[Congressional Record Volume 140, Number 17 (Thursday, February 24, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: February 24, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
      MANAGED COMPETITION: MAKING THE MARKET WORK TO CONTAIN COSTS

  Mr. DURENBERGER. Mr. President, the phrase managed competition has 
achieved a great deal of currency in the debates on health care reform. 
It is therefore regrettable that the concept of managed competition is 
often misrepresented and misunderstood.
  Managed competition is not about Government. It's about markets, and 
making markets work. In its essence, managed competition is a simple 
concept. It is based on the fact that competition among providers of 
services for the business of informed consumers drives prices down, and 
drives quality and innovation up. That's the definition of a market.
  Under managed competition, Government is used to facilitate the 
market through incentives, not replace the market with regulation.
  I cannot stress enough, Mr. President, that managed competition is 
not just a theory. It is up and working in communities all over 
America. Minnesota happens to be one of the leaders in competitive 
health care delivery systems on the managed competition model. By 
reducing costs and improving quality, Minnesota's market is providing 
health care at a cost 15 percent below the national average.
  And the California Public Employees Retirement System--Calpers--has 
shown that a large health care purchasing agent can succeed in putting 
downward pressure on premium costs. After 4 months of negotiations with 
California HMO's, Calpers has concluded a deal that will reduce health 
care premiums for its members by an average of 1.1 percent.
  This debate is going to be won on the basis of facts--and the facts 
prove that markets, not mandates, are the key to health care cost 
containment. I ask unanimous consent that an article from Business & 
Health outlining Minnesota's experiment in managed competition be 
included in the Record, along with a news story from the Wall Street 
Journal describing the achievement of Calpers in reducing premium 
costs, and an important American Spectator article by Fred Barnes 
entitled ``Health Care Costs Are Going Down.''
  There being no objection, the articles were ordered to be printed in 
the Record, as follows:

          How Twin Cities Employers are Reshaping Health Care

                          (By Marion Torchia)

       Last January, nine members of the Business Health Care 
     Action Group, a coalition of employers in the Minneapolis-St. 
     Paul metropolitan area, began offering their workers a new 
     health plan. The coalition adopted a plan that operated as an 
     integrated system of care because its members believed such a 
     system had the greatest potential to deliver high-quality, 
     cost-effective care.
       This year, BHCAG's founding companies have just completed 
     their first re-enrollment and are happy with the results. The 
     per-employee costs are about 10% below the average cost of 
     the HMO options offered previously, and costs have increased 
     4% to 5% in the past year, compared with average increases of 
     7% to 8% in the greater Minneapolis market, reports BHCAG's 
     Executive Director Steve Wetzell. On average, employers are 
     paying $2,900 per family and $1,200 per individual.
       The plan, called Choice Plus, is a typical point-of-service 
     plan, allowing enrollees to choose care from a network of 
     participating providers and go outside the network for 
     coverage at a lower reimbursement rate. But it is also 
     unusual in many ways. The network is large and can therefore 
     offer its enrollees a considerable degree of choice among 
     providers. It is highly standardized--all participating 
     companies have agreed to use a standard benefit design.
       Technically, an ISC coordinates care provided by groups of 
     doctors and hospitals and accepts financial risk for the 
     population. Choice Plus borrows features of an ISC by using a 
     primary gatekeeper physician as the coordinator for all care, 
     financial incentives to improve the delivery of care and 
     contain costs, and a range of continuous quality improvement 
     techniques.
       Choice Plus is a first step in the coalition's effort to 
     reform health care by demonstrating that improved quality, 
     increased provider competition, increased consumer 
     responsibility, and enhanced efficiency of health care 
     delivery are compatible goals. These goals can best be 
     accomplished within an ISC, BHCAG members believe.
       When Choice Plus was created, a statewide health care 
     reform movement was under way, and the coalition members 
     wanted to influence its outcome by creating their own health 
     care financing and delivery system. ``This is not just a 
     purchasing activity. It's an effort to change the basic 
     structure of health care through an ongoing dialogue among 
     payers, providers, and consumers,'' says Larry Schwanke, vice 
     president for human resources of The Bemis Co. Inc., a 
     packaging manufacturer.
       Adds Dee Kemnitz, vice president of the Minneapolis-based 
     Carlson Cos. Inc., ``When the coalition's effort to get cost 
     containment features incorporated into the state's health 
     reform legislation was not successful, the companies decided 
     to demonstrate that they could contain costs themselves.'' 
     Carlson Cos., a hospitality services company that includes 
     Radisson Hotels and TGI Friday's restaurants, has 5,300 
     covered lives in the Twin Cities area.


