President Bill Clinton's proposal for national health care reform will push medical institutions at Dartmouth toward adopting managed health care services in providing medical care and health care education to Dartmouth students and Upper Valley residents.
Stephen Marion, vice president of Regional Planning for the Mary Hitchcock Memorial Hospital, said Clinton's health plan would change the way the Dartmouth-Hitchcock Medical Center and the Hospital operate.
"I think the impact would be in many areas," Marion said. "Clinton's proposal would probably make us move towards managed health care services" such as Health-Maintenance Organizations (HMO's), which allow patients to choose a network of physicians, he said.
In an HMO, patients see one primary care physician regularly, who refers them to hospitals or other physicians that are part of the network if the patient needs special care.
Marion said managed health services often allow more communication between patients and their primary care physician because the physician is responsible for referrals to specialists.
Managed health systems tend to be more coordinated and more cost-effective, he said.
The hospital is already moving toward managed systems, Marion said, but Clinton's proposal "would accelerate this trend." Presently, two percent of patients at the Hospital are covered by HMO's.
Clinton's plan would also change the relationship the DHMC has with other hospitals and physicians.
Referrals represent a large proportion of the patients that are treated at the DHMC. Only 30 percent of the patients at the Medical Center are from the Upper Valley. The rest are referrals from other states and areas.
"Under the President's plan, providers within health care regions would form Accountable Health Partnerships," Marion said. The AHP's would serve as a formalized referral service.
"We would have to form an affiliation with hospitals and physicians throughout the region," Marion said.
Clinton's proposal will also alter how hospitals are paid for their services.
According to Marion, Clinton's proposal would move health care towards capitated payment instead of the current fee-for-service. In a capitated plan, the hospital would be paid a certain amount each year for every person in the area.
This budget would then have to last hospitals the entire year.
The Clinton administration hopes tighter budgetary controls will lead to efficiency and cost-containment, but if the capitation limit on hospitals is lower than current expenditure, hospitals will have trouble providing care to everyone who needs it.
"It could lead to rationing," Marion said. "Hopefully it wouldn't. It depends on where they set their capitation."
Marion said if the capitation is set at a reasonable amount, the plan will lead to increased efficiency in hospitals.
Funding for hospitals is further complicated by the extra reimbursement the DHMC receives for its medical education program.
Marion said he does not know whether this reimbursement will be continued or not.
According to Marion, if capitation is instituted and reimbursements from medical education programs are eliminated, the hospital will not be able to compete with other hospitals, "unless we cut out our teaching program."
Marion said Clinton also wants medical schools to place more emphasis on training primary care physicians instead of more specialists. Clinton's goal is to have one out of every two physicians trained as primary care physicians.
Currently, the national average is 70 percent specialists and 30 percent primary care physicians.
The DHMC is no exception. "DHMC has a very high proportion of specialist physician trainees," Marion said.
Although Clinton's proposals will alter drastically the health care system in the nation and at the DHMC, Marion said most physicians at the hospital support the changes.
He said doctors at the hospital support regional provider networks and Clinton's goal of better efficiency and coordination.
Even the more ambitious goal of steering medical students away from becoming specialists is supported by the doctors, he said.
"It's a challenge to us," Marion said. "But we think it's the right thing to do."
Overall, Marion said most physicians at the DHMC are "optimistic and supportive" of Clinton's proposals.
