WASHINGTON _ If you listen to Alan Hillman, President Clinton'scomprehensive Health Security Act is "dead in the water" andCongress will enact an incremental overhaul of the nation's health caresystem. He also believes that the road to health care's future will bepaved with cost-effectiveness studies.Hillman may know what he is talking about: he was one of the original100 members of Clinton's Working Group on Health Care Reform lastyear and he is a widely published expert on outcomes research,managed care and physician behavior from the University ofPennsylvania's Leonard Davis Institute of Health Economics.Since the public debut of Clinton's Health Security Act last fall,Hillman has publicly disowned the document. "It is unworkable _ it's1,350 pages of totally incomprehensible nonsense," said Hillman lastweek during the Eighth International Biotechnology Meeting &Exhibition in Toronto. Hillman was one of four experts that spoke in aworkshop called Health Care Reform Comparisons: United States andCanada."After they got input from the first 100 experts [the Working Group],they consulted several hundred more," he explained to BioWorld. "Theplan was transmogrified, like Dr. Jekyll and Mr. Hyde."But Hillman believes that the Clinton administration's drive to reformhealth care is not fueled by altruism (i.e., providing coverage for the 37million people who are uninsured) but rather by economic crisis. "Thisis no longer a moral, social problem," said Hillman. He cited thefederal deficit, skyrocketing Medicare costs and a phenomenon called"job-lock," whereby people are afraid to start new businesses for fearof losing their health care."Eight hundred dollars of the average cost of a Chrysler car goes topaying the health care premiums for the workers who build that car,"said Hillman. "That means Chrysler can't be as competitive worldwide,another economic reason for reform."Hillman acknowledged that political foes of the Clinton reform planwho have attacked it for its "big government" approach, includingglobal budgets, may win out in the short-term. Some in Congress haveadvocated a more gradual and less comprehensive overhaul of thesystem. Such incremental reform might be effected through changes intax and insurance laws and would rely more heavily on market forcesto cut costs than Clinton's plan.Try Managed Competition"I believe we should try managed competition as a marketplacesolution to this (rising health care costs) and see how efficient it can beand see if we can make choices in a free market kind of way," saidHillman. "But I have my doubts if that's going to work and if itdoesn't, we're going to need global budgets."A global budget would place a cap on spending and thus force healthcare suppliers and providers to lower costs. The concept has beenequated with rationing and many legislators view rationing as apolitical poison pill.But Hillman argued that the U.S. must ration health care if it is tocreate a workable, affordable system. "We absolutely have to ration.It's a silly idea that we are not rationing already. We are rationing byability to pay," said Hillman. "Eighteen to 25 percent of the population,depending on how you count, has to wait until their diseases are end-stage and have to go the emergency room."Rationing can be explicit, as it is in the state of Oregon where coveredprocedures and medicines are listed, or implicit. According to Hillman,the implicit rationing of the nationalized health care system in Englandcreates an environment where "patients just don't ask and doctors justdon't offer certain very high-tech technologies to old people withmetastatic cancer."The light at the end of the rationing tunnel, according to Hillman, iscost-effectiveness analyses of new medical technologies. "Cost-effectiveness analyses are determining the value of new interventionsso you can make these rationing and allocation decisions," saidHillman. But cost-effectiveness is far more than simply buying "thecheapest thing," he said.Outcomes Research Determines Needs"Outcomes research is a very sophisticated science and we are movingalong toward studying true outcomes, designing true prospectivestudies of new technologies to decide what is appropriate to offer ourpopulation and what is not."Hillman's advice has already been heeded by the biotechnologyindustry. In fact, two California biotechnology companies _ AmgenInc., of Thousand Oaks, and Genentech Inc., of South San Francisco,_ last year joined a task force headed by Hillman to establishvoluntary principles and guidelines for the reporting and conduct ofresearch in health economics. The group, funded by drug companieswith a $500,000 grant, consists of representatives from drugcompanies, scientific journals, the U.S. government and academia. Thetask force could finish its work by the end of the year.Hillman initiated the project out of his concern that outcomes researchand pharmacoeconomics, both "valid scientific fields," would becomemarketing tools in the hands of companies scrambling for market share.He said one possible recommendation might be the establishment of anindependent panel to serve as a watchdog for the quality of outcomesresearch data compiled by companies."The most effective way to cope with change is to help create it and Ithink what we need to do is make a cultural shift in the U.S. towards acost-effective way of allocating resources," said Hillman.Although Hillman predicts that Clinton's health care reform plan won'tbe passed into law, he does believe that health care legislation will beenacted. I believe that Mr Clinton will do what is necessary to getlegislation passed. If necessary, [he will] give up a second term for it inorder to go down in history as the president who finally got health carecovered."

-- Lisa Piercey Washington Editor

(c) 1997 American Health Consultants. All rights reserved.