Democrats Seek to Force Health Networks to Admit Any Doctor

Setting the scene for a high-stakes brawl between doctors and managed care networks, Senate Democratic leaders intend to include in their health reform bill a provision that forces the networks to admit any physician, informed sources said Thursday.

The so-called any-willing-provider provision is coveted by doctors--especially high-priced specialists--who fear that they may be shunned by the growing numbers of health maintenance organizations and other managed care groups.

By limiting the number of doctors and ensuring that they follow the group’s guidelines on medical care, the organizations can negotiate lower fees in return for giving physicians access to large numbers of patients. HMOs also tend to concentrate on primary-care doctors, restricting patients’ access to specialists.

Physicians say that the any-willing-provider provision would ensure that health care reform does not end a patient’s right to choose his or her doctor--or restrict a doctor’s ability to do what he or she deems is best medically.

But managed care networks--and many of the nation’s large employers that use them--say that the provision would seriously undermine cost-containment efforts by preventing the networks from negotiating the best possible rates with providers.

“It would be devastating to us,” said John M. Gibbons, a spokesman for the Alliance for Managed Competition, which represents the nation’s five largest insurers, who have a combined managed care population of 65 million Americans.

In a letter to members of Congress this week, leaders of the managed care industry warned that the any-willing-provider provision would “seriously undermine two key objectives of health care reform--cost containment and quality improvement--by eliminating health plans’ ability to select high quality, cost-effective providers.”

Until now, the fight between medical providers and the insurance industry-dominated managed care networks has been waged largely in state capitals. But with the impending introduction of major health reform legislation in the House and Senate, the issue is about to boil over in Congress--just one of many sleeper issues that have gone virtually unnoticed amid the debate over universal coverage and employer mandates.

Any one of such “second-tier” issues could “make or break” health care reform, one senior congressional aide said Thursday.

The divisiveness of the any-willing-provider issue can be seen in the fact that in recent years 19 states have enacted it while 10 have rejected it. And its fate in Congress is highly uncertain.

Also on Thursday, both Senate Majority Leader George J. Mitchell (D-Me.) and House Majority Leader Richard A. Gephardt (D-Mo.) were putting the final details on the bills that they hope to take to the floors of their respective chambers within the next few days.

With Gephardt set to unveil his measure today, House leaders continued their efforts to determine how many votes the bill--a version of legislation passed last month by the House Ways and Means Committee--could get.

“I think they are having very good success in talking to individual members and groups of members,” House Speaker Thomas S. Foley (D-Wash.) said, describing the initial reaction as “very positive.”

But Rep. Bill Richardson (D-N.M.), another member of the leadership, said that there will not be a clear picture of support for the measure until next week.

Some conservative Democrats were not enamored with the emerging package, which retains President Clinton’s controversial proposal that requires employers to pay at least 80% of a worker’s insurance premiums.

“I’m not at all interested in the leadership plan. It’s like the third variation of the Clinton plan,” Rep. Timothy J. Penny (D-Minn.) said.

Many House members are also reluctant to commit their votes to the health bill--especially on the employer mandate issue--until they have some indication of whether the Senate will retain the employer mandate.