On a shelf in Dr. Marvin Kaplan's office in Downey sits a two-inch-thick loose-leaf notebook containing instructions, procedure codes and billing forms for 72 health insurers.
Kaplan hopes that President Clinton's health reform will let him toss the notebook into the trash as insurance companies convert to standardized forms and uniform payment criteria for appendectomies, gallbladder removals, hernia repairs and other treatments.
But Kaplan, a 56-year-old general surgeon who says he earns less than the national average of $166,000 per year for his type of specialist, expects that any savings from the Clinton plan in his administrative costs will be dwarfed by the income he stands to lose as a result of a one-two punch of reduced fees and less work.
"And this is hitting me with three kids still in college," Kaplan said.
Under the Clinton plan, officials of the regional health purchasing alliance could set fee schedules for doctors below current levels. Many insurers already demand discounts from doctors and limit patient access to expensive procedures such as surgery.
Kaplan said any new reductions could come at the expense of quality. For example, he said, fees for second surgeons who assist lead surgeons in the operating room would probably be eliminated for certain operations deemed by health plan managers to require only one surgeon.
That would be fine, Kaplan said, if all patients responded the same to the trauma of surgery. But "patients surprise you in the operating room," he said. In major cases, Kaplan likes the assurance of another surgeon by his side.
"It's not just if the patient starts bleeding that I need an extra pair of skilled hands," he said. "It's cognitive too. I want what's in his head, the experience."
He said he was willing to test the Clinton plan's theory that lower-paid but highly trained surgical nurses or physicians' assistants are adequate substitutes in simple operations. Kaplan said he recognizes the need for cost controls, especially if the trade-off is a guarantee of health care for all Americans. The emergency rooms that Kaplan sometimes covers in the event that someone requires surgery have given him a sobering view of the plight of the nation's 37 million residents who lack health insurance.
Fewer than half of the emergency patients that he operates on have health insurance. Almost none of the uninsured can pay for Kaplan's or the hospital's services, even though many of these patients have jobs.
The Clinton plan would require all employers to provide workers with health insurance, a provision that could avert some costly emergencies by enabling patients to obtain care before they are in crisis. In addition, Kaplan says, his earnings from the emergency rooms--now about 20% of his annual income--could improve enough to offset losses in other areas.
Even if Kaplan's income dips under Clinton's plan, he takes comfort from another likely result: fewer insurers. Besides jettisoning his billing code notebook, he looks forward to having more time to care for patients.
"It's unbelievable what I have to go through to file a claim and how much office help I need just to keep track of these insurance companies," Kaplan said. "The amount of money that now disappears into non-patient-care, administrative apparatus is incredible."
Kaplan figures that 50% of his revenue goes toward his administrative expenses, up from 30% a decade ago. And the prospect that the Clinton plan might allow him more time to practice medicine is enough to make him talk up the profession to the oldest of his four children, a student at UCLA's School of Medicine.
"The overall compensation may be less," he said, "but the life may be better."