Issue of Choosing One’s Own Doctor More Myth Than Reality for Many : Health: Despite perceptions, few insured workers are free to select physicians. Proposed reforms are designed to maximize choice.

When Jennifer Merrill faced possible surgery for a gynecological ailment, her new insurance plan refused to pay if she went to the specialist she had been seeing for nine years. He was not a member of the plan.

Instead, Merrill’s insurer wanted her to see a total stranger, an obstetrician-gynecologist who is a participating provider in her health maintenance organization.

That makes the 23-year-old Baltimore woman one of a fast-growing number of Americans who, even before enactment of national health care reform, are losing the freedom to choose their own doctors.

In Merrill’s case, the story does not end there. She became so uncomfortable with her new doctor that when the time came for the $2,000 surgery, she returned to her own specialist and--with a loan from her grandparents--paid the entire bill out of pocket.

Merrill’s dilemma arose out of one of today’s less-welcomed trends in health care: Insurance companies are aggressively imposing restricting “managed care” systems on their clients.

In the name of curtailing soaring health care costs, individuals enrolled in these systems receive maximum coverage only when they visit participating doctors who agree to abide by price controls negotiated with the insurer. Clients may go outside the network of participating doctors--but only if they pay much or, as in Merrill’s case, all of the price.

Perhaps no issue has aroused so much emotion as that of whether Americans will be able to select their doctors. “Choice is one of the things people most jealously guard against erosion--and they are willing to pay for it,” said Edward F. Howard, head of the nonpartisan Alliance for Health Reform.

Critics complain that President Clinton’s health reform plan would not do enough to preserve choice--a charge that First Lady Hillary Rodham Clinton has branded as “one of the great lies” in the health care debate. The President has said that the allegation, more than anything else, has “made me the maddest in the relentless campaign against this plan.”

In fact, Clinton’s prescription for change, more than any other politically viable reform proposal, would increase choice of doctors for most patients. “Clinton’s plan has, if anything, bent over backward to give people the maximum choice,” said Stanley B. Jones, a Shepherdstown, W.Va., analyst.

But there’s a catch: People would have to pay something extra for that freedom, although hardly the full cost that Merrill and her grandparents had to bear.

Managed care systems have grown so explosively that there are no reliable figures on how many exist. “Nobody can say for sure,” said Phil Caper, a New Hampshire physician who sells computer software programs to managed care networks that monitor patients and doctors. “All I know is that things have really taken off in the past few years.”

KPMG Peat Marwick, a benefits consulting firm, says the percentage of American workers enrolled by their employers in fee-for-service plans--the traditional plans that reimburse workers for a percentage of their health costs, no matter who the doctor--dropped from 71% in 1988 to just 49% by last year.

At the same time, the percentage of private employees in managed care systems grew from 5% in 1980 to 55% by 1992, the government’s General Accounting Office reports. That percentage is even higher in larger firms, which have moved most aggressively in channeling workers into managed care networks, says Derek Lifton, associate director of Peat Marwick in Washington.

And according to the Employee Benefit Research Institute, the number of Americans enrolled in HMOs--the most tightly run form of managed care--rose from 9.1 million in 1980 to 37.2 million by 1992. The regional differences in HMO acceptance are stark: more than one in three Californians belong, compared to 7% in Texas and less than 1% in Alaska, Montana and Wyoming.

In all, as many as 95% of Americans with private insurance are subject to some form of utilization review, possibly leading to a denial of coverage either before or after a specific treatment, according to Lewin-VHI Inc., a health care consulting firm.

“Fewer than half of American workers have any choice at all over their doctors or their health care plan today,” Clinton has said.

Why hasn’t there been a huge public outcry over the loss of choice if, as everyone says, it is such a potent consumer issue?

“I don’t think the public understands how pervasive this is becoming,” said Dr. James Todd, executive vice president of the American Medical Assn.

Clinton’s plan, like most other viable proposals in Congress, contains strong financial incentives to prod consumers into managed care systems. A central hallmark in such arrangements is the “gatekeeper,” a primary care physician whose permission is needed before a patient may consult with a specialist.

So it’s hardly surprising that the most vocal critics of the erosion of choice are high-priced specialists. Last month, the American Academy of Orthopedic Surgeons, for example, took out full-page newspaper ads to clamor for “direct (public) access to specialty care.”

