But ironically, Stebbins' and many other independent doctors' relationship with Stanford's medical center and university has caused them to change the way they practice medicine, or at least the economics of how they practice.
Last April, Stanford President Gerhard Casper announced that Stanford's 18,000 employees' health care would be primarily covered by a health maintenance organization, and no fee-for-service plan, except for a modified one provided by an HMO, would be offered. Since Stanford employees make up a significant part of the practices of Stebbins and some of his colleagues, the announcement had a major impact on them.
Whereas before, doctors were paid for exactly the amount of service they provided, now they would basically be paid a flat rate no matter what service they provided, and the HMOs would work with groups of doctors. The several hundred independent doctors, such as Stebbins, who practice within a stone's throw of the hospital but had no official affiliation with each other stood to lose the most.
"This is a bone of contention, and there's a need for discussion as to how further to integrate. Our patients contribute $75 million a year to the hospital's budget," Stebbins said. "We're helping to support the enterprise."
Yet, he and other doctors would be shut out of the insurance plan because they were independents.
"It's a great economic imbalance. We are professional colleagues (of the faculty doctors) and increasingly we have become business competitors. And this new formulation of the hospital has only exacerbated that."
To increase their negotiating strength and ultimately to survive, since thousands of their patients are Stanford employees, Stebbins, along with 212 other private doctors, recently formed the Private Physicians Group at Stanford. The group has hired lawyers and administrators to deal with the bureaucracy of the new system, and created an economic affiliation so that insurance companies of Stanford employees can, effective Jan. 1 of this year, do business with them.
"This is not what I went to medical school for," Stebbins said with a sigh. "We're called independent physicians for a reason. We like our independence."
Stebbins and many of his colleagues have found a way to survive economically, but he is still cautiously concerned about how much insurance companies will ultimately intrude on the day-to-day practice of medicine.
"The idea is to make physicians more financially responsible. But it can threaten to put a fence between the physician and the patient," he said.
With the fee-for-service system, "The more you do, the more you get." With "capitation"--a negotiated flat fee per patient paid to each doctor by the insurance provider--"The more you do, the less you get," Stebbins said. Under capitation, no matter how much treatment a doctor provides a patient, the pre-negotiated rate will stand.
The insurance companies' intention is to make sure doctors are carefully budgeting treatment and ordering tests (such as lab work and magnetic resonance imaging exams) when they are absolutely necessary.
That means insurance companies will have more say about care.
"Increasingly the insurance companies are going to be dictating patterns of care," Stebbins said. "The administration and decision making gets further and further removed from the patients and the physician. And there is that possibility that in trying to make things economically efficient, that it will be less patient and doctor-friendly."
Under many newly-reformed health care plans, doctors are given incentives for referring patients within their group of physicians. If they want to refer to someone outside, they must go to a board who makes the decision about whether the referral is warranted or not, and must pay a fee.
One of the reasons Stebbins, 54, chose to practice near Stanford was because doctors "passed patients back and forth. That's one of the glories of Stanford, is that we have a tremendous number of really good physicians."
He fears that, while it's good to have one primary physician ultimately responsible as a "gatekeeper" for a patient's care, there could be situations where that doctor may do things that could exceed his or her level of competence if there is an economic penalty for referring patients to other doctors.
He also worries that the new system could create new layers of health care bureaucracy.
"I'm quite concerned about the idea of creating big halos of superstructures to govern all this. The more regulation, the more (it will be) the economics of medicine, and the less the medicine of medicine," Stebbins said. "And yet I think doctors really want to do a good job. The question is how to make do with less."
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