k downs" t h a t o v e r r u l e a l l p r i o r s c h e d u l i n g d e c i s i o n s , and t h e
custom o f most p r i s o n systems t o t r a n s f e r inmates r e g u l a r l y t o
p r e v e n t a l l i a n c e s and power o r g a n i z a t i o n s , i t would be i m p o s s i b l e
f o r p r o v i d e r s o u t s i d e o f t h e system t o e n t e r i n t o t h e p r i s o n t o
p r o v i d e p r i m a r y c a r e t o a s t a b l e p o p u l a t i o n over which t h e y c o u l d
have some management c o n t r o l . I t would be e q u a l l y i m p o s s i b l e f o r
inmates t o be b r o u g h t t o t h e l o c a t i o n o f t h e AHP t o r e c e i v e c a r e .
O p t i o n # 1 : Given t h i s i n a b i l i t y t o i n t e g r a t e s e r v i c e s o r t o
g i v e t h e AHPs any r e a l c o n t r o l o f t h e t i m i n g o r substance o f c a r e
i t seems n e i t h e r f a i r n o r reasonable f o r t h e AHP t o bear t h e
a d m i n i s t r a t i v e o r t h e f i n a n c i a l burdens o f c a r e .
I t m i g h t be p o s s i b l e , i n t h e t r a n s i t i o n , t o c o n s i d e r t h e
j a i l a s i t e f o r e n r o l l i n g those persons who have n o t p r e v i o u s l y
j o i n e d a p l a n under some n o t i o n o f a P o i n t o f S e r v i c e e n r o l l m e n t .
Given t h e f a c t t h a t many inmates w i l l be unemployed and some w i l l
be homeless, t h i s might seem a t t r a c t i v e .
I t would, however, be
d i f f i c u l t t o a d m i n i s t e r , r u n c o u n t e r t o t h e focus o f t h e c r i m i n a l
j u s t i c e system and i g n o r e t h e f a c t t h a t inmates may be i n t h e
j a i l f o r a m a t t e r o f o n l y hours o r days i f t h e y can manage t o
post b a i l .
E d u c a t i n g an inmate about h e a l t h c a r e when h i s g o a l
i s b a i l and freedom i s n e i t h e r f a i r nor l i k e l y t o be e f f e c t i v e .
O p t i o n #2: T h i s might make sense a t some p o i n t i n t h e
f u t u r e b u t c e r t a i n l y n o t i n t h e t r a n s i t i o n . Some y e a r s from now,
once a l l persons a r e e n r o l l e d i n an AHP, i t might make sense t o
charge t h e AHP f o r some o f t h e c a r e p r o v i d e d by j a i l h e a l t h
s e r v i c e s , a t l e a s t those charges f o r c o n t i n u e d c a r e f o r "pree x i s t i n g problems" ( a l t h o u g h t h e mere statement o f t h e language
r a i s e s t h e s p e c t e r o f bad f a i t h and u n f a i r r e s t r i c t i o n s i n
coverage) i n t h e p e r i o d b e f o r e t h e inmate i s sentenced t o p r i s o n .
There i s another reason t o c o n s i d e r t h i s r o u t e i n t h e
future.
I t may be t h a t an AHP would reap a " w i n d f a l l " from
h a v i n g some o f i t s e n r o l l e e s i n c a r c e r a t e d .
I f an AHP had a l a r g e
number o f i n c a r c e r a t e d p a t i e n t s f o r whom i t had been p a i d a
c a p i t a t i o n and f o r whom i t had no r e s p o n s i b i l i t y , i t m i g h t be
more e q u i t a b l e t o t r a n s f e r some o f t h a t c a p i t a t i o n payment t o t h e
jail.
O p t i o n #3: T h i s o p t i o n probably makes t h e most sense g i v e n
t h e r e a l i t i e s o f c o r r e c t i o n a l h e a l t h care, t h e p l a n s f o r s i m i l a r
i n s t i t u t i o n a l p o p u l a t i o n s and t h e g e n e r a l r e q u i r e m e n t f o r t h e
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63
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000
1. -*^ iTtl CM
�B. Jaye Anno, Ph.D.
^^y"^
Bernard P. Harrison, J.D.
Consultants in Correctional
Care
A p r i l 7, 1993
Nancy N. Dubler, LL3
Department o f S o c i a l Medicine
M o n t e f i o r e H o s p i t a l & Medical Center
111 East 210th S t r e e t
Bronx, New York 10467
Dear Nancy:
C o n g r a t u l a t i o n s on your appointment t o t h e H i l l a r y
Rodham C l i n t o n t a s k f o r c e on h e a l t h care r e f o r m !
I am
p a r t i c u l a r l y pleased t h a t t h e n a t i o n ' s i n c a r c e r a t e d p o p u l a t i o n
may f i n a l l y have a v o i c e t h r o u g h you.
I b e l i e v e s t r o n g l y t h a t p r i s o n e r s should be i n c l u d e d i n
any p l a n f o r h e a l t h care r e f o r m .
Some o f t h e major issues a r e
o u t l i n e d i n t h e enclosed JAMA e d i t o r i a l .
I wish you w e l l i n your new endeavor and l o o k f o r w a r d
t o t a l k i n g w i t h you when your l i f e resumes i t s normal ( r a t h e r
than f r e n e t i c ) h e c t i c pace.
Warmest r e g a r d s ,
aye^nno
BJA/pb
Enc. JAMA e d i t o r i a l 2/3/93
54 Balsa Road Santa Fe, New Mexico 87505
Tel: (505) 986-8382 Fax: (505) 986-8312
�puters or most other goods and services because the purchaser must balance the cost against the prospective benefit.
When it comes to medical care, neither the insured patient
nor the insured patient's physician must make a similar type
of reckoning.
Improvements in efficiency, like reductions in services, will
also impose burdens on particular individuals and groups.
Every dollar spent on administration is a dollar of income to
someone, and it should come as no surprise that where one
stands on "administrative waste" depends on where one sits.
Elimination of excess capacity sounds like a tempting strategy, but in practice it requires reducing the number of hospitals that offer high-tech services and curbing the proliferation of surgical and medical specialists. Some patients would
undoubtedly be inconvenienced by the elimination of excess
capacity, either because they may have to wait for procedures
or because they may have to travel to a different hospital eleven a different city to obtain them.
The pain experienced by physicians and drug companies
when their income and profits are reduced is so obvious as to
require no elaboration. Such reductions may also have negative
effects on some patients through changes in the behavior of
physicians or in the research activities of the drug companies.
In summary, there are three good reasons why American
society would be better off if we spent less on health care and
more on other kinds of consumption and investment. But
society as a whole does not consume health care; the services
are provided to particular individuals and groups by particular individuals and organizations. A careful assessment of
the only three possible ways to contain spending shows that
if there is no pain there will be no gain.
Victor R. Fuchs
1. Aaron HJ, Schwartz WM. The Painful Prescription. Washington, DC: Brookings
Institution; 1!)H4.
2. Wnollmntilur S, Himmdstcin DU. Thu deterioniting administnit.ivo efficiuncy of
the U.S. health care system. N Engl J Med. H>!H;:i24:i:SM258.
3. US General Accounting Office. Canadian Health Insurance: lessons for the
United Status. Washington. DC: US Government IVinting Office; 1!>!M. GAO/HUDill-!)().
•1. lliispital Statistics. I'.liU Kditatu. Chicago, III: American Hospital Association;
liKll.
.». Fuchs VR. Hahn .IS. How tines Canada do it? a comparison of expenditures for
physicians' services in the United St ales and Canada. S K"(//. I Mud. IWO-.K^SRI-MWI.
r
Editorial
1
EUilUfials iopI'G ofjnl IIK-J upiiituML'. ol Uiu .'.lulhoi:;. .'.mil I ML JUUHNAL •'HHJ nol [IIOL'.G ut Ihc Amunc.'.in McUicol AoL'.ocii.iliuii
Health Care for Prisoners
How Soon Is Soon Enough?
1
The article by Keller et al addressing diabetic ketoacidosis
among recently arrested prisoners raises some disturbing issues. The authors found that 70% of the prisoners brought to
a single hospital in New York City during a 30-month period
with this life-threatening condition had not received their insulin during the period immediately following arrest. The authors are critical of the lack of on-site health personnel and
facilities at police lockups and court holding cells and suggest
that reliance on emergency departments to provide care for
arrestees is inefficient and costly. They recommend instituting
a health screening for all arrestees and providing health facilities and personnel on site for those in need of medications.
See also p 619.
These findings and recommendations parallel those of an
American Medical Association (AMA) study—except that
study was reported 20 years ago and the focus was on jails.-'
(Jails are facilities operated by local government entities—
cities and counties—to detain individuals from the point of arrest through trial. Many jails also hold persons convicted of
misdemeanors as well as felons awaiting transfers to state
prisons.) The AMA developed standards and a voluntary accreditation program. The first Hi jails were accredited under
this program in 1977.^
In the early H)80s, the program evolved into the National
From Ihe Consultanis in Correclional Care. Santa Fe. NM.
Reprint requests to Consultants m Correctional Care. 54 Balsa Rd. Santa Fe. NM
87505 (Dr Anno)
JAMA, February 3, 1993—Vol 269, No. 5
Commission on Correctional Health Care (NCCHC). It includes individuals from 3(5 professional associations (including the AMA), and accredits jails, prisons, and juvenile detention and correctional institutions. Currently, there are
more than 250 jails, more than 100 prisons, and a handful of
juvenile institutions accredited by the NCCHC. Several hundred additional institutions use these standards as the basis
for operating their health care provision systems.
Unquestionably, great strides have been made in increasing inmates' access to care and providing on-site health care
during the past 20 years, largely because of the efforts of
professional associations and the courts. What is most disturbing about the article by Keller and colleagues' is not only
that, current efforts to improve correctional health care may
be missing large numbers of inmates, but also that this information comes at a time when the gains made thus far with
jails and prisons arc seriously threatened.
Harsher sentencing practices as well as the "war on drugs"
have caused jail and prison populations to more than double
in the last decade.' Many institutions are bursting at the
seams, which has encouraged more construction of facilities
but not more health care funding. Limited correctional health
care resources must be stretched to cover not only serious
illnesses (eg, heart disease, diabetes, and hypertension) of
increasing numbers of inmates, but also infectious diseases
that are exacerbated by prison conditions, such as hepatitis,
human immunodeficiency virus infection, and tuberculosis.
Staff as well as inmates may be affected by multidrug-resistant tuberculosis.
Superimposed on these problems comes the news from
1
5
Commentary/Editorial
633
�Keller et al that while inmates in New York City do receive a
medical evaluat ion if they are sent to jail after arraignment.,
that may not be fast enough. Medical intervention may be needed immediately after arrest. Even if inmates arc held only a
matter of hours in police lockups or court holding cells before
release to the community or transfer to a jail, Keller et al suggest there should he an immediate health screening and personnel available to provide medications and referral for care.
Philosophically, this position is consistent with the mandates of the courts ' and with the requirements of NCCHC's
standards for health services in jails. Under our system of justice, these individuals are innocent until proven guilty. What
is troublesome are the cost implications and the larger question of the responsibility of the criminal justice system to provide for the health needs ol'arrestees, however brief their stay
and regardless of the availability of resources to do so.
In 1990, there were an estimated 14 195 100 arrests in the
United States." There are no estimates of how many of these
arrestees have been held in a police lockup or a court holding
cell. While the lack of adequate health facilities and personnel
in lockups and holding cells cited by Keller et al likely affects
primarily large urban centers (since smaller communities
usually have a single facility to which arrestees are brought),
these large urban centers also experience the greatest difficulties coping with overcrowding, human immunodeficiency
virus infection, and tuberculosis.
A recent article'-' suggests that chest roentgenogram screening may be more effective than purified protein derivative
skin tests at identifying active cases of tuberculosis due |o the
short stay and transient, nature of this population. 11'we really
want to halt the spread of tuberculosis, perhaps we should
institute chest roentgenogram screening in the police stations and the courts in our large urban areas. Furthermore,
a national study" in lockups and jails showed that 51'/;. of
suicides occur within the first 24 hours of incarceration and
29% within the first A hours. Should mental health staff be
'
employed around the clock in police stations and during court
hours to screen for suicides and other mental disorders?
The primary issue is that criminal justice agencies are
asked increasingly to address public health concerns and to
provide health care to large segments of the US population
with little consideration of the availability of resources. Many
jails and prisons are not sufficiently funded to address adequately the health needs of their prisoners, let. alone urban
police departments and city courts that are involved in the
holding of prisoners for only a matter of hours.
There is no quarrel with those who argue that it is the responsibility of government to care for those it incarcerates.
Correctional health professionals embrace that duty—but it is
not theirs alone. Correctional institutions are part and parcel
of the communities they serve. Many of the 14 million people
arrested annually and the more than 1.3 million Americans behind bars on any given day are part, of the uninsured and underinsured in the United States. They are the least likely to
have received preventive care or to have had access to regular
health services. The prisoners' life-style choices (tobacco use,
alcohol and other drug abuse, and multiple sexual partners) and
their socioeconomic status make them most susceptible to serious illness, debilitative conditions, and injury from violence.
Furthermore, 99% of incarcerated individuals are released
back into the community; for convicted felons, the average
length of stay is only about 2 years.
1
7
1
634
J A M A , February 3, 1993—Vol 269. No. 5
In spite of these facts, no proposals for general health care
reform explicitly include the population served by criminal
justice agencies (with the possible exception of Oregon). The
problems of access to care, adequacy of services, availability
of qualified health personnel, and escalating health care costs
also affect law enforcement and corrections agencies. These
problems may he even more pronounced for correctional health
professionals owing to the severity of need of their patients,
the constraints imposed by maintaining security, the unfair
but persistent image of their profession as second class, and
an uninformed public that chooses to incarcerate more individuals than any other country in the world but does not
allocate sufficient funds to provide the care to which the
courts have said they are constitutionally entitled.
I ronically, inmates are the only gi-oup of Americans who have
a constitutional right to health care established by the Supreme
Court (of course, other groups have legal rights to health care.)
Yet, as stated by Keller et al and others ', there are many detainees and inmates for whom the provision of adequate health
care still seems to be considered a privilege. In attempting to
extend the right to health care to all Americans, government
officials, health policymakers, and others engaged in developing proposals for health care reform must include the population served by criminal justice agencies. This position may not
be popular, but it is necessary. Detainees and inmates should
not receive better medical care than the average citizen, nor
should they receive less. Under our system of justice, those arrested are innocent until proven guilty, and even for convicted
offenders, their punishment is the deprivation of liberty and not
the withholding of needed medical care.
It is incumbent on us as a society to provide for the health
needs of prisoners precisely because they are not free to seek
care on their own. Furthermore, since criminal justice agencies are expected to serve as health care facilities, they must
be funded as such and tied to other health agencies in the
community. Isolating lockups, jails, and prisons from mainstream health resources and from each other means duplicating services for some inmates and limiting access for others. F'or health care reform to be truly efficient and effective,
we must develop a seamless approach to the provision of care.
The problems associated with providing adequate health
care to this nation's prisoners are not those of law enforceinent and coireetions alone. They are public health problems—
societal problems—and as taxpayers, citizens, and human
beings, their resolution affects us all.
1
B. Jaye Anno, PhD
1. Keller AS, Link R N . Hickell NA, Champ M H , Kalet A L , Schwartz MD. Diabetic
katoacidosis in prisoners without access to insulin. J A M A . 10i)3;26!):()l!Mi21.
2. American Medical Association Mnlicnl Cnn' iti I/N .InI/.T A / f T i ' Siirrrif. Chiea
go, 111: American Medical Association. i;t7:t.
•I. Anno ltd. The role ofnrgani/.ed medicine in cnrrectional health care. .MAM. 1!IH'2;
•Z.]~ 2!r>:l-y.\2f:.
I. Aoi,:ricari ( Allege n!' I 'hysicians. National Commission on (.'.niToetiMiiiil llealtli
< iare, and American Correctional Health Services Association. The crisis in correctional health care: the impact of the national drug control strategy on correctional
health sorvuvs. Ann I n l r n i M a l 1!I'.I2:117:71 77.
o. Sknlnick AA Son
xprrts suggest the nation's 'war on dniKS is helping tuheicnlosis stage a deadly cmchack. J A M A l!l!K;a;,S::tl77-:tl7S.
'v Monuv .!M. Duhlec N N . Rold W.I. The legal right to health care in correctional institutions. In: Anno R I . Prixnti H a i l l f i Can'.: Giiiilr.lirws for tht> MatinflfHttent 0/'an
Atlf.tjiuitc. Dnlii'c.rii Si/stem. Longmont, Colo: National Institute of Corrections
Information Center; liliM.
7. National Commission on Correctional Health Care. Staiittanh f o r Health Scr/•ifn.t in Jails. Chicago, III: National Commission on Correctional Health Care: in>:7.
K. Bureau of Justice Statistics. Soitrr.r.book of (Criminal. Justice Statistics, t'.liil.
Washington. DC: US Dept nf Justice; 1M2:4:!2.
!t. Skolnick A A. Correction facility TB rates soar: some jails hring hack chest roentgenograms. J A M A . l!);)2;2t;S::U7!i-:U7(;.
10. Hayes L. Rowan J. National Study of J a i l Smcides: Seven Years Later. Alexandria, Va: National Center on Institutions and Alternatives; 1088:3(1.
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A
I TO"ON 6S:ST 26'6
^
O 131
N
�Conractng
CM
O
How much did agencies spend on inmates per day during
1991 ? What were food and health care costs per day?
In 1 M 1 , 5 0 a g « n c i M «vM»g«d •panding * 4 a . 5 l p«r l i m u t t p w d a y .
An • v « f « 9 * o( $3.13 w u span! on lood san4c« by 44 agenciM and
$S.04 on ha ami c a r * by 44 aganctM.
1**
O
O
cn
ID
in
to
cn
cn
CE
AL
A2
AR
CA
CO
CT
C€
DC
FL
GA'
HI
D
I.
W
IA
KS
KY*
LA
M>
MN
US
MO
MT
28.06
45.00
27.76
57.36
50.36
54.94
53.87
S3^4
4020
48.90
67.90
40.76
40^0
42.06
54.03
56^2
34^3
2S.75
46 .S9
£2J9
6638
7651
2636
2S.72
3571
Food
1.46
2-86
2.64
2.75
2-52
4.08
239
3.98
2.90
1.90
7.00
2.79
4.60
3.00
1.48
ASO
2.22
1.99
3.02
2 50
1.10
2.16
1.78
1.01
HMtth
Tola I
49.10
4334
47.68
65.93
76i)1
72.36
5322
46.09
3229
36.10
47.06
49.68
89.10
3225
3239
54.00
38 52
46^6
57.69
4659
60 44
29.00
5123
5153
5439
M£
NV
NM
NJ
253
273
3.84
m
6.10
543
4.17
7.54
6.00
7.00
3.97
6.43
NV
NC
NO
OH
00
on
PA'
RI
SC
SO
2.95
6/49
nt'
1-89
TX
UT
VT
VA
WA
WV
Wl
WY
J=EO* FWt.
4J04
10.16
4.09
4.54
230
1439
2.49
'Food
'enoiei.
m aAnniatntiM <mrf>M« food «ca
Food
4.07
HuRh
6.67
3.00
4.89
4^2
265
5.12
321
238
272
4 51
2.72
5.05
255
3.45
2.70
154
230
3.32
4.49
283
3.62
351
3:78
£38
5.95
633
822
4.64
6.80
225
209
3.04
4.48
4.67
853
427
304
4.01
425
4.77
5.68
3.08
4.63
3.78
S22
4.66
HaaMi Same*
mautaa
FoodSantea
PrtMina
kmaM
6
6
1
4,507
1.302
3
1,000
4
3
1
1
PoriOa
Geofgia
ISnoo
M M M
2.115
2
42
23
T
3
26
22
8
a
86
2
Kansas
Kentucky
UMylaivd
Massachusetts'
IMinnasota)
Mteassppi
Nebraslu
Nevada
North Carolina
''North Dakota
Oregon
Pennsylvania'
South Carolina
South Dakota
Tennessee
Texas
Vfegnia
Washington
WaslVrginia
wyomiig
Fadefai System
3
16,947
5.418'
1,391
918
6.128
2.400
8.3431
550
120
150
88
689
6
2.SS2
2
1.125
3
649
56
Total
18.383
550
11
7
6
2
7
1
12
1
2
llOM
21.187
26.398
830
5,911
1.000
18.390
9.854
3.406
32.649
339
163^32
u x c n . 'Eitriv)adL 'CaAui poroon* at
'8ui)e«tadFY-«2 'Food
1
i indnct cost* tar FVBtt. *Total
l. aquipmew. ml iprln
rrml*
Avaras* Daily Coat Par Inmate
SM
Which agencies are contracting tor food and health services ?
