Here Comes Doctor No

By NANCY GIBBS

Politicians can't seem to resist playing doctor when they start talking about health-care reform. They diagnose a system in critical condition that only their wise prescriptions can save. So maybe turnabout was fair play last week when the doctors decided it was time to play big-league politics and rolled out the polls, direct mail and satellite hookups in a lobbying assault the likes of which had not been seen in Washington since -- well, since 1965, when the American Medical Association decided it didn't much like the idea of Medicare.

It was the A.M.A.'s annual National Political Education Conference in the capital, and twice as many doctors as usual showed up. They came looking for a fight, not only over the Administration's plan but over the profession's soul. Watching 600 or so doctors troop up the steps of Capitol Hill, it was tempting to assume they had come to defend their right to earn six times as much money as the average American family and still play golf on Wednesdays. But to dismiss their motives as selfish and their concerns as unfounded meant ignoring the people who know firsthand what is wrong with American medicine, and who will have to be allies in fixing it.

And so the politicians came and listened. Senate majority leader George Mitchell appeared, as did Bob Michel, Richard Gephardt, Bob Dole, Newt Gingrich and Jay Rockefeller. It was not, on the whole, a happy meeting. The only member of the Administration who dared to show up, HHS Secretary Donna Shalala, was booed.

"How many here favor the Clinton plan?" asked one of the presenters. Only two people had the nerve to clap.

By the time the conference ended, it was clear that the Administration, despite its best efforts, had failed to win over a crucial partner. After months of coy hand holding, the A.M.A. broke free last week and emerged, if not as an enemy of the Clinton plan, at least as an obstacle to it. Unveiling a $7 million lobbying effort, the A.M.A. leaders vowed to "broadly inform our patients of our concerns and activate an unprecedented national network of physicians" to fight for changes in the plan. Chief among the complaints was the imposition of cost controls and new bureaucracies and the failure to put financial limits on malpractice judgments.

The American Medical Association represents less than half of America's 650,000 doctors, down from 70% in the 1970s; but it is still the nation's largest medical organization and one of its richest lobbies. "Without the tacit support and approval of the medical profession," warned the A.M.A.'s chief executive, James Todd, "health-care reform is not going to go very far." If the medical rank and file rises up, President Clinton could find his moral authority challenged by the far more personal persuasion of a hundred thousand healers, some of whom have developed a close relationship with their patients, and many of whom feel they will be fighting for their professional lives.

Indeed the warnings in Washington are echoed in examining rooms all around the country. "We're being handed this massive program for reform," says Pittsburgh cardiologist Dean Kross, "and we're troubled that none of the systems they're proposing have ever been tried . . . Why should we accept a system that bureaucrats have proposed based on information that's not been properly tested?" Says Dr. Gordon Schiff, an internist at Chicago's Cook County Hospital: "The problem is that the people who are being listened to for the solutions are the people who have been most responsible for creating and denying the problem, especially the insurance industry."

Even doctors themselves, however, are divided about where the best solutions lie; older doctors find themselves arguing with younger ones, primary-care givers with specialists. And that leaves the Administration with an opportunity. If it cannot possibly hope to please everyone, it may at least win enough support for reform within the medical community to discredit the efforts of those who oppose it.

For a while it looked as though the A.M.A. was pledging neutral cooperation, as when board chairman Lonnie Bristow promised last week to "support those provisions that are good for our patients and work to change those that are wrong for our patients." But such accommodating sounds were the exception. In a 15-page letter to every doctor and medical student in the country, the A.M.A. announced that it was "adamantly," "staunchly" and "unequivocally" opposed to several of the Administration's "unacceptable" proposals. "It's the old-line A.M.A.," says ethicist George Annas at Boston University, who viewed the campaign as a "typical, self-serving, maximize-my-income" stance. "They don't know what's happening in medicine. That's why less than half of doctors belong. If they are going to be obstructionist, they are irrelevant, as they should be."

The A.M.A. leadership knew better than to try to block reform altogether. Back in 1988 the doctors' own polls found growing support for a total overhaul of health care, and the A.M.A. leadership recognized that it would be better to join the process and try to shape a package that doctors could live with. Other physicians' groups were positioning themselves to challenge the A.M.A. as the voice of organized medicine in Washington: the American College of Physicians and the American Academy of Family Physicians have supported the idea of comprehensive reform.

And so with much fanfare the A.M.A. unveiled its own reform plan, "Health Access America," calling for universal coverage, cost containment and the requirement that employers provide health care for workers. When Bill Clinton took office in January, the A.M.A. ran upbeat newspaper ads announcing a "new partnership" to work for health-care reform. But the A.M.A. was quickly shut out of the process once the White House task force headed by Ira Magaziner set to work behind closed doors.

