PERSPECTIVES ON PROPOSITION 186 : Spare These ‘Dinosaurs’ an Untimely Death : The family doctor is already under siege from insurance-industry bureaucrats; who would you call in a state plan?

There’s an expression sometimes used in health care for a doctor who cares enough about patients to be accessible, to listen to their needs and ease the pathway to care by other trustworthy care-givers when they cannot provide it themselves, to be honest and always work in the patient’s best interests. When a crisis arises, the doctor is available for the patient.

These doctors are “dinosaurs.”

Although the expression also can apply to specialists and nurses, it usually refers to old-fashioned family doctors who, in the view of most people in this country, are becoming extinct.

What caused this? The health-insurance industry. In the name of cost control, the insurance industry has taken decision-making and choice away from the care-giver and the patient.

Insurers will protest that this isn’t true; that decisions are still in the hands of patients. Just ask the teachers of the Los Angeles Unified School District, who were wrenched out of the care of their family doctors and assigned to primary-physician “gatekeepers.”

The gatekeeper is responsible for doing as much as possible in the primary setting. When something cannot be done at the primary clinic, the gatekeeper is expected to produce a prolific stream of paperwork documenting the need for specialty care.

This paperwork is reviewed by a utilization-review doctor, nurse or sometimes a clerk following a set of preordained guidelines. This is known as “managed care.” If a gatekeeper is frugal in the use of costly specialists and services, there may be a reward at the end of the year in the form of a share of the profits.

If there was a tendency to overutilize in the fee-for-service arena, there certainly is the risk of underutilization in the managed-care arena.

Meanwhile, health insurers’ profits and executive salaries have become obscene. And much of the health-insurance dollar is being spent on advertising in pursuit of “market share.” This has resulted in an administrative overhead of up to 50 cents of the health-premium dollar before one cent is spent on medical services and products.

A “single payer” proposal will be on the November ballot: Proposition 186, the California Health Security Act. It will provide universal access to medical care and roll all services into one program. There will be no separate Medi-Cal or Medicare, but there will be increased coverage, such as for medicines and long-term care. Medical treatment for injury on the job, in a car accident or on someone’s property will all be covered. Thus the need for most medical or health insurance will be eliminated.

The administrative overhead of the California Health Security Act is capped at 4% instead of the insurers’ 25% to 40%-plus. But the biggest incentive for many people will be the return to real choice--choice of doctor, hospital, specialist and even alternative care.

The decision-making will be returned to the patients and their doctors. And the doctors whose patients were taken away by restrictive insurance programs, who weren’t allowed access to managed-care groups, who wanted to refer their patients to specialists they knew and trusted will again be able to do what they always did best--care for patients. The dinosaurs will return.