On J w i u a r y 1,1082,16 a g a n d e a eontractad tor food aarvtcaa In 56
instlbiCkMie and 23 lor haalth aarvlcaa In 339 InetituUons.
food5»nte*
Pitaona taokau*
o
i
LU
1
—
Alabama
AhBtna
Artansas
Cobfado'
Coonecbojt
Delaware
DBLOICOI.
50
Santo*
Pitnna
30
1,324
2^59
3,450
2.008
7^85
15
6
1
9285
3,450
1*82 j
9,130
2
7
13.394
15
5
3
iaea
isaz
isaa
leaa
iseo
leet
51
�O
O
O
cn
in
On Jtanu&y 7, 7 99Z /ww many stale and federaJ inmates wen
confined in prisons, out in other programs/facHbes/agendes,
and waiting in jailstorprison admssbn?
cn
kvnatea
In Prison
cn
cr
Atabama
Alaska
Anavia
Alabama
Alaska
Arizona
Arkansas
Calttomia
Cotorado'
ConneCbaut
Delaware
D e l 0/Col.
Rorida
Gewva
Hawae
Idaho
Knots
Inrfana
Iowa
Kansas
Keniucfcy
Louisiana
Maine
Marytand
Massatftusetts
Mfcrtgan
Mmnesola
Vfesisswi
Mssour
Montana
Nebraska
Nevada
New Hampshire
Hem Jersey
NawManoo
NeM York
NarttCarafina
North D a k o *
ONo
OktalHxna
Oregon
13,142
2,427
14.115
13.894
2.432
15,286
7.385
95.642
7.342
10.573
3.717
9.716
46,533
23.644
2.444
2.056
29.115
13.008
4.527
5,774
6.110
14.508
1564
18,390
9.991
31.517
3.453
8,915
15.467
1,441
2,539
5.048
1590
18.002
3,137
57.862
19.115
534
35.446
10.694
6.494
InOtlMr
Program*
1.081
260
146
1.140
369
129
65
9.131
969
8.016
144
1,815
105
400
301
127
Innutaa
In Jaik*
1.151
52
1.401
44
37
71
168
106
2,025
325
81
2.464
74
866
5.028
2
31
822
3,426
?,35ft
12
16
296
2447
317
15,374
2687
14.313
16.443
2,oa\
49
259
711
52
205
614
467
45
251
98
2831
123
Grand
Total
404
15.464
7.709
104,773
8.3$e
18.569
3.861
11.531
46.638
26,528
2745
2257
29.115
13,719
4.579
5.979
9.790
20.003
1.611
18.672
10.911
34,348
3.S76
8.915
15511
1,478
2510
6,016
1.696
23.483
3.462
60217
1SM27
550
35,744
13,545
6.811
j PopubOon Courts
Uunatea
In Prison
(n Other
Programs
PunnsyVa/na
Rhode Island
South Carolina
South Dakota
Tenftessee
Texas
Utah
Vermoni
Virginia
Washington
West Virginia
Wisoonsr
Wyoming
Federal
22.794
2763
15.962
1,391
9288
50,5)6
2798
908
16.929
8.343
1.534
7.666
920
66.472
611
98
2,263
II
170
1.639
121
200
31
862
95
274
164
7.733
776,059
14,924
47,743
995
1
1
Total
Average
kvnatM
In Jail*
4,782
13,659
96
19
2123
267
38,959
1,855
fcjdMi&siietiMk
J
2n/9a.
Ralativw Oitfarence in Growth of Relad
CapacdjM 1 Irunaua (In Thousand*)
IZU ,
Moa»-i
600000
400000
IMS
iaea
Grand 1
Total)
23.406
2.861
18.225
1,<V02
14.240
66.814
3.015
1.127
19.083
9.205
1.916
7.960
1.084
74.205
662761
16,592
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Audley F. Connor, Jr., M.D.
Medical Staff, Jackson Park Hospital
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Vice President
Freddye M. Smith
community
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Certified Financial Planner
Waddell i Reed, Inc.
8704 South Constance Avenue
Secretary
Bill Harlan
Phone: 3)2/734-4033
Olive Harvey College
Chicago, Illinois 60617
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Fax: 312/734-5994
Assistant Treasurer
Anthony Leggett
Vienna Sausage Mfg.
ShaffdMn A. Amuwo, Ph.D.
University of Illinois at Chicago
Stanley J. Brown
Mldcon Corporation
Evelyn Byrdsong
Illinois Department of Public Aid
Kenneth Hennlngs
Sesl Chef, Inc.
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Frances Holllday, Ph.D.
Chicago Board ol Education
Rev. Darryl F. James
Messiah t St. Bartholomew
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St. Mark United Methodist Church
MelbaT. Lewis
Retired
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Chicago Board of Education
Loretta J. Martin
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Chicago Board ol Education
Dennis McCullum
Baxter Healthcare, Inc.
Dorrlstene Q. Neely
Neely Bros. Enterprises
Velma A Moman
Olive-Harvey College
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Wanda Norrls
Soft Sheen Products, Inc.
James Palmer
Executive Service Corps.
Mazle Robinson
Chicago Department on Aging
Anne Coggs Myles-Smith
Atlornev at Law
Anne C. Myles P.C. & Associates
Judy Woods
Chicago Osteopathic Hospital
i Medical Center
Executive Director
Carl C. Bell, M.D., F.A.P.A.
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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White House Health Care Task Force
Health Care Task Force
Carolyn Gatz
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2006-0885-F Segment 3
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Box 9
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56
5
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3
�May 17, 1993
MEMORANDUM FOR: BOB BOORSTIN AND IRA MAGAZINER
FROM: CAROLYN GATZ
RE: MEDIA COVERAGE OF HEALTH REFORM
Responding to Bob's request for suggestions about timing and message strategy, I
spent some time thinking about aspects of the proposal that could be highlighted during each
of the seven time periods you outlined last week. This list trails off after Phase 4/5, although
Ifront-loadedthe whole thing so much that there's enough for 7 phases:
•
Phase 1: Despite all the hunger for details of the plan
and its financing, we still need to focus on defining the
problem — lest all the coverage of the possible scale of
change frighten people into thinking we can avoid
dealing with this issue.
The message: Although the prospect of change may be
frightening, the prospect of no change is even more
frightening — unthinkable.
1.
Small business owners who pay exorbitant premiums
for their own coverage. Maybe Mrs. Clinton could go
visit some of the people who've written her letters about
this, of which there are many.
2.
We need to drum in the message that we pay for health
care countless ways in this country: We pay, we pay,
we pay — through federal taxes, through local and state
taxes, through the inability to address other problems...
"The hidden costs of health care:" States in which the
budget burden thwarts education reform (I know some
of these)....States in which the budget burden crowds
out social services...
We need to call attention to those numbers Ken Thorpe
had the other day that showed exactly how much each
of us spends for Medicaid, Medicare, etc. — We need
to send the message that we're all paying much more
than we think we are.
1
�County officials and mayors across the country could
talk about the drain on their budgets....Make the
connection between the problem of health insurance and
uncompensated care funds in communities all across the
country.
Make the connection between limits in private insurance
for mental health coverage and the need for massive
spending on public mental hospitals and the fact that
homeless mentally ill people wander the streets of our
cities.
Mrs. Clinton could go visit a hospital and talk about
how much money the uncompensated care delivered at
that institution will cost every other patient who comes
into that hospital this year.
3.
A different message: We can't overcome our economic
problems unless we address the economic drag of health
care costs...Maybe an event built around the $670 in
wages that American workers would have earned in
1991 if health insurance premiums had not increased at
the rate they did as a share of total compensation in the
1980s.
Maybe the President or First Lady could go someplace
where a labor conflict has arisen because of health
benefit cutbacks/ retiree benefit cutbacks — supposedly
the leading cause of labor-management conflict.
4.
Other possible focuses of events or story angles:
Administrative waste
Workers' compensation (waste and duplication)
People between the ages of 58 and 65 who can't get
insurance because of health problems — early retirees
not yet eligible for Medicare but on their own in the
insurance market.
An event built around the theme that any gathering of
Americans includes a bunch who are uninsurable —
including the Task Force working groups.
�An event that focuses on: Who are the uninsured? By
and large they're not people living in poverty...They're
working-class Americans, most of them employed,
people just like you and I...
An event about "coding" and other ways providers game
the system — the existence of whole hospital
departments devoted to figuring out what codes to use
on insurance claims.
Maybe we could talk some reporter into following a
nurse around in a hospital to clock how much time she
really spends taking care of people and how much she
spends on paperwork. Follow a doctor around for the
same purpose — We could tout this as replicating the
research that Ira's people did in Rhode Island.
Spend a shift in an emergency room (we have an
emergency physician from LA on our provider review
group) keeping track of how much time goes into
bureaucracy, dealing with lack of insurance, etc.
Lack of substance abuse treatment coverage — social
repercussions
Maybe we could interest somebody in writing about
major hospitals that have adopted quality management - we have the CEOs of several on our administrative
review group, including the University of Michigan
teaching hospital. They are developing what's called
"critical paths," which is a method for determining the
best course of treatment for specific diagnoses within
the hospital.
Underlying message for all these: The system's got to
change
Other issues that warrant coverage:
o Variations in practice patterns across states.
o The development of practice guidelines
o The trend toward managed care —
Message: Even if we were all sitting around
the OEOB twiddling our thumbs, in a few
years we'd all be in managed care plans —
the Clinton plan is a way for consumers to
�wrest control of where we're headed away
from the managed care bureaucrats.
o The Medicare mindset that dominates
official Washington (including Congress and
agencies) — There's every reason to believe
the federal government will stand as the last
bastion of fee-for-service medicine, the
most costly structure for health care
delivery.
o State models — Places new approaches
work — Rochester, etc.
Phase 2: Releasing pieces of the plan before the President's address.
Possible pieces include:
Malpractice reform^Altemative dispute -resohrtiem-scheme
Consumer protection under health reform
Administrative simplification^^.
<^ /QualityAssurance
~~~ ^
>j/ Fraud and abuse
Long-term Care
Treatment of Medicare under health reform
ERISA reform (and how it has stymied state efforts to
bring about reform)
Insurance reform — new protection
^
National Health Budget
Regulatory relief under health reform
Health workforce development — mix of providers,
% changes in ORE funding, etc., expanded practice latitude
for nurses.
�•
Phase 3: Release of the plan — themes of Security and Cost
Control. Built around developing familiarity with new system. See
attached memo.
•
Phases 4 and 5: Continue themes of security and cost control and
add emphasis on Quality.
A. Do an event that says hospitals won't have to spend
so much money on marketing — perhaps make fiin of
current state of hospital marketing, which involves a
very large sum of money and revolves more around
color of the wallpaper and taste of the food than
anything having to do with medical care.
Message: In the new system, hospitals won't compete
on the color of wallpaper but on quality of care, quality
issue.
B. Mental health — because the benefit is different
from conventional insurance coverage.
C. Prevention — we'll cover more — a whole new
approach to insurance coverage.
D. Reducing hassle factor for provider and consumer.
•
Phase 6: Church picnics — see attached memo
•
Phase 7: Relaunch — If a march on Washington is too big
logistically or too risky, maybe a very large gathering of people
who gain from the Clinton plan — i.e. those who do not have
health insurance, or have pre-existing conditions, or own small
businesses that offer insurance, etc. We could invite everyone
who's written a letter to the White House.
�This material m a y be protected by copyright l a w
(Title 1 7 . U.S. Code)
N.V.TIMES.05/03/93
because total spending on health care
$270 billion over five years. That monin the United States s already increas
ey is to reduce the Federal budget
ing by $100 billion a year. They say Mr. deficit, not to pay for his health-care
Clinton's plan will eventually slow the plan, which will require large amounts
increase.
of revenue beyond those already reMost of the new money — $69.5 bil- quested.
lion to $82.2 billion, not all of it from the
In a speech last week, Mr. MagaGovernment — will be needed to pro- ziner seemed to minimize the political
vide coverage for people who do not difficulty of getting Congress to raise
h f v e any health insurance, the actu- taxes.
"Often," he said, "our friends in the
aries said.
media focus their whole attention on
•The Health Care Financing Adminisi health-care reform as if what specific
tration runs Medicare and Medicaid,
piece of money might have to be raised
the programs for 67 million people who
next year to help us insure the uninare elderly or poor. The agency's chief
sured is the most important thing in
actuary, Roland E. King, and his staff
health care.
have decades of experience estimating
"We know better. We know that what
l i ^ l t h costs jmd.|Mpulatjon,tr^^
C^pttoI^Hill, th^y are respected for is really going to matter to the Ameriindependence, integrity and accuracy. can people five years from now. 10
Out some economists at other agencies years from now, is not what amount of
money was raised initially to get over
still f a v w loWer"estimates. ''
the hump of getting the uninsured in- I
Hillary Rodham Clinton, the head of
sured What's really going to matter is
the task force, said in an interview IrtSi
what happens when I go to my doctor.
week that it was "very difficult" to get
What happens when I get ill? How does
Government agencies to agree on cost
estimates or even on procedures fnr my insurance coverage look? Does it
estimating. To some extent, the dis
really protect me or not?"
agreements involve technical issues.
Businesses, households and GovernBut they could have a big political ment are listed in the documents as the
ef/ect on members of Congress, who main sources of money for Mr. Clinwill be asked to help finance Mr Clin- ton's plan, if the Federal Government
ton's plan with new taxes.
pays less, businesses and households
pay more.
Clash Between Agencies
HATCR C SS
ELHAE OT
MY B ICESD
A E NRAE
$0 BL N A YA
10 I I
LO
ER
FIGURES BEGIN T EMERGE
O
U.S. Financial Experts Estimate
Spending on 3 Proposals
Clinton Is Considering
;
:
By ROBERT PEAR
Special to The New York Times
WASHINGTON. May 2 - Government financial experts have told the
White House that President Clinton s
health-care plan may require $100 billion to $150 billion a year in new public
and private spending by Government,
business and consumers, depending on
the scope of benefits guaranteed to all
Americans.
Several Administration officials contend that those numbers are too high
and are urging the financial experts to
f^uce-.theirvestunates, So far. they
Have? refused to do so
The estimates, coming at a time
when Congress is anxious about new
taxes needed to pay for a reorganization of the health-care system, are in
confidential work papers from the
President's Task Force on National
Health Cjre Reform.
Beginning to Circulate
Financial experts have been working
on cost analyses for months, but only
recently, as the Administration's thinking has crystallized, have estimates of
overall costs begun to circulate inside
the Government. They have not been
made public before.
The financial experts, from the Federal Health Care Financing Administration, estimated the cost of three
possible packages of benefits. The least
generous would cost $99.5 billion a
year, while the most generous would
cost $150.6 billion, they said.
Not all that money would come from
the Government, but the Administration has not decided how the cost might
be divided among government, businesses and households. Nor has Mr.
Clinton decided which type of package
to propose when he unveils his plan this
month, though White House officials
have said it will be comprehensive.
Cost and Coverage Vary
The three possible benefits packages
» ould cover hospital and doctors' services and some prescription drug costs,
but they vary widely in how much of
the cost would be covered by insurance
and how much consumers would have
to pay
The manager of the task force, Ira C.
Magaziner, estimated in early February that the health program might
require $30 billion to $90 billion a year
in new spending by the Federal Government alone. The nation as a whole is
expected to spend more than $900 billion on health care this year.
While House officials say the new
estimates are subject to change because final decisions on the details of
the President's plan have not been
made. Moreover, they argue, people
should not be alarmed by the estimates
The Cost of Employers
Work piapers from the task force
Thus, under one set of assumptions
* o w - i disagreements between two
^ e h c l e s in particular. The Agency for used by the White House, American
Health .,Care Pblicy^and .Resea rch. ;'a businesses would pay $168 billion a
unit of UielUnitetf States Public Health year in health insurance premiums for
9ervice;v.6ffered lower, estimates for' employees under current law Many
"insuring'the uninsured": $42.6 billiqri* small businesses do not now provide
to'$49:3>bilIi6n a year from all sources, i health coverage, but if the Governmeni
o r i r o u g h t y M . percent of the cost corri^ required all employers to provide a
piiteti by financial experts from the' low-cost set of health benefits, spendHealth Care Financing Administration ing by employers would rise by $59
The lower estimates assume that billion, to a total of $227 billion a year,
imihsured
people
are
generally the work papers say.
If the Government required empln;. •
lieaith^, like ihsiired - workers. The
h'ighe'restimates assume that .subsian- ers 10 provide a generous set of health
tial numbers'* of the uninsured will be benefits to their workers, the emp! : .
heavy users of health care, like Medic-: ers' cost mighi rise by $87 billion :u
$255 billion a year, the documents s.r.
aidiriecipients.
Mr. Clinton has said for more than a
At (he heart of M r Clinton's pian is i
year that he wants to require employers to provide or arrange health insur- proposal to guarantee a uniform set -M
ance coverage for their workers. He health benefits for all Americans All
has said his plan will provide "the three packages would help pay for hossecurity of guaranteed access to com- ! pital and doctors' services. X-rays and
prehensive health care" for all Ameri- laboratory tests, prescription drugs
and some mental health services. Dencans.
tal care would be covered under two of
White House officials say it will rethe three plans.
duce administrative costs, curb inflaThe austere plan, as conceived by
tion in the health-care industry and
sa^e money in the long run. But signifi- the Administration, would provide
cant savings are not expected for five more extensive coverage than 20 peror TIB 'years, and Mr. Clinton wants to cent of private health insurance plans
take immediate action to provide cov- now in force. The generous plan would
e r i g e tor the 37 million people who lack provide more protection than 90 percent of the existing private plans. The
health insurance.
medium-cost proposal would provide
Kenneth E. Thorpe, the Federal offi- more coverage than half the plans now
cial j n charge of cost estimates for the in effect. Under Mr. Clinton's proposal,
task force, said the work papers were private health insurance would continprepared as part of " a conceptual exer- ue, but the Government would regulate
cise" to help Mr. Clinton understand the industry to guarantee that all
the cost of various options proposed by Americans had access to a minimum
his health-policy advisers.
set of benefits.
Work papers from the task force
In public comments over the last
show these costs for other elements of three months, Administration officials
the President's plan but do not specify have often discussed their desire to
how these costs would be divided:
guarantee comprehensive health beneflBetter coverage for families with fits. But they have generally refused to
meager health insurance could cost discuss the cost or the tax increases
$12.5 billion to $38.3 billion a year, needed to finance it, and they have
depending on the scope of benefits. In emphasized potential savings rather
many families, the head of the house- than new costs for employers or emhold has coverage from an employer, ployees.
but his or her dependents have no
When asked for an estimate of cost.
insurance.
Robert O. Boorstin, a spokesman for
^Coverage of prescription drugs for the task force, said. " I ' m not going to
Medicare beneficiaries would cost $8 talk about that one."
billion to $10.3 billion a year.
Mr Magaziner said: "There will be
•(Coverage of long-term care, in the significant savings in what we propose.
form contemplated by the White The difficulty is that those savings
House, might cost $7.7 billion to $15 mostly begin to come in a five- to 10billion a year.
year time frame. If you want to move
o Upgrading care for poor people, quickly to expand coverage, you've got
homeless people, migrant farm work-ij to spend money before that. So there is
ers and others who are "medically j a liming issue here."
underserved" would cost $1.8 billion to
$4.8 billion a vear.
|
Mr Clinton has already asked Con-;
gress for a tax increase of more than j
(
1
�This material m a y be protected by copyright l a w
(Title 17. U S Code)
'
) r
N.Y.TlMES:05'03/93
The Hearth-Care Plan: How Much Will It Cost?
Government estimates of various proposals, in billions of dollars a year. Costs would be divided
among Government, businesses and households.
EE
AUSTERE PLAN
GENEROUS PLAN
$69.5
$75.5
$82.2
12.5
22.2
38.3
Prescription drugs for
Medicare beneficiaries
8.0
9.3
10.3
Long-term care
7.7
13.8
15.0
Upgrading public health
programs for the needy
1.8
4.8
4.8
$99.5
$125.6
$150.6
Insurance for the uninsured
Improved coverage for people
with meager health insurance
Totrf
How Benefit Packages Might Look
Possible combinations of benefits. Final decisions have not been made.