“Those pushing the issue tend to be providers who don’t want to be excluded,” said Bill Custer, EBRI’s research director.

Stephen M. Shortell, a Northwestern University management professor, called the issue of choice--in the context of health care reform--”a red herring.”

The President’s proposal, which seeks to guarantee a lifetime of comprehensive benefits to all Americans, would increase choice by pooling most people into regional insurance-purchasing alliances that negotiate rates with specific groups of providers and insurers.

As an alliance member, Shortell says, “you end up having to choose your doctor from a panel. But in most areas, that list will be pretty long.”

Under Clinton’s proposal, each alliance must offer at least three types of plans--including a traditional but costlier fee-for-service plan and an HMO with lower premiums, no deductibles and co-payments of $10 or less per visit.

Each plan also must offer a “point-of-service” option, which allows consumers to see any doctor outside the plan, but for a higher out-of-pocket fee.

Under such arrangements, says Joseph M. Davis, president of Medimetrix, a Cleveland-based consulting firm, consumer choice “goes up significantly.”

Congress is sure to make major changes in Clinton’s plan. But, as currently written, it would require employers to pay at least 80% of a worker’s premiums, with the individual paying the rest.

Administration analysts estimate that the average annual premiums (subject to regional variations) will be $4,200 for a family of four and $1,800 for an individual. Twenty percent of that, the consumer share, would be $840 and $360, respectively.

For those who opt for more choice under a fee-for-service plan, premiums, co-payments and annual deductibles will be higher, with a cap on out-of-pocket spending of as much as $3,000 per year per family.

“That’s a high hurdle most people can’t get over,” warned the AMA’s Todd. True choice, he said, “will depend on what that threshold is.”

The mandatory alliance structure proposed by Clinton also would let consumers--rather than their employers--pick which plan to join. As the President boasted last month in a speech: “We give choice of providers back to the employees themselves.”

His plan would also allow physicians to join more than one plan, increasing their availability to patients. “Our plan is designed to increase the choices that consumers have,” Clinton said.

“This idea that every American today has a choice of doctors is a myth,” he told a Minneapolis town hall meeting on April 8. “More than half the American people who are insured in the workplace today don’t have a choice. They get one plan and that’s it. Ninety percent of the American people who are insured in small businesses with 25 or fewer employers have no choice.”

One drawback to Clinton’s approach is that different family members may find their longtime doctors belonging to different managed care plans. And since a family may belong to only one plan, some members will find themselves having to pay a premium to see their regular doctors.

The estimated 27 million people on Medicaid, the federal-state health program for the poor, would also gain more choice than they now have.

Many doctors currently refuse to accept these patients because Medicaid payment schedules are so much lower than private-sector fees. Under Clinton’s plan, Medicaid recipients would be enrolled in the alliances and able to select their own plan.

The one reform agenda that offers unrestricted consumer choice is Rep. Jim McDermott’s (D-Wash.) single-payer proposal, which would have the government collect a tax--taking the place of all public and private insurance premiums--and then pay everyone’s medical bills.

But the plan is widely considered politically non-viable--even by Clinton, whose plan would allow states to adopt a single-payer system.

Whatever the outcome of the health care debate, for people like Merrill, a social researcher, it is the onset of a potentially grave medical crisis that crystallizes the choice issue.

Until she was married last year, Merrill had her own health plan, which covered her visits to Dr. Joseph Moser, a Baltimore gynecologist whom she had been seeing since age 14.

Even after joining her husband’s plan, an HMO, because of its lower premiums, Merrill continued going to Moser for regular checkups, paying for all the costs herself.

In January, things suddenly became anything but routine. Moser detected a widespread pre-cancerous condition and recommended further tests, including a biopsy. Merrill’s plan refused to cover the expenses unless she went to a doctor in her HMO.

Moser even offered to lower his fees to that charged by doctors in the network, but he was rebuffed. Moser then offered to sign up as a participating doctor in the HMO; again he was turned down.

Meanwhile, Merrill complained, protested and appealed, also to no avail. After finally seeing a network specialist, Merrill returned to Moser.

“It was upsetting and frustrating,” Moser recalls. “And Jennifer Merrill isn’t alone.

“Today, many people have new doctors every few years. And the continuity that’s developed in a doctor-patient relationship may be destroyed. If people are traded from doctor to doctor in exchange for fee discounts, they are no longer consumers, they are commodities.”