FULL AND EQUAL PARTICIPATION – A CONSUMER PERSPECTIVE I
(includes a 2.5 page CCAHS Position Paper on the ‘Consumers’ role in health care delivery, planning, evaluation, etc.)

The CCAHS board and staff were aware that federal legislation was attempting to develop and be inclusive of consumers in many areas of life in America. “Maximum feasible participation” was a buzz term with few clear guidelines and little in the way of effective monitoring to ensure compliance.

The previous issue of Health Perspectives addressed the undercurrent and explosion of alphabet soup agencies created to address the crisis in medical care delivery and the absence of the poor, disadvantaged, women and minorities and the challenges consumers faced to effectively participate in any meaningful way. This issue attempted to crystallize ways to effectively incorporate health consumerism into the mainstream of American medical care delivery.

The first task was to establish a rationale to support health consumerism. This was attempted by equating government with the people and the people to consumers. Since government funded a growing portion and total amount of all medical care expense, it seemed clear the government in behalf of the people and therefore consumers had obligations to ensure that what was purchased was effective, safe and fairly priced. Simultaneously, several current myths had to be debunked including those which supported the status quo relationship of the private sector providers and suppliers, the so-called private provider dominated, controlled and run non-profit organizations with the supposedly democratic government.

The organizations delegated to do the business of government followed the principle that the public would not tolerate direct government involvement in medical care delivery or even its payment. This principle was incorporated into the Medicare Act in its prologue and within various sections of body. The Medicare Act specifically stated that the government would have no role not interfere in the delivery of medical care. Hospitals would be monitored and their services paid for by independent third party organizations that had created the crisis.

Examples were the Joint Commission on the Accreditation of Hospitals (JCAH) to justify that the hospitals met standards set by providers. The JCAH’s board consisted of hospital and medical professionals with a rare sprinkle of public representatives. Payments to hospitals and doctors would be made through intermediaries and carriers which in fact were the insurance companies that were part of the problem. Blue Cross Association’s (BCA) affiliates (i.e. Associated Hospital Service of Greater New York, Inc. the then local New York City Blue Cross affiliate) handled hospital bills and commercial and non-profit insurers handled doctor claims. In a few cases for political purposes a geographical area might have several intermediaries and/or carriers. Medicare also split many service claims into components so that one part of the claim went to an intermediary (part A) and another part went to the carrier (part B).

The principles and the practical aspects of implementing Medicare ensured three main points. The aging public and middle class families responsible for them were (in conjunction with Medicaid passed in tandem with Medicare) had insurance and could walk away from financial responsibility for their parents and great grandparents; hospitals and doctors would be paid for services that were formerly reduced or written off and paid with few questions asked; and, the insurers which had left the field of covering the aged because they were financial losers for the bottom line were now paid and paid well to process payment (i.e. accept the claim, check with the SSA main computers in Baltimore, MD for eligibility and then apply the Medicare standards for payment to the providers and calculate the beneficiaries’ responsibility).

Johnson was a determined president and a master of passing federal legislation. And he was also astute enough to know that compromises would be necessary to pass this critical and massive medical care coverage for Social Security participants/beneficiaries.*

But in doing so, the JCAH maintained control over hospital participation as a provider. State licensing agencies which also has authority to approve hospitals as qualifying participating providers soon were marginalized as provider controlled organizations were delegated under the law to evaluate the necessity (not the quality) of hospital and doctor services. Eventually hospitals gained delegated power to evaluate care delivered within their own walls. Doctors controlled the original Professional review organizations (PRO) which were replaced by the Independent Professional Review Organizations (IPRO).

And with the massive funding, guaranteed and not often questioned, the role of the lobbyist became paramount and most effective in quieting any meaningful consumer role. And as the funds increased the private sector entrepreneurs invaded the once somewhat idealistic medical care delivery sector.

This issue in response to the political and economic drivers sought to offer positions in the form of a 2.5 position paper on health consumerism. The key seen at the time was that rationale planning of medical care services combined with government monitoring would make the system work. Goals and sub-goals are laid out in this position paper. As can be seen, the issues are still there today.

*Despite the fact that the federal government and many states had provided what would today be called socialized medicine, mostly for the armed forces, maritime services and prisoners, presidential efforts to cover everyone, or at least a significant portion of the American population, with a government medical insurance program were consistently overwhelmed by coalitions of providers, corporate and other employer coalitions, organized labor, conservative factions and the general population though fronts supported by behind the scenes ideologues. While the CCAHS publications touched on prior efforts here and there, it failed to put together a publication outlining this history. See (add a link here to a piece ETG will write summarizing that history).