'AUSTERE PLAN
MEDIUM PLAN
GENEROUS PLAN
G e n e r a l plan d e s i g n
$200
$400
$150
$300
None
Coinsurance
(patient's share of the bill)
20%
20%
$10 per encounter
Annual out-of-pocket limit
per individual
$3,000
$1,000
Overall
deductible
Individual
Family
None
Hospital MTVICM
Inpatient
$250 deductible
per admission
Outpatient
Subject to overall deductible, coinsurance
Full coverage
Surgical services
Subject to overall deductible, coinsurance
Full coverage
Physician services
Subject to overall deductible, coinsurance
$10 per encounter
X-ray and laboratory teste
Subject to overall deductible, coinsurance
$10 per encounter
Prescription drugs
$50 a year deductible
40 percent coinsurance
$7 payment for
each prescription
Mental heaMi servtces
Details undecided
Dental services
No coverage
Source. White House. Task Force
on National HeeAn Can Raform
Subject to overall
deductible, coinsurance
Full coverage
$25 a year deductible
Patient pays $10 a
$1,000 maximum
visit for preventive
annual benfit for each
services. $25 a
person. Patient pays
visit for treatment
20 percent of the bill for
prevention and treatment.
�May
10,
1993
MEMORANDUM FOR:
BOB
BOORgPTIN AND
IRA MAGAZINER
FROM: CAROLYN GATZ
RE:
PROSPECTIVE NEWS EVENT
I want to make a new p i t c h for c r e a t i n g a news event around
members of the working group t a l k i n g about t h e i r own experiences
with the h e a l t h c a r e system, i n l i g h t of the F i r s t Lady's request
for l o c a l media coverage of working group members.
The notion here i s to c r e a t e an event t h a t i l l u s t r a t e s
through r e a l people the problem of the h e a l t h c a r e system (why we
are undertaking reform) and simultaneously sends the message t h a t
the working group i s made up not j u s t of "experts" but of people
who are l i k e any other group of people -- i . e . Americans with
l o t s of personal experience with how our system doesn't work.
We could introduce the two babies born during the t a s k f o r c e
process and then have people t a l k about t h e i r own experiences.
Let me remind you of some of the p o s s i b i l i t e s I l o c a t e d :
L o i s Quam brings with h e r Y T i t t l e boy who i s
so s e v e r e l y asthmatic.
•
Jane Schadel, the r u r a l h e a l t h expert from
Iowa who had to only work on the task f o r c e
p a r t time because she couldn't r e s i g n her
p o s i t i o n because she was r e c e n t l y diagnosed
as d i a b e t i c .
Josh Wiener, whose son has a heart d e f e c t
Robyn Stone, who had a benign " c a r d i a c
episode" t h a t makes her uninsurable.
Me, who
outside
to Mrs.
similar
discovered that she's uninsurable
of a l a r g e group by reading a l e t t e r
C l i n t o n from a c i t i z e n who shares
medical conditions.
Steve Gleason, who has a chronic d i s e a s e the
name of which I cannot r e c a l l .
•
Bob B o o r s t i n
•
A woman from the mental h e a l t h group i s a
small business owner ( c o n s u l t i n g firm) who
has a c h i l d with a s e r i o u s h e a l t h problem and
has had trouble g e t t i n g insurance.
�Gatz memo/ page 2
Susan Daniels, from HHS, or Fernandes Torres,
both of whom are disabled, so they have
first-hand experience dealing with health
insurance from that perspective.
Plus however many more we think we need -- l i k e I said,
there's a million stories i n the OEOB.
�c
ITEM
Policy Publication
LIST OF MATERIALS FOR RELEASE OF PLAN
DESCRIPTION
DATE OF RELEASE
A compilation of policy papers describing in great
detail the current situation, all elements of the plan,
and likely effects of reform - written for academics
and health care policy experts.
By the end of the
summer
Legislation
For submission to Congress.
June?
The Plan
Pre-legislative language ("specs") describing the plan
and its components in relatively detailed policy
language, including changes in current laws and
regulations. For Congressional staff, health care
policy experts, etc.
Day of the President's
speech.
Reportto Congress
A 100-page document ~ similar to the OMB report
Sent to Congress the
produced for the day after the Joint Session Address morning after the
~ that outlines the current situation and the way in President's speech.
which our reform solves these problems. It will be
detailed yet written for more popular consumption - with graphs, sidebars, charts, etc.
Booklet
A 20 to 30-page document for health professionals
that write in asking for information about the plan.
Pamphlet
An 8-page document to be very widely distributed — Day of the President's
speech.
at rallies, speeches, in letters, etc.
Day of the President's
speech.
.03
Single Claim Form
To illustrate how the plan will reduce paperwork.
Event the week before
the plan's release.
�LIST OF MATERIALS FOR RELEASE OF PLAN
ITEM
DESCRIPTION
DATE OF RELEASE
Contract with the American People
A statement of principles - i.e., a covenant between
the President and the American people ~
guaranteeing affordable comprehensive care.
A preface to the Report
to Congress as well as
pamphlet and booklet.
Health Security Card
A sample card to be held up by the President during Night of the speech to
his speech to Congress.
Congress.
Talking Points: General
1-2 pages of talking points about the plan for White
House officials who are not surrogates.
Day of the President's
speech.
Talking Points: Process
1-3 pages of talking points about the Task Force,
the Tollgate Process, the President's role, etc.
Day of the President's
speech.
Talking Points for Groups: Older
Americans, Disability Community,
Veterans, Providers, Unions, SinglePayer, Rural, Business Leaders,
Children and Families, Consumers,
Labor, Indian Health, Military
An update of what we will have already prepared
for Congress - from this constituency's perspective:
the current problems, a description of the plan and
how it will solve these problems, talking points for
surrogates, and likely questions and answers.
Day of the President's
speech.
Talking Points for the States
To highlight the state/federal partnership and the
flexibility states will have in implementing these
reforms.
Day of the President's
speech.
Talking Points: Timetable
To explain which aspects of the plan will be
available by 1994, at which stage each component
will be implemented, etc.
Day of the President's
speech.
�LIST OF MATERIALS FOR RELEASE OF PLAN
ITEM
DESCRIPTION
DATE OF RELEASE
Attack and Response
For White House officials, cabinet members, and
surrogates -- outlining the likely attacks and our
responses to them.
Day of the President's
speech.
Reforms: Models, States, Foreign
To highlight the successful "real-life" application of
many of the principals that guide our proposal and
inoculate us against expected attacks.
Day of the President's
speech.
Stump Speech
For surrogates' use following the plan's release.
Day of the President's
speech.
Graphics Package for Media
To be distributed to media (print and TV) as well
Day of the President's
as made into overheads and slides for speeches. [See speech,
attached list]
A series of Op Eds from noted health care
authorities that will appear across the country
endorsing the plan.
Videos
Week after the Plan
release.
Videos with the four principals outlining the
specifics of the plan. To send to events/groups we
are unable to attend.
Week after the Plan
release.
�LIST OF MATERIALS FOR RELEASE OF PLAN
OUTLINE OF GRAPHICS PACKAGE FOR PLAN RELEASE
Costs
1.
2.
3.
4.
5.
6.
7.
What you pay now and what you will pay (for different constituencies)
Savings projections — for individuals, deficit - under our plan
U.S. costs over time
Cost comparison: U.S. vs. Other Industrialized Countries
How health care costs affect employee compensation / business profits / government spending
Projected health care costs until 2000 -- and affect on wages, budgets, economy
What happens if we do nothing - Families, Workers, U.S. businesses, Deficit
Administration
8.
Administrative Costs: U.S. vs. Other Industrialized Countries
9.
Graphic depiction of hassle factor for doctors and patients
Security/Insurance
10.
Increase in number of uninsured
11.
Middle-class uninsured
12.
Number of Americans in "job lock"
Our Plan
13.
14.
15.
16.
17.
18.
19.
20.
21.
Sample Health Security Card
List of guaranteed benefits
Comparison with "cadillac" programs today
Structure of new system
Comparison of relationships between employers, employees, health alliances, MDs in old and new systems
Sample Report Card
Single Claim Form
A Community Health Information Network (Information systems)
A Timeline for Change
Miscellaneous
22.
Declining numbers of primary care doctors
23.
Polling information
�LIST OF MATERIALS FOR RELEASE OF PLAN
April 2,1993
WHAT
WHO
COORDINATE/
WHO DO
DEADLINES
DRAFT
NOTES/COMMENTS
FINAL
Report of the President's Task Force
Paul/Caroline
All policy papers/500 pages??
Report to Congress
Paul/Caroline
100 pages/similar to OMB document
Booklet (letter response)
Bob's Shop
20-30 pages
Pamphlet (mass distribution)
Bob's Shop
8 pages
Single Claim Form
Jason/Paul
Contract with the American People
Bob/Stan G
Health Security Card
Jason/Christine
Talking Points: General
Bob's Shop/Christine
Talking Points: Process
Bob's Shop/Christine
Talking Points for Groups: Older
Americans, Disability Community,
Veterans, Providers, Unions, SinglePayer. Consumers
Bob's Shop/Christine/
Mike Lux
Model Reforms/State Reforms/
Foreign Systems
Stump Speech
Paul
Bob's Shop
Graphics Package for Media
Meeghan
Op Ed Project
Caroline
Video Scripts for Principals
Bob's Shop
�MATERIALS FOR RELEASE OF PLAN
April 2,1993
WHAT
WHO
COORDINATE/
WHO DO
DEADLINES
DRAFT
FINAL
NOTES/COMMENTS
TO PRODUCE FOR DNC
Video #1
Mandy
Video #2
Carter E
Pamphlet
Bob/Celia
Stump Speech
Bob's Shop
Graphics Package
Meeghan
Op Ed Project
Caroline
Personal testimony/Assuage fears
Technical Q & A
�BOB'S HEALTH CARE SHOP: LIST OF ASSIGNMENTS
April 2,1993
WHAT
Follow FACA lawsuit
WHO
COORDINATE/
WHO DO
DRAFT
FINAL
Meeghan
—
--
DEADLINES
NOTES/COMMENTS
Public reading room
Health Professionals Review Group
Jason
Get materials, press release, choose
release day
Interviews and Press Requests
Jason
Calendar, request form, file for each
person, record of past stories (Josh?)
Surrogate List & Scheduling
Jason
9 categories, by state (with Caroline)
National Institute of Mental Health
Bob
Budget, Personnel
Media Benefit Packages
Health Clips
Lorraine - Press
Materials List - Update
Attack and Response
Meeghan
Jason/Josh
5/3
with Linda Bergthold/Jennifer Smith
20 copies to 8 a.m.
Bob
Meeghan
Running sheet
Jason?/Meeghan?
Running sheet
Political Audit
Jason
Agenda, 4 assignments from 3/31
Hollywood Project
Julia
HealthRite video/Creative guy in CA
Ricchetti Memo on timetable
Jason
Call to remind/to Maggie today
Network TV offers/week of plan
Jason
Calendar/List
Article requests
Insurance for Task Force Members
Meeghan/
Paul & Caroline
Bob
Bob's file? NEJ/Small Business/Q&A
Talk to Kevin Thurm
|
�May 19, 1993
MEMORANDUM TO:
IRA MAGAZINER AND BOB BOORSTIN
FROM: CAROLYN GATZ
SUBJECT: ANSWERS TO QUESTIONS POSED BY G O D HOUSEKEEPING
OO
MAGAZINE
Attached I s a d r a f t o f proposed answers f o r Good
Housekeeping's "The Better Way" section f o r t h e i r August issue.
Please review f o r accuracy, c l a r i t y , focus, e t c .
Thanks
�Good Housekeeping
D r a f t : May 19, 1993
1. Under the P r e s i d e n t ' s h e a l t h care reform plan, what w i l l a
t y p i c a l h e a l t h c a r e p o l i c y cover? What w i l l not be covered?
The P r e s i d e n t ' s plan w i l l guarantee to a l l Americans the
s e c u r i t y of coverage for a comprehensive package of h e a l t h
b e n e f i t s , i n c l u d i n g the f u l l range of h o s p i t a l and p h y s i c i a n c a r e
normally included i n the best insurance p o l i c i e s .
The comprehensive b e n e f i t package w i l l emphasize primary and
preventive care, o f f e r i n g coverage for c l i n i c a l preventive
s e r v i c e s such as p e r i o d i c checkups and mammograms often not
covered i n other insurance p o l i c i e s .
The n a t i o n a l l y guaranteed b e n e f i t package a l s o w i l l provide
coverage f o r i n p a t i e n t and outpatient mental h e a l t h s e r v i c e s ,
another f e a t u r e not always provided by other p o l i c i e s .
2.
way,
For persons who a r e now insured by t h e i r employers, i n what
i f any, w i l l t h e i r coverage or b e n e f i t s change?
A l l Americans w i l l gain s e c u r i t y from the C l i n t o n plan f o r
h e a l t h reform. Americans who c u r r e n t l y have insurance w i l l know
t h a t they need never f e a r l o s i n g coverage because of a change of
jobs, l o c a t i o n or h e a l t h s t a t u s .
Americans already insured w i l l have the option of continuing
i n t h e i r c u r r e n t h e a l t h plan and with t h e i r c u r r e n t doctor i f
they want to do so. Americans who c u r r e n t l y have adequate
insurance coverage w i l l have a wider choice of h e a l t h p l a n s . I n
most c a s e s under the current system, employers o f f e r only l i m i t e d
c h o i c e s -- and often choose one plan to cover a l l employees.
Once h e a l t h reform i s implemented, most Americans w i l l have
a wider choice of plans, s e l e c t i n g the one t h a t f i t s t h e i r needs
best from among a v a r i e t y offered through a l o c a l h e a l t h
alliance.
For many Americans whose employers c u r r e n t l y provide only
minimal insurance coverage, the n a t i o n a l l y guaranteed
comprehensive b e n e f i t w i l l expand both s e c u r i t y and b e n e f i t s .
Health reform w i l l mean lower c o s t s , greater s e c u r i t y and more
e x t e n s i v e coverage f o r those Americans.
For a l l Americans, the comprehensive b e n e f i t package w i l l
cover some h e a l t h s e r v i c e s that probably a r e not provided under
r r e n t p o l i c i e s , such as preventive c l i n i c a l s e r v i c e s and mental
�health services.
3.
How w i l l persons who are not currently covered apply for
ealth insurance?
I f Americans who are not currently covered by health
^/insurance are employed, they probably w i l l receive information
'''Ijabout health a l l i a n c e s and plans from their employers. I f they
are not associated with a work place, they w i l l v i s i t the o f f i c e
of a regional health alliances to review information about health
plans offered i n their area and choose among them.
4.
Will persons be given any choice as to the ty
'care plan they will be enrolled in?
i/ujLaYes, a l l Americans w i l l choose the typ<
in which they e n r o l l . Local health alliances w i l l "offer a
variety of plans -- although how many and how they are organize
w i l l vary from one community to another -- from which consumers
w i l l choose their plan. Consumers who want to continue r e c e i v i n
care through the t r a d i t i o n a l fee-for-service system w i l l have t h
option of doing so.
^|^tr>JL Ov
1
5.
Will persons be able to remain under the care of t h e i r fj)/
current physician?
A l l Americans w i l l be able to continue receiving care froi
their current physicians. Physicians and other health providers
w i l l i ^ ^ t h e opportunity to participate i n a number of health
plans, i f they desire, and patients can follow their physician
into a p a r t i c u l a r plan. Consumers also w i l l have the opportunity
^ , to^change) <|)hysie±an or plans during'?an annual enrollment ,;per±od. /
l^t A> ^ . f c d L - c ? ^ ^ ^ ^ fv ^^^itfLU-c^ . -HHO, o^J 4* wis p tstA' £
J
6. Will ajpersoji be ablef to obtain private insurance to pay for^-,,
services not covered under his or her plan?
^<Z4^Cl
I t i s too soon to know i f a supplemental insurance market + A
w i l l develop once health reform i s implemented. Because the
guaranteed national benefit package includes a comprehensive
array of health services, a supplemental insurance market may not
develop. I f a market for supplemental benefi<ts e x i s t s , consumers
w i l l be free to purchase policies.
/
7.
Will Medicare s t i l l exist, or w i l l 1 t become part of the new
/
plan? Will there be any significant changes i n cost predelivery
for older Americans?
(LAA
^ M e d i c a r e w i l l s t i l l e x i s t , d e l i v e r i n g the 4gaa- b e n e f i t s 0
tsl5rough the~same~ providers^. Health reform w i l l p r e v i a
b^nel^tZjEKajb^will Gicpan&rM^iicare eoverage-to include
p r e s c r i p t i o n drugs.
A^J^.
x
�Health reform also will expand public funding for long-term
care services delivered at home and in the community and will set
a course for the gradual expansion of long-term care benefits.
The Clinton plan for health reform also calls for reforming the
private long-term care insurance market.to improve its quality
and reliability. ~4nfL- d A j ^ d J f r J ^
^^JtUn^tA^
8.
W i l l persons have t o pay taxes on t h e h e a l t h c a r e coverage
t h e i r own?
r
The t a x e n ^ S ^ a is make/p
t o w a r d t h e c o s t o f t h e i n s u r a n c e coverage f o r t h e compi l e n s i v e 1
b e n e f i t package w i l l remain unchanged from c u r r e n t law. Some
l i m i t may be imposed on tax-exemptions f o r spending t o purchase
a d d i t i o n a l coverage beyond t h e comprehensive b e n e f i t package, b u t
any l i m i t w i l l a f f e c t a s m a l l number o f Americans who choose t o
dS^c.
spend t h e most on h e a l t h c a r e . (???? -- t h i s i s t r i c k y -- CG) / V - ^ ^ J J .
9.
What changes w i l l t h e r e be i n t h e way c a r e i s d e l i v e r e d ?
For example, w i l l t h e r e be t r e a t m e n t p r i o r i t i e s o r r e s t r i c t i o n s ?
One o f P r e s i d e n t C l i n t o n ' s p r i m a r y g o a l s i n h e a l t h r e f o r m i s
t o e s t a b l i s h a n a t i o n a l framework t h a t w i l l c r e a t e i n c e n t i v e s f o r
h e a l t h p r o v i d e r s t o search f o r i n n o v a t i v e approaches t o
d e l i v e r i n g t h e h i g h e s t y - q p a l i t y care i n t h e mqfst cos t ^ e f f e e t i v
manner.
Many American enjplqyers, health care) institutions, (/oca^/^"—*
communities and state*"have led the way in designing new and
effective approaches to health care delivery, improving
tYi&jKLj
quality of care and controlling costs. Under health
reform/
President Clinton intends to build on that track record of
innovation, creating incentives for those ideas to spread,./ C
improving care for everyone.
(JML
Treatment p r i o r i t i e s and r e s t r i c t i o n s w i l l n o t a r i s e as
r e s u l t o f h e a l t h r e f o r m . Opponents o f change o f t e n r a i s e t h e
s p e c t e r o f h e a l t h c a r e " r a t i o n i n g " i n an a t t e m p t t o f r i g h t e n
American consumers i n t o r e j e c t i n g p r o p o s a l s f o r change. The
t r u t h i s t h a t t h e American h e a l t h c a r e system wastes so many
r e s o u r c e s on unnecessary t r e a t m e n t and bureaucracy t h a t
e l i m i n a t i n g t h o s e d r a i n s on t h e system w i l l f r e e up r e s o u r c e s t o
d e l i v e r c a r e t h a t i s needed.
10. What p r o v i s i o n s a r e b e i n g made f o r l o n g - t e r m n u r s i n g home
and at-home care?
P r e s i d e n t C l i n t o n ' s p l a n f o r h e a l t h c a r e r e f o r m makes a
comprehensive system of
s e r i o u s s t a r t toward p u t t i n g i n p l a c e
derly citizens who
l o n g - t e r m c a r e f o r America's d i s a b l e
r e q u i r e such care.i
�The President's plan emphasizes home and community-based
long-term care because most Americans prefer to remain secure i n
their homes for as long as possible. The President's plan
attempts to right the imbalance i n the current system that
inadvertently favors entering nursing homes rather
than obtaining long-term care at home or i n the community.
11. How long w i l l i t take before the national health plan i s i n
operation? What w i l l happen i n the meantime? I f people have
questions, where can they c a l l or write for information?
Fully implementing national health reform w i l l require a
number of years. The schedule for implementation cannot even
begin u n t i l Congress enacts reform, a goal that President Clinton
hopes can be accomplished this year. The President's plan c a l l s
for providing thA^gr-.^^Jty of gnarantP.eri health coverage to a l l
Americans by thgt|end^of^~the decade7^>at the l a t e s t . The length of
time required to implement tne new neaith system w i l l vary from
state to state, with some states already i n position to move ^
quickly and others further behind.
