Health Reforms May Alter Definition of Doctor Choice : Medicine: Picking physician is seen as a basic freedom, and many resist limits. But some limits are already here.
Greg Kirschner’s patients find his family medicine practice in mysterious ways.
Some simply like the sound of his name. Some hear of him through his involvement in church-sponsored medical missions to Latin America; they assume he shares their spiritual values. Some have friends whom he has treated and beguiled with his unpretentious manner and his obvious concern.
With nine years’ experience, Kirschner can count on the fingers of one hand the number who have asked him where he went to college (Northwestern) or medical school (Duke) or whether he’s board-certified (yes). They certainly don’t inquire about his fees.
It is a delicate dance, fraught with intangibles. No statistics can adequately capture how today’s American decides who will tend to his or her health. Only one thing is certain: Rightly or wrongly, a significant chunk of the public will resist changing the way it’s done, even in the name of holding down costs and the security of universal coverage.
Depending on how the question is asked, anywhere from 32% to 85% feel strongly about choosing doctors on their own. Survey after survey shows that when the Clinton Administration unveils its national health care reform plan in coming weeks, one of the biggest questions for the average person will be, Can I keep my doctor?
And most people will wonder, too, Can I go to the best specialist around if I get gravely ill? How much control, they will be thinking, will I have?
On the answers will likely hang the fate of any reform bill. Slightly more than three-quarters of this country’s adults have established patient-doctor relationships and very few of them want the bonds disrupted. “Choice will be the equivalent of busing,” said Drew E. Altman, president of the Henry J. Kaiser Family Foundation, which polls extensively on health care questions. “It is one of the hot-button issues.”
First Lady Hillary Rodham Clinton, who heads President Clinton’s health care task force, is well aware of the matter’s political importance. At a recent gathering of consumer groups in Washington, she predicted that opponents would attack the overhaul with commercials featuring “a Marcus Welby look-alike saying, You’re not going to be able to choose your doctor,” according to Ron Pollack, executive director of Families USA. Pollack took notes at the meeting.
Choice, Mrs. Clinton told her audience, is “a crucial part of what we’re trying to achieve here.”
But there is choice, and then there is choice.
With the Clintons’ proposal outlined only vaguely so far, it is impossible to gauge the effect of reform on freedom of choosing a physician. Clearly, the Administration is counting on being able to make the case that a different notion of choice can actually lead to better decision-making.
An insurance plan that provides access to any doctor would be offered in every location under the Administration’s proposal, said Bob Boorstin, special assistant to the President for policy coordination.
But that free-access plan, also known as fee-for-service, would have to operate on a budget. A maximum would be placed on the amount of money that could be spent annually on each patient, Boorstin said. The plan might not cover any expenses incurred above the cap.
Patients also might have to make partial payments for certain examinations or treatments, even if the cap had not yet been reached, Boorstin said.
These are not minor details. “If it could cost you an extra $1,000, that could be in effect a non-choice,” Altman said.
The open-access price should be high enough, Boorstin said, to encourage most people to join managed-care plans--either a health maintenance organization (HMO) with doctors on staff or a preferred-provider network, which allows patients to select their assigned doctor from a list of those agreeing to discount prices.
The physicians reduce their fees because they anticipate a steady flow of business from the network. The lists are limited because the network loses leverage over price and treatment if there are too few patients per doctor.
Otherwise, “if you don’t get large movement to the HMOs,” said health economist Stephen Zuckerman of the Urban Institute, “I question the ability of this system to cut costs.”
This is not exactly unfamiliar territory. In 1980, only 2% of insured Americans had coverage that limited their choice of doctors, but by 1990, the figure had risen to 27%, according to the Employee Benefits Research Institute. A Consumers Union poll released in April found that 1 in 12 respondents had been forced to change doctors in the past two years because of restrictions imposed by their health care plans.
As businesses try to rein in dizzying increases in health care costs, that trend is expected to continue. In a decade or two, traditional, wide-open choice might well be a memory, not the norm, reform or no reform.
If the Clinton proposal is adopted, everyone would be covered for a basic list of benefits. That would mean that more than 37 million Americans who are currently uninsured would certainly get a broader selection of doctors than they have now. The National Center for Health Statistics says that in 1990, 12% of the nation’s poor used a hospital emergency room for primary medical care.
And those who already have insurance, Pollack noted, generally are restricted to one of only a few plans offered by their employer. Under reform proposals, they would be able to get any health care plan offered in their geographical area.
Theoretically, a patient ought to be able to stay with his or her doctor by enrolling in one of the plans the physician joins.
In practice, of course, there would be glitches. Take a family with an asthmatic father, a pregnant mother and a child. It would be difficult to find one plan that encompasses their internist, pediatrician, allergist and obstetrician.
Consumer groups and some lawmakers contend that better information could compensate for the need to make some changes. They talk of demanding public access to figures that heretofore have not been gathered, or have been kept confidential: the percentage of favorable outcomes of certain procedures performed by a particular doctor, for instance, or a physician’s malpractice history, or whether a medical license has ever been revoked in any state.
