All roads lead to Rome.

By the time this issue of Physician Executive reaches you, Bill Clinton will have been President for roughly two months. It is even possible that something other than the broad outlines of an Administration plan for health care reform will be in the legislative hopper. Whatever the status of the national debate as you are reading this column, it is certain that much of the "action" on health care will be taking place East of the Potomac River for the foreseeable future.

Many of you are no doubt receiving daily notices of meetings scheduled for Washington, D.C., to help inform the health care industry of changes projected for 1993. Everyone expects the new Administration to make significant changes in payment and delivery mechanisms for health care in this country. Many physician executives and others expect Washington--the President and the Congress--to have answers to this complex problem.

Members of the College, through societies and forums, have been active in studying these issues. We have many colleagues in this effort. The primary specialties of internal medicine and family practice have promoted programs to enhance the availability of medical care for the uninsured. The American College of Medical Quality (ACMQ) recently spent a year in the development of policies that concern quality of care and mechanisms of managed care. Even the American Medical Association is supporting new mechanisms to expand the availability of health care to all citizens. The Health Insurance Association of America (HIAA) has recently undergone major internal political struggles in an attempt to find a common ground among its members. Traditional indemnity and managed care, small insurers and large insurers accuse each other of promoting the wrong solutions.

The "managed competition" approach being promoted by the new Administration as a solution to the ills of the health care system is only a broadening of market forces that are giving larger employers the best break in the current insurance market. Everyone is discounting to the large employer and to the "younger and well" patient through selective rates and leaving the "smaller, older, and sicker" patients to others. Price shifting has left the individual patient and the small employer with either no options or ones that are unconscionably expensive. Many employees are excluded by underwriters because of their adverse claim histories. Physicians often complain about insurance companies and their profits and expenses, but most companies are now self-insured under ERISA and most contracts with insurance companies are written for administrative services only.

The "pay or play" solution under managed competition would find me, as a small employer, only too welcome to "play," as anything would be better than what insurance companies could offer (and, fortunately, all my employees are healthy.) The newest twist in Indiana is to "noncover" sick employees and their dependents and throw them into the "high-risk pool" available in our state. Indiana's number one concern in the current legislative session is to cut the services available to Medicaid recipients, whose costs now make up one-third of the state budget and threaten to bankrupt the state. The additional 100,000 patients added for absolutely needed prenatal and obstetrical care to many of our young working families have increased short-term health care costs 20 percent per year.

The bottom line is that all of the players are being squeezed as we attempt to patch the system without pain. ERISA self-insured companies have added new problems to the system by limiting coverage for their retired workforces and for certain diseases--i.e., HIV diseases and mental and addiction services. Federal programs continue to cost shift by reductions in services and payments. The consensus seems to be to view health care as being only on the cost side of the ledger and to forget that it is now one of the few growth industries in the United States. This service industry in the '90s creates wealth and value just as manufacturing has in the past.

Abuses in the system, including fraud, seem to be unmanageable except through power and regulations available to government programs. Restrictions on health care for certain diseases and/or treatment programs are outside the ability of payers. The American public wants maximum health care for every individual, all paid for by the common community. I have come to the conclusion that the public wants "free care" paid through "invisible" mechanisms.

Solutions to the payment mechanisms dilemma will have to involve the physician community. Efficiencies needed for the delivery system will be designed and implemented only by the provider community. We must get through this period of blaming others and continuing this patchwork method of dealing with the problem. Until we have all Americans covered under a basic health care plan, we will never improve health care delivery efficiency. Quality improvement and outcomes management will be haphazard or will provide only lip service until the system has to live with the long-term care of the entire public.

It is impossible for our current insurance payment system to invest in longterm outcome concerns when the average individual changes insurance plans every 18 months. Switching to a tax-based system with basic coverage for all and allowances for additional services for those with private means is the best solution.