Winning passage for President Clinton's plan from the
Congress i s the f i r s t order of business, however. I t i s a
challenge on which the President w i l l require the support o
Americans interested i n health reform.
As the process of consideration i n Congress unfolds,
Americans interested i n obtaining additional information about
President Clinton's plan can c a l l or write
�May 19, 1993
MEMORANDUM TO:
IRA MAQAZINER AND BOB BOORSTIN
FROM: CAROLYN GATZ
SUBJECT: ANSWERS TO QUESTIONS POSED BY GOOOD HOUSEKEEPING
MAGAZINE
A t t a c h e d i s a d r a f t o f proposed answers f o r Good
Housekeeping's "The B e t t e r Way" s e c t i o n f o r t h e i r August i s s u e .
Please r e v i e w f o r accuracy, c l a r i t y , focus, e t c .
Thanks
�Good Housekeeping
D r a f t : May 19, 1993
1. Under the P r e s i d e n t ' s h e a l t h care reform plan, what w i l l a
t y p i c a l h e a l t h care p o l i c y cover? What w i l l not be covered?
The P r e s i d e n t ' s plan w i l l guarantee to a l l Americans the
s e c u r i t y of coverage f o r a comprehensive package of h e a l t h
b e n e f i t s , i n c l u d i n g the f u l l range of h o s p i t a l and p h y s i c i a n c a r e
normally included i n the best insurance p o l i c i e s .
The comprehensive b e n e f i t package w i l l emphasize primary and
preventive care, o f f e r i n g coverage for c l i n i c a l preventive
s e r v i c e s such as p e r i o d i c checkups and mammograms often not
covered i n other insurance p o l i c i e s .
The n a t i o n a l l y guaranteed b e n e f i t package a l s o w i l l provide
coverage f o r i n p a t i e n t and outpatient mental h e a l t h s e r v i c e s ,
another f e a t u r e not always provided by other p o l i c i e s .
2.
way,
For persons who a r e now insured by t h e i r employers, i n what
i f any, w i l l t h e i r coverage or b e n e f i t s change?
A l l Americans w i l l gain s e c u r i t y from the C l i n t o n plan f o r
h e a l t h reform. Americans who c u r r e n t l y have insurance w i l l know
t h a t they need never f e a r l o s i n g coverage because of a change of
jobs, l o c a t i o n or h e a l t h s t a t u s .
Americans already insured w i l l have the option of continuing
i n t h e i r c u r r e n t h e a l t h plan and with t h e i r c u r r e n t doctor i f
they want to do so. Americans who c u r r e n t l y have adequate
insurance coverage w i l l have a wider choice of h e a l t h p l a n s . I n
most c a s e s under the current system, employers o f f e r only l i m i t e d
c h o i c e s -- and often choose one plan to cover a l l employees.
Once h e a l t h reform i s implemented, most Americans w i l l have
a wider choice of plans, s e l e c t i n g the one that f i t s t h e i r needs
best from among a v a r i e t y offered through a l o c a l h e a l t h
alliance.
For many Americans whose employers c u r r e n t l y provide only
minimal insurance coverage, the n a t i o n a l l y guaranteed
comprehensive b e n e f i t w i l l expand both s e c u r i t y and b e n e f i t s .
Health reform w i l l mean lower c o s t s , greater s e c u r i t y and more
e x t e n s i v e coverage f o r those Americans.
For a l l Americans, the comprehensive b e n e f i t package w i l l
cover some h e a l t h s e r v i c e s that probably a r e not provided under
c u r r e n t p o l i c i e s , such as preventive c l i n i c a l s e r v i c e s and mental
health s e r v i c e s .
�3.
How w i l l persons who
h e a l t h insurance?
are not c u r r e n t l y covered apply f o r
I f Americans who are not c u r r e n t l y covered by h e a l t h
insurance are employed, they probably w i l l r e c e i v e information
about h e a l t h a l l i a n c e s and plans from t h e i r employers. I f they
are not a s s o c i a t e d with a work place, they w i l l v i s i t the o f f i c e
of a r e g i o n a l h e a l t h a l l i a n c e s to review information about h e a l t h
plans o f f e r e d i n t h e i r area and choose among them.
4.
W i l l persons be given any choice as to the type of h e a l t h
c a r e plan they w i l l be e n r o l l e d i n ?
Yes, a l l Americans w i l l choose the type of h e a l t h c a r e plan
i n which they e n r o l l . Local health a l l i a n c e s w i l l o f f e r a
v a r i e t y of plans -- although how many and how they are organized
w i l l vary from one community to another -- from which consumers
w i l l choose t h e i r plan. Consumers who want to continue r e c e i v i n g
care through the t r a d i t i o n a l f e e - f o r - s e r v i c e system w i l l have the
option of doing so.
5.
W i l l persons be able to remain under the care of t h e i r
current physician?
A l l Americans w i l l be able to continue r e c e i v i n g c a r e from
t h e i r c u r r e n t p h y s i c i a n s . P h y s i c i a n s and other h e a l t h providers
w i l l be the opportunity to p a r t i c i p a t e i n a number of h e a l t h
plans, i f they d e s i r e , and p a t i e n t s can follow t h e i r p h y s i c i a n
i n t o a p a r t i c u l a r plan. Consumers a l s o w i l l have the opportunity
to change p h y s i c i a n or plans during an annual enrollment period.
6.
W i l l a person be able to obtain p r i v a t e insurance to pay
s e r v i c e s not covered under h i s or her plan?
for
I t i s too soon to know i f a supplemental insurance market
w i l l develop once h e a l t h reform i s implemented. Because the
guaranteed n a t i o n a l b e n e f i t package includes a comprehensive
a r r a y of h e a l t h s e r v i c e s , a supplemental insurance market may not
develop. I f a market for supplemental b e n e f i t s e x i s t s , consumers
w i l l be f r e e to purchase p o l i c i e s .
7.
W i l l Medicare s t i l l e x i s t , or w i l l i t become part of the new
plan? W i l l there be any s i g n i f i c a n t changes i n c o s t or d e l i v e r y
for older Americans?
Medicare w i l l s t i l l e x i s t , d e l i v e r i n g the same b e n e f i t s
through the same providers. Health reform w i l l provide a new
b e n e f i t t h a t w i l l expand Medicare coverage to include
p r e s c r i p t i o n drugs.
Health reform a l s o w i l l expand p u b l i c funding for long-term
c a r e s e r v i c e s d e l i v e r e d at home and i n the community and w i l l s e t
a course f o r the gradual expansion of long-term c a r e b e n e f i t s .
The C l i n t o n plan for h e a l t h reform a l s o c a l l s for reforming the
�p r i v a t e l o n g - t e r m c a r e i n s u r a n c e market t o improve i t s q u a l i t y
and r e l i a b i l i t y .
8.
W i l l persons have t o pay t a x e s on t h e h e a l t h c a r e coverage
t h e y g e t from t h e i r employers o r purchase on t h e i r own?
The tax-treatment of payments employers and employees make
toward the c o s t of the insurance coverage f o r the comprehensive
b e n e f i t package w i l l remain unchanged from c u r r e n t law. Some
l i m i t may be imposed on tax-exemptions f o r spending to purchase
a d d i t i o n a l coverage beyond the comprehensive b e n e f i t package, but
any l i m i t w i l l a f f e c t a small number of Americans who choose to
spend the most on h e a l t h care. ( ? ? ? ? -- t h i s i s t r i c k y -- CG)
9.
What changes w i l l t h e r e be i n t h e way c a r e i s d e l i v e r e d ?
For example, w i l l t h e r e be t r e a t m e n t p r i o r i t i e s o r r e s t r i c t i o n s ?
One o f P r e s i d e n t C l i n t o n ' s p r i m a r y g o a l s i n h e a l t h r e f o r m i s
t o e s t a b l i s h a n a t i o n a l framework t h a t w i l l c r e a t e i n c e n t i v e s f o r
h e a l t h p r o v i d e r s t o search f o r i n n o v a t i v e approaches t o
d e l i v e r i n g t h e h i g h e s t - q u a l i t y care i n t h e most c o s t - e f f e c t i v e
manner.
Many American employers, h e a l t h c a r e i n s t i t u t i o n s , l o c a l
communities and s t a t e have l e d t h e way i n d e s i g n i n g new and
e f f e c t i v e approaches t o h e a l t h care d e l i v e r y , i m p r o v i n g t h e
q u a l i t y o f c a r e and c o n t r o l l i n g c o s t s . Under h e a l t h r e f o r m .
P r e s i d e n t C l i n t o n i n t e n d s t o b u i l d on t h a t t r a c k r e c o r d o f
i n n o v a t i o n , c r e a t i n g i n c e n t i v e s f o r those i d e a s t o spread,
i m p r o v i n g c a r e f o r everyone.
Treatment p r i o r i t i e s and r e s t r i c t i o n s w i l l n o t a r i s e as a
r e s u l t o f h e a l t h r e f o r m . Opponents o f change o f t e n r a i s e t h e
s p e c t e r o f h e a l t h c a r e " r a t i o n i n g " i n an a t t e m p t t o f r i g h t e n
American consumers i n t o r e j e c t i n g p r o p o s a l s f o r change. The
t r u t h i s t h a t t h e American h e a l t h c a r e system wastes so many
r e s o u r c e s on unnecessary t r e a t m e n t and bureaucracy t h a t
e l i m i n a t i n g t h o s e d r a i n s on t h e system w i l l f r e e up r e s o u r c e s t o
d e l i v e r c a r e t h a t i s needed.
10. What p r o v i s i o n s a r e b e i n g made f o r l o n g - t e r m n u r s i n g home
and at-home care?
P r e s i d e n t C l i n t o n ' s p l a n f o r h e a l t h c a r e r e f o r m makes a
s e r i o u s s t a r t toward p u t t i n g i n p l a c e a comprehensive system o f
l o n g - t e r m c a r e f o r America's d i s a b l e d and e l d e r l y c i t i z e n s who
r e q u i r e such c a r e .
The P r e s i d e n t ' s p l a n emphasizes home and community-based
l o n g - t e r m c a r e because most Americans p r e f e r t o remain secure i n
t h e i r homes f o r as l o n g as p o s s i b l e . The P r e s i d e n t ' s p l a n
a t t e m p t s t o r i g h t t h e imbalance i n t h e c u r r e n t system t h a t
i n a d v e r t e n t l y f a v o r s e n t e r i n g n u r s i n g homes r a t h e r
�than obtaining long-term care a t home or i n the community.
11. How long w i l l i t take before the n a t i o n a l h e a l t h plan i s i n
operation?
What w i l l happen i n the meantime? I f people have
questions, where can they c a l l or w r i t e f o r information?
F u l l y implementing n a t i o n a l h e a l t h reform w i l l r e q u i r e a
number of y e a r s . The schedule f o r implementation cannot even
begin u n t i l Congress enacts reform, a goal that P r e s i d e n t C l i n t o n
hopes can be accomplished t h i s year. The P r e s i d e n t ' s plan c a l l s
for providing the s e c u r i t y of guaranteed h e a l t h coverage t o a l l
Americans by the end of the decade, a t the l a t e s t . The length of
time r e q u i r e d to implement the new h e a l t h system w i l l vary from
s t a t e to s t a t e , with some s t a t e s already i n p o s i t i o n to move
q u i c k l y and others f u r t h e r behind.
Winning passage f o r President C l i n t o n ' s plan from the
Congress i s the f i r s t order of business, however. I t i s a
challenge on which the President w i l l r e q u i r e the support of a l l
Americans i n t e r e s t e d i n h e a l t h reform.
As the process of c o n s i d e r a t i o n i n Congress unfolds,
Americans i n t e r e s t e d i n obtaining a d d i t i o n a l information about
P r e s i d e n t C l i n t o n ' s plan can c a l l or w r i t e
�phi I Lr<L.
6
To: I r a Magaziner, Judy Feder, Carolyn Gatz
Fr: Bob B o o r s t i n , Jason Solomon
Re: Surrogates
Date: A p r i l 26, 1993
i
SURROGATE LIST
Obviously, we w i l l be using a wide range o f working group members
t o speak t o d i f f e r e n t audiences and t a l k t o d i f f e r e n t members o f
the media i n t h e weeks f o l l o w i n g t h e release o f t h e plan.
However, we need approximately 10 surrogates f o r extensive r a d i o ,
TV and p r i n t i n t e r v i e w s — as much as an hour a day f o r t h e three
weeks f o l l o w i n g t h e release o f t h e plan. These i n t e r v i e w s w i l l
supplement t h e work o f people l i k e I r a , Judy and Carol Rasco.
The surrogates were chosen based on t h e f o l l o w i n g c r i t e r i a :
1) Professional c r e d i b i l i t y , ( i . e . doctors are great)
2) Geographic d i v e r s i t y .
3) A b i l i t y t o t a l k i n English about h e a l t h care. They w i l l be
used e x t e n s i v e l y on l o c a l TV and r a d i o — i n places from Indiana
t o Arizona.
The f o l l o w i n g people are t h e people who we are considering asking
t o make t h e necessary time commitment. Please comment on t h e l i s t
and suggest possible changes.
Walter Zelman
Paul Starr
/ L o i s Quam )
v.
Dr. Risa Lavizzo-Mourey
Dr. Roz Lasker
/. Shoshana Sofaer
Denise Denton
Robyn Stone
y-* Dr. David Eddy
S a l l y Richardson
Linda Bergthold
Dr. Arnie Epstein
-Dr. Bob Berenson
7^
�To: I r a Magaziner, Judy Feder, Carolyn Gatz
Fr: Bob B o o r s t i n , Jason Solomon
Re: Surrogates
Date: A p r i l 26, 1993
SURROGATE LIST
Obviously, we w i l l be using a wide range o f working group members
t o speak t o d i f f e r e n t audiences and t a l k t o d i f f e r e n t members o f
the media i n t h e weeks f o l l o w i n g t h e release o f t h e plan.
However, we need approximately 10 surrogates f o r extensive r a d i o ,
TV and p r i n t i n t e r v i e w s — as much as an hour a day f o r t h e three
weeks f o l l o w i n g t h e release of t h e plan. These i n t e r v i e w s w i l l
supplement t h e work o f people l i k e I r a , Judy and Carol Rasco.
The surrogates were chosen based on t h e f o l l o w i n g c r i t e r i a :
1) Professional c r e d i b i l i t y , ( i . e . doctors are great)
2) Geographic d i v e r s i t y .
3) A b i l i t y t o t a l k i n English about h e a l t h care. They w i l l be
used e x t e n s i v e l y on l o c a l TV and r a d i o — i n places from Indiana
t o Arizona.
The f o l l o w i n g people are t h e people who we are considering asking
t o make t h e necessary time commitment. Please comment on t h e l i s t
and suggest possible changes.
Walter Zelman
Lois Quam
Dr. Risa Lavizzo-Mourey
Dr. Mark Smith
Dr. Roz Lasker
Shoshana Sofaer
Denise Denton
Robyn Stone
Dr. David Eddy
S a l l y Richardson
Linda Bergthold
Dr. Arnie Epstein
Dr. Bob Berenson
Paul S t a r r
�HEALTH CARE COMMUNICATIONS CALENDAR
April 16,1993
Page 1
Date
Event
Location
Person
Organizing
R: Educate Congress
M: Mental Health is cost effective
Hill
Skila
DC
John Edgell
Gn
PO:
Gn
PO:
Principal
MEG
Rationale/Message
4/27 [??]
Mental Health: Tipper
to Hill
4/26 - 4/28
Technology Fair:
Commerce Dept.
AGJ/
Sec. Brown
R:
M: Quality; low cost, broad
application
End April/
Early May
Second Task Force
Hearing: Model
Reforms
Task Force
R:
Present the successful reforms
from across the country: to highlight elements of our plan and
inoculate against attacks
M: Our plan is based in reality not
untested theories
D.C.
[Hospital?]
Meeghan/
Bob/Jennifer
Early May
Trip to Rochester/
Kodak/Xerox
BC/HRC
R:
Very successful example of many
parts of our plan
M: It works well in Rochester; costs
down, 94% insured, waste cut,
cooperation
Rochester,
NY
[Kodak
employees?]
Bob/Jason
Farly May
Meeting with Physicians
BC
R:
White House
Alan
Sunday, 5/9
MOTHER'S DAY
Form "Physicians for Health
Reform"
M: Our plan is supported by family
doctors
Groups to Include/
Public Officials
Notes:
Gn [Bemie?/Skila?]
PO: House Mental
Health Working
Group, Chafee,
Domenici
Gn Chamber of
Commerce (Alan?)
PO: D'Amato, It^fi^j ^
Moynihan, Roch. ^
Mayor
Gn AAFP, ACP,
Pediatricians,
Emergency
Physicians
PO:
HRC and Chelsea
�HEALTH CARE COMMUNICATIONS CALENDAR
April 16,1993
Page 2
Date
Event
Principal
5/6 - 5/9
National Nurses Week
BC/HRC
5/10
[Monday]
Small Business Event
[5/9 begins "Small
Business Week"]
BC/
Sec Brown/
E. Bowles
Wk of 5/10
[Wed/Thurs]
Reducing Paperwork:
Single Insurance Form
Wk of 5/10
Interview with Business
Wk of 5/10
1 Wk of 5/10
| or 5/17
R: Build up nurses; get on our side
M:
Location
White House
Alan
R:
Groups to Include/
Public Officials
Gn American Nurses
Association,
Pediatric Nurses
PO:
Notes:
Virginia Kelly to
come; nurses from
50 states; satellites
Inoculation on small business,
key constituency
M: Go to business whose insurance
got cut off, our plan guarantees it
can't happen
Mike Lux
BC
R: Appeal to MDs
M: Our plan will ease administrative
burdens of patients and doctors
so they can spend more time
together
Christine
Gn AMA, Hospital
Administrators
PO:
Stack up insurance
forms; visit
record/billing dept
of hospital, private
BC
R:
Explain our plan to [small]
business community
M: Health Care and Business
DC
Bob/Lisa
Gn
PO:
Delay?
Interview with Inc.
IraM
R:
Explain our plan to [small]
business community
M: Health Care and Business
DC
Bob/Lisa
Gn
PO:
Interview with Wall
Street Journal
Mac
R:
Explain our plan to [small]
business community
M: Health Care and Business
DC
Dwight/
Bob/Lisa
Gn
PO:
** Reno/Justice Event
Reno
R:
M:
DC
PaulB
Gn
PO:
Week
I Wk of 5/10
Rationale/Message
Person
Organizing
PO:
-—
�HEALTH CARE COMMUNICATIONS CALENDAR
April 16,1993
Page 3
Date
Event
Principal
Rationale/Message
Location
HRC/MEG/
Shalala
R: Helps with women's groups
M: Concern about women's issues/
focus on preventive care
Cannon
Caucus
Room??
BC
R: Appeal to MDs/Public
M: Cost control and less hassle for
MDs with malpractice reform;
not afraid to go against
traditional constituency
5/13
[4 - 7 p. .]
Prevention Event/
Women's Issues
Wk of 5/17
Malpractice Reform:
Speech
Wk of 5/17
Prescription Drugs:
Return to Mary Annie
and Edward Davis
BC/HRC
Wk of 5/17
Workers' Compensation
BC
May
Mental Health/Older
Americans event in
Rhode Island
MEG
R:
Older Americans and mental
health are big issues for Chafee
M: Community-based mental health
and senior programs are key to
our plan
May
Union event
BC/
Reich
R: Build labor support
M:
m
R: Older americans event
M: No longer have to choose
between drugs and food
Person
Organizing
Groups to Include/
Public Officials
Notes:
Combine with event
in Cannon Caucus?
Public? Real
people? Union
members?
Mike Lux
New Hamp/
Florida
Gn Society for
Advancement of
Women's Health
PO:
Gn
PO:
ATLA Speech?
Bob B
Gn
PO:
Lisa C
Bob
Gn Business community
- small and large
PO:
Rhode Island
Skila/
Jennifer
Gn AARP
PO: Sen. Chafee [Pell?]
White House
Mike Lux
R: Attract business support
M: Workers' comp will be reduced
(15-30%) through our plan
Gn
PO:
Go out? HOLD
�r
Date
Event
Waste/Fraud Event:
launch crackdown w/
800 number and new
criminal penalties
Latex Glove Event
(Chiles)
Principal
AGJ/Reno/
Shalala
HEALTH CARE COMMUNICATIONS CALENDAR
April 16,1993
Page 4
Rationale/Message
R:
M: part of VP's reinventing
government
Location
Person
Organizing
DC
K. Pollitz
Groups to Include/
Public Officials
Gn
PO:
R;
Demonstrate Cost Shifting/
Uncompensated care [Buyers 4Club theme?]
