patients with arm fractures requiring orthopedic referrals]. She made 20 calls to the HMO, the patients, and several orthopedists before finding one with the requisite affiliation who could see the patients that day. . . . Pacific HMO patients with hyperlipidemia will be treated one way; PruNet hyperlipidemics, another. And if those same patients switch to Blue Cross California Care HMO, they'll get plugged into yet a third protocol. (Bodenheimer, 1992, pp. 29, 30)

Their bitter and understandable complaints notwithstanding, most U.S. medical organizations do not favor adoption of such simpler systems as those found in England and Canada, where network health plans and managed care requirements have not proliferated. One fear is that any system dominated by a single payer will be able to more effectively limit the resources going to the health sector, thus reducing incomes, investments in new technology, opportunities for specialized practice, and other advantages experienced by U.S. health care practitioners and providers. The ever-increasing level of complexity, growing restrictions on consumer choice, and the decreasing reliance on professional judgment may, however, be causing many practitioners to change their outlook. On balance, complexity and diversity may be viewed by others as a lesser burden—and one more susceptible to provider influence—than uniform government dictates about payment methodologies, appropriate care, and similar matters.

Public and private insurers have periodically been pressed by health care providers to agree on simpler and more uniform administrative procedures. In addition, some supporters of health care reform have argued vigorously that the nonuniformity of the current system wastes as much as $100 billion per year that could be saved under a single public program (Woolhandler and Himmelstein, 1991), although others have questioned these assumptions (Danzon, 1992, but see also Barer and Evans, 1992, and the discussion in Chapter 3 of this report). The most recent simplification initiative involved a summit called by the Secretary of the U.S. Department of Health and Human Services. Agreements were reached among some large payers, and legislation was proposed to reduce paperwork and increase consistency of claims administration rules (McIlrath, 1992).

Furthermore, an increasing number of physicians are simplifying their practice by abandoning fee-for-service medical practice and contracts with multiple health plans and going to work for prepaid group practices and other integrated systems. By virtue of their recruitment processes, their use of salaried or similar reimbursement methods, peer influence, and other characteristics, these organizations may use less intrusive means of constraining discretion and costs.

In any event, an end to employment-based health benefits in the United States would almost certainly not mean an end to all oversight. This seems ensured by the public interest in accountability, performance and outcome



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