                         assessing choice plus

       Benefits managers of participating companies say their 
     employees are happy with the new plan. Paula Roe, vice 
     president for compensation and benefits for Norwest, a 
     nationwide financial services company headquartered in 
     Minneapolis, says 70% of the bank's employees chose Choice 
     Plus over the other alternatives the company offered, and 
     this year's enrollment has increased to 87%. The company has 
     14,300 covered lives participating in Choice Plus.
       Such numbers and the coalition's growth mean BHCAG now 
     possesses sufficient purchasing power to exert a significant 
     influence on the area's health care market. Now numbering 22 
     members, the coalition includes most of the major employers 
     in the Twin Cities.
       Collectively, the companies are responsible for some 
     250,000 covered lives, about 10% of the population of greater 
     Minneapolis, Wetzell estimates. Enrollment in Choice Plus in 
     1994 is expected to be about 100,000, and it will continue to 
     grow as member companies adopt to the plan.
       In developing the network of providers, ``The coalition's 
     founders wanted to find a group of providers who were 
     committed to conservative, cost effective medical practice 
     and who were willing to engage in an ongoing dialogue with 
     employers about health care delivery issues,'' says Schwanke. 
     ``They were convinced that efficient delivery of health care 
     was achievable. They wanted to bring a greater degree of 
     vertical integration to the health care system.''
       So the coalition considered the multispecialty group 
     practices in the area because ``these large groups have the 
     administrative sophistication to support the development of 
     integrated systems of care,'' says James L. Reinertsen, M.D., 
     a rheumatologist with Healthsystem Minnesota, the parent 
     organization of Park Nicollet Medical Center and Methodist 
     Hospital. ``They also have a capacity for collective action 
     impossible among many small independent practices.''
       Early in 1992, BHCAG invited bidders to develop a health 
     plan meeting their specifications. The winning bid came from 
     a consortium that consisted of HealthPartners, an entity 
     formed from two HMOs (Group Health and MedCenters) that had 
     counted many of BHCAG's employees among their members; the 
     Park Nicollet Medical Center; and the Mayo Clinic.
       Careful to structure its arangements so members can retain 
     their self-insured status under the Employee Retirement 
     Income Security Act of 1974, BHCAG individual member 
     companies signed a three-year contract with HealthPartners, 
     which became the administrator of Choice Plus. Since they are 
     not technically insurance plans, self-insured plans come 
     under ERISA, which preempts state law. Such plans are thereby 
     exempt from state regulation. Minnesota failed this summer to 
     get an ERISA waiver, which would have allowed the state to 
     tax self-funded plans.


                          financial incentives

       During 1993, the first year of operation, members companies 
     paid physicians a fee-for-service. Though the coalition hopes 
     to move away from fee-for-service, it chose this payment 
     method during start-up because it needed to collect baseline 
     information on the cost of treating patients, says Wetzell. 
     This information can then be used to set rates and to 
     quantify cost savings.
       To meet its goal to change the way health care is 
     delivered, BHCAG has devised a complex strategy of gain and 
     loss sharing to influence providers' behavior. Under its 
     contract, HealthPartners receives bonuses for efficiently 
     accomplishing administrative functions such as claims 
     adjudication, for containing the utilization of services, and 
     for the quality of its guideline development and research 
     activities. The physician groups also share the savings when 
     their expenditures fall below a certain level.
       This year, each clinic will be given a monthly budget for 
     each enrollee. The budget limits will be different for each 
     employer. The clinic will be liable for the part of costs it 
     incurs in excess of the monthly budget limit. Catastrophic 
     care, however, is not included in the risk-sharing 
     arrangement.
       Ultimately, BHCAG wants to create a series of risk 
     adjustments--for patient characteristics and for local 
     economic conditions--that will eliminate cost variations 
     among clinics resulting from factors outside their control. 
     It is considering using the ambulatory patient group patient 
     classification system to adjust for the risk of treating 
     costlier cases. (The APG system was developed by 3M Health 
     Information Systems, Murray, Utah. It classifies patients 
     according to the medical or surgical outpatient treatments 
     they receive.) Eliminating all cost variations among medical 
     groups may be impossible, however, Wetzell says. ``If we 
     can't scientifically adjust for all cost variations that do 
     not reflect the efficiency of medical practice, we may 
     consider using variable premiums and allow the employee to 
     select a higher cost clinic and pay the difference.''
       Roe of Norwest, who serves on BHCAG's provider payment 
     committee, says that much more work needs to be done to 
     devise proper payment incentives for physicians. ``Pure 
     capitation is not the answer,'' she wants. ``We need to 
     reward physicians for their cognitive work, for the 
     counseling they provide to patients, and for preventive 
     services.''
       As far as hospitals are concerned, says Wetzell BHCAG 
     members pay hospitals at per diem rates based on diagnostic-
     related groups. ERISA prevents self-insured companies from 
     capitating payments to entities such as HealthPartners, which 
     would, in turn, pay the hospitals.
       Only for Healthsystem Minnesota, which owns a clinic (Park 
     Nicollet Medical Center) and a hospital (Methodist Hospital), 
     is BHCAG negotiating a single payment for physician and 
     hospital care, explains Wetzell.


