Benefits vs. Costs Debate Likely to Stall Care Reform : Health: Public demands the best in medical treatment, which could hobble efforts to contain expenses.

Arthur Caplan remembers that morning six years ago when he awoke with itchy, runny eyes. “You’ve got an infection,” his ophthalmologist said. “ . . . Now, before I do anything, let me tell you the risks and benefits of the medicines I could give you.”

But Caplan, a medical ethics professor at the University of Minnesota who regularly exhorts future physicians to keep their patients fully informed, didn’t even allow the doctor to finish. “I don’t care--just fix it,” he blurted.

Knowing the professor’s views, the physician was astonished. “But you’re the person who demands informed consent,” he said.

“Yeah,” Caplan retorted. “But that’s when I’m healthy !”

The story, which Caplan now often tells his students, illustrates some of the differing expectations--even contradictions--with which Americans view major medical care issues. “Your expectations are very much a function of how sick you are,” Caplan points out.

According to polls, most Americans are dissatisfied with the existing health care system, think that medical care has become too costly, believe that hospital bills are outrageously high and resent the fact that medical care has become so impersonal.

But they also demand the best care, no matter how much it costs. They insist on choosing their own doctors, rather than selecting one from an assigned list. And they are incensed at having their health benefits reduced in an effort to put the squeeze on costs.

Such attitudes on the part of consumers seem likely to present a major stumbling block in the coming years as the nation struggles toward health care reform--and eventual restructuring--of the current system in an attempt to control skyrocketing costs, experts say.

With pressures increasing daily, both businesses and medical professionals are convinced that in the end the only way to hold costs down will be to ration medical care by restricting some services and forcing consumers to pay more of the bill.

Tomorrow’s medical insurance plans also are likely to limit consumers to a narrower choice of physicians. Patients will have to pick from among a small group of doctors and hospitals who agree to become part of a price-discounting program, rather choosing any one they like.

But such options also seem certain to ignite a backlash among consumers, who--while vehemently critical of the current health care system--are equally stubborn in resisting the notion of giving up any of its current benefits.

“The public wants change in the structure of their health care system, but not in their personal health care arrangements,” says Robert J. Blendon, a health policy expert at the Harvard University School of Public Health.

Caplan agrees. “First of all, American consumers expect that whatever they’ve got, medicine will fix it,” Caplan says. “Second, they take a dim view of being told that there’s something out there that won’t be done--they assume more is better.

“Third, they assume that technology is good. This notion that it costs too much, or isn’t necessary--forget it. That is not the patient talking. The bigger the machine you wheel out, the more secure they feel.”

Part of the problem is that until very recently, health insurance has covered virtually everything. There has been little effort to question whether a fee or a particular treatment was justified, or whether a patient could have been treated less expensively elsewhere--say, at a small, neighborhood clinic rather than a large, downtown medical center.

“There is a correlation between architectural size and level of confidence,” Caplan says. “We assume that the little hospital and clinic can’t be as good as the medium-size suburban hospital, which can’t be as good as the facility that has towers and lots of glass downtown. In reality, it depends on what you’ve got. Sometimes, you’re better off getting your finger stitched up in that little place where they probably do a lot of fingers.”

Through most of the 1960s and 1970s, the nation’s top medical insurance programs were controlled directly by physicians and hospitals, who had little incentive to ride herd on skyrocketing medical costs.

And as coverage expanded amid postwar prosperity, consumers came to expect that they could obtain “the best” in care free of charge. Even today, patients who do ask about prices often are brushed aside. “Why do you care--you have insurance, don’t you?” they are asked.

But today, with medical costs running virtually out of control, such luxuries aren’t likely to be available very long, health care experts and analysts predict.

Employers and insurance companies already are taking steps to negotiate package deals with physicians and hospitals that will guarantee lower medical bills in exchange for a monopoly on employees’ business.

They also are requiring that employees pay a higher proportion of the bills that they incur from non-participating doctors. And they are moving to discourage physicians and hospitals from misusing expensive new technology where less-expensive procedures and treatments will do.

Expectedly, however, all that isn’t sitting well with consumers, who have become accustomed to generous benefits and will likely find it difficult to accept any employers’ arguments about why their coverage will have to be cut back.

Over the last several years, disagreements over reductions in health insurance coverage have become a major point of friction between employers and workers, and experts say they may well turn into the principal battleground for unions in the decade to come.

Last month, employees at a nuclear power plant in suburban New York finally settled a dispute over medical benefits that had held up a new contract settlement for almost two years. Similar impasses have kept some 160,000 telephone workers in 15 states on strike for weeks.

Yet, many health care experts believe that consumers will have to alter their expectations somewhat if political leaders and health care professionals are to succeed in regaining control of medical care costs.

Dr. Daniel Ein, president of the Medical Society of the District of Columbia, says that while most consumers do not demand procedures or tests they do not need, they often do want unnecessary medications.

“The requests for antibiotics are unreal,” Ein asserts. “The pressure to prescribe medication is enormous. And such drugs can be very expensive.”

