Even doctors need doctors, and every year Dr. Ezekiel Emanuel, a cancer specialist who also teaches medical ethics at Harvard University, has the freedom to pick from among five health plans for his personal medical care.
To Emanuel it is an awful chore--the forms, the cumbersome literature, the confusing process of figuring out which plan offers the highest quality at the cheapest price. And so every year he takes the easy way out, picking the plan that, although the most expensive, gives him the ability to visit any doctor he pleases.
"Hell, I don't know (what the brochures say) and I don't want to spend the time reading this chart; so I pick the one with the most flexibility," he says. "I haven't joined a managed care (plan), even though four of the five options are managed care."
Like Emanuel now, all Americans will eventually have to choose a health care plan if President Clinton's agenda for reform is enacted. While the President has ballyhooed "choice" as a key attraction of his proposal, make no doubt about it: For many consumers, choice will be as wrenching as it is rewarding.
Doctor-patient relationships will undoubtedly be severed. Consumers will be put in the position of evaluating the quality of health plans, doctors, hospitals and health centers--something many never thought about before. Even those such as Emanuel, whose employers already offer several plans to choose from, will have more range of choice than ever.
"People will have to cope with different types of choices," says Judith Bell, a co-director of the west coast office of Consumers Union. "It's not choosing between two Chevrolets. It's choosing between different types of plans, each of which will have its pros and cons. . . . I don't think it's going to be easy."
Nor will the choices always be palatable. Many people will simply follow their doctors into new health plans. But what about families who can't afford the plans that their doctors choose? Or those who rely on several physicians, each of whom selects a different plan?
"The kinds of people who are going to have the bumpiest time are the people with the most complicated problems and the least money," predicts Michael Podhorzer, health campaign director of Citizen Action, a consumers group. "The Clinton plan preserves as much choice as you want if you can afford" more expensive plans.
"But it can cause people at the lower end to make hard choices," Podhorzer said. "If you have a kid with leukemia and the cancer specialists you are going to don't sign up with an HMO, you have to make a choice between paying to get on the plan they are in or having to start all over again with a new doctor."
This is already occurring to some extent. As more and more people are pushed into health maintenance organizations and managed care plans by employers seeking to cut costs, patients who lose their long-time physicians are being forced to pick new ones--and to think more about their criteria for doing so. Armed with lists of doctors they have never met, they are working the phones, asking questions that even a few years ago would have been unthinkable.
Dr. Jeffrey Helfenstein, a Beverly Hills internist, is on the receiving end. Many of his long-time patients breathed a sigh of relief when he recently signed on with a so-called preferred provider network run by Aetna Health Plans, because it meant they could keep him as their primary care physician. Some of his new patients simply plucked his name off a list, often after calling his office to glean whatever particulars they could, such as how old he is and where he went to medical school.
"This is a terrible problem for most patients," Helfenstein says. "They will call on the telephone, look in the book, not knowing any of the doctors by name. And they'll have to choose by how the name sounds, like choosing a racehorse."
Some doctors have gone so far as to publish brochures about themselves, but Helfenstein finds that distasteful.
"It's very difficult," he says. "You feel like you have to sell yourself to people, like you're no longer (evaluated) based upon your reputation and your professional status, you're more of a marketer. . . . It's like you're running a store."
All of this points up a cold truth: Americans have never been very systematic about the way they select the people who care for them. With unlimited choice, most simply ask their friends and family for recommendations. Some use referral services advertised on radio or television. And some, said Rosemary Sweeney, a policy analyst for the American Academy of Family Physicians, get their doctors from the phone book.
"They use the Yellow Pages," she said, somewhat astounded. "They wake up in the morning and they sprain their ankle and they look in the Yellow Pages under orthopedic surgery. It's kind of a haphazard approach."
The Clinton plan, which for most consumers would narrow the choice of physician, seeks to inject a little order into this chaos. It would require regional health care alliances--the organizations that would select the health care plans available to consumers in their regions--to provide information about the plans' doctors and hospitals.
"You should be getting a very clear document that will describe each of the plans," said Ron Pollack, executive director of the consumer group Families USA. "It is supposed to have an assessment related to quality, and tell you what the costs are."
How well this works, Pollack said, would depend on the health alliances, whose governing boards are to consist of employers and consumers chosen according to mechanisms established by each state. Pollack said his organization and other consumer groups must "make sure the boards are as consumer friendly as possible."
Even with good information at their fingertips, however, consumers do not always relish health care choice.
Take the experience of Managed Care Innovations, a Seal Beach-based company that processes insurance claims for three networks of physicians. Until recently, Managed Care's 53 employees had to enroll in a particular HMO for their company-provided health care.
Then the firm signed on with a new California program that helps small businesses get health insurance--a program run by an alliance that functions in the same way as those proposed by the President. Now Managed Care employees can choose from 11 health plans, all of which offer the same basic benefits.
Although Managed Care's employees are well-versed in the intricacies of managed health care, they found the process of choosing their own health care plan to be bewildering.
"I think I have more astute shoppers than most because they work in managed care," says Judith Hook, Managed Care's chief executive. "But they were a little bit taken back. They didn't like the idea of having so many choices. They liked it better than having one choice, but they kept saying, 'Why do we need 11?' "
In the end, Hook says, some employees picked for convenience--doctors who worked close by, clinics that offered weekend hours. Some picked health plans they had worked with on the job. But most, she says, simply chose the least expensive HMO on the list.