                            implementing cqi

       As envisioned by BHCAG, integrated systems use practice 
     guidelines as a basis for standardizing health care delivery, 
     and engage in continuous quality improvement efforts based on 
     outcomes information generated while delivering health care. 
     Competing integrated systems, of which Choice Plus is the 
     first, will be encouraged so that consumers could use 
     objective data to choose among them.
       Therefore, following the ISC model, BHCAG's contract with 
     HealthPartners commits both employers and providers to an 
     active continuous quality improvement program based on best 
     practice guidelines developed by the clinical professionals, 
     the monitoring of provider performance based on data gathered 
     in the course of practice, and on outcomes research. This 
     effort is coordinated through a separate non-profit entity, 
     the Institute for Clinical Systems Integration.
       ICSI Chairman Reinertsen explains that the institute, which 
     is funded by BHCAG at a level of approximately $225,000 a 
     year--10% of the institute's budget--facilitates development 
     of guidelines, analyzes data the providers submit on the 
     costs and outcomes of treatment, and reports the information 
     to providers and to member companies. In effect, adds Larry 
     Schwanke, ``The Institute is the Coalition's R&D arm.''
       The practice guidelines are the key to the process, says 
     Reinertsen. Sixteen sets were distributed for pilot testing 
     in July, and all clinics received them in November.
       While clinical guidelines, as expressions of the standard 
     of good medical practice, should be applicable universally, 
     the clinics are encouraged to develop their own 
     implementation protocols, adds Kemnitz. ``Our relationship 
     with the providers is built on a high level of trust,'' she 
     says. ``People tend to support policies they had a share in 
     creating.''
       To maintain this climate of trust and cooperation, explains 
     Reinertsen, the plan's information handling policy is 
     designed to ``drive out fear.'' No information will be 
     released identifying an individual physician, practice, or 
     employer without explicit permission. The coalition also has 
     rejected as counterproductive the idea of publishing rankings 
     of providers' performance. Any reports with physician-
     specific data remain inside the clinics. Companies will 
     receive information on their own enrollees' costs and 
     utilization patterns compared with the group. And providers 
     will be entrusted with the responsibility of internally 
     identifying outliers.
       To support CQI, ICSI has a variety of projects under way, 
     says Wetzell. The institute is planning a survey of 
     enrollees' health status, so that each company can see 
     whether its employees' health is improving. It has developed 
     a prototype automated medical record. And it has research 
     projects planned on the cost effectiveness of several new 
     technologies used in the clinics.


                              future plans

       Now the Choice Plus has completed its first year, the 
     coalition must decide whether to allow the network to add 
     more companies and accept more enrollees, or whether BHCAG 
     should begin developing a competing ISC, Wetzell says. Choice 
     Plus has already expanded geographically, accommodating 
     employers in Rochester, Minn., 90 miles south of Minneapolis, 
     via a contract with the Mayo Clinic's primary care group.
       Rather than allow the network to grow indefinitely, BHCAG 
     may prefer to develop competing provider networks, using 
     essentially the same benefit structure, Wetzell says. To do 
     so would promote competition and allow for a greater degree 
     of consumer choice. Not coincidentally, it also would be more 
     compatible with the managed competition proposals being 
     considered. ``What our board decides,'' say Wetzell, ``will 
     depend to some extend on what decisions are made in D.C.''
       Meanwhile, reports Wetzell, BHCAG's board of directors has 
     taken a significant step to counter criticism that 
     coalitions of large employers do not contain health costs 
     but simply shift them to smaller companies that lack 
     buying power. It has decided to offer an insured product 
     for small businesses, using community rating within the 
     risk pool of the businesses that choose to participate.
       The small group plan's structure will be significantly 
     different from that of Choice Plus, since it will be subject 
     to state regulation and must include all of state-mandated 
     benefits. Wetzell also expects that the project will face 
     problems of adverse selection, since competitors will no 
     doubt market lower priced products to attract the companies' 
     healthier employees.