Some doctors suggest that the Clintons might have avoided last week's trouble if they had schmoozed the A.M.A. a little sooner. But even as Todd and Magaziner were arm wrestling in the privacy of the health honcho's office in the Old Executive Office Building, the A.M.A. offensive was in the works. The organization's leaders and media advisers gathered in Chicago in August to refine their analysis of the Clinton proposal and their public reaction. Speakers were coached in sound bites: "The A.M.A. doesn't want to see the calculator replace the stethoscope." As the day for the unveiling of Clinton's plan approached, A.M.A. spokesmen fanned out across the country to provide local TV stations and newspapers with a response. Brochures and other materials were shipped out to county and state medical societies. Satellite hookups allowed A.M.A. officials to visit editorial boardrooms across the country. Meanwhile, local medical associations had been moving to shape the debate. Ever since Clinton placed reform on the agenda, the stack of magazines in the waiting rooms often included brochures praising certain reform plans; that kind of in-house advertising is bound to grow as the argument over Clinton's plan unfolds. "If it looks like it's really going to mean a problem for us," says David Holley, president of the California Medical Association, "we'll take whatever means necessary to educate the public." The only reason it hasn't started yet, says Holley, is that "we don't know what we're commenting on."

Many doctors feel they know enough already to share their concerns with patients who ask their opinion. Doctors fear that the hated insurance-company bureaucrats will be replaced by hateful government bureaucrats, that the regulations, paperwork and workload will increase while flexibility and autonomy will disappear. The doctor-patient relationship, they worry, won't just be harmed. It will be eliminated.

Dr. Melvin Kirschner, a family practitioner for 32 years in Van Nuys, California, does not hide his disdain. "With managed care," he says, "the decisions are made by a utilization review board, which sometimes has a doctor and sometimes not. We get lots and lots of rejections." Some of his patients have been with him for more than three decades, he says, and are used to having some control over their treatment. "They see some black wart on their forearm, and they worry it's cancer," he says. "That was great when the indemnity paid, but now what I get from managed care is, 'If it's benign, you don't need to take it off,' or, 'If it's malignant, you'd better show us' -- as if I have microscopic eyes that detect every lesion and can tell you ahead of time whether it's cancerous or not."

Though the Clinton plan aims to simplify health-care delivery, doctors see the trend moving in the opposite direction. Some private physicians join dozens of different insurance plans so their patients can continue to see them. But each one holds the physician to different rules. "Some plans crucify you if you don't do a throat culture in a given case," says Dr. Richard Chamberlain, an osteopath in rural Franklin, Ohio, "while in other plans you're practically strung up and quartered if you do a culture. The administrative work involved in these plans is so incredibly detailed and complex that it's probably costing us money to see our patients."

Doctors worry about the "cookbook" plan that tells them what they are allowed to do for each different condition. "That's what government medicine is all about," says internist Morgan Meyer of Lombard, Illinois, a former president of the state medical society. "There will be hospitals closing, people out of work, and we're going to be expected to make all health-care decisions according to imposed guidelines. The benefits of this plan are vastly overrated, and the savings they anticipate in Medicare are illusory."

Many doctors agree that holding down costs is harder than it looks, even if millions more patients are forced into joining health maintenance organizations. Physicians note that in the past 10 years 31 million new patients have entered HMOs, but costs have continued to rise. "Much of the criticism of health-care delivery is directed toward the financial rewards of overutilization," notes Dr. Jay Skyler, a University of Miami endocrinologist. "But in an HMO, the financial incentive for not doing procedures is equally as bad, and may even border on the dangerous." Dr. Pepi Granat, a South Miami family practitioner who used to work for an HMO, goes even further. "You have to be loyal to whoever is paying you. If an organization is your boss, you can't be a true advocate for the patient." The HMOs, she says, "will end up wiping us out. They will eventually replace us with nurse practitioners and physician's assistants who will have the appearance of doing the same thing but won't have the expertise."

A more effective way to hold down costs, doctors argue, is to confront the controversy over rationing care. It simply is not possible, they argue, to provide high-tech, high-cost care without limit. "Should a 95-year-old with lung cancer be given expensive chemotherapy if it's only going to give him three months more life?" asks Dr. Peter Cassileth, chief of the hematology- oncology division of the University of Miami. "That's the most expensive, least effective sort of medicine. By making hard choices, the cost savings would be extraordinary. But it's just not something you can do without engaging the country in a dialogue."

For many doctors, however, the dialogue on rationing and other painful issues does not belong in the examining room. "The examining room is not the time to push political issues," says Boston University's Annas. "The patient is very vulnerable. The implication is, If you don't listen, I am not going to take an interest in you; or worse, If you don't say yes, I am not going to treat you. It is totally inappropriate."

If doctors can't win over their own patients, they have little hope of blocking fundamental aspects of the Clinton plan. But they also have to be viewed as a constructive force in the debate. Republican pollster Linda DiVall informed the physicians assembled in Washington that three-quarters of the American public think that the health-care system is headed toward a crisis because of cost. Nearly 70% thought the Clinton plan was better than doing nothing at all. And in conversation among themselves, many doctors agree. It is Clinton's direction, not his intentions, that scares them. "I have a feeling that five years from now we're going to look back on this time as the good old days," Dr. Chamberlain muses. "And if these are the good old days, we're really in trouble."

With reporting by Greg Aunapu/Miami, Dan Cray/Los Angeles and Dick Thompson/Washington