a. Medical technology
b. Practice variations
c. Effectiveness of medical practices and drug therapies based on research performed by the Agency for Health Care Policy and Research
d. Information from clinical and epidemiological studies
e. Information provided by Accountable Health Plans including AHP specific information on clinical health, functional status, well-being, and plan satisfaction of enrolled individuals.
The Health Benefits' Board will also work to provide the National Health Board with its assistance in developing standards for the National Data Reporting System, which will protect confidentiality of enrollees, but may provide for the disclosure of information of particular providers within Accountable Health Plans. Such reporting will be on a national, state, and community basis. The National Data Reporting System will permit Accountable Health Plans comparisons on the ability of AHPs to maintain and improve clinical health, functional status, and well-being and to satisfy enrolled individuals. The reports formulated by the board will be sent to Accountable Health Plans, Health Plan Purchasing Cooperatives, governors and each state legislature.
Health Plan Standards' Board
The members of the Health Plan Standards' Board will be taken from nominations submitted from organizations that represent various groups with an interest in the health care system and the functions of the National Health Board. The function of the Health Plan Standards' Board is to recommend to the National Health Board standards for Accountable Health Plans (other than comprehensive plans which include services and procedures that are not included in the uniform set of effective benefits, but employers and individuals who purchase those plans will receive a tax break only for the least costly package of benefits. Accountable Health Plans must also require copayments for medical services, except for preventative care.
Each Accountable Health Plan must provide for the collection and reporting of standardized information, in electronic form, to the National Health Board. This information shall include at least the following:
a. Information on the characteristics of enrollees that may affect their need for or use of health services.
b. Information on the types of treatments and outcomes of treatments with respect to the clinical health, functional status, and well-being of individuals.
c. Information on enrollee satisfaction, based on standard surveys prescribed by the National Health Board.
d. Information on health care expenditures, volume and prices of procedures, and the use of specialized centers of care.
e. Information on the flexibility permitted by plans to enrollees in their selection of providers.
The Accountable Health Plan must enroll all individuals who apply for coverage and may not deny, limit, or make conditional the coverage (or benefits) under the plan based on the health status, claims experience, receipt of health care, medical history, or lack of insurability of an individual. The Accountable Health Plan may exclude coverage with respect to services related to treatment of a pre-existing condition, but the period of such exclusion may not exceed six months beginning on the date of coverage under the plan. The exclusion of coverage shall not apply to services furnished to newborns and to pregnant women.
Each Accountable Health Plan will receive pre-emption from state laws that mandate benefits. Under the Managed Competition Act, no state shall establish or enforce any law or regulation that requires the offering, as a part of an Accountable Health Plan, of any services, category of care, or services of any class or type of provider that is different from the uniform set of effective benefits. This is important to the chiropractic profession, because the precedent could be set for exclusion of standards related to the uniform set of effective benefits and the National Health Data System.
The Managed Competition Act of 1992 also provides for malpractice reform through uniform standards for malpractice claims and for paperwork reduction and administrative simplification.
Malpractice Reforms
The Managed Competition Act calls for the formation of "uniform standards for malpractice claims." Defensive medicine is recognized as being a chief reason for the escalating health care system in the U.S. and the associated legal expenses of malpractice actions. The bill makes substantial changes in the law, including limiting noneconomic damages to an amount that shall not exceed $250,000, regardless of the number of health care providers, health care providers, health care professionals, and health care producers that claims are brought against or the number of actions or claims brought with respect to the injury. Additionally, no person may be required to pay more than $100,000 in a single payment in damages (whether economic or noneconomic losses) for expenses to be incurred in the future. The bill provides for mandatory offsets for damages paid by collateral sources to the individual. The total amount of damages received by an individual shall be reduced by any other payment that has been made or will be made to the individual that will compensate the individual for the injury that was the subject of the action or claim.
Attorneys' fees will be substantially limited to an amount that will not exceed 25 percent of the first $150,000 of any award or settlement paid to the claimant, or 15 percent of any additional payments to the claimant. The total amount of punitive damages that may be assessed with respect to an action or claim may not exceed twice the total amount of the damages awarded to the claimant. This is regardless of the number of providers, professionals, or producers involved. Furthermore, a statute of limitations will be adopted in which no medical malpractice claim may be initiated after the expiration of the two year period that begins on the date of the alleged injury. Exceptions will be allowed for minors under six years of age who have suffered injury. This legislation supersedes state laws, except where they are more stringent than federal laws.