                          Is It Transportable?

       Although the BHCAG views its project as proof that provider 
     competition, quality of care, and cost efficiency are 
     compatible, Wetzell concedes that the Twin Cities is an ideal 
     location for the experiment. It has several distinct 
     advantages: a physician community already used to 
     standardized practice in large multispecialty groups; managed 
     care penetration on the order of 70% to 80% hospital bed 
     capacity already reduced through mergers and consolidations 
     in the 1970s and 1980s; and a population healthier, more 
     prosperous, and more homogeneous that the national average.
       Nevertheless, Wetzell believes the Choice model is 
     transportable, though elsewhere it may first be necessary to 
     lay the groundwork of integrated systems. He believes the 
     effort is definitely worthwhile. ``How can you argue that a 
     piece-rate system of health care, with dispersed providers 
     and primitive communication among them, does a better job 
     than a vertically integrated health care system?
                                  ____


             Calpers Proves Insurance Costs Can Be Reduced

                  (By Marilyn Chase and Carrie Dolan)

       After four months of negotiations with 18 health-
     maintenance organizations, one of the nation's largest group 
     purchasers of health insurance has secured an average 1.1% 
     premium reduction for $920,000 public employees and family 
     members.
       The California Public Employees Retirement System (Calpers) 
     won the one-year contracts yesterday. The process and its 
     result may be seen as a model for Clinton health-care reform: 
     A large public health-care purchasing agent squeezing even 
     low-cost providers, like HMOs, into making extra savings. But 
     Calpers's success may also show that an elaborate government 
     bureaucracy isn't needed to lower health-care costs.
       The reduction ``shows managed competition can bring down 
     the cost of health care,'' particularly in areas like 
     California where HMO's are well-developed, said Alain C. 
     Enthove, a professor at Stanford University's Graduate School 
     of Business and a Calpers advisory committee member. 
     ``Competition works, not compulsion,'' he said.
       Calpers said it has kept premium increases over the past 
     three years to 6.4% compared to the national average of 
     30.1%. For the 1994-95 contract year, when the rate reduction 
     takes effect, Calpers said its savings will be about $321 
     million. While not all the contracts met its demand for a 5% 
     rate cut, Calpers said it hopes to achieve that goal in the 
     next several years.
       Calpers--once known as a languid and not particularly 
     choosy buyer of health care--has recast itself as a tiger in 
     recent years. In 1991, after California's budget crises, 
     Calpers froze its contributions to health care, making its 
     HMOs responsible for cost variations.
       Last October, Calpers demanded that its 18 HMOs cut health-
     care premiums 5% effective Aug. 1, the start of the 1994-95 
     contract year. It called the demand ``modest,'' given 
     California's stagnant economy. But that demand followed two 
     years of strict cost containment. So Calpers' demand left 
     some HMOs a little testy.
       ``They're a 900-pound gorilla, and they know it,'' grumbled 
     one HMO negotiator who asked not to be identified. ``They 
     don't have to be real sophisticated. They know the volume 
     they represent. Bottom line is, they are holding most of the 
     cards.''
       About a third of the HMOs doing business with Calpers 
     offered premium reductions, said Tom Elkin, the agency's 
     assistant executive officer. Others--with lower base rates or 
     older, sicker patient populations--asked for ``modest, 
     single-digit'' premium rises, while a few argued for double-
     digit increases, he said. The latter group got little 
     sympathy.
       ``We're out of cash,'' Mr. Elkin said he told them. ``And 
     we can't entertain increases of that magnitude. We'd like 
     some sign that you can, in fact, manage care.''
       Among the key issues, Mr. Elkin said, were the price of 
     prescription drugs, surgeries and administrative expenses--
     including profit margins and consultants' fees.
       As an example, he noted, ``There's a 30% difference between 
     what one plan is paying for drugs and another,'' Mr. Elkin 
     told the HMOs this can be corrected by buying in bulk and 
     changing vendors, then passing on the savings.
       ``If they'd succeeded in pushing us to the absolute wall, 
     we'd have said no. We're not in the business of charity. We'd 
     have gone without their business,'' said one health-care 
     officer. ``But the ultimatum never occurred.''
       Mr. Elkin conceded that negotiations ``can get a little 
     lively. If the expectation is much higher than we can pay, it 
     gets a little tense. On average, though, we get good 
     cooperation.'' And in the end, Calpers relented on the 5% 
     rollback demand, as many had predicted.
       Mr. Elkin said Calpers was impressed by the efforts of 
     Kaiser Permanente, the Oakland, Calif., HMO that cares for 
     320,000 Calpers subscribers. A year ago, Kaiser's northern 
     California region considered increasing its premiums 6% for 
     all its customers, including Calpers. Instead, it looked hard 
     at results of its cost-cutting programs and raised premiums 
     an average of 2%.
       Kaiser spokesman Jerry Fleming said it wasn't simply 
     prodding by Calpers that led to Kaiser's change of heart. 
     ``We're doing better with our cost targets than we'd budgeted 
     for,'' he said.
       Kaiser's most potent cost controls are simple things: 
     lowering hospital inpatient rates, substituting outpatient 
     surgeries when possible and aggressively keeping Kaiser 
     members out of more expensive, non-Kaiser institutions.
       ``At the same time, the satisfaction of our members was 
     going up, so we knew [these savings] weren't because we were 
     skimping on care,'' he added.
       Other HMOs said they cracked down on high diagnostic test 
     prices charged by certain hospitals trying to offset losses 
     on inpatient business.
       HMOs said they're also trying to limit the budget havoc 
     wrought when hospitals buy costly new psychiatric drugs.
       ``They're a significant piece of the total pharmaceutical 
     cost, and the trend has been very steep,'' said one HMO 
     officer, adding that his group plans more seminars on cost-
     effective alternative drugs.
                                  ____