To be sure, part of consumers’ demand for top-notch care is a normal reaction. Ein remembers an incident where he suddenly became the consumer-- not the doctor. His younger son, then about 12, had fallen off a skateboard and was groggy--a sign of a possible head injury.

It was the late 1970s, when CAT-scan technology had just been introduced, and performing such procedures were not as routine as they have since become.

“At that time, people were looking at the issue of whether the CAT scan was cost-effective and who should have it,” Ein recalls. “We had the scan done. And it was normal. But it told me something about what happens when it’s a one-on-one decision.”

Ein is more sympathetic now. “You can talk all you want about cost containment and what’s best for society, but when it’s your child, you don’t care about any of that. You care about what’s best for your kid, and, frankly, that’s what drives our costs.”

But consumers alone are not responsible for these attitudes, experts say. Physicians--often worried about the consequences of failing to use all the technology available to them--also play a significant role.

“Patient expectations are such that bad outcomes are equated with malpractice,” Caplan says. “It has basically made doctors risk-averse to the point where they will do anything to get that extra margin of safety--or liability reduction. If you’ve got it, use it.”

Harvard’s Blendon calls it a “chemical reaction” set off by “doctors who are overly trained to be high technology-oriented and a public that is very technology-oriented.

“People in many other countries don’t feel this need . . . “ Blendon says. “No one in Great Britain owns microwaves. They have a low rate of telephones. All the British faculty members I know open cans manually.”

William S. Custer, director of research for the Employee Benefit Research Institute, argues that the real problem is that with medical costs paid primarily by insurance companies, neither professionals nor consumers have a good sense of when new technology is worthwhile.

“Physicians themselves don’t really understand the relative benefits vs. costs,” Custer says. “They will perform tests that have a one in a million chance of showing anything because there is some positive probability of finding something .”

Custer believes that part of the problem is that there is little objective criteria for making such cost-benefit decisions.

“As a society, we might want to continue to err on the side of doing too much, as opposed to trying to restrict services,” he says. “We still don’t yet know the consequences of what doing too little might be.”

Health care attitudes in this country are deeply rooted in education levels and economic status, policy experts say.

“If you have insurance, or are wealthy, you approach the system with great expectations,” Caplan says. “If you have no insurance, or are poor, you approach the system with a mixture of fear, dread and trembling--if you’re willing to go there at all.”

Blendon agrees. “My instinct is that the appreciation for medical technology is an education-related issue,” he says. “The average low-income person is also less well-educated and is much less aware of the choices that are available.”

Along with the changes wrought by technology has come a dramatic shift in the doctor-patient relationship--a far cry from the traditional relationship where the patient was vulnerable and helpless, experts say.

“Patients are better informed than they used to be because they have more access to information about health care,” Ein says. “As a result, we have an extraordinarily demanding consumer. They come in with lists of questions, complaints, articles and medical references. They want to know: ‘How come you didn’t do this when this paper says so-and-so?’

“This is good and bad,” Ein says. “I think consumers should be better educated about medicine. But they want perfection in their medical care. They want their doctors to be right every time. They expect every outcome to be perfect. And when things don’t turn out, they are not tolerant of mistakes.”

In an era where through-the-roof health care costs are forcing many Americans into managed care programs, those who still have ample coverage and freedom of choice are extremely nervous about losing both.

They also have become increasingly upset over the inevitable trade-off that comes with maintaining freedom of choice: rising out-of-pocket expenses.

“This has become the real battle,” Blendon says. “The average American doesn’t want to go that (managed care) route. The average employer decides this is all he can do. The next three to five years will bring numerous confrontations on a personal level between employers who want to offer limited choices and employees who just don’t want that kind of medical care.”

But some say while forcing consumers to pay more of the bill may make them more cost conscious, it also could have some unwelcome side-effects. “It makes consumers think twice about seeking care,” Ein says, “but it also makes them put off things they shouldn’t.”

Ein, who once was a provider for a managed-care program, contends the incentives are distorted there. “People take advantage of the system,” he says. “They tend to go in for more minor problems. People came in for the most idiotic things, and you couldn’t keep them out--they insisted. It was a waste of their time, and ours.”

Ein and others predict that most Americans would never accept a system, such as Canada’s, where everyone is covered and the government pays a fixed price for every procedure, but patients must often wait months to have non-emergency procedures.

“There would be considerable resistance in the beginning to such a system,” says Bob Leitman, senior vice president of Louis Harris & Associates Inc., a polling firm that has done extensive surveys on health care issues. “We’re not used to having to make hard choices. We’re used to being able to get whatever we want.”

Yet Custer, the employee benefit researcher, and others believe that hard choices are inevitable.

“However you reform the system, you are going to have to make rationing decisions,” he says. “You could do it in a number of different ways, like Canada, with a limited amount of money and the lines form, or weigh costs versus benefits and it will mean someone’s going to suffer a poor result. Somebody’s got to make these difficult choices, and . . . we’re not.”