Around the Nation

Around the Nation

HMO says doctors will decide treatment

United is the nation's second-largest health insurer, covering 14.5 million people.

The move accelerates a trend among health maintenance organizations to give doctors and patients more freedom. But it raises questions about how HMOs will control rising costs and whether consumers will be best served by a return to the "doctor-knows-best" philosophy.

United said its decision makes fiscal sense because it was paying more money to scrutinize and deny questionable treatments than the practice saved.

United will still ask doctors to justify such decisions as ordering surgery or expensive diagnostic tests. And the change doesn't mean that United will pay for services that are currently not covered, such as cosmetic surgery.

But under the new policy, the doctor will have the final say on how the patient will be treated, the company said yesterday.

United said doctors will be evaluated over the long term instead of case by case, and those found to be practicing wasteful medicine will be dropped from the health care network.

"This is a double-edge sword for patients," said Charlie Inlander, president of the People's Medical Society, a consumer health group based in Allentown, Pa.

He said doctors and consumers will benefit from no longer having treatment delayed or rejected - a major complaint that has prompted patient rights legislation in Congress and lawsuits against HMOs.

However, managed care is also intended to protect consumers from falling prey to unnecessary or ineffective procedures.

United's approach could result in higher insurance premiums, said John Erb, a health benefits consultant in Boca Raton, Fla. "The corollary here is: Be careful what you wish for, you might get it," Erb said.

Karen Ignagni, president of the American Association of Health Plans, said she expects more plans to follow United's strategy.

"Doctors and health plans are going to work collaboratively," she said. "Health plans are evolving to respond to the key objectives of patients and physicians."

Dr. Thomas Reardon, president of the American Medical Association, said: "Doctors will receive this news well. We've always advocated that it should be doctors making the determination of what is medically necessary."

The ability of HMO managers to overrule doctors' decisions about what procedures and services are medically necessary - and thus covered by insurance - has been a basic rule of managed care. It also has been a policy that HMO officials insist was responsible for bringing down the steep health cost increases of the late 1980s and early '90s.

Doctors and patients have argued, however, that the policy put patient care in conflict with HMO profits.

In response, United and other HMOs in recent years have relaxed many of their stringent rules. They have reduced the number of procedures requiring pre-approval, allowed patients to go directly to specialists in the health plan's network and have given patients the ability to appeal coverage decisions to an independent arbiter.

Some observers noted United's move might also have been spurred by liability concerns. A number of leading trial attorneys have sued several leading health plans in the past two months.

Rep. Greg Ganske (R-Iowa), a key backer of House-backed legislation to make health insurers more accountable to patients, said United's move was "sort of an admission on their part that their management techniques have not only been wrong for the patient but it's been wrong for them, for their bottom line."

United was one of the first major health plans to evaluate doctors against their peers and national standards on a variety of criteria such as giving mammograms to women and vaccines to infants. United has provided the information to doctors, and soon will be giving it to members.

High court declines death penalty cases

The court rejected appeals from Florida and Nebraska inmates who had been on death row for nearly 25 and 20 years, respectively, and claimed that delayed executions violates their Eighth Amendment rights.

There was no statement on behalf of the full court in its denial of the separate petitions, but Justice Clarence Thomas penned a concurrence.

"I write only to point out that I am unaware of any support in the American constitutional tradition or in this court's precedent that a defendant can avail himself of the panoply of (appeals) and then complain when his execution is delayed," Thomas began.

He then detailed what he called the Supreme Court's "Byzantine death penalty jurisprudence," which permits several levels of court hearings intended to ensure a defendant has not been unfairly sentenced to die.

In a painstaking dissent heavy on comparisons to foreign law, Justice Stephen G. Breyer wrote, "A growing number of courts outside the United States - courts that accept or assume the lawfulness of the death penalty - have held that lengthy delay ... renders ultimate execution inhuman, degrading, or unusually cruel."

Breyer noted that most of the delays in the Nebraska and Florida cases arose from constitutional problems with those states' death penalty procedures. Both states' methods had been declared unconstitutional, and the inmates involved were subject to new proceedings and again sentenced to death.