                    Health Care Costs Are Going Down

                            (By Fred Barnes)

       President Clinton has a story and he's sticking to it. 
     ``Rampant medical inflation,'' he declared last September in 
     unveiling his health-care plan, ``is eating away at our 
     wages, our savings, our investment capital, our ability to 
     create new jobs in the private sector and this public 
     Treasury.'' A month later, he sent the plan to Congress and 
     said ominously: ``If we do nothing, almost one in every five 
     dollars spent by Americans will go to health care by the end 
     of the decade.'' Don't sugarcoat it, Clinton was advised just 
     before Christmas by William Cox, vice president of the 
     Catholic Health Association. It's worse than that. ``Sometime 
     in the next thirteen years we're going to be spending 22 to 
     25 percent of our income on health care,'' Cox said. At that 
     rate, ``if you want to go out for dinner and a movie, you're 
     going to have to check into a hospital.'' Clinton chuckled at 
     the joke. ``That's pretty good!'' he said.
       It was hogwash. There's a new direction in health-care 
     costs--down, down, down. No, spending isn't actually 
     declining. That will never happen in a nation with rapid 
     population growth and lifesaving but costly advances in 
     medical science. But the rate of growth in medical spending 
     is dropping precipitously. Every month brings a fresh 
     decrease in what the U.S. Labor Department calls ``price 
     inflation for consumer medical goods and services.'' It was 
     5.8 percent for the year ending last August, 5.7 percent for 
     October, 5.5 percent for November. That's still nearly twice 
     the rate of general inflation, but a lot better than 1989 
     (8.5 percent) or 1990 (9.6 percent). In fact, the 5.5 percent 
     increase is the lowest since January 1974. Better yet, the 
     4.9 percent rise in the third quarter of 1993 was the lowest 
     quarterly hike since 1973. And it's a good bet medical 
     inflation will fall further.
       Don't thank Bill and Hillary Clinton. The downward trend is 
     the product of a revolution in health-care financing caused 
     by market forces, not government. It started several years 
     before the Clintons arrived in Washington and began harping 
     on ``skyrocketing'' (Hillary's favorite adjective) medical 
     cost increases. It was triggered by businesses and consumers 
     confronted in the late 1980s with annual health benefit 
     increases of up to 20 percent or more. Corporate health plans 
     cover roughly 140 million Americans. Something had to give, 
     and it has. For the first time in years, the percentage of 
     payroll costs devoted to health and dental insurance dropped 
     from 8.4 percent in 1991 to 8.1 percent in 1992, according to 
     a U.S. Chamber of Commerce study of 1,100 firms.
       Such signs of downward pressure on health-care costs are 
     largely the result of two changes. One is the willingness of 
     businesses--especially insurance companies and firms that 
     self-insure--to challenge medical bills. Dan Clark, a 
     benefits consultant in Seattle for Howard Johnson and Co., 
     recently advised a client whose employee had been murdered to 
     balk at a $75,000 hospital bill (the victim had lingered near 
     death for five days). The mere threat of hiring a firm that 
     aggressively scrutinizes medical bills prompted the hospital 
     to slash the bill by $15,000. This process, once rare, is now 
     routine. ``The thing the large employer did early on, the 
     small employer is now doing,'' says Clark. One result: growth 
     of the total cost of private health insurance premiums 
     decreased from 18.6 percent in 1988 to 12.1 percent in 1991 
     and 10.1 percent in 1992, the consulting firm Foster Higgins 
     found.
       More important, companies are steering employees away from 
     fee-for-service medicine (with each doctor visit billed) and 
     into managed care particularly health maintenance 
     organizations (doctor groups charging an annual fee per 
     patient). This lowers insurance payments. HMO membership has 
     doubled since 1986, from 25 million people to an expected 50 
     million this year. Not only are HMOs less expensive than fee-
     for-service medicine, their premium hikes have fallen for 
     five straight years, from 16 percent in 1990 to 5.6 percent 
     in 1994. A 1993 study concluded that if all Americans went to 
     HMOs the 19 percent chunk of GDP projected for health care in 
     2000 would shrink to 15 percent. Then there are ``preferred 
     provider organizations'' (PPOs), networks of doctors who 
     agree to discounted fees. Clark surveyed fifteen Seattle-area 
     companies at random recently and found every one was part of 
     a PPO network with cut-rate fees. One result of the surge in 
