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Clinton's Health Plan : Health Plan: A User's Guide : Picking a Plan Can Be as Wrenching as It Is Rewarding : Choices: The poor and those with complicated illnesses face the roughest decisions. Each has its pros and cons. Many Americans likely will opt for the least expensive.

September 26, 1993|SHERYL STOLBERG | TIMES MEDICAL WRITER

Even doctors need doctors, and every year Dr. Ezekiel Emanuel, a cancer specialist who also teaches medical ethics at Harvard University, has the freedom to pick from among five health plans for his personal medical care.

To Emanuel it is an awful chore--the forms, the cumbersome literature, the confusing process of figuring out which plan offers the highest quality at the cheapest price. And so every year he takes the easy way out, picking the plan that, although the most expensive, gives him the ability to visit any doctor he pleases.

"Hell, I don't know (what the brochures say) and I don't want to spend the time reading this chart; so I pick the one with the most flexibility," he says. "I haven't joined a managed care (plan), even though four of the five options are managed care."

Like Emanuel now, all Americans will eventually have to choose a health care plan if President Clinton's agenda for reform is enacted. While the President has ballyhooed "choice" as a key attraction of his proposal, make no doubt about it: For many consumers, choice will be as wrenching as it is rewarding.

Doctor-patient relationships will undoubtedly be severed. Consumers will be put in the position of evaluating the quality of health plans, doctors, hospitals and health centers--something many never thought about before. Even those such as Emanuel, whose employers already offer several plans to choose from, will have more range of choice than ever.

"People will have to cope with different types of choices," says Judith Bell, a co-director of the west coast office of Consumers Union. "It's not choosing between two Chevrolets. It's choosing between different types of plans, each of which will have its pros and cons. . . . I don't think it's going to be easy."

Nor will the choices always be palatable. Many people will simply follow their doctors into new health plans. But what about families who can't afford the plans that their doctors choose? Or those who rely on several physicians, each of whom selects a different plan?

"The kinds of people who are going to have the bumpiest time are the people with the most complicated problems and the least money," predicts Michael Podhorzer, health campaign director of Citizen Action, a consumers group. "The Clinton plan preserves as much choice as you want if you can afford" more expensive plans.

"But it can cause people at the lower end to make hard choices," Podhorzer said. "If you have a kid with leukemia and the cancer specialists you are going to don't sign up with an HMO, you have to make a choice between paying to get on the plan they are in or having to start all over again with a new doctor."

This is already occurring to some extent. As more and more people are pushed into health maintenance organizations and managed care plans by employers seeking to cut costs, patients who lose their long-time physicians are being forced to pick new ones--and to think more about their criteria for doing so. Armed with lists of doctors they have never met, they are working the phones, asking questions that even a few years ago would have been unthinkable.

Dr. Jeffrey Helfenstein, a Beverly Hills internist, is on the receiving end. Many of his long-time patients breathed a sigh of relief when he recently signed on with a so-called preferred provider network run by Aetna Health Plans, because it meant they could keep him as their primary care physician. Some of his new patients simply plucked his name off a list, often after calling his office to glean whatever particulars they could, such as how old he is and where he went to medical school.

"This is a terrible problem for most patients," Helfenstein says. "They will call on the telephone, look in the book, not knowing any of the doctors by name. And they'll have to choose by how the name sounds, like choosing a racehorse."

Some doctors have gone so far as to publish brochures about themselves, but Helfenstein finds that distasteful.

"It's very difficult," he says. "You feel like you have to sell yourself to people, like you're no longer (evaluated) based upon your reputation and your professional status, you're more of a marketer. . . . It's like you're running a store."

All of this points up a cold truth: Americans have never been very systematic about the way they select the people who care for them. With unlimited choice, most simply ask their friends and family for recommendations. Some use referral services advertised on radio or television. And some, said Rosemary Sweeney, a policy analyst for the American Academy of Family Physicians, get their doctors from the phone book.

"They use the Yellow Pages," she said, somewhat astounded. "They wake up in the morning and they sprain their ankle and they look in the Yellow Pages under orthopedic surgery. It's kind of a haphazard approach."

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