In his nine-page statement arguing that the court should have taken up the appeals, Breyer observed that high courts in India and Zimbabwe consider protracted delays when deciding whether the death penalty can be carried out. He also said the Privy Council in Jamaica had concluded it is "inhuman" to keep a person facing the agony of execution over a long period of time. And he noted that the European Court of Human Rights had prohibited the United Kingdom from extraditing a potential defendant to Virginia a decade ago partly because "the 6- to 8-year delay that typically accompanied a death sentence amounts to "cruel, inhuman, or degrading treatment or punishment' forbidden by the convention."

While such foreign authority is not binding in the United States, Breyer said, "this court has long considered as relevant and informative the way in which foreign courts have applied standards roughly comparable to our own."

The most recent statistics from the Department of Justice show that as of December 1997, 24 inmates had been on death row for more than 20 years and dozens of others were close to that tenure. The cases were Knight v. Florida and Moore v. Nebraska.

Senate to debate agribusiness mergers

Now the Justice Department is being asked to approve a deal in which the largest pork processor would take over its nearest competitor.

It would be the latest in a wave of mergers and acquisitions reshaping the U.S. agriculture and food industries.

The Senate is to vote this week on a proposed 18-month moratorium on agribusiness mergers.

Telecommunications, banking and other industries are going through similar consolidation. But some farmers say they are especially vulnerable, and the concentration of market power threatens their traditional independence if not their livelihoods.

"We're not anti-merger, we're just pro-competition," said Missouri farmer Charles Kruse, who lives near a Mississippi River grain terminal that the Justice Department is forcing Cargill to sell in order to buy Continental Grain Co.'s grain operations.

"You're never going to go back to the time where you have the small, very geographically determined, companies in the seed business or whatever," Kruse said. "But by the same token, it's really important from a farmer's perspective to have legitimate competition for the things that you buy and also to have legitimate competition for the things that you sell."

The farm economy is stuck in its worst downturn since the mid-1980s, and while economists say the problem stems from worldwide overproduction, many farm-state lawmakers point to agribusiness mergers as a culprit.

A handful of companies, including Cargill, IBP Inc., Smithfield Foods Inc. and ConAgra Inc., control much of the beef and pork that's processed in the country. More than 60 percent of the flour milling and 80 percent of the soybean crushing is done by four companies.

"These conglomerates have muscled their way to the dinner table. There's a direct relationship between this concentration of market power and low prices," said Sen. Paul Wellstone (D-Minn.), who has been pressing for tougher administration reviews of possible antitrust violations.

Many economists say it's more complicated than that. They say companies cut their costs by merging and pass the savings on to both farmers and the public.

Farmers are divided over the question. Many producers, such as poultry growers and farmers who provide vegetables for food manufacturers, find they can manage their financial risks more easily by having contracts with processors. Such contracting, in turn, allows processors to control the quality of the commodities they buy and more easily trace problems with food safety.

"I don't believe that stopping these changes in their tracks is necessarily the right option. Nor is averting one's eyes from these changes," said Alan Barkema, an economist with the Center for the Study of Rural America at the Federal Reserve Bank of Kansas City. "They are sea changes in the way the industry does business."

The American Farm Bureau Federation, the nation's largest farm organization, has come out against a moratorium. The smaller National Farmers Union and some other groups support it. "There are a lot of different opinions," said Farm Bureau lobbyist Caroline Anderson.

Food processors, from the American Bakers Association to the American Meat Institute, also are fighting the moratorium. They told senators in a recent letter that it would force faltering businesses to shut down and put employees out of work.

Although the Clinton administration has taken no position, Justice Department officials have told Congress existing antitrust laws are adequate to protect the interests of farmers and consumers.

Cargill, North America's second-largest grain trader, was allowed to acquire the grain operations of No. 5 Continental Grain, provided the companies sold some of their facilities, including the terminal near Kruse's farm at Caruthersville, Mo.

Last week, farm machinery makers Case Corp. and New Holland NV were told they could merge only after selling some of their holdings.

Last year, the department allowed the seed and chemical giant Monsanto Co. to spin off some corn technology interests, then acquire DeKalb Genetics Corp. The department is currently reviewing Monsanto's acquisition of Delta and Pine Land Co., the world's largest producer of cotton seed.

Smithfield, the biggest pork processor as well as the largest hog producer, is seeking the department's approval to acquire No. 2 producer Murphy Family Farms of Rose Hill, N.C.

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