     managed care: fewer patients hospitalized and a decline in 
     the growth of hospital expenses nationally, from 10.2 percent 
     in 1992 to 8.1 percent in 1993.
       What's striking about the revolution in health costs is the 
     absence of government. ``This revolution has been driven by 
     frustrated employers,'' says Michael Bromberg, executive 
     director of the Federation of American Health Systems. 
     ``They've forced the insurance industry to change from an 
     indemnity industry to a managed-care industry. It's all 
     happened without legislation.'' The real question, he adds, 
     is whether Washington ``will accelerate that trend or screw 
     it up.''
       Don't get your hopes up. While the private sector has begun 
     to get a grip, the federal government allows its health-care 
     programs to roar out of control. ``Medicare and Medicaid have 
     tripled since 1982,'' Clinton correctly told an entitlements 
     summit in Bryn Mawr, Pennsylvania, in December, Medicare 
     spending jumped 12 percent in 1992. Medicaid is expected 
     to grow 16.6 percent in 1993. That's just at the federal 
     level. State outlays for Medicaid rose 30 percent from 
     1991 to 1992. By 1996, states will spend more on Medicaid 
     than on education.
       If you suspect the cost revolution in the private sector 
     undermines health-care reform, you're right. ``There's a 
     torpedo heading for the great ship health-care reform,'' says 
     Democratic Senator Bob Kerrey of Nebraska. By mid-1994, he 
     says, HMO cost increases will have dropped to the rate of 
     inflation (about 3 percent) and non-HMO price hikes will be 
     well under twice the inflation rate. Numbers like those alarm 
     the Clinton administration, since they knock out the 
     overarching rationale for Clinton's sweeping plan. ``They 
     can't let the public think this has gone very far, because it 
     takes the steam out of what they want to do,'' insists Paul 
     Elwood, the respected health-care expert at the Jackson Hole 
     Group and father of the managed care movement. (Elwood's son 
     David, by the way, is an assistant secretary of health and 
     human services in the Clinton administration. As a Harvard 
     professor, he came up with the idea of cutting off welfare 
     recipients after two years on the dole.)
       The administration and its allies are desperately seeking 
     to minimize the new trend, particularly because it's 
     beginning to draw press attention (from Business Week to 
     Fortune to Time to columnists James K. Glassman and George 
     Will). Clinton offered this putdown: ``A couple of times 
     before when an administration's made a serious effort at 
     health-care cost control, health-care costs have moderated 
     for a year or so, then they start up again.'' He cited the 
     Nixon administration as an example. HHS Secretary Donna 
     Shalala echoes Clinton. ``We clearly have had some 
     experience,'' she said in December. ``Every time a president 
     starts talking about health-care reform, there has been some 
     moderation, probably a mixture of politics and economics 
     going on.'' Buttering up Clinton at Bryn Mawr, she added, 
     ``Certainly there has been some moderation under your 
     administration.'' She credited the ``Hillary factor.''
       Clinton and Shalala are dead wrong. Their implication, of 
     course, is that insurance companies, doctors, and hospitals 
     hold down cost increases when Washington is threatening to 
     impose controls, then jack up prices wantonly once the crisis 
     passes. This hasn't happened. National health-care 
     expenditures have risen less in some years than others, but 
     for economic, not political, reasons. When President Nixon 
     put on price controls, the rise abated. When controls were 
     lifted, its rapid climb resumed. Chatter about reform hasn't 
     been a factor. Consider 1986, the year national health 
     expenditures rose by the lowest percentage (7.6) since 1961. 
     Was President Reagan jawboning the health-care industry in 
     1986? Get serious.
       The Washington Post suggested in a December editorial that 
     health-care providers are purposely defusing the crisis 
     atmosphere as Clinton's legislation moves through Congress. 
     This makes superficial sense. ``Nobody wants to invite 
     special attention while restrictions and ceilings are being 
     written into the bill,'' the Post said. True, but nobody 
     wants an artificially low floor for health-care prices as 
     price controls are being enacted, either. This means health 
     companies have an incentive to get large price increases now, 
     because they won't be able to impose them later under the 
     Clinton plan.
       Contrary to the Administration's line, the current dip in 
     health cost increases reflects what Paul Elwood calls ``a 