Paperwork Reduction and Administrative Simplification
The Managed Competition Act would establish national goals for health plans to achieve efficiencies from the use of standardized claim forms and electronic transmission of data. This action would take place under the responsibility and authority of the National Health Board. Currently, it is estimated that at least five billion dollars in annual health care expenditures could be saved by reducing the paperwork required by the nation's 1,500 insurance companies with their multitude of forms.
The Texas Chiropractic Association's legislative team for National Health CAre, comprised of DCs S.M. Elliott, Steve Elliott, Ben Beard, Craig Benton, Jim Zaruba, Charles Argubright, and myself, have been active in promoting chiropractic inclusion in the Managed Competition Act through meeting with the key sponsors of the legislation. Meetings to date have been extremely positive and the group has been able to offer suggestions to aid the implementation of the legislation. The Texas Chiropractic Assoc. has experience operating in a system similar to the proposed national health care system through its involvement with the current Texas Workers' Compensation system, and has direct working knowledge of the positive and negative aspects of such a system. More meetings are planned with some of the key individuals that will be responsible for implementation of the the Managed Competition Act and the previously mentioned group.
Implications for Chiropractic Practice in Managed Competition
It is readily apparent that clinicians will be subjected to a high level of accountability for their services under a managed competition system. The rising costs of health care and the public outcry for reform will mandate this accountability. Such levels of accountability will impact on each physician's practice in the area of record keeping and case reporting. Furthermore, the pre-emption of state laws related to the practice of utilization review agencies will also impact on record keeping, reporting, and standards of care for the profession, as previously mentioned. Chiropractic has a rich history of cost-effective health care delivery and it is imperative that each chiropractic physician get behind the current legislative push to obtain chiropractic inclusion in the uniform set of effective benefits. Through chiropractic inclusion, tremendous savings can be realized in the health care system. Chiropractors must be in a position to act as gatekeepers for spine related complaints, rather than letting the specialist community dictate the course of care for the patient. Thus, positive outcomes may be realized throughout the health care system.
There is a move in the Managed Competition Act to push health care back into the primary care realm and away from fractionated treatments rendered by multiple specialists. The bill will stress greater use of preventive care, a concept that was unheard of outside the conservative care arena a few years ago. Because Accountable Health Plans will be offering insurance and health care as one product, there will be a strong financial incentive to keep enrollees healthy. It is essential that chiropractic physicians position themselves as primary care physicians in the upcoming system and avoid the pitfalls of specialization, which would imply access to patients via referral only.
The next few years will be exciting. Rapid-fire changes will most likely occur. It is essential that the chiropractic profession avoid the divisions in the ranks that have limited it over the years in order to achieve the best possible health care for the most important person in the system -- the patient.
Brad McKechnie, D.C., DACAN
Pasadena, Texas
Editor's Note: The 16-member multidisciplinary Texas Workers' Compensation Commission's Medical Advisory Committee that Dr. McKechnie has been on the past two years as the chiropractic representative, is responsible for recommending changes to the workers' comp. system. Dr. McKechnie says his team has been "active in formulating standards of practice guidelines that will go beyond the Mercy Guidelines, by analyzing the top 100 ICD-9 diagnoses for chiropractic and then constructing a statistical data base for claims analysis." The data base they using can assist length of care, modality usage, office visit frequency, and amounts billed and paid. These items are subjected to a bell-curve statistical analysis.
Dr. McKechnie also serves on groups responsible for the Physical Medicine Treatment Guide, Spinal Manipulation Guides (for use by DCs, MDs, and DOs), impairment rating standardization, and a group that is responsible for recommending additions to the North American Spine Society Code Manual, which may replace the ICD-9 diagnosis system for spine-related diagnoses in the Texas workers' compensation system.
Dr. McKechnie reports that he has kept a good line of communication between Mike Andrews (D-TX) and his staff, and with Charlie Stenholm (D-TX).
"I spent almost two hours with Congressman Stenholm last month and he recently sent me a letter inviting comments and suggestions to HR 5936. We spent over three hours with Dave Kendall, the staffer from Congressman Andrews' office last November and he was extremely impressed with the chiropractic profession's grasp of economic reality. Andrews's office wrote to us and indicated they were going to take a second look at chiropractic inclusion based on our efforts and due to the cost-effectiveness data that we are able to provide.
"The similarities between HR 5936 and the Texas workers' compensation system are uncanny. Neither Andrews or Stenholm were aware of the sophistication of data collection and of the mandated standardization of claims submission that exists in Texas at the present time. I have also been advised that every state in the country is watching the events in Texas, as no other state is running a system as sophisticated as this one."