"As the American health care system has become more complex, specialized, and technical," says the official summary of the Clinton administration's health-care plan, "it has neglected some simpler and, ironically, less costly needs....If the American health care system is to provide high-quality care at affordable prices, it must strike a better balance between physicians, nurses, and other professionals who take care of basic needs and those who provide the most sophisticated and specialized treatment for serious illness."
To many health-care reformers, the need for "a better balance" is clear. About 30 percent of U.S. doctors are considered "general practitioners," while in some countries the percentage is almost 70 percent. In Canada, a single governmental organization controls the number of specialists trained. But most Americans still believe that patients acting as consumers, and medical students themselves, should have some say in the matter. Bill and Hillary Clinton have decided to guide medical education onto a more enlightened path. In reply to a question from a medical student worried about being forced into primary care, the First Lady told the annual meeting of the Association of Medical Colleges, "There will clearly still be opportunities to go into specialties and subspecialties. But you know, it's about time we start thinking about the common good and the national interest, instead of just individuals, in our country." If the Clintons have their way, the federal government will decide how medical students will be trained and what they will do when they graduate.
In all the hype over ClintonCare's more conspicuous components--employer mandates, new taxes, restrictions on patient choice, etc.--the plan's new rules regarding medical schools and teaching hospitals have received relatively little attention. Yet the attempt to achieve the "right" mix of specialists and general practitioners has far-reaching implications that go beyond the obvious limits on the freedom of medical students to shape their careers. It would threaten the economic viability of the nation's premier medical institutions and undermine the quality of health care without reducing costs over the long run.
Policy makers have for years been trying to change the mix of general practitioners and specialists in the belief that more preventive care will help control health-care costs. Several states have established financial incentives and funded G.P. residencies to encourage students to pursue primary care, particularly in rural areas. Bills have been passed in New York and New Jersey limiting the number and types of residency positions, and legislation almost passed in California that would have allocated half of all University of California positions to primary care. In 1992, the federal government began phasing in a new fee schedule for Medicare that cut payments to surgeons by between 8 percent and 14 percent while increasing payments to family practitioners by about 15 percent.
Under the Clinton administration's plan, within five years at least half of new U.S. physicians would be trained in primary care rather than specialty fields. Primary care, according to the administration, includes family medicine, general internal medicine, obstetrics/gynecology, and general pediatrics. During the five-year period, the plan would increase the number of primary-care residency positions in the nation's hospitals by 7 percent a year. The number of filled specialty training positions in which "excess supply exists" would drop by about 10 percent annually.
Each year, Secretary of Health and Human Services Donna Shalala would determine the number of training positions that should be available in each specialty. The secretary would appoint a National Council on Graduate Medical Education to advise her in this process. HHS would also appoint 10 regional councils, reporting directly to the department, to allocate residency slots to each teaching hospital.
The federal government would "encourage" hospitals and medical schools to go along with these rules by changing medical education funding. The plan would offer about $6 billion, pooled from Medicare funds and a surcharge on health-plan premiums, to support medical training. The money would be available only to residency programs approved by the federal government. This funding mechanism is intended to replace today's system for supporting medical training, which relies on a combination of federal research grants and cross-subsidization of medical schools and residency programs by hospital bills. The administration also promises "transition assistance" for both doctors and hospitals, so they can retool to supply more primary care, and a loan-forgiveness program for medical students who go into general practice rather than specialties.
It is true that medical schools and teaching hospitals have a strong incentive to encourage their students to work in specialty fields. Medical schools get roughly 21 percent of their revenue from federal research grants, 42 percent from treating patients, and just 4 percent from tuition and fees. The federal grants are frequently tailored to studies of specialized treatments or procedures. And medical schools' patients are generally those seeking treatment by specialists for conditions their family doctor or local hospital could not adequately treat. So when these centers are pressured to emphasize general practice rather than specialties, they face potential losses of both research grants and patient revenue.
Meanwhile, the health of academic medical centers is already threatened by the more familiar parts of the Clinton plan: The Regional Health Alliance monopolies will elevate cost considerations above all else, harming academic hospitals that usually compete on the basis of quality and charge patients a little more to subsidize research and medical education. These medical centers are some of the most prestigious and innovative parts of American medicine. More than half of the 15 hospitals U.S. News & World Report ranked as "America's Best" in 1993 were university medical centers.
Even if these institutions could be protected, there is a more fundamental problem with ClintonCare's plan to push physicians into general practice. The administration's rules on medical training are motivated by a widely held belief that the key to reducing burgeoning costs and improving medical services is expanding so-called preventive care. Generally speaking, preventive care is any measure--including tests, examinations, diet and exercise regimens, and other behavioral changes--designed to head off a potential medical problem. If an ounce of prevention really is worth a pound of cure, as the old saying goes, then preventive care would seem to be the solution to America's health-care needs. By making use of relatively cheap, simple procedures, patients can avoid medical conditions that could require more expensive treatment, including surgery, later on.
But preventive care as the Clinton administration envisions it is not a reliable recipe for cost savings. Indeed, overconsumption of tests and procedures--encouraged by tax-free, low-deductible insurance and the resulting sense that such services are "free"--is a major driving force behind health-care cost inflation. "The fact is, we can't afford all the 'preventive care' that it is possible to consume," says John Goodman, president of the National Center for Policy Analysis in Dallas and co-author of Patient Power: Solving America's Health Care Crisis.
While the wisdom of providing generous preventive care to the American population is widely assumed, research in medical economics suggests a murkier picture. Dr. Jane Sisk of Columbia University's Department of Health Policy and Management reports that, "based on health effects, costs, and equity considerations, some preventive measures, such as adult and childhood vaccinations, are clearly underused. Others, such as cholesterol screening for elderly people, may be overused."
The economics of preventive care often depends on a doctor's response when a test comes back positive. One potentially deadly disease in the news lately is prostate cancer. High-profile deaths from the disease, such as those of actor Bill Bixby and musician Frank Zappa, have intensified a campaign to encourage screening and early treatment. But since the disease isn't usually fatal, it's not clear how often men should be tested and whether they should undergo radical treatments such as surgery or radiation.
Take the case of Tom Wirth, a 52-year-old Masscchusetts architect whose father died of prostate cancer. Wirth was diagnosed in 1992 with some cancerous cells in his prostate gland. He asked five different doctors what he should do next and got five different answers. Finally, he decided not to take drastic action but instead to seek acupuncture therapy. "Each expert feels hat his option is the panacea," Wirth told Newsweek.
Wirth's predicament is not unique. Doctors have no unanimous verdict on early treatment of prostate cancer, and many counsel patients not to undergo any significant treatments unless the cancer begins to spread. A 1988 study of U.S. urologists found that 80 percent favored radical prostatectomy for a man in his 60s with a tumor confined to the gland. On the other hand, 92 percent of radiation oncologists recommended radiation rather than surgery.