M: Hold up two latex gloves - 1 cost
$15 in a hospital and 1 cost 14
cents at the local Price Club
Gn
PO:
R:
M:
Gn
PO:
R:
M:
Gn
PO:
R:
M:
BC
Gn
PO:
HOLDING FOR LAUNCH OF PLAN:
Contract with the American People (Stan)
Carville Stack of Studies (Paul B: use in response to charges that we are going too fast/need to study more)
Chiles Emergency Room Event
Car event, steel company
Mandy/Lisa - Big Media - month of May - Sunday Shows - Network: launch and pre-launch
Notes:
IG problem? AG?
State & local
governments?
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Boorstin
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Carolyn Gatz
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 4
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 42
<a href="http://clinton.presidentiallibraries.us/items/show/36149" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093616" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
4/16/2015
Source
A related resource from which the described resource is derived
12093616
42-t-12093616-20060885F-Seg4-042-005-2015
-
https://clinton.presidentiallibraries.us/files/original/3a1ca1c54527490fac584e25c54d3b4d.pdf
42c952cb18d5f442fa0d4114b852926a
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Gatz, Carolyn/Klein, Jennifer
Subseries:
OA/ID Number:
5107
FolderlD:
Folder Title:
Overview of Health Reform
Stack:
Row:
Section:
Shelf:
Position:
S
56
5
5
3
�V
\
fh6
^
^'^d^thJ^^
��OVERVIEW OF HEALTH REFORM:
ALL AMERICANS ARE GUARANTEED:
•
COMPREHENSIVE BENEFITS
•
SECURITY AND PORTABILITY OF COVERAGE
•
•
CHOICE OF PLANS AND PROVIDERS
HIGH QUALITY CARE
FEDERAL GOVERNMENT WILL:
•
DEFINE BENEFITS
•
DEVELOP QUALITY, ACCESS, INSURANCE STANDARDS
•
REFORM MALPRACTICE
•
ESTABLISH FRAMEWORK FOR STATE-RUN SYSTEMS
•
SET BUDGETS
STATES WILL:
•
SET UP ALLIANCE TO REPLACE FRAGMENTED INSURANCE
MARKET
•
•
•
GUARANTEE AFFORDABLE COVERAGE THROUGHOUT STATE
ENFORCE QUALITY, ACCESS AND INSURANCE STANDARDS
ENFORCE BUDGETS
HEALTH ALLIANCES WILL:
•
ENSURE AVAILABILITY OF VARIETY OF HEALTH PLANS
•
NEGOTIATE PREMIUMS WITH HEALTH PLANS
•
MANAGE ENROLLMENT
•
PROVIDE CONSUMER EDUCATION AND PROTECTION
HEALTH PLANS WILL:
•
ACCEPT ALL APPLICANTS AT COMMUNITY RATE
•
PROVIDE GUARANTEED BENEFITS WITHIN AGREED-UPON
RATE
DETERMINED TO BE AN
ADMINISTRATiVE MAP '
INITIALS:3MiDATE:!2
4-24-W HETOEAT 1
fBTVTLBWD
fcTXBSEBB&VBBF
"^V.
^9
�ADDRESSING THE PROBLEMS: THE WORK TEAM PROPOSALS
PROBLEM
SOLUTION
LACK OF SECURITY
• ALL AMERICANS ARE INSURED
• INSURANCE CANNOT BE DENIED OR TAKEN AWAY
REGARDLESS OF HEALTH STATUS
• BENEFITS AT A COMPARABLE LEVEL CONTINUE
REGARDLESS OF EMPLOYMENT OR INCOME STATUS
• ALL AMERICANS AND THEIR EMPLOYERS PAY INTO THE
SYSTEM AT THE SAME RATE REGARDLESS OF THEIR
HEALTH STATUS
^GREATER-CHOICE OF PLANS FOR^IANY^AMERICANS
CONSUMER CONFUSION
• SIMPLE UNDERSTANDABLE BENEFITS PACKAGE
• ONE COVERAGE PACKAGE FOR A FAMILY ^
•-NO-COVERAGE BA'ITLES AMONG INSURERS
• GUARANTEED ACCESS TO PLANS
• CONSUMER COMPLAINT MECHANISM IN PLANS AND
ALLIANCE
• SIMPLE REIMBURSEMENT AND CLAIMS FORMS
• PUBLISHED QUALITY INFORMATION
4-M-M RETREAT 1
nOVILEOED A
�ADDRESSING THE PROBLEMS: THE WORK TEAM PROPOSALS (CONT'D)
PROBLEM
SOLUTION
• STANDARD REIMBURSEMENT AND ENCOUNTER FORM
PROVIDER HASSLE
• SIMPLIFICATION OF REGULATIONS
HIGH ADMINISTRATIVE COSTS
• ELIMINATION OF INSURANCE UNDERWRITING AND
MULTIPLE RISK PRODUCTS
• SIMPLIFICATION OF CLAIMS AND REIMBURSEMENT
- MOVE TOWARDS CAPITATED PAYMENT SYSTEMS
- SIMPLE UNIVERSAL CLAIMS AND REIMBURSEMENT
FORMS DRIVEN BY UNIVERSAL ENCOUNTER FORMS
• ELIMINATION OF DUAL COVERAGE AND COVERAGE
DETERMINATION PRACTICES
• SIMPLIFICATION OF PRODUCT REDUCES NEED FOR
AGENT TO ASSIST CONSUMERS
• REDUCTION IN COSTS OF SMALL GROUP
ADMINISTRATION
• REDUCTION IN REGULATORY REQUIREMENTS — FORM
FILLING
• REDUCTION IN MALPRACTICE PREMIUMS
• REDUCTION IN TIME SPENT BY PROVIDERS AND
INSURERS INVESTIGATING OR DEBATING
RE 1MB URSABILITY
•-M-W RETREAT 8
PMVIUEOED *
cam
�ADDRESSING THE PROBLEMS: THE WORK TEAM PROPOSALS (CONT'D)
PROBLEM
SOLUTION
UNNECESSARY TESTS AND
PROCEDURES
• BUDGETED/CAPITATED SYSTEMS DISCOURAGE
UNNECESSARY UTILIZATION AND INTENSITY OF SERVICE
BY PROVIDERS
• GATEKEEPERS GN HMOs OR PPOs), SOME USE OF COPAYS
IN FEE FOR SERVICE PLANS AND PRICE COMPETITION
WILL DISCOURAGE UNNECESSARY CONSUMER USAGE
• NATIONAL TECHNOLOGY ASSESSMENT AND BETTER
INFORMATION ON PRACTICE PATTERN DIFFERENCES AND
EFFECTIVENESS OF TREATMENT WILL ENHANCE COST
CONSCIOUS/HIGH QUALITY PRACTICE
• BUDGETED/CAPITATED SYSTEMS ENCOURAGE MORE
PRUDENT USE OF TECHNOLOGY AND MORE COST
EFFECTIVE CAPITAL INVESTMENT
• MALPRACTICE REFORMS WILL CUT THE COSTS OF
MALPRACTICE INSURANCE AND DEFENSIVE MEDICINE
UNDERSERVED POPULATIONS
• UNIVERSAL COVERAGE
• INCREASED INVESTMENTS IN INFRASTRUCTURE IN
POOR URBAN AND RURAL AREAS AND IN PUBLIC HEALTH
• PREVENTION OF "RED LINING" OF HEALTH ALLIANCES
• RISK ADJUSTMENT OF POOR POPULATIONS
• HEALTH ALLIANCE RESPONSIBILITY FOR BUILDING
HEALTH NETWORKS WHERE NONE EXIST
4-M-M RFTHEAT 4
PRIVILEGED it I
�ADDRESSING THE PROBLEMS: THE WORK TEAM PROPOSALS (CONT'D)
PROBLEM
SOLUTION
INADEQUATE LONG-TERM CARE
• EXPANDED OPPORTUNITIES FOR HOME CARE AS
BEGINNING OF SOCIAL INSURANCE PLAN
• RAISING MEDICAID SPEND DOWN LIMITS
• INCENTIVES/REGULATION FOR PRIVATE INSURANCE
MARKET
4-M-M RenBAT 6
PRIVILEGED *
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FRIDAY, APRIL 23,1993
THE WASHINGTON POST
A23
Charles Krauthammer
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the Jewish exp<
America, iwhy
^cafst'Why^
,:; *:such an epK
selves to P
7 - the grea
" Jew a?
. .want
may r
cam
ft
Iv
••••. V
3
;
raticxom-:„
1 of^hesel^ f
1
the^cere^, \
•impeachr^
to
filve^
hesWklu.
^ntm^sf|t
!g? W ^ ^ ^ B L
^utKwe-'donlElkJr
cW& W&™* $?'?
how'are we |oing to determme if the new system costs "
a
n
J
C0
4
tot^x^ife <4J3£**s
ca>ta
^ basis, jye are spending more or less' '
.
ion,'and * "i^ ^ M # e ^ i s - t h m M t h e sources of funding m the new
'^ystem^will tngt)ie t^s^bfuscated, it mayreality it will
expensive to & ^ v ^ i J m e r K a n , when in look more
w^Je^Sl
••eslPin-).
side of
u l
r
unveiled and i t s W s are analyzed- knowmgovhat we pay
noVfis our only hope if each American isfto honestly
evaluate this--:plah. If we-can compare costsriwe .can-ask
smart ^questions and make good decisions: .If: we cannot,;
we will be choosing blind
• •,'' v : V, T .: j
v
• In this case, the old saw is wrong: What you don't know!
can hurt you
A '. ' . .
_
The writer ts aDemocrattc senator from South Dakota.
:
;
: ;
:
�THE U.S. SPENDS FAR MORE PER PERSON THAN ANY OTHER COUNTRY
o
In 1990, the U.S. ($2,566) spent 45% more per person on health care than Canada
($1,770), the second highest country.
o
Americans spend almost 75 percent more than the French ($1,532) and Germans
($1,486), and over twice as much as the Italians ($1,236), Japanese ($1,171), and
British ($972).
o
Even taking account of its greater wealth, the U.S. spending is over $700 per capita
higher than it would be, if it were based on the average GDP-health spending
relationship found in other western industrialized countries.
o
Worse still, the gap between the U.S. and other countries has been widening over
time.
�THE U.S. SPENDS THE LARGEST SHARE OF ITS GDP ON HEALTH
o
In 1990 the U.S. spend 12.1% of its GDP on health, 59% more than the 7.6%
OECD average.
o
The next highest countries were Canada (9.3% ), France (8.8% ), Sweden (8.6% ),
Iceland (8.6% ), Austria (8.2% ), the Netherlands (8.2% ), and Germany (8.1% ).
o
The U.K. (6.2%) and Japan (6.5%) were substantially lower.
While most other OECD countries have had relatively stable shares since the erly 1980's,
the U.S. share continues to increase.
�1
I
DISCUSSION
We cannot make definitive judgements due to our inability to evaluate outcomes.
Nevertheless, there do appear to be large differences in availability, use, costs, and gross
outcomes across countries.
The United States generally differs from other countries in these respects:
1.
No single payor or set of rules affects the whole system.
2.
Other countries generally make greater use of prospectively-established global
budgets for hospitals and inpatient physician services. Ambulatory care physicians
are often paid on a salary or capitation basis.
3.
Many countries have stringent planning for both hospital capital investment and
outpatient diagnostic equipment.
4.
Some countries place far greater responsibility for thefinancingof health care at
regional and local levels.
5.
Private insurance and insurance subsidies are much less pervasive and private
insurers see themselves as secondary to the public system.
�Acute Hospital Average Length Of Stay For
Selected OECD countries
14
12 in
11.2
10.5
o
X)
10 -
in
8-
CP
7.0
6-
c
V
0)
o
Canada
(89)
France
(90)
Germany
(89)
Italy
(85)
S U C : Schleber, G J., Poullier. J. P . Greenwald, L. M,
ORE
.
.
.
" . S. Health Expenditure Performance: A International
U
n
Comparison and Data Update,"
Health Care Financing Review, S m e 1992,
umr
�. .
Inpatient Days Of Care Per Capita
for Selected OECD Countries, 1990
4. 1
I
I
.I
OECD
-----+-j..... Average
1.8
~
!
2.0
•
1.2
~~~
.....
2.6
.
�Nutnljer of Meflicfil ttetln prr 1,000 population
tor Hnh^'itMl (WV\) iMHinlricR, l J«9
f
IB
•i 1
4
I
OECO
Average
9.1
7,2
6..6
1
5
< 3f< < 2
& fi & & i
fPrQfPKc^
©^fWK3rf^
Uttfiri^
UK.
�U.S. HAS FEWER HOSPITAL BEDS, AN AVERAGE NUMBER OF PHYSICIANS,
USES LESS SERVICES PER PERSON, AND HAS THE
HIGHEST COSTS PER UNIT OF SERVICE
o
The U.S. has fewer inpatient medical care beds per capita than most other OECD
countries.
o
The U.S. has lower use rates of inpatient medical care beds than most other OECD
countries.
o
U.S. average lengths of hospital stays are the lowest of all major OECD countries.
o
U.S. costs per day, per stay and for specific medical procedures are the highest in
the world.
We appear to practice a much more intensive and costly style of medicine in the U.S.. but
we don't know if we have a sicker population, are merely inefficient, have more amenities,
and/or have a higher quality of care.
�Number of physicians per 1,000 population
41
-l
I
I
I
!
.3.0
3 :0
0
0
'
I
- 2 !t-
2."i
-----------
2.2
------------·-·
-----~-
~~-
~-2.3
~
1.6
'
"QJ
a..
1.4
1.3
1
'
L.
.
'
!
I
I
oL
Canada
(90)
France
(90)
Germany
Italy
(89)
(89)
Japan
(90)
SOURCE: Schieber. G. J .• Poull1er. J. P .. Greenwald. L. M
..
"U. S. Health Expenditure Performance: An International
Comparison and Data Update. •
Health Care Financing Review. Summer 1992.
U.K.
(89)
u.s.
(88)
- - - 1 ·.......
OECD
Average (90)
2.4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
�Volume and Intensity Explains Most of the Growth in Health Spending
3.50%-
3.00»-
1980-1990
1970-1980
VOIUBM & bitaMitjr Per Capita
H
1990-2000
Mediod Inflation in Exoew of Gcnenl Inflation Q Relative Aging of Population
D
fHEDECMPJCLWJsourceB of red growth
�Inpatient Hospital Services Today Contribute Less to Health Care Cost Growth than Physician
Services
-i
Inpatient
Hospital
Outpatient
Hospital
Other
Hospital
1
Physician
Services
1
Dental
Services
1
1
1
1
r
Other
Home
Drugs*
Durable
Nursing
Other
Professional Health Care
NonMedical
Home Care
Personal
Services
Durable
Equipment
Health Can
11970-1980 E l 1980-1990 B 1990-2000
(COSJ(LW]contrib 7040,80-90,90-00
�Administrative Costs Are Higher for Health Insurance Sold to Small Business
40% - r
mm
3 35%
I
& 30%
s
£ 25%
WM
20%
3 15%
10% - -
5% - 0%
--i
<5
Workers
5-9
10-19
20-49
50-99
101-499
5002499
25009999
>10000
Workers
Small Business Admin
�Despite Having Higher Inpatient Costs, the US has Fewer Hospital Beds Than Most Other
Countries
Canada
Franco
Germany
1977 • 1986
UK
US
�US Physicians Earn More than Physicians Elsewhere
160000
140000
120000
100000
80000
60000
Mi
Sill
•unit
ittti
Pi
40000
ft
20000
M r
Canada
Germany
i i 1975 •
UK
US
1981 • 1986
ancbttctwrtlS
�WHAT IS RIGHT WITH AMERICA'S HEALTH CARE SYSTEM?
MOST AMERICANS ARE HAPPY WITH THE QUALITY OF CARE
THEY RECEIVE FROM THEIR DOCTORS.
MOST AMERICANS HAVE ADEQUATE CHOICE OF DOCTORS
AND TYPES OF CARE (THOUGH NOT IN UNDERSERVED
AREAS).
MOST AMERICANS HAVE NEGOTIATED HEALTH CARE
BENEFITS WHICH THEY FEEL ARE ADEQUATE (THOUGH THEY
FEAR LOSING THEM).
DETERMINED TO BE AN
ADMINISTRATiVE MARKING
INITIALSi-l^-DATE^lpi/t^
�MAJOR PROBLEMS WITH TODAY'S HEALTH SYSTEM
COSTS ARE HIGH AND RISING TOO FAST — OVER 14% OF GDP
VS. LESS THAN 9 IN GERMANY AND LESS THAN 8 IN
%
%
JAPAN.
LACK OF SECURITY ~ ONE IN FOUR AMERICANS LOSES
COVERAGE EVERY TWO YEARS.
NOT USER OR PROVIDER FRIENDLY — IN SURVEYS, MOST
CONSUMERS AND PROVIDERS FIND THE SYSTEM TO BE
BUREAUCRATIC, CONFUSING AND FRUSTRATING.
MANY AMERICANS ARE UNDERSERVED — 37 MILLION LACK
COVERAGE; 22 MILLION HAVE ONLY "BARE BONES"
COVERAGE; MANY RURAL AND POOR URBAN AREAS LACK AN
ADEQUATE MEDICAL INFRASTRUCTURE.
INADEQUATE LONG-TERM CARE — AN INCREASING NUMBER
OF PEOPLE REQUIRE LONG-TERM CARE.
WHIVIUCZD* tioiirnBwnii'i n-m-i
�WHY COSTS ARE RISING IN HEALTH CARE
HIGH ADMINISTRATIVE AND TRANSACTION COSTS
•
INSURANCE UNDERWRITING AND CLAIMS
PROCEDURES
•
INEFFICIENT REIMBURSEMENT AND QUALITY
SYSTEMS
INCENTIVES FOR UNNECESSARY CARE
•
PROVIDERS PAID BY THE TEST OR PROCEDURE
ENCOURAGING MORE TESTS AND PROCEDURES TO
BE PERFORMED
•
CONSUMERS ABLE TO ACCESS THE SYSTEM AS
THEY WISH WITH FEW INCENTIVES TO LIMIT USE
TO NECESSARY OCCASIONS
•
FEW INCENTIVES TO EVALUATE NEW TECHNOLOGY USAGE AND CAPITAL INVESTMENTS FOR
COST EFFECTIVENESS
•
TO A LESSER EXTENT, DEFENSIVE MEDICINE
PRACTICED TO AVOID LAWSUITS
HMWILBGED
* miliumin n-w-i
�WHY THERE IS LACK OF SECURITY
THE ORGANIZATION OF THE U.S. INSURANCE MARKET
•
INSURANCE COMPANIES COMPETE BY RISK
SELECTION — TRYING TO INSURE ONLY THOSE
WHO ARE UNLIKELY TO BECOME ILL AND
DROPPING THOSE WHO DO BECOME ILL — IF YOU
ARE LIKELY TO NEED CARE, YOU HAVE DIFFICULTY
BEING COVERED
•
HEALTH CARE BENEFITS FOR MOST AMERICANS
(THOSE WHO ARE NOT OVER 65 YEARS OLD OR WHO
ARE NOT POOR OR SEVERELY DISABLED) ARE TIED
TO EMPLOYMENT
NOT ALL EMPLOYERS PAY TO COVER THEIR
EMPLOYEES
LOSING OR CHANGING JOBS CAN MEAN LOSS
OF COVERAGE
-
AS COSTS RISE, MORE EMPLOYERS ARE
DROPPING COVERAGE AS A COMPANY PAID
BENEFIT OR INCREASING THE EMPLOYEE
REQUIRED PAYMENTS WHICH CAUSES SOME
EMPLOYEES TO CANCEL COVERAGE
�WHY THERE IS LACK OF SECURITY (CONT'D)
AS A RESULT, 37 MILLION AMERICANS ARE
UNINSURED AND ANOTHER 22 MILLION LACK
ADEQUATE INSURANCE. MANY ADDITIONAL
AMERICANS LIVE IN FEAR OF LOSING THEIR
COVERAGE IF THEY LOSE THEIR JOB, THEIR
EMPLOYER CUTS BACK ON HEALTH CARE
PAYMENTS OR THEY OR A FAMILY MEMBER
BECOME ILL
ntrameoED * OONRBMIMM-U-W - •
�THE SYSTEM IS NOT USER OR PROVIDER FRIENDLY
THOUGH MOST AMERICANS FEEL OKAY ABOUT THE QUALITY
OF CARE THEY RECEIVE, THEY ARE FRUSTRATED BY:
•
THE COMPLEXITY OF THE CLAIMS AND
REIMBURSEMENT PROCESS
•
UNCERTAINTIES ABOUT WHAT IS OR IS NOT
COVERED IN THEIR INSURANCE POLICY
HEALTH CARE PROVIDERS ARE ALSO FRUSTRATED BY THE
BUREAUCRACY THEY MUST ENDURE AND THE MICROMANAGEMENT BY GOVERNMENT AND INSURANCE
COMPANIES OF THEIR DAILY ACTTVITIES.
