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JAMES FLANIGAN

One Casualty of Clinton's Health Plan: Freedom to Choose

September 22, 1993|JAMES FLANIGAN

Like a family doctor, the Clinton Administration wants to put Americans on a healthy diet--so it's going to restrict their use of health care, particularly the high-priced services of specialists.

That's the heart of the program the President will present to the nation Wednesday night. In order to extend care to all, Clinton has to cut care for some. That's why reining in specialists is central to the plan.

Financially speaking, the plan has a shot at curbing the growth of America's health care bill--which ran to roughly $800 billion last year.

But medically speaking, the plan will reduce the amount of health care most Americans are used to.

Finance is the easier part. The Administration's aim is to slow the growth of medical costs from last year's 9.4%--almost double the growth of the total economy including inflation--to a rate equal to the overall economy by 1997.

That means medical costs could still rise 6% by 1997, so it's not an impossible target. If the reforms can wring $50 billion a year out of the system--after allowing for costs that will rise as a result of this plan--the Administration will be on target.

But medical care for most people will change dramatically. Most individuals will not have a choice of doctors. Rather, they will have a choice of insurance plans. If they choose the plan their family doctor belongs to, then they also accept other consequences.

As it used to be long ago, the family doctor will be responsible for all of a patient's medical care, including the costs of that care. The primary-care physician--a family practitioner, pediatrician or obstetrician-gynecologist--will be a gatekeeper, with the authority to decide when and if to refer patients for specialized care or treatment.

The insurance group or regional health alliance will be looking over the primary doctor's shoulder, whose role in the new system will be like that of a plant manager who must stay within budget or answer to the front office. Patients will not be able to go directly to specialists for treatment--at least if they want insurance to pay for it.

The Administration's thinking is that gatekeepers will hold down referrals and thus reduce medical costs. "This is budgeting, not rationing," says Dr. Stephen Miles approvingly. Miles, who is head of the Center for Biomedical Ethics at the University of Minnesota, believes that overuse of specialists accounts for much of America's excess health costs--so cutting back won't affect quality.

But reality will be different, say family practitioners on the front lines. Dr. Terence Hammer, a family doctor in Torrance, notes that there's an absolute shortage of primary-care physicians, so reform will bring turmoil and argument. "There's no infrastructure for this plan to work in," says Hammer.

He has a point. Primary-care physicians number 40% of America's 653,061 doctors. The surgeons and specialists in heart, brain, blood and bone medicine number 60%, which is not surprising considering that since the 1950s the vast majority of medical students have gone into specialized practice because that's where the higher incomes have been.

Now the Clinton plan seeks to elevate primary-care doctors, but it will take years to train enough people. Meanwhile, First Lady Hillary Rodham Clinton has identified her model for the new health system: It is Park Nicollet Medical Center in Minneapolis, a group practice of 45 salaried physicians.

A giant compared to the typical medical practice, Park Nicollet can achieve economies of scale and also innovate. Its doctors have developed a test for breast cancer that cuts costs by 30%, boasts the group's president, Dr. James Reinertsen.

That may be the ideal, but most people will experience more mundane cost cutting in everyday medicine. "For example, we know that almost all backache patients get better within a year whether we take extraordinary measures or not," says Dr. Marian Wymore, a family practitioner at Los Angeles' Little Company of Mary Hospital. "So if you have a backache, you might want physical therapy to speed your recovery, but I might refuse and tell you only to rest because therapy will put you over budget."

Most Americans, who have enjoyed fully insured medical care, with access to specialists and instant treatments, "will have to lower their expectations," says Wymore.

There will be a political outcry when the middle class realizes it must accept less. But there are advantages too: The new health plan will bring all Americans into medical coverage and it will make coverage secure for all, so no one needs to fear being cut because of chronic illness or loss of job.

How will it all come out? The American Health Security Act will be passed by October, 1994, "before the midterm elections," says Michael Bromberg, a Washington lobbyist for a federation of 1400 nonprofit hospitals. "Clinton will get some but not all of what he's asking," he predicts.

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