     fundamental and permanent change.'' It's structural, not 
     temporary. There are, Elwood says, ``very basic differences 
     in provider and purchaser behavior.'' Take HMOs, which didn't 
     exist on any scale before the mid-eighties. They've gained 
     from experience, becoming leaner and more cost-effective as 
     they've had to compete for customers. Many HMOs participating 
     in the Federal Employees Health Benefits Program, which 
     covers nine million federal workers and their dependents, 
     offered dramatically reduced fees for 1994. That's actual 
     cuts, not merely cuts in the growth rate. For example, U.S. 
     Healthcare slashed the employee payment for its ``high 
     family'' plan by 29 percent. Overall, the 300-plus plans 
     competing for the business of federal bureaucrats this year 
     averaged fee hikes of 3 percent.
       What's been done in the private sector? The examples are 
     many and spectacular. But first, a question: Why hasn't all 
     this free-market cost-trimming been reflected in the 
     government's projections on national health expenditures? The 
     Congressional Budget Office last October predicted health 
     spending at 18.1 percent of GDP in 2000, down from its June 
     projection of 18.9 percent, but still quite high. Well, 
     there's a simple explanation: the government is operating off 
     of old numbers. The most recent year for which it has 
     calculated national health expenditures is 1991. So that's 
     its baseline for projections. But in 1991, the revolution in 
     private health-care financing was just getting off the 
     ground. Its full impact hadn't been felt.
       That was the year Digital Equipment Corporation began 
     offering a new series of health plans. Employees can go to an 
     HMO that's part of the company's program or outside the HMO 
     network. But they pay a bigger share of their medical 
     expenses if they go outside. By 1993, 70 percent of Digital's 
     employees were enrolled in HMOs, up from 30 percent in 1990. 
     And the yearly increase in HMO fees paid by the company 
     has fallen from 12 to 14 percent in 1992 to 9 percent in 
     1993 and 4.5 percent this year. It paid a higher rate for 
     fee-for-service insurance, but fewer employees chose that 
     option.
       It wasn't until 1992 that International Paper, whose 
     medical costs had been rising at better than 20 percent a 
     year, gave its employees an incentive to be cost-conscious in 
     buying health care. It boosted the level at which the company 
     would pay 100 percent of expenses and began informing 
     employees how much it would pay for each medical procedure 
     and how much physicians in their area charge. The idea was to 
     encourage employees to shop around. The firm has also shown 
     employees a video on how to negotiate lower fees with 
     recalcitrant doctors. One emboldened employ got $400 shaved 
     off the cost of his knee operation, according to the Wall 
     Street Journal. Overall, the firm's annual increases in 
     medical costs have fallen to 9 percent--not a breathtaking 
     improvement, but good for starters.
       IBM has produced even more impressive savings from its 
     mental health program. It negotiated fees with a network of 
     20,000 providers nationwide and cut its spending in half, 
     saving $30 million annually. Four corporations in 
     Cincinnati--Procter & Gamble, Kroger, General Electric, and 
     Cincinnati Bell--banded together to prod the city's fourteen 
     hospitals to reduce wide disparities in treatment fees and 
     hospital stays. This generated a 10 percent drop in the 
     average hospital stay in 1992 from 1991 and a 5 percent 
     decrease in the cost per case (an average saving per hospital 
     admission of $350). After health insurance premiums soared 30 
     percent in 1990, Forbes magazine gave its employees an 
     incentive to avoid filing claims for routine medical care. 
     They'd be refunded twice the difference between their major-
     medical and dental claims and $500. The results are eye-
     popping. In 1992 claims fell by 23 percent and the magazine's 
     insurer, CIGNA, gave it a $200,000 rebate. Premiums were then 
     cut 17.6 percent for major-medical and 29.7 percent for 
     dental. In 1993, Forbes boosted the refund to twice the 
     difference between their claims and $600.
       I could go on and on, citing both companies and health-care 
     organizations that have increased efficiency and cut costs 
     while maintaining quality. (The Washington Business Group on 
     Health has published such a list, in a booklet called ``The 
     Health Reform Challenge: Employers Lead the Way.'') It's not 
     the private sector but the federal government that has failed 
     to curb exploding costs.
       There's an obvious solution here: extend the managed-care 
     revolution to Medicare and Medicaid. This, rather than 
