by Elizabeth Darling
As talk of health care reform sweeps the nation, California, as usual, is on the forefront of change.
Physicians and patients in the Golden State already have experienced many of the growing pains, such as shifts toward "managed care," that reforms now under discussion in Washington are likely to bring to the rest of the nation.
In anticipation of a Feb. 5 Centennial Symposium titled "Centennial Perspectives on Health: Prescriptions for the Next Century," (see story on page X), the Palo Alto Weekly talked with local physicians about how the ongoing changes in health care economics are affecting the way they practice medicine.
Among the typical stories they had to tell:
A woman is forced to stop seeing her favorite doctor when her employer switches to a new health plan that does not include that doctor.
A doctor has to go to a patient's insurance company to get permission to go ahead with an experimental treatment for breast cancer.
Another doctor has patients who choose to pay out of pocket for his care, regardless of the whims of their insurance companies, because they are loyal to him.
A high proportion of Californians already belong to "health maintenance organizations" (HMOs) or other forms of "managed care" programs that are the backbone of President Clinton's plan. Such plans attempt to save money and make service allocation more efficient by paying doctors a pre-negotiated flat fee per patient. Regardless of how much or how little care that patient ends up needing, the pre-negotiated fee will stand. This is a departure from the traditional fee-for-service method, in which doctors are reimbursed for whatever care they provide and not paid if they provide none.
The biggest change for many doctors is that as health insurance carriers consolidate, with major carriers merging to form huge conglomerates, the insurers will buy services from groups and organizations of doctors, leaving solo practitioners virtually in the dust.
"The physician is going to have to be affiliated with one or another (organization)," said Dr. R. Hewlett Lee, a member of the boards of the Palo Alto Medical Foundation and Stanford Hospital, as well as the former executive director of the Palo Alto Medical Clinic. "It's going to be so difficult for the solo practitioner.
"They'll have to learn to work with it, accept it, adapt to it," he said.
Employers also will face some changes, especially smaller ones such as shop or gas station owners who may have to shoulder more of the cost of their small staffs' health care. Most large employers already have moved toward "managed care" systems, in which their health insurers pre-negotiate a rate the company will pay for its employees' care.
Local consumers are experiencing the changes in a variety of ways. Those who work for large companies may be somewhat buffered because they already belong to an HMO. Others may be forced to change doctors because their employer is switching from a "fee-for-service" plan to an HMO that requires them to choose from the doctors who have agreed to accept the pre-negotiated rates offered by the plan.
And there are many unanswered questions.
"The question nobody knows yet is, will there be limitations to care?," says Lee.
Will insurers cover expensive treatments if they have a low likelihood of success? A recent example is Nelene Fox, a southern California woman who was in the last stage of breast cancer and sued Health Net after the Woodland Hills insurer declined to cover a last-resort bone marrow transplant. Fox died last April; in December, a Superior Court jury awarded $12 million to her estate, saying the transplant should have been covered.
Teaching hospitals like Stanford University Hospital will be in a unique position. Many health care providers will likely look to them to do research into the cost-effectiveness as well as the success rate of medical treatments in order to find the most efficient, cheapest ways of providing care.
These hospitals tend to receive a bulk of patients on Medi-Cal as well as those who are uninsured. Under the Clinton plan, they would stand to benefit, since all people would be insured and the hospital would receive payment for its services rather than having to absorb the cost, as it does now.
Certain questions--such as whether surgery or some other procedure would work better for a given patient--will be steered toward academic hospitals, according to Don Holloway, director of management, research and development for Stanford University Hospital.
"We should be playing a major role in answering those questions," Holloway said. Thus, it is likely such hospitals will receive many grants to research these issues.
But there is a Catch-22. "The bad side is that people will want to know 'Why does it cost more for an academic medical center to care for a patient than a community hospital?'" Holloway said. "We'll have to either get our costs down, or we have to explain why we cost more."
Less traditional medical practitioners such as homeopaths and acupuncturists worry that insurance companies will consider their treatment too unorthodox to be covered. They may fall through the cracks and ultimately be put out of business. Also, solo doctors like cardiologists for example, who are highly skilled and highly paid, could be hit hard as the insurance industry emphasizes that primary care physicians be gatekeepers to keep costs down, and rewards those who are group-affiliated.
But the most fundamental questions posed by health care reform cannot be answered by doctors, government or the insurance industry. They are philosophical questions that society as a whole must answer about what it is willing to pay for, and what it is willing to give up.
"The health appetite of Americans is insatiable," Lee said. "Where are we going to draw the line? Society has to make these decisions."
Back up to the Table of Contents Page