•
DRG AND RBRVS REQUIREMENTS
•
MULTIPLE UTILIZATION REVIEWS
•
CLIA
•
PRO'S
•
MULTIPLE REGULATING AUTHORITIES
OtmOVILIQB) * K.miUMWMll 11-W • •
�WHY MANY AMERICANS ARE UNDERSERVED
PROVIDING COMPREHENSIVE HEALTH BENEFITS FOR
UNINSURED AND UNDERINSURED AMERICANS WILL STILL
LEAVE MANY AMERICANS WITHOUT ADEQUATE HEALTH
CARE.
•
INADEQUATE INFRASTRUCTURE— DOCTORS,
HOSPITALS, ETC. — IN MANY RURAL AND POOR
URBAN AREAS
•
POOR HEALTH EDUCATION AND INADEQUATE
PREVENTIVE SERVICES
M/PEVmOED
U U I H M I W m i l I I I I -T
�INADEQUATE LONG-TERM CARE
AN INCREASING NUMBER OF AMERICANS WILL REQUIRE
LONG-TERM CARE AT SOME TIME DURING THEIR LIVES
•
AGING OF THE POPULATION
•
INCREASING ABILITY TO MAINTAIN LIFE AFTER
SEVERE ACCIDENTS, BIRTH DEFECTS, SEVERE
ACUTE ILLNESSES
THE FAMILY IS LESS ABLE TO PROVIDE CARE AT HOME
(
•
MOBILITY OF POPULATION
•
AGING OF POPULATION MEANS CHILDREN OF OLD
ELDERLY MAY THEMSELVES BE ELDERLY
•
INCREASED PARTICIPATION OF WOMEN IN THE
WORK FORCE
•
DECLINING REAL INCOMES OF MANY FAMILIES
THE PROBLEM GROWS DRAMATICALLY IN 20-30 YEARS
DUWILBOED
* eamDBnuM-u-n - •
�4
�TOPS FORM
75<81
�To.
Data.
.Time
f.
WHBLE Y O U W S R E O U T
^ Tom eicR-e.
at.
Phone
Area Code
Extension
Number
TELEPHONED
PLEASE CALL
CALLED TO SEE YOU
WILL CALL AGAIN
WANTS TO SEE YOU
URGENT
RETURNED YOUR CALL
Message.
c
Operator
AMPAD
EFFICIENCY®
23-021 -200 SETS
23-421 -400 SETS
"7
CAR BONLESS
�04-20-1993 15:34
P.13
THE
PPBERTWCJDD
JOHNSON
FOUNDATION
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VA* /**
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Post Office Box 2316
Princeion, New Jersey 08543-2316
(609)452-8701
�04-S0-1993
P.01
15:29
(had)
convftraationt on Health«
Text and Conmentary
(copy)
w
o
fditor'0 note; In March, the foundation
hosted tour "Conversation* on Jfealth,"
at vhich pro and con puJblic comment vas
elicited on the condition of the
nation's health care system. The forums
in Tampa, Florida and Des Moines, lova
were attended hy Mrs. Hillary Aodhara
Clinton and the joeetingr in DearJborn,
Michigan and f/ashingrton, DC were
attended by Sec. ot HHS, Division of
and by Mrs. T. Gore.
The full proceedings o/ those
hearings will he availahle this summer.
This Aflyances
provides a
sampling ot the testimony, interleaved
vith commentary on the hearings and the
issues they addressed from Dr. Stephen
Schromdmr, the Foundation's president,
who chaired
the
hearings.
There are people left out, hurting,
dying, who have no place to go. I have
minimal insurance tbat does not cover m
y
••
�P.02
04-20-1993 15:29
probl*a. X'B toarad to daath.
I'M a
prof•••ional, I have tvo children and
Z'a tingle, who ia going to help «•
when I have ohaaotbarapy and have to go
home along and don't even have anybody
to pay Ay billa?
Helen* Kramer, Tampa bladder
cancer patient who is unable
to obtain health insurance
Several factors impelled us to hold
• 'i
I:
if'..:. •
»
these hearings — the most powerful
being that, for the first time in the
Foundation's history, health care reform
had moved to a position of high
r•
prominence in public debate, and a very
real prospect existed that major changes
might be eminent.
We also had polling data that
indicated there was a major discrepancy
between what the public thought was at
the root of the problem, and what the
experts thought — the kind of dichotomy
that makes i t hard to convert political
intent into good public policy.
Remember what happened with catastrophic
•til.
�04-20-1993
P. 03
15:30
health insurance several years ago.
The
experts thought that a specific type of
legislation vould benefit the elderly.
It vas proposed by the Reagan cabinet,
passed by a Democratic Congress and
instantly shouted out of existence by
the very people i t was intended to
assist.
We saw a role for the Foundation in
o
bringing to the surface the public's
perception of the real issues in health
care, in part for the benefit of the
administration's health care task force.
o
The task force at that point was an
anonymous group of academic experts
working behind closed doors. We thought
o
i t worthwhile to expose the task force
2
or, at least, i t s spokesperson,
Mrs. Clinton — to what real people
thought about these issues.
I don't like to go into town
anymore, beoause I just can't see how
I'm going to buy anything because a l l my
money i s going for health oare.
You
have to sell a oow every month to pay
for health insurance — a big one.
�04-20-1993
P. 04
15:30
Jin Kaplan, Chelsea, Iowa,
fanner
My husband and daughter are both
diabetic, whieh males a them ineligible to
obtain any other inauranoe than we have
at the present time ... This year we are
paying $0/400 in premiums. Our income
this year from our 160-acra farm was
$12,300 ... Ky ooneern is, if we had to
drop our insuranee and had to be in the
'
I., . v
hospital for any length of time, i t
would deplete our resouroes and our
farm, which has been in my husband's
family for •6 years, would be in
jeopardy.
Betty Lange, Garner, Iowa
I came away from these
Conversations with several impressions:
First, how central an issue health
care is, how deeply it touches many,
many people. And not just those we
invited to talk, but those who commented
from the audience or spoke to me at
intermissions, or who wrote the many,
•»
o
�04-20-1993 15:31
P.05
5
many letters we received after the
hearings
Health ears eeverage fer the
uninsured, childhood immuniiation and
other preventive oars, long-term
institutional oare, in-home nursing
©
ears, servioes for the chronically i l l
and disahled, prescription drugs, mental
health oare, substanoe abuse treatment,
?
ehiropraotio treatment, transportation
and other outreaoh servioes to the
disadvantaged, continuation of the
Indian Health serviee as a separate
entity, genetio research, servioes of
nurse praotitionera, physician's
assistants and physical therapists, AIDS
researoh and treatment, skilled nursing
oare, dental oare, oatastrophio illness
ooverage, hospice oare.
Partial l i s t of services
requested for inclusion under
universal health care by
1
"Conversations' participants
Secondly, we learned that the needs
and demands that people had of health
r
,
�04-20-1993
P. 06
15:31
car* ware almost inexhaustible.
Everybody was able to say what they
wanted. But how to pay for that was
less clear. We could see the dilemma
that Congress will have to face. There
is a huge public appetite for more, but
there i s a public resistance to paying
more. Somehow, Congress must reconcile
<
those two.
* - « :
>
Third, the importance of
voluntarism and the spirit of
«v • • •i
'
"• 'A <•••••
voluntarism is crucial to any current or
future system.
a
i
V.,4'
And, perhaps above a l l , we must
maintain an emphasis on need values and
caring: that came up over and over
again.
There is a real concern that, in
our quest for efficiencies, and the
tendency recently to view health care as
a business, we run the risk of turning
i t into a bloodless commodity.
I work for the Department of Health
and Rehabilitative servioes ... X deal
with a lot of poor people ... who didn't
choose to be poor. They are people who
worked hard a l l their lives, they
'.
'
•.
1
�04-20-1993 15:31
P.07
7
retire, tbey come to Florida, one of
tbea gets »ioX end they kiss their
••vings goodbye, vow they're very poor.
They era people who have to nake very
baaio ohoioea betveea food and aedioine.
They Make partial payment! on their
•0
«»*
eleotrioity every month beoauae they
have to buy their medicine ... A great
<
mieooneeption ia that xedioare buya
medioine. That'a not true.
fc i ;
Florida, social worker
What the Conversations did not do
C.
V'-i .-.
f'-'
Ruby Gackney, Sarasota,
I'..
I.
i
d
well was get at the issue of trade-offs,
which were only hinted at, but which
will be the core of the debate to come.
I think that mirrors a problem with the
political process. It's much better at
responding to groups trying to mobilize
support for something than i t is at
judging how to balance the inevitable
trade-offs and options.
Our Bodioal staff consists of two
medical doctors and tvo physician's
assistants, but 16 full-time and two
n
�04-20-1993 15:32
P. 08
8
part-tiat •mployaai. four and a half of
thaaa amployaaa do nothing but inauranoe
billing and rebilling...1 spend
approxiaataly an hour and a half a day
doing office paperwork, whioh inoludea
dictation, signing records, doing
insurance reports, billing and
rebilling.
a
Dr. Gerald Stanley, Onawa,
Iowa, family practitioner
if.l'.a;'
if.,.
<f....
W estimate that the cost of a car
e
produeed in Japan has $500 less health
oare cost in i t than a oar produced in
the U.S. And the situation gets even
worae in trying to ooapete in our own
country against German and Japanese
transplant companies. The average age
of a B W worker coming into Spartanburg,
M
South Carolina i s 15 years less than the
average age of our employees. They will
not have any retirees for probably tbe
next 20 to 30 yeara...we have
approziaately one retiree for each
aotive worker.
�04-20-1993 15:32
P.09
9
Richard O'Brien, Vice
President, corporate
personnel, General Motors
The Clinton administration i s to be
congratulated for bringing the issue of
• *.-vi
.*
YH
Si,,"-
health care reform to center stage, and
imbuing i t with a sense of urgency.
But
. ,
1
i t may have set a trap for i t s e l f by
,,
('i
,,
promising a solution to the problem
•
!
\ ,:''
this year.
The fact i s , we w i l l never
fully resolve i t . W w i l l be working on
e
1
•
•
'
1
•
1|
!
health care and trying to get i t right
forever.
I don't know any country has
1
1
i t right. Some countries have i t better
in some respects than ours.
But the
conflict between what people want and
our ability to pay for i t , given the
state of technology, may well be
irreconcilable.
Even i f our political
leaders came up with a solution that
everyone considered "right" in 1993, i t
would be inadequate to deal with
whatever situation exists in 1997.
i s a perpetually moving target.
This
.VL,
.V-
�04-20-1993
P. 10
15:33
10
M f«tfa«r-ia-Uv, at tha aga of 52,
y
had to zatiro uadar peraaaant dlaabllity
or two major heart attaeka. He brings
in a total of fio ooo per year for him
#
and his wife. Over $5/000 of that goes
Z
0
for his health ooverage. Ha lives on
$319 a months/ whioh is a disgraoe.
Something has got to be done.
Linda Snyder, Tampa witness
•ran
a
u, n
Some Republican leaders have been
highly critical of the "Conversations on
Health," accusing the Foundation of
allying itself with the Democratic
administration, i f the G P had retained
O
the White House, the Democrats would
probably be mad at us for inviting the
head of the Republican administration's
health care reform team to such
hearings.
Health care reform was destined to
be on the American agenda, regardless of
which party won last year's election,
and these Conversations flowed very
directly from the Foundation's
21-year-old mission to improve to
o
�0 4 - 2 0 - 1 9 9 3 15:33
P.11
11
improve hoalth and health oare for a l l
Amerioane.
Anything this — one-seventh of our
national budget — takes on powerful
political aspects,
so the price of
getting involved in i t i s the assumption
of some political vulnerability.
2!
But
*'
*
that risk was worth taking, because to
be inactive was to become irrelevant to
AW- '
our own mission.
I know we need change, but please
go at i t slowly and precisely.
Investigate a l l avenues. Keep asking
\*>"
^
h
^
V: " t ^
'
> "'i
a l l these questions over and over. W
e
do not need to exchange one set of
problems for another. And please, I
enoourage you, please keep government
and the politicians out of your final
plan. Their record on management i s not
one I look up to.
Bonnie Dellinger, small
business office manager in
Detroit
I greatly hope that health care
will not be framed as a partisan issue.
•_„
.O
�04-20-1993 15:33
P. 12
12
I t i s too vital, too laden with values.
Our best hope of giving this country a
system that meets its needs rests with
keeping those values always before us.
To the extent that we fragmented i t ,
make i t partisan, make i t parochial, we
endanger our hopes of an adequate
solution.
•«
V
o
�Average Annual Percent Change: Private Health Insurance Spending
Per Insured Person, and Medicare Spending Per Enrollee, 1975-98
Time Frame
P r i v a t e Insurance
1975-80
1975-85
1975-90
1975-95
1980-85
1980-90
1980-98
1985-95
1980-95
Medicare
15.96%
13.97%
12.20%
11.07%
12.02%
10.36%
NA
8.25%
9.49%
SOURCE: O f f i c e o f the Actuary, HCFA
14.72%
15.92%
NA
10.75%
11.93%
9.66%
9.17%
8.25%
9.46%
�Average Annual Percent Change: Private Health Insurance Spending
Per Insured Person, and Medicare Spending Per Enrollee, 1975-98
Time Frame
P r i v a t e Insurance
1975-80
1975-85
1975-90
1975-95
1980-85
1980-90
1980-98
1985-95
1980-95
Medicare
15.96%
13.97%
12.20%
11.07%
12.02%
10.36%
NA
8.25%
9.49%
SOURCE: O f f i c e o f the Actuary, HCFA
14.72%
15.92%
NA
10.75%
11.93%
9.66%
9.17%
8.25%
9.46%
�REPORT TO CONG
POLICY PAPERS
OP-ED/OTHER
WEEK1: 4/17
ORGANIZE/
OUTLINE/
ASSIGN/
BEGIN DRAFT
COMPILE
TOPICS/
ORGANIZE
EDITORS/
ORGANIZE STAFF
LETTER FROM
IRA/BOORSTIN
SOLICIT IDEAS
WEEK 2: 4/24
WRITE
ASSIGNMENTS
DUE 4/19,20,21
SET TENTATIVE
TOPIC LIST/
MAKE
ASSIGNMENTS
SOLICIT IDEAS
WEEK 3: 5/1
DRAFT COMPLETE
REVIEW
NEW
ASSIGNMENTS
STRATEGY FOR
DISTRIBUTION/
ARRANGE
PLACEMENTS
WEEK 4: 5/8
REWRITE
REVIEW
PAPERS DUE/
EDITING
DRAFT NEW
ENGLAND
JOURNAL/
ACCEPT
SUBMISSIONS
WEEK 5: 5/15
REWRITE/POLISH
REVIEW
EDITING
COMPLETE NEW
ENGLAND
JOURNAL/
ACCEPT
SUBMISSIONS
WEEK 6: 5/22
REVIEW
COMPLETE
EDITING
PLACE OP-EDS
WEEK 7: 5/29
PRINTING -RELEASE DATE
OF PRESIDENT'S
ADDRESS
EDITING
PLACE OP-EDS
REVIEW/REWORK
PUBLISH IN
JUNE
PLACE OP-EDS
CONTINUE
THROUGH SUMMER
WEEK 8: 5/31
j
�A p r i l 14, 1993
EDITORIAL ORGANIZATION
HEALTH CARE REFORM WORKING GROUP
FOR REPORT TO CONGRESS:
WALTER ZELLMAN
SECTION DRAFTERS:
LOIS QUAM
MARK SMITH
GARY CLAXTON
ROBYN STONE
CHRISTINE HEENAN
JENNIFER KLEIN
BERNIE ARONS/CHARMAN STEVENS
SHOSHANA SOFAER
ATUL GAWANDA
SHERRY GLEAD
ARNIE EPSTEIN/ REESA LAVISSO-MOUREY/ ROZ
LASKER
LIAISONS:
JENNIFER KLEIN
JUDY WANG
SCENARIOS:
JENNIFER KLEIN
CHRISTINE HEENAN
SIMONE RE«zSN¥BER'fc.\)£$CU&M<&V£K.
JUDY WANG
SHOSHANA SOFAER
LINDA BERGTHOLD
RESEARCHERS:
POLICY ASSISTANTS
(MEET 8 A.M. THURSDAY, APRIL 15)
POLICY COMPENDIUM:
EDITORS:
PAUL STARR
CAROLYN GATZ
ROBYN STONE
KATHY MARCONI
JENNIFER KLEIN
BILL SAGE
CHARMAN STEVENS
LYNN MARGHERIO
�A p r i l 15, 1993/P.S.
AN AMERICAN CHALLENGE
National Health Security
Report t o Congress
Rough O u t l i n e
Introductory
Letter of transmittal
C o n t r a c t w i t h t h e American people
Chapter 1. AMERICA'S ACHIEVEMENT, AMERICA'S CHALLENGE
Our achievements i n h e a l t h care
The nature of the challenge
What we cannot do
What we can do (goals of reform)
Accepting the challenge
Chapter 2. WHY WE NEED COMPREHENSIVE REFORM
The s p i r a l of c o s t s
The s p i r a l of i n s e c u r i t y
The s p i r a l of complexity
The case f o r comprehensive reform
Chapter 3. A NEW SYSTEM OF HEALTH SECURITY
Capsule d e s c r i p t i o n : how new system works
Consumers' p e r s p e c t i v e : c h o i c e s and b e n e f i t s .
Consumer h e a l t h a l l i a n c e s
New r u l e s f o r h e a l t h plans
R e s p o n s i b i l i t i e s of stand-alone employer p l a n s
How coverage would be financed:
f o r t h e employed p o p u l a t i o n
f o r t h e nonworking p o p u l a t i o n
�Cost control
State f l e x i b i l i t y i n organizing health care
Chapter 4. IMPROVING HEALTH CARE
P r i o r i t y : Quality
P r i o r i t y : Less Hassle
P r i o r i t y : Prevention and Primary Care
P r i o r i t y : Protecting Vulnerable
Chapter 5. REINVENTING REFORM
The path to a reformed system
The future of current programs
The health care devolution
Populations
�A p r i l 15, 1993/P.S.
AN AMERICAN CHALLENGE
National Health S e c u r i t y
Report t o Congress
Rough O u t l i n e
Introductory
Letter of transmittal
C o n t r a c t w i t h t h e American people
Chapter 1 . AMERICA'S ACHIEVEMENT, AMERICA'S CHALLENGE
Our achievements i n h e a l t h care
s c i e n t i f i c and t e c h n i c a l e x c e l l e n c e ;
w e a l t h o f p r o f e s s i o n a l t a l e n t , commitment;
improvement i n h e a l t h o f t h e aged and t h e
poor s i n c e Medicare and Medicaid;
c r e a t i v e a p p l i c a t i o n t o medicine o f new
technologies;
i n n o v a t i o n s i n o r g a n i z e d systems o f c a r e .
The n a t u r e o f t h e c h a l l e n g e :
( 1 ) i n s e c u r i t y - - l a c k o f r e l i a b l e coverage;
j o b l o c k ; uninsured.
( 2 ) c o s t s - - t o i n d i v i d u a l , t o economy, t o
public sector.
misuse o f r e s o u r c e s - - o v e r i n v e s t m e n t
and u n d e r u t i l i z a t i o n o f h o s p i t a l s
and t e c h n o l o g y ; b i a s toward
s p e c i a l i z a t i o n and h i g h - c o s t
procedures; inadequacies o f
p r e v e n t i v e and p r i m a r y c a r e .
(Theme: Because we m i s d i r e c t
r e s o u r c e s , we f a i l t o p r o v i d e b a s i c
s e r v i c e s Americans need.)
( 3 ) admin c o m p l e x i t y , h a s s l e , waste
C h a r t s : # u n i n s u r e d ; c o s t s — U S and
abroad; d e c l i n i n g p r i m a r y care
docs.
Sidebar: t h e p u b l i c ' s view o f
problems i n h e a l t h c a r e .
Sum up: o u r i n s u r a n c e system no l o n g e r p r o v i d e s t h e
�s e c u r i t y t h a t i n s u r a n c e i s supposed t o r e p r e s e n t . The
h e a l t h c a r e system, w i t h a l l i t s achievements, has a
m i x t u r e o f w a s t e f u l excess and gaping i n a d e q u a c i e s .
