With health care reform at the top of the Congressional and White House agenda, it’s prime time for industry lobbyists.

Booming business, however, can have its own complications.

With all facets of the health industry — from insurance companies to drugmakers and provider groups — facing cuts, K Streeters with a speciality in health care are having to work around potential conflicts of interest that could put a crimp in their business boom.

While some lobbyists say they have clear lines about what kind of clients they will take, others say it’s something they deal with issue by issue with their clients’ guidance.

There’s an old saying in Washington that explains the idea: “Two clients is a conflict; three clients is a niche.—

“There’s no way to find a health care consultant in this town who doesn’t have some type of conflict,— said an in-house health care industry lobbyist. “It’s more about how do you manage conflicts. The bar in health care is to avoid conflicts on specific issues.—

The worry among some lobbyists and clients is that as health care reform takes shape, new client conflicts may arise that could pit client against client.

“Conflicts are way more nuanced because the lines of battle haven’t been clearly drawn yet,— said Stephanie Silverman of Venn Strategies, a firm with a large health practice. “There are so many different players at the table, and right now not knowing whose ox is likely to get gored and at whose expense … the best we can do is try and anticipate conflicts and be clear with our clients in advance.

“We certainly would not lobby on both sides of an issue. It’s also entirely possible that conflicts may emerge in the next two to six months, and we hope we don’t have to make hard choices, but we will if we have to.—

Some health care lobbyists say setting up coalitions is one way around the thorny issue of potential conflicts.

Michael Gaba, a top health care lobbyist at Holland & Knight, said his firm requires rigorous conflict checks before signing on new clients.

“Because the issues are so large in health care reform and there are more unknowns than knowns, what we’re finding is that when we do get approached, the way to manage a potential conflict is we can create a coalition,— Gaba said.

Recently his firm put together a group of physicians and health information technology companies to form the Imaging e-Ordering Coalition to push for policies they say would lower the cost of health care through new technologies.

Other firms establish internal barriers to manage the appearance of conflicts.

The Glover Park Group represents the Pharmaceutical Research and Manufacturers of America as well as the Pharmaceutical Care Management Association, which represents pharmacy benefit managers that are often at odds with PhRMA.

“We have a great working relationship with Glover Park, and we’re confident they have erected the appropriate firewalls,— said Ken Johnson, PhRMA’s senior vice president. “We expect our consultants to build the appropriate firewalls. And if they don’t, they’ll probably end up being fired.—

He added, “These companies go to great lengths to assure that sensitive information is not shared with competing interests.—

One lobbyist who leads a firm’s health care practice said that even when companies compete in the marketplace, those same companies are likely to have a similar agenda in Washington, D.C.

Lobbyists say it would be difficult to represent provider groups like the American Medical Association and health insurers, which are at odds over the funding for programs such as Medicare Advantage. Lobbyists who take pharmacy clients are often conflicted out of representing lucrative drug manufacturers.

But the bottom line comes down to what a client wants and what the lobbyist is willing to do.

“When I represent a client on the Hill, I want people to look at me and feel I’m a credible voice on behalf of the client,— said Rich Tarplin, a lobbyist who served as assistant secretary for legislative affairs at the Health and Human Services Department during the Clinton administration.

“I’d rather decline a client if there’s a potential conflict and maintain the credibility for my existing clients and try to make those relationships last as long as possible,— added Tarplin, who represents the AMA.

Another health care lobbyist, who did not wish to be identified, said that every client faces the same, competing pressures.

“Everybody you represent is on the chopping block,— the lobbyist said. “It’s about how do you manage the amount of pain being distributed across the board.—