     reforming the entire health-care system; should be Clinton's 
     first priority. Billions could be saved simply by sending 
     Medicaid patients to HMOs, a step implemented thus far only 
     in Arizona, and billions more by encouraging Medicare 
     beneficiaries to try managed care. The savings in Arizona 
     haven't been epic--6 percent less than traditional Medicaid 
     costs--but with its large number of retirees the state had 
     start-up problems other states won't face. Elwood is 
     convinced that, through HMOs, Medicaid costs can be 
     stabilized at the level of general inflation and patients can 
     get better care.
       Medicare is trickier. The Clinton administration backed 
     away from steering the Medicare elderly into HMOs after a 
     study found the government was losing money by doing so. Only 
     2.5 million of the 36 million Medicare beneficiaries had 
     signed up for HMOs, and these tended to be the younger, 
     healthier ones. The government was paying HMOs too much for 
     their care. The answer is either to pay HMOs less or get more 
     Medicare patients, including the older, less healthy ones who 
     need more care, enrolled. Or both.
       Bringing managed care to government programs is the 
     brainchild of David Harrington, vice president of Chicago's 
     Grant Hospital and former chief strategic planner for Aetna 
     Insurance. ``Energy and creativity are already producing 
     results in the private market,'' he told columnist Morton 
     Kondracke. They can do the same with Medicaid and Medicare. 
     More broadly, Harrington insists, market forces, if left 
     alone, will gradually push down insurance costs far enough so 
     that small employers can afford to cover workers. And if the 
     government chooses to let the uninsured join HMOs, perhaps 
     with subsidies, we'd have universal coverage. Of course, 
     there would still be medical inflation. Heavy demand for 
     care, the intensive brand of medicine practiced in the United 
     States, pharmaceutical research, technological innovation, 
     union contracts with lavish health benefits, a growing and 
     aging population--these guarantee some inflation. But it 
     would stay near the general rate of inflation.
       One thing stands in the way: the Clinton administration. 
     Its health-care plan would remove the force driving the 
     downward trend in health costs--businesses that insure 
     employees--from the game. Under Clinton's scheme, 
     companies would pay a set amount to a ``health alliance'' 
     and have no further involvement. They would have no 
     financial incentive to curb the health costs of their 
     employees. Their bottom line wouldn't be affected if 
     workers rang up heavy medical expenses.
       In fact, Clinton's scheme would spur individuals to do 
     exactly that. And this would drive up medical inflation, not 
     control it. Clinton's plan, as he put it at a White House 
     meeting in January, would guarantee ``comprehensive benefits 
     that can never be taken away.'' The benefits--including 
     thirty psychotherapy sessions a year, treatment for drug 
     abuse and alcoholism, eye exams, and so on--would be much 
     broader than most Americans now have. My guess is folks would 
     take advantage, as they have in Germany and Japan (where 
     doctor visits occur three to six times more often than here). 
     This would increase national health expenditures. Or, if a 
     cap were put on health-care spending, inflation would take 
     another form, waiting lines for medical care, as it has in 
     Canada.
       Don't count on preventive care, Hillary's favorite 
     solution, to hold down costs either. True, patients would get 
     more preventive care, because the Clinton plan includes it, 
     free. But there's no evidence this would lead to lower 
     medical costs later as a result of early detection. More 
     likely, it would create a large increase in costs--just to 
     pay for the burst of preventive care. And, sorry to say, more 
     preventive care will have only a marginal impact on the 
     serious diseases like cancer and heart trouble that generate 
     huge health-care costs.
       In his first chat with White House staffers in 1994, the 
     president set the stakes very high in the fight over health-
     care reform. It's a question, he said, of ``whether we are 
     going to be able to maintain a health-care system and still 
     have the money that we need to invest in a growing and highly 
     competitive global economy so that America will be strong.'' 
     Clinton has the right question, but the wrong answer. Instead 
     of accelerating the revolution in health-care financing that 
     has contained costs while protecting the best medical system 
     in the world, he would end it. Not smart.

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