Sidebar: The e t h i c a l b a s i s o f
h e a l t h care reform
What we cannot do: o f f e r everyone h e a l t h c a r e f o r f r e e
(we can make i t a f f o r d a b l e , b u t n o t f r e e ) ; r e s o l v e many
o f t h e p r o f o u n d e t h i c a l q u e s t i o n s about modern m e d i c i n e
(we b e l i e v e those should be l e f t t o i n d i v i d u a l s ) ;
d e c i d e what s t y l e o r t y p e o f h e a l t h c a r e i s t h e b e s t
( a g a i n , Americans should have t h e r i g h t t o make t h o s e
decisions).
What we can do ( c a p s u l e statement o f o b j e c t i v e s ) :
p r o v i d e f o r s e c u r i t y from r u i n o u s c o s t s ;
c r e a t e a framework f o r a r a t i o n a l system
a wide range o f c h o i c e and f l e x i b i l i t y ;
with
enable Americans t o g e t b e t t e r v a l u e f o r
t h e i r h e a l t h care d o l l a r s ;
p r o t e c t t h e i n t e r e s t s o f t h e most v u l n e r a b l e
among us.
For 12 y e a r s , t h e problems have grown worse, t h e
i n a t t e n t i o n o f n a t i o n a l l e a d e r s h i p ever more c o s t l y .
T h i s a d m i n i s t r a t i o n now accepts t h e burden o f
r e s p o n s i b i l i t y . The p u b l i c wants r e f o r m . N a t i o n a l
l e a d e r s h i p groups, i n c l u d i n g those o f t h e h e a l t h c a r e
i n d u s t r y , accept t h e need f o r fundamental change. We
must now g a l v a n i z e t h a t consensus around t h e
fundamental need f o r change and make i t t h e b a s i s o f a
new e r a f o r h e a l t h c a r e .
Chapter 2. WHY WE NEED COMPREHENSIVE REFORM
[Note: T h i s c h a p t e r a m p l i f i e s and develops t h e themes
announced i n Chapter 1 . I t e x p l a i n s how t h e t h r e e c o r e
problems ( c o s t s , i n s e c u r i t y , c o m p l e x i t y ) developed and
why r e f o r m must be comprehensive r a t h e r t h a n piecemeal
or i n c r e m e n t a l . ]
.
The s p i r a l of c o s t s
How growing h e a l t h c a r e c o s t s have a f f e c t e d
r e a l employee compensation; p r o f i t s ; f e d e r a l ,
s t a t e , and l o c a l budgets.
Concrete meaning t o f a m i l i e s (examples)
P r o j e c t i o n s f o r t h e 9 0 s — i m p a c t on wages,
economy, budgets.
�C h a r t s ; r e c e n t growth and
p r o j e c t i o n s i n t o t h e 90s.
What w i l l happen i f we don't do a n y t h i n g :
W i t h o u t r e f o r m , t h e a b i l i t y even t o s u s t a i n
e x i s t i n g l e v e l s o f coverage w i l l be i n
jeopardy.
The
s p i r a l of i n s e c u r i t y
How t h e h e a l t h i n s u r a n c e market became
segmented by r i s k - - t h e d e c l i n e o f community
r a t i n g , emergence o f r e d l i n i n g and p r e e x i s t i n g c o n d i t i o n clauses, d e v a s t a t i n g r a t e s
f o r s m a l l business, u n i n s u r a b l e i n d i v i d u a l s ,
e t c . , and r i s i n g numbers o f u n i n s u r e d .
Sidebars
S t o r i e s about i n d i v i d u a l s and s m a l l
b u s i n e s s e s — p e r h a p s from l e t t e r s t o
the task force.
The
s p i r a l of complexity
Growth o f a d m i n i s t r a t i v e burdens i n system-why a d m i n i s t r a t i v e c o s t s a r e so much g r e a t e r
i n U.S. t h a n i n o t h e r c o u n t r i e s .
The impact on d o c t o r s , nurses, and o t h e r
providers—frustration of professional
i n i t i a t i v e ; d e p e r s o n a l i z a t i o n o f c a r e ; sheer
loss o f time.
Sidebar: examples o f u n p r o d u c t i v e
hassle.
Problems o f m a l p r a c t i c e
litigation.
The consumers' p e r s p e c t i v e : c o p i n g w i t h
b i l l s , c l a i m s forms, i n s u r a n c e c o n t r a c t s .
The case f o r comprehensive reform:
Merely adding t o e x i s t i n g system c o u l d
compound problems o f c o s t and c o m p l e x i t y .
Merely c u t t i n g p u b l i c programs would s h i f t
c o s t s t o t h e b e n e f i c i a r i e s and t o t h e
p r i v a t e l y insured, thereby i n c r e a s i n g
i n s e c u r i t y among b e n e f i c i a r i e s and
a g g r a v a t i n g problems i n t h e p r i v a t e s e c t o r .
Some suggest t h a t t h e r i s i n g h e a l t h c o s t s may
n o t be so u r g e n t a problem. A f t e r a l l , we
don't worry about r i s i n g spending f o r f a s t
�food.
But h e a l t h spending i s d i f f e r e n t : most c o s t s
t a k e n o u t o f paychecks b e f o r e people e v e r see
t h e money. They can't c u t down c o s t s on t h e i r
own. And when t h e y ' r e s i c k & i n h o s p i t a l ,
i t ' s also largely out of t h e i r control. At
t h a t point, everyone—the doctor, t h e
h o s p i t a l , and t h e p a t i e n t - - i s drawing on an
i n s u r a n c e f u n d , i n e f f e c t spending o t h e r
people's money.
A genuine s o l u t i o n has t o i n t r o d u c e a b r a k e
on c o s t s as much i n t h e p r i v a t e s e c t o r as f o r
government, i f Americans a r e t o have a system
o f coverage t h a t ' s secure, a f f o r d a b l e , and
understandable. But t h a t brake must n o t b l o c k
improvements i n q u a l i t y and i n n o v a t i o n s i n
s c i e n c e , n o r r e s t r i c t Americans from choosing
t h e s t y l e o f h e a l t h care t h e y want. Can
c h o i c e be combined w i t h i n n o v a t i o n and
g r e a t e r consciousness and c o n t r o l o f c o s t s ?
We t h i n k i t can.
Chapter 3. A NEW SYSTEM OF HEALTH SECURITY
Opening capsule d e s c r i p t i o n : how new system works and
w i l l achieve s e c u r i t y , assure access, c o n t r o l c o s t s
Consumers' p e r s p e c t i v e : how people w i l l o b t a i n h e a l t h
s e c u r i t y c a r d ; what choices t h e y w i l l have; what
b e n e f i t s t h e y w i l l be guaranteed.
I l l u s t r a t i o n s : sample c a r d .
Sidebar
L i s t o f guaranteed b e n e f i t s
Consumer h e a l t h a l l i a n c e s : b a s i c concept,
work.
how t h e y
will
New r u l e s f o r h e a l t h p l a n s : open e n r o l l m e n t , community
r a t i n g , no pre-ex e x c l u s i o n s , no r e d l i n i n g , e t c .
R e s p o n s i b i l i t i e s of stand-alone employer plans
How coverage would be financed:
f o r t h e employed p o p u l a t i o n
f o r t h e nonworking p o p u l a t i o n
I l l u s t r a t i o n s : (1) structure of
h e a l t h a l l i a n c e s , showing f l o w o f
funds from employers, employees,
g o v t . , t o t h e a l l i a n c e s and h e a l t h
plans.
�(2) comparison o f r o l e s o f
employers, employees, aHrionooa,
and h e a l t h plans i n o l d and new^
systems.
[Note: Depending on decisions, there could be
a discussion o f long-term care and Medicare
here.]
Cost control
[short-term measures]
the concept o f a global budget
t o o l s a v a i l a b l e t o the s t a t e s t o enforce the budget
State f l e x i b i l i t y i n organizing health care
Single-payer o p t i o n
Other decisions facing the s t a t e s
how t o set up and govern a l l i a n c e s
how t o achieve budgets
Chapter 4. IMPROVING HEALTH CARE
P r i o r i t y : Quality
Why q u a l i t y improvement i s c e n t r a l t o reform
The o l d regulatory model o f q u a l i t y c o n t r o l :
formal c e r t i f i c a t i o n , minimum standards f o r
process, u t i l i z a t i o n review, l i t t l e focus on
outcomes.
The new concepts o f a c c o u n t a b i l i t y — r e p o r t
cards, benchmarking, TQM.
Sidebar: a sample report card.
Other elements i n q u a l i t y
assurance.
Provider-patient r e l a t i o n s h i p s — c l e a r i n g away
b a r r i e r s t o good care.
P r i o r i t y : Less Hassle
malpractice reform
administrative simplification
Illustrations:
the
uniform claim form,
i n f o r m a t i o n system o f the f u t u r e
�I l l u s t r a t i o n : a community
i n f o r m a t i o n network
health
P r i o r i t y : Prevention and Primary Care
coverage o f p r e v e n t i v e
services
p r i m a r y c a r e i n t h e new system
Sidebar: mental h e a l t h
services
new p o l i c i e s f o r p r o f e s s i o n a l e d u c a t i o n
expanding n o n - p h y s i c i a n p r o v i d e r s '
scope o f p r a c t i c e
P r i o r i t y : P r o t e c t i n g Vulnerable Populations
how t h e new system addresses t h e needs o f t h e
underserved: r e s p o n s i b i l i t i e s o f t h e h e a l t h
alliances; special allocations f o r
i n f r a s t r u c t u r e ; expansion o f N a t i o n a l H e a l t h
S e r v i c e Corps; e t c .
s p e c i a l needs o f h i g h - c o s t and c h r o n i c a l l y
i l l patients
S i d e b a r s : AIDS
Persons w i t h d i s a b i l i t i e s
TB?
Chapter 5. THE WAYS AND MEANS OF CHANGE
The path t o a reformed
system
Where we can achieve economies--elements o f
a d m i n i s t r a t i v e and c l i n i c a l s a v i n g s .
C h a r t s : Savings p r o j e c t i o n s .
How we can expand c o v e r a g e — c o s t s ; t i m i n g ;
the r o l e of the states.
Sidebar: A t i m e l i n e f o r change.
The f u t u r e of c u r r e n t programs
I n t e g r a t i o n o f Medicaid
Medicare (???)
Long-term c a r e
�VA
DOD
Indian Health Service
Federal Employees Health Benefit Plan
^—Chapter 6. REINVENTING REFORM
Reform through devolution
This approach proposes t h a t t h e f e d e r a l govt
set broad guidelines; states be given t h e
leeway t o carry out the program i n d i f f e r e n t
ways; the p r i v a t e sector provide t h e care;
consumers have chance t o choose.
A d i v e r s i t y of solutions i s l i k e l y — a n
opportunity f o r experiment, adaptation, midcourse c o r r e c t i o n s .
Thus, while guaranteeing i n d i v i d u a l h e a l t h
s e c u r i t y and i n s i s t i n g on o v e r a l l spending
l i m i t s , fed govt i s not mandating how s t a t e s ,
h e a l t h a l l i a n c e s , and consumers choose t o
carry out those o b j e c t i v e s .
Rather, we are o f f e r i n g a framework f o r
devolving change downward--on t h e s t a t e s ,
h e a l t h a l l i a n c e s , health plans, and
u l t i m a t e l y i n d i v i d u a l consumers and
providers.
Even f o r f e d e r a l government (e.g., VA) reform
should devolve decisions on lower l e v e l s ,
reducing c e n t r a l c o n t r o l .
The concept o f reform: a strategy f o r
empowering consumers and f r o n t - l i n e
providers. I t o f f e r s s e c u r i t y ; i t imposes
responsibility—that i s , responsibility to
make choices.
V
�APPENDIX
How the plan evolved
consultation process
involvement of congressional and state and l o c a l
government staff
L i s t of working group members
�Report t o Congress
Sidebars, C h a r t s , and
Illustrations
Chapter 1 .
Charts:
# uninsured
(Ken)
c o s t s — U S and abroad
(George S c h i e b e r )
d e c l i n i n g p r i m a r y c a r e docs ( F i t z h u g h M u l l a n , Steve Schroeder)
Sidebars
t h e p u b l i c ' s view o f problems i n h e a l t h c a r e
(Stan?)
The e t h i c a l b a s i s o f h e a l t h c a r e r e f o r m ( e t h i c s
group)
Chapter 2.
Charts
r e c e n t g r o w t h i n c o s t s and p r o j e c t i o n s i n t o t h e 90s
o r Randy L u t t e r )
(Len N i c h o l s
Sidebars
S t o r i e s about i n d i v i d u a l s and s m a l l b u s i n e s s e s — p e r h a p s
l e t t e r s t o t h e t a s k f o r c e (Steve E d e l s t e i n ) .
Examples o f u n p r o d u c t i v e h a s s l e (LiyiTit^glLJi^Bwa^^^ I r w i n
from
Redlener)
Chapter 3.
Illustrations
sample c a r d
(???)
u n i f o r m e n r o l l m e n t form (Tim H i l l , Shoshana S o f a e r )
s t r u c t u r e o f h e a l t h a l l i a n c e s , showing f l o w o f funds from
employers, employees, g o v t . , t o t h e a l l i a n c e s and h e a l t h p l a n s
( W a l t e r Zelman & h e l p e r s ) .
comparison o f r o l e s o f employers, employees, a l l i a n c e s , and
h e a l t h p l a n s i n o l d and new systems (words done; needs g r a p h i c
design c o n s u l t )
�Sidebar
L i s t of guaranteed b e n e f i t s (Linda Bergthold & b e n e f i t s group)
Chapter 4.
Sidebar
a sample r e p o r t card (Arnie Epstein)
mental h e a l t h services (Bernie)
C k* r
* n -^/^-t«^
AIDs (Mark Smith)
Illustrations
uniform claim form (Tim H i l l )
a community h e a l t h information network (Mark S i l v a )
Chapter 5.
Charts
Savings p r o j e c t i o n s (Rick Kronick)
Sidebar
A t i m e l i n e f o r change (Lois Quam, post-decisions)
�The Vice President of the United S t a t e s
Address to the American Medical A s s o c i a t i o n
March 24, 1993
I'M DELIGHTED TO BE WITH YOU TODAY.
THE FIRST LADY REGRETS VERY MUCH THAT HER FATHER'S ILLNESS
PROHIBITS HER FROM BEING HERE WITH YOU TODAY.
I KNOW YOU JOIN ME
IN WISHING HER WELL.
IN THE LAST SEVERAL WEEKS NO ONE HAS WORKED HARDER THAN SHE
TO IMPROVE HEALTH CARE IN AMERICA.
SHE HAS REACHED OUT TO SO
MANY WITH HER CARING HEART AND SHARP MIND TO HELP US SHAPE NEW
AND BETTER POLICIES, AND WE ARE IN HER DEBT.
IN OUR CAMPAIGN AND IN THE FIRST WEEKS OF OUR ADMINISTRATION
WE HAVE FOCUSED MOST INTENSELY ON THE TWO ISSUES THAT THE
AMERICAN PEOPLE ARE MOST CONCERNED ABOUT: RESTORING OUR ECONOMY
TO LONG-TERM HEALTH AND RESTORING OUR HEALTH CARE SYSTEM TO WELLBEING.
DURING MY ENTIRE CAREER, BUT ESPECIALLY IN THE LAST YEAR,
I'VE
TALKED TO THOUSANDS OF PEOPLE ABOUT HEALTH CARE AND, AS
VICE-PRESIDENT, HAVE SAT IN OUR CABINET MEETINGS AND VISITED AT
LENGTH WITH THE PRESIDENT AS WE COLLECTIVELY TRY TO COME TO GRIPS
WITH THE ENORMOUS HEALTH CARE PROBLEMS.
BUT I BELIEVE WE CAN DO I T .
�IN FACT, I BELIEVE WE ARE ON THE BRINK OF AN HISTORIC MOMENT
—
THAT WE ARE ABOUT TO DELIVER THE CHANGE THAT AMERICAN PEOPLE
VOTED FOR IN NOVEMBER, AND FUNDAMENTALLY REFORM THE HEALTH CARE
SYSTEM IN AMERICA.
ON JANUARY TWENTY-FIRST, THE PRESIDENT ASKED THE FIRST LADY
TO CHAIR THE TASK FORCE ON NATIONAL HEALTH CARE REFORM.
AND THE
PRESIDENT CHALLENGED THEM TO WORK EXTREMELY HARD TO SEEK OUT THE
VERY BEST ADVICE, TO REACH OUT, AND TO HEAR ALL SIDES, AND TO
PREPARE COMPREHENSIVE LEGISLATION THAT THE PRESIDENT CAN SUBMIT
TO CONGRESS THIS SPRING.
ALL TOLD, 500 PEOPLE SERVING ON 3 0 WORKING GROUPS, AND
INCLUDING MORE THAN 60 PHYSICIANS, HAVE HAD HUNDREDS OF MEETINGS,
AND LISTENED CAREFULLY TO LITERALLY THOUSANDS OF EXPERTS AND
CONCERNED MEN AND WOMEN ACROSS THE NATION.
WE ARE STILL IN THE FACT-FINDING STAGE, AND TRYING TO BUILD
ON THE GOOD WORK OF SO MANY OTHERS.
HOW DIFFICULT THIS I S —
NOBODY KNOWS BETTER THAN YOU
BUT THE TASK FORCE I S DEADLY SERIOUS
ABOUT MEETING ITS DEADLINE AND DELIVERING TO THE PRESIDENT THE
FULL SET OF OPTIONS HE NEEDS TO WRITE AND PASS HEALTH CARE REFORM
THIS YEAR.
I T HASN'T BEEN A PERFECT PROCESS, BUT I T I S A VERY
GOOD ONE GIVEN THE SIZE OF THE TASK, THE SHORTNESS OF THE TIME,
AND THE ABSOLUTE IMPORTANCE OF ACHIEVING COST CONTAINMENT AND
OTHER BASIC REFORMS NOW.
�BUT MY PURPOSE TODAY I S NOT TO DESCRIBE OUR PROCESS.
MOST
OF YOU READ THE PAPERS SO YOU PROBABLY K O WHAT I T I S WE ARE
NW
DOING - ALTHOUGH I CAN TELL YOU AS SOMEONE WHO HAS BEEN I N THE
ROOM THAT A LOT OF WHAT YOU'VE READ BELONGS IN THE FICTION
SECTION.
I WANT YOU TO KNOW WHERE WE ARE AND WHAT WE'VE LEARNED,
BECAUSE I T I S SO VITALLY IMPORTANT THAT WE REFORM THE HEALTH CARE
SYSTEM THIS YEAR.
AND I WANTED TO COME HERE AND SPEAK WITH YOU
DIRECTLY BECAUSE AS OUR PRIMARY CARE-GIVERS YOU MUST BE PART OF
ANY SOLUTION TO THIS PROBLEM.
ONE OF THE THINGS THAT I DON'T LIKE ABOUT THE HEALTH CARE
DEBATE IS THAT WE THROW AROUND SLOGANS AND JARGON, AND I'M AFRAID
WE SOMETIMES LEAVE THE IMPRESSION THAT HEALTH CARE REFORM IS SOME
ABSTRACT NOTION.
JUST THE OPPOSITE I S TRUE.
THIS CRISIS HITS AT
THE HEART OF EVERY AMERICAN FAMILY.
WE HAVE LEARNED THIS, AND A GREAT DEAL MORE, MUCH OF I T VERY
PAINFUL, SOME OF I T HOPEFUL, ALL OF I T CRITICALLY USEFUL.
WE'VE LEARNED WHAT I T IS LIKE FOR A HARD WORKING FAMILY TO
SIT AROUND THE DINNER TABLE AND DECIDE TO DECLARE BANKRUPTCY
BECAUSE A PARENT HAS ALZHEIMER'S.
�WE'VE LEARNED HOW FRIGHTENING AND FRUSTRATING I T I S TO LOSE
YOUR COVERAGE.
I T IS EVERY BIT AS DEVASTATING AS GETTING LAID
OFF, AND IT'S HAPPENING TO MORE THAN 100,000 OF US EVERY MONTH.
WE'VE LEARNED WHAT I T I S LIKE TO BUILD A SMALL BUSINESS AND
HAVE TO DENY YOUR EMPLOYEES HEALTH CARE BECAUSE YOU CAN'T AFFORD
TO PROVIDE I T .