Members of the task force have indicated they agree with some of these ideas. But the dissemination of such numbers would almost certainly be opposed by practitioners. Many, including Greg Kirschner, argue that the data can be easily misconstrued.
In any case, the immediate reaction to the thought of so much upheaval--even if it settles down after a few years--is more likely to be visceral than rational, predicts Robert J. Blendon, a Harvard University health policy expert.
The young, the healthy and those who move from place to place will be more accepting of limits on choice, said Blendon, who has studied a multitude of surveys, while the elderly, the ill and those who put down roots in one locale will be less amenable.
In Park Ridge, founded by German brickyard workers, later hometown to one Hillary Rodham Clinton, there will be plenty of convincing to do. The sentiment here is as split as the town’s shopping district, bisected by commuter train tracks that run to Chicago, 27 minutes away.
“There are plenty of good doctors out there,” said a retired social worker. “I’d give mine up to get costs down.” In fact, he will need to find a new physician soon; his house is for sale and he’ll divide his time between Florida and a Wisconsin lakeside home.
Countered a purchasing manager for a medium-sized manufacturer: “I know my doctor. He has my family values. And he knows when it’s big, you pull out all the stops.”
At the north end of town, Kirschner maintains a second-floor office in a boxy tan building across the street from Lutheran General Hospital. About 60% of the patients are already in managed-care plans. The doctor is on the lists of 10 restricted-access networks.
Consequently, his office does more paperwork than a traditional fee-for-service practice, and he sees marked shifts in patient loads whenever employers change insurance carriers.
But he is only 35 and needs the volume. “The younger physicians accept this pretty much as a reality. It’s been very difficult for the older doctors.”
He understands their reluctance. “It takes a while to kind of get into the rhythm of the relationship.” He has to review a new medical record, try to draw out details in person, figure out what’s important and the best approach to earn trust and get results.
The patients feel the burden just as much. When Joseph Del Re retired from his job as a machinist, he decided to seek out his first regular doctor. His retirement benefits offered only health maintenance organizations.
A colleague recommended Kirschner after looking at the names on one of the HMO lists. She had heard that he was a good doctor. And his office was just a five-minute drive from Del Re’s house.
“I loved him from Day 1,” Del Re said. “The guy was honest, and he didn’t leave a stone unturned. He sent me through all kinds of tests at Lutheran General. He don’t give you that ‘uh huh, uh huh’ and just walk away.”
But then the hospital and the physician group to which Kirschner belongs dropped out of the HMO for various business reasons. Del Re was wedded to his health plan for another year. He couldn’t change until a specified open enrollment period came along.
He had to find someone else on the HMO’s rolls. This time, he wasn’t so lucky. The new doctor kept him waiting 2 1/2 hours one day; he had to leave the waiting room at one point to stick a few more quarters in the parking meter.
Then Del Re’s wife started slurring her words. He took her to the new doctor, who explained that she had had a stroke, that she was lucky she wasn’t paralyzed, but she’d be all right.
Months later, the open enrollment period began and Del Re found Kirschner’s name on another plan’s list. There was an asterisk next to it. He was not accepting new patients.
He called his former doctor and begged, “Please take me back.” And Kirschner did. That was a year ago.
First thing, Del Re took his wife in. Kirschner sent her to speech therapy at Lutheran General. It hasn’t helped much, but Del Re was grateful that the doctor at least tried. He wonders what would have happened if she’d started earlier.
“I’ll never switch again,” Del Re said. “If I have to pay more to keep him, I will. I would just have to squeeze blood somewhere else. Maybe I’d have to sell my home, but I’d even do that.”
To James Todd, executive vice president of the American Medical Assn., tales like Del Re’s have a moral: “The ability to opt out, to make a change, is very important” if the right selection isn’t available through a particular plan.
Added Kevin Anderson, a consultant to the Alliance for Health Reform: “The thing that scares most people is the fear that they won’t be able to fire their (new) doctor.”
One answer is a plan that has a limited network of doctors and hospitals but allows a subscriber to see an outside physician if they assume more of the burden--30% of the cost, say, instead of 20%.
Sears and its subsidiaries offer such a plan to most of their 200,000 employees in 48 cities. It has proven more popular than the other options, two HMOs, combined. In 1992, three years after the first pilot programs began, 87% of those not enrolled in an HMO were seeing doctors in the network.
Every year, said James B. Bronson, the corporation’s director of compensation and benefits, the plan’s percentage of in-network care has grown, a move he attributes to growing confidence in the quality of doctors that signed up.
But even so, the plan doesn’t save nearly as much money as the HMOs do.
“We are going to be under constant pressure” to tighten choices further, Bronson said.
Times researcher Tracy Shryer contributed to this story.
* AN URBAN PROGNOSIS: Universal health care alone may not be able to address the needs of the inner city. A28
