Health Plan Calls for Variety of Quality Controls : Medicine: Proposals include information to help consumers assess performance of providers. System of treatment standards is also pushed.

For millions of middle-class Americans struggling to decide what to make of President Clinton’s health care reform plan, perhaps the most pressing question is: How will it ensure top quality when all the emphasis seems to be on cutting costs?

True, 37 million Americans lack health insurance. But some 200 million have access to a system that, for all its shortcomings, still offers the world’s best medical care.

The Administration’s answer is to create a consumer-oriented National Quality Management Program that would promulgate a “core set of quality and performance measures” to assess the quality of every health insurance plan, medical institution and doctor in the country.

Such information would be made public regularly as a way to help citizens become more discerning consumers of health care as they go about selecting health plans, doctors and hospitals in a newly designed health care system.

The system is also intended to inject more public accountability on the part of all medical providers.

At the same time, Clinton’s plan would move medicine toward a comprehensive system of standards of what constitutes the best course of treatment for any particular injury or disease, thus eliminating excessive or ineffective care.

Toward that end, the President’s plan calls for the federal government, assisted by the states, to accelerate the development of a relatively new field of medical inquiry known as “outcomes research,” in which experts attempt to use statistics and other analytical and diagnostic tools to decide the best course of treatment for certain conditions and diseases.

The government already has three such projects in the works, involving anesthesia, emergency medicine and gynecology.

The Administration’s ambitious plan to ensure high levels of quality is revealed in a near-final draft of Clinton’s proposed American Health Security Act.

First Lady Hillary Rodham Clinton, who led the White House task force on health care reform, drew attention Friday to the new information network designed to improve and monitor the overall quality of a newly designed health care system.

“We need better information,” she told a group of state legislative leaders in Washington.

“The federal government and the state government will have to take more responsibility for collecting information about quality and for disseminating it so that . . . physicians, hospitals, providers, patients--all of us--know, so we can make more informed choices,” she said.

“I’m very excited about some of the proposals that we will have for quality because the kind of quality we’re talking about will change the way we practice medicine and how we take responsibility for ourselves. . . .”

The President’s proposals would create a seven-member National Health Board to set federal standards and oversee state implementation of health care reform. A 15-member advisory council would be established as an adjunct to the board and administer the National Quality Management Program.

The program is necessary, Clinton’s proposals state, because “patients play a minor role, lacking reliable information upon which to compare the quality of health plans, providers or treatments.”

The foundation of the President’s health care reform agenda is the creation of large “alliances” of consumers who band together to shop among medical providers for insurance plans at the best price and quality.

The quality program would conduct consumer surveys to assess public satisfaction with the health plans and publish annual reports outlining the results of these and other measurements of the quality and performance of health plans, institutions and practitioners.

Another program goal is the development of standard “practice guidelines” for specific medical conditions and illnesses. Recent research has uncovered huge variations in what different doctors and hospitals do--and charge--for essentially the same diseases.

Hillary Clinton spoke about such discrepancies in her speech Friday.

“You might have a coronary bypass in one hospital in a state costing $20,000 (but) in a hospital down the road or across the state costing $60,000,” she said. “And when outcomes have been carefully compared, the more expensive operation doesn’t necessarily have the better outcome. . . . Quality has to be the key to everything we do.

“We have to ask ourselves: Will this be good for patients? Will this be good for physicians, nurses? Will this make quality better? I will not want a health plan that . . . can’t answer that question affirmatively.”

But the National Quality Management Program could run into strong opposition on at least two fronts. Many physicians ridicule practice guidelines as “cookbook medicine” and say the notion is not as simple or straightforward as it might seem.

For instance, they say, many patients have multiple conditions or other complicating factors that do not lend themselves to anything but individual treatments.

In proposing a vast electronic network to gather and disseminate data measuring the quality and effectiveness of doctors, hospitals and health insurance plans, the President’s proposal faces certain opposition from legions of doctors who will view it as more government intrusion into the once-sacrosanct physician-patient relationship.

On the other hand, some doctors embrace the practice guidelines because they could potentially serve as evidence in defenses against medical malpractice lawsuits--if a doctor can prove that he or she followed such procedures.

Clinton’s plan calls for the Department of Health and Human Services to set up a pilot program in which physicians relying on practice guidelines would not be liable for medical malpractice if they can demonstrate compliance with such guidelines. The state of Maine already has embarked on such an experiment.

A second potential trouble spot for the program is the opposition of civil libertarians, who say privacy violations or abuses are almost inevitable when a national databank comes into play.

Such concerns, at least in part, persuaded the Administration to back off from a proposal to issue to all citizens and legal residents “health security” cards containing their personal medical histories. Instead, the identification cards will contain only “a minimal amount of information,” according to the Clinton proposals.

To allay fears about privacy violations, Clinton will propose the creation of a “national privacy panel” to focus on such issues.

The Administration also hopes to use the new information network to crack down on cheaters, and it is seeking new criminal and civil penalties against those found guilty of fraud and abuse in the health care system.

Basics of Clinton Plan

The broad outline of the President’s proposal, to be unveiled Sept. 22, is expected to call for the plan to work this way:

1) You pay here: Workers and employers contribute a percentage of employee’s paycheck as a premium. Additional revenue would come from likely increase in federal tax on cigarettes and possible increase in alcohol tax. Government would pick up tab for the unemployed and others.

2) Money goes to alliance: A government established agency becomes the go-between for patients and doctors. It negotiates with networks of doctors and hospitals for the best prices for services.

3) You pick a plan: The networks--either actual HMOs or functioning like them--offer several plans. You pick the plan that suits your needs. If you wanted to retain your doctor, you’d pick a plan he or she joins.

You should know . . .

* Worker premium expected to be 2% to 3% of paycheck.

* A “plan” would list the doctors, hospitals and clinics available to each member.

* Those 65 and over would still he covered by Medicare.

* Once a year, every consumer would have the chance to change plans.

* Companies with more than 5,000 employees could offer coverage independent of the alliances.

Sources: Los Angeles Times