AND I'VE LEARNED FROM PHYSICIANS WHAT I T I S LIKE TO BE
TRAPPED IN A NIGHTMARE OF PAPERWORK AND REGULATION THAT YOU HAD
NO ROLE IN DESIGNING, BUT THAT BASICALLY FORCES YOU TO PRACTICE
WITH THE GOVERNMENT LOOKING OVER YOUR SHOULDER.
-
IT'S NOT RIGHT -
AND IT'S WRECKING THE SYSTEM.
YOU BECAME DOCTORS TO GIVE CARE AND FIND CURES, TO BE AMONG
THOSE WHO SERVE A HIGHER PURPOSE AND FEEL BETTER FOR I T .
I KNOW
YOU ARE THE BACKBONE OF OUR SYSTEM, AND THAT MANY OF YOU ARE
ANGUISHED WHEN TALENTED YOUNG PEOPLE CHOOSE TO AVOID MEDICINE
BECAUSE THE REWARDS NO LONGER EXCEED THE DEMANDS.
PART OF OUR GOAL IS TO HONOR YOUR ORIGINAL MOTIVES —
MOTIVES —
BY RE-CREATING A SYSTEM THAT ALLOWS YOU TO PRACTICE
MEDICINE THE WAY YOU THOUGHT YOU WOULD WHEN YOU CHOSE YOUR
CAREER.
GREAT
�THAT'S WHY I'M DELIGHTED AT THE FLEXIBILITY AND LEADERSHIP
AND REFORM-MINDEDNESS
SHOWN BY THE AMA AND DOCTOR TODD.
THIS ADMINISTRATION KNOWS THAT WE CANNOT, AND DO NOT WANT
TO, BUILD A BETTER HEALTH CARE SYSTEM WITHOUT THE COOPERATION AND
LEADERSHIP OF THE AMA.
BUT THE DAYS WHEN ONE ASSOCIATION —
MATTER HOW PRESTIGIOUS —
NO
CAN DOMINATE THE HEALTH REFORM DEBATE
ARE OVER, AND THEY SHOULD BE.
WE MUST ALL JOIN IN AND PULL IN
THE SAME DIRECTION.
I BELIEVE THAT NO AMERICANS HAVE MORE TO GAIN FROM A
COMPLETE OVERHAUL OF THE MEDICAL SYSTEM THAN DOCTORS.
YOU'RE THE
ONES WHO SEE THE SCARED FACES OF THE MOTHERS WHO DELAY SEEKING
CARE FOR A FEVERISH CHILD.
YOU'RE THE ONES WHO SPEND HOURS
WORKING THE PHONES IN SEARCH OF PERMISSION TO ADMIT YOUR PATIENTS
OR TO PRESCRIBE A CERTAIN TREATMENT.
YOU'RE THE ONES WHO WONDER
WHAT TO DO WHEN A NEIGHBOR OR FRIEND COMES FOR TREATMENT AND HAS
NO INSURANCE.
YOU'RE THE ONES FOR W O THE STATUS QUO I S
HM
UNACCEPTABLE.
AND SO HERE IS WHAT WE OFFER YOU: WE ARE GOING TO ASK YOU TO
HELP US CONTROL SKYROCKETING HEALTH CARE COSTS.
IN RETURN, WE
ARE GOING TO WORK VERY HARD TO REFORM THE MALPRACTICE LAWS AND
CUT THE BUREAUCRACY AND THE PAPERWORK WHICH MAKE I T DIFFICULT FOR
YOU TO BE CAREGIVERS.
�FIXING THIS SYSTEM, AS YOU WELL KNOW, WILL NOT BE EASY.
BUT
THE AMERICAN PEOPLE HAVE DEMANDED THAT WE FUNDAMENTALLY REFORM A
SYSTEM THAT COSTS TOO MUCH AND WASTES TOO MUCH AND SERVES TOO
FEW; AND, THAT WE MAKE THE SYSTEM WORK BETTER FOR REAL PEOPLE
WITH REAL PROBLEMS.
WE WILL NEVER SUCCEED I F OUR REFORMS FAIL AT THE CRUCIAL
MOMENT WHEN SOMEONE IS SICK AND NEEDS HELP.
OUR GOALS ARE SIMPLE.
THAT I S THE TEST.
FIRST, WE MUST CONTROL COSTS THAT ARE
RISING FOUR TIMES THE RATE OF INFLATION.
I F WE DO NOT I T WILL
COST OUR NATION AN AVERAGE OF $14,000 PER FAMILY BY THE END OF
THE DECADE.
WE MUST CUT WASTE AND INCREASE COMPETITION AND STOP
THOSE IN THE INSURANCE AND PHARMACEUTICAL INDUSTRIES WHO ARE
PROFITEERING EXCESSIVELY.
SECOND, WE WANT PEOPLE TO BE SECURE AND TO BE GUARANTEED A
BENEFITS PACKAGE THAT IS TRULY COMPREHENSIVE.
THIRD, WE WANT THE SYSTEM TO BE SIMPLE.
THE PRESIDENT HAS
ALREADY MADE A SERIOUS COMMITMENT TO REFORM THE WAY GOVERNMENT
DOES BUSINESS.
HE HAS MADE HISTORIC CUTS IN THE BUDGET, STARTING
WITH HIS OWN STAFF AND FEDERAL WORKERS.
WE MUST MAKE THE SAME
COMMITMENT TO BETTER MANAGEMENT AND GREATER SAVINGS IN THE HEALTH
CARE SYSTEM, INCLUDING IMPLEMENTING TOUGH NEW ANTI-FRAUD AND
ABUSE MEASURES.
�I F WE DO NOT, WE WILL WASTE ANOTHER 8 0 BILLION DOLLARS NE^T
YEAR AND EVERY YEAR ON PAPERWORK AND^BURESUCRA"CY-,—WHEN—THG'Sl
RESOURCES ARE NEEDED TO IMPROVE THE SYSTEM AND CARE FOR PEOPLE.
AND YOU WILL KEEP SPENDING THE EQUIVALENT OF TEN WORKING DAYS
EACH MONTH JUST TO KEEP UP WITH THE PAPERWORK.
FOURTH, OUR HEALTH CARE PLAN WILL PROVIDE CONTINUITY IN TWO
SENSES: WE WILL PRESERVE YOUR PATIENTS' RIGHT TO PICK THE DOCTOR
THEY WANT, AND WE WILL CONTINUE TO OFFER THEM THE HIGHEST QUALITY
CARE IN THE WORLD.
IN ADDITION, WE WILL PROVIDE THEM WITH A NEW
RIGHT: TO CHOOSE THE COVERAGE THEY WANT, NOT SIMPLY WHAT THEIR
EMPLOYER OR INSURANCE COMPANY WILL ALLOW.
FINALLY, HEALTH CARE REFORM SHOULD ALSO BE COMPREHENSIVE, IN
THE SENSE THAT ALL AMERICANS SHOULD BE COVERED.
IN REACHING THESE GOALS, REST ASSURED THAT WE WILL TRANSLATE
WHAT YOU HAVE TOLD US INTO REALITY.
THAT MEANS MALPRACTICE
REFORM.
TODAY, MALPRACTICE TOO OFTEN LIVES UP TO ITS NAME - I T HAS
MADE THE PRACTICE OF MEDICINE WORSE AT THE JUNCTURE I T MATTERS
MOST - THAT CRITICAL POINT OF COMMUNICATION AND TRUST BETWEEN
DOCTOR AND PATIENT.
I T IS AN ANCILLARY INDUSTRY WHOSE
PRACTITIONERS OFTEN ONLY DO WELL I F YOU ARE ACCUSED OF DOING
WRONG, AND THAT IS WRONG —
AND WE SHOULD DO SOMETHING ABOUT I T .
�IT ALSO MEANS RELIEVING PRESSURE ON YOU.
WE'VE HEARD AND WE BELIEVE THAT PRACTICING MEDICINE HAS
BECOME TOO BIG A HASSLE.
THE BUREAUCRACY HAS GOTTEN TOO BIG AND
THE TIME FOR TREATMENT TOO SMALL. THE TRADITIONAL AUTONOMY
BETWEEN YOU AND YOUR PATIENTS HAS GIVEN WAY TO THE NEW TRIAD OF
MEDICINE - A DOCTOR, A PATIENT, AND AN ACCOUNTANT.
WE WANT TO WRITE A PLAN THAT ALLOWS YOU TO RETURN FULL TIME
TO MEDICINE.
LIKE YOU THE AMERICAN PEOPLE ARE FRUSTRATED WITH THE COST
AND THE WASTE AND THE FRUSTRATION AND THE FEAR.
NOW.
THEY WANT CHANGE
MOST OF YOU HAVE YOUR OWN DEEP DISAPPOINTMENTS IN THE
SYSTEM.
YOU WANT CHANGE NOW.
AS A DOCTOR TOLD MRS. CLINTON AND MY WIFE WHEN THEY VISITED
ST. AGNES HOSPITAL IN PHILADELPHIA: "YOU KNOW THE SAYING, ' I F I T
AIN'T BROKE DON'T FIX I T . ' WELL MRS. CLINTON, THE SYSTEM I S
BROKE AND IT'S TIME TO FIX I T . "
THE AMERICAN PEOPLE DESPERATELY NEED A SYSTEM THAT WORKS FOR
THEM AGAIN, AND THE TIME HAS COME TO BALANCE YOUR NEEDS WITH
THEIRS.
UNDER A GOOD PLAN NO ONE WILL GET EVERYTHING THAT THEY
WANT, BUT EVERYONE WILL GET A BETTER DEAL ALL AROUND.
�LAST YEAR, THE AMERICAN PEOPLE PROVED THAT THEY HAVE THE
COURAGE TO CHANGE.
NOW I T IS TIME FOR US TO PROVE OURS, BY
ENACTING REAL HEALTH CARE REFORM.
OUR SYSTEM CAN BE IMPROVED, DRAMATICALLY IMPROVED.
WE KNOW
WE CAN DO BETTER BECAUSE MANY IN OUR NATION ARE DOING BETTER
ALREADY.
BUT THIS IS THE YEAR TO ACT.
THE PRESIDENT UNDERSTANDS THIS.
HE HAS SAID HE WILL TAKE THE HEAT WHEN THINGS GO WRONG AND
DOESN'T CARE WHO GETS THE CREDIT WHEN THINGS GO RIGHT.
AND THE AMERICAN PEOPLE HAVE RALLIED TO HIS SIDE.
AFTER YEARS OF POLITICAL GRIDLOCK WE ARE BEGINNING TO MOVE
QUICKLY TO SOLVE OUR MOST SERIOUS PROBLEMS.
MOST IMPORTANTLY,
WE HAVE BEGUN THE GLORIOUS ACT OF UNITING AGAIN AS AMERICANS
DETERMINED TO LEAVE OUR CHILDREN THE AMERICAN DREAM.
THANK YOU VERY MUCH.
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�REPORT TO CONG
POLICY PAPERS
OP-ED/OTHER
WEEK1: 4/17
ORGANIZE/
OUTLINE/
ASSIGN/
BEGIN DRAFT
COMPILE
TOPICS/
ORGANIZE
EDITORS/
ORGANIZE STAFF
LETTER FROM
IRA/BOORSTIN
SOLICIT IDEAS
WEEK 2: 4/24
WRITE
ASSIGNMENTS
DUE 4/19,20,21
SET TENTATIVE
TOPIC LIST/
MAKE
ASSIGNMENTS
SOLICIT IDEAS
WEEK 3: 5/1
DRAFT COMPLETE
REVIEW
NEW
ASSIGNMENTS
STRATEGY FOR
DISTRIBUTION/
ARRANGE
PLACEMENTS
WEEK 4: 5/8
REWRITE
REVIEW
PAPERS DUE/
EDITING
DRAFT NEW
ENGLAND
JOURNAL/
ACCEPT
SUBMISSIONS
WEEK 5: 5/15
REWRITE/POLISH
REVIEW
EDITING
COMPLETE NEW
ENGLAND
JOURNAL/
ACCEPT
SUBMISSIONS
WEEK 6: 5/22
REVIEW
COMPLETE
EDITING
PLACE OP-EDS
WEEK 7: 5/29
PRINTING -RELEASE DATE
OF PRESIDENT'S
ADDRESS
EDITING
PLACE OP-EDS
REVIEW/REWORK
PUBLISH I N
JUNE
PLACE OP-EDS
CONTINUE
THROUGH SUMMER
WEEK 8: 5/31
|
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Overview of Health Reform
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Carolyn Gatz
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 4
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 42
<a href="http://clinton.presidentiallibraries.us/items/show/36149" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093616" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
4/16/2015
Source
A related resource from which the described resource is derived
12093616
42-t-12093616-20060885F-Seg4-042-006-2015
-
https://clinton.presidentiallibraries.us/files/original/21bc40a8ec76d62d19215efc4267d4ad.pdf
21ad2519991604abc4272a5056be7a54
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Gatz, Carolyn/Klein, Jennifer
Subseries:
OA/ID Number:
5107
FolderlD:
Folder Title:
Papers
Stack:
Row:
Section:
Shelf:
Position:
S
56
5
5
3
�4/20 GEOGRAPHIC AREAS THAT MUST BE DEFINED FOR PC OPERATION
Definitions
PC area--Govemance and redistribution: The place of residence determines the PC to which
people belong. Many PC areas are likely to be statewide. Risk adjustment (see below) may
redistribute dollars geographically.
Rating area--Communitv rating: In order to require community rating, one must define the
community geographically. Within a "community" (that is, rating area), each health plan may
submit only one premium bid, even though its costs may vary within this area.
Service area-Service delivery: Each health plan is likely to have its own service area, that is.
the area in which residents would have adequate access to care if they enrolled in the health
plan. Delineating the boundary of a service area involves identifying the location of the
plan's facilities (including physicians' offices) and determining where enrollees might live and
still be able to obtain health care at those facilities. (A health plan may contract with
providers outside its service area, most likely for tertiary care.)
Benchmark premium area--Pavment to the PC: Premium payment entails two steps: first the
employer/employee/govemment pays the PC and then the PC pays the health plan. The
benchmark premium affects the payment made by the employer/employee/government to the
PC, whereas risk adjustment (see below) directly affects the payment made by the PC to the
health plan. The benchmark premium must be defined for a specified geographic area (e.g.,
county).
Risk adjustment area—Payment to the health plan: To the extent that residents of certain areas
have high costs, health plans might be paid more for enrolling those residents.
Proposals
If a state is subdivided into PC areas, each purchasing cooperative area would have (option 1)
a resident population of at least 1 million or (option 2) at least 1 million people who would
be enrolled in the PC.
The benchmark premium for low-income subsidy would be defined at the county level. The
benchmark premium would be the lowest premium for a plan (or plans) with the capacity to
enroll everyone who might want to enroll. The maximum subsidy would be 105 percent of
the benchmark premium.
Benchmark premium for employer mandate:
Employers would have to pay 80 percent of the benchmark.
Option 1: Defined above.
Option 2: The area would be the community rating area. The benchmark premium would be
the average premium paid by the 30 percent of enrollees who pay the lowest premiums.
The risk adjustment by area could be the county or the five-digit zip code.
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Find the county where you work. The
plan you see displayed is the low-cost
health plan that applies to you.
the county where you live or work;
however, the state's contribution to
table in this guide which applies to
your health insurance is based on the
that low-cost plan. Remember, you
low-cost health plan in the countv
may choose a health plan based on
where vou work.
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Aitkin
Anoka
Becker
Beltrami
Benton
Big Stone
Blue Earth
Brown
CarltonCarver.
Cass
Chippewa
Chisago
Clav
Clearwater
Cook
Cottonwood
Crow Wing
Dakota
Dodge
Douglas
Faribault
Fillmore
Freeborn
Goodhue
Giant
Hennepin
Houston
Hubbard
Isanti
Itasca
Jackson
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Kanabec
Kindivohi
Kittson
Koochiching
Lac Qui Parle
Lake
Lake of the Woods
Le Sueur
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County
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Renville
Rice
Rock
Roseau
St. Louis
Scott
Sherburne
Sibley
Stearns _
Steele
Stevens
Swift
Todd
Traverse
Wabasha
Wadena
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Lincoln
Lyon
McLeod
Mahnomen
Marshall
Martin
Meeker
Mille Lacs
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Morrison
Mower
Murray
Nicollet
Nobles
Norman
Olmsted'
Otter Tail
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Pennington
Pine
Pipestone
Polk
Pope
Ramsey
Red LakeRedwood
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Waseca
Washington
Watonwan
Wilkin
Winona
Wright
Yellow Medicine
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LOCATION OF ALTERNATE PLANS
NOTE:
Many of the plans have providers in additional counties not included on this page. Plans are shown here
only if they have hospital, primary physician and chiropractor services (plus dental and pharmacy, if
applicable) all physically located in the county. If you have any questions about the number or location of
providers, you should contact the plan or the provider directly.
Standard Plan and Standard Plan II coverage available statewide.
You may enroll in any plan regardless of your residence—but care must be received from that plan's
physicians.
See preceding page for explanation of abbreviations.
B-5
�MEMORANDUM
TO:
FROM:
RE:
DATE:
Judy Feder, Ira Magaziner, Sara Rosenbaum
Roz Lasker and cross-cutting group on special populations
Subsidy payments for low-income persons
4/21/93
While finalizing the cross-cutting paper on mechanisms to assure access and quality of care
for low-income, underserved, and vulnerable populations, we were informed of some recent
decisions that had been made re subsidy determinations. Below, are some thoughts about
implications of the decision to:
provide subsidies for low-income persons equal to the premium of the lowest
cost plan offered in a health alliance, regardless of availability; and
require all plans to:
enroll an undetermined number of low-income persons at the
premium cost of the lowest cost plan
enroll as above or pay a tax
This policy minimizes federal subsidy obligations and maximizes choice of plan to lowincome persons. However, to the extent that the subsidy payment is insufficient to cover the
costs of providing care to low-income persons (and plans cannot or do not identify ways to
provide such care more efficiently), plans will have incentives to fill their quota with the
"cream" (e.g. lowest-risk) of the low-income population. Plans will also have incentives to
provide low-income persons with a lower quality of service and care.
Regardless of whether the policy does or does not incorporate a tax option, it would have
the serious consequence of:
discouraging the introduction of low-cost plans anywhere in the HA region
(since this would both decrease federal subsidies to the state and would result
~ if a tax is used -- in a higher tax to plans not enrolling their full quota of
low-income persons).
If the policy is implemented without a tax, assuring comparable access to care for lowincome persons (without bussing) will require that all plans provide primary care and
emergency services in locations throughout the HA- However, this strategy:
�will not assure that low-income persons have access to services of comparable
quality or to services that are tailored to meet their special needs (i.e., will
not protect against differential care within plans);
will discourage the development of new plans (since HA areas will be large)
and of community-based plans (since true costs of providing care for lowincome persons will likely be higher than the subsidy);
will encourage the development of insurance-run oligopolies;
will be burdensome to providers in low-income areas, who will have to work
with a large number of plans, all of whom may manage care in different ways.
All plans would not have to be required to cover the entire HA region if they were given
the option of paying a tax (e.g., the difference between the subsidy and the [100 + x]% of
the plan premium) instead of enrolling their full quota of low-income persons. In this case,
only plans actually providing care for low-income persons would have to make services
readily available in the areas in which low-income persons lived. Allowing plans to serve
smaller areas would solve some of the problems listed above (e.g., disincentives to the
formation of new plans). The tax could remove disincentives for developing communitybased plans if the monies collected were targeted for this purpose. Nonetheless, even under
this option, the economic disincentive for lowering the premium of the low-cost plan would
persist.
In light of these problems, it may be advisable to refine the definition of the lowest-cost plan
in the subsidy decision. We suggest that the subsidies provided for low-income persons be
equal to the premium of the lowest cost plan (or group of plans) in a relatively small service
area (e.g., a county or 3-digit zip code area) that meet the following criteria:
cover the entire service area;
have the combined capacity to serve 133% of the subsidized population; and
have the capacity to accept all subsidized enrollees wishing to join.
Plans would still be required to enroll a proportional number of low-income persons at the
premium of the lowest cost plan (as defined above) or to pay a tax. To assure that taxes
are used to improve access and quality of care for low-income persons, we recommend that
they be targeted to:
services tailored to meet the needs of low income populations (such as
enabling services) that are made available to all plans caring for these
populations;
support for the development of community-based plans; or
socioeconomic risk-adjustments of plan premiums.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Papers
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Carolyn Gatz
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 4
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 42
<a href="http://clinton.presidentiallibraries.us/items/show/36149" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093616" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
4/16/2015
Source
A related resource from which the described resource is derived
12093616
42-t-12093616-20060885F-Seg4-042-007-2015