As the U.S. health care system is being remade from top to bottom, the upheaval has shaken the most basic and personal of all the pieces -- the relationship between patients and their doctors.
Helen and Joseph Marchand just lost the physician who detected a life-threatening build-up of plaque in Mr. Marchand's arteries. Charles Hall will lose the doctor who he feels has come to know him as no one else could.
Celeste Dunstan said goodbye twice to the family physician she could call at 10 p.m. if she had a problem with one of her children. He's the doctor who diagnosed her colitis when several others were stumped.
Now she swears she'll pay out of pocket rather than lose Dr. Joseph Zebley again.
"He's not only a doctor," said the Baltimore woman. "He's a friend of our family, and we all love him very much."
Dr. Zebley, who still makes house calls to the elderly, has many patients who come and go so quickly that he doesn't get to know them the way he would like. In the past, when he got a call from an emergency room, he could recite a patient's history off the top of his head. Now when he gets those calls, he says, "I don't have a clue as to who they're talking about."
To cut health insurance costs after years of increases, companies have turned to managed care, where all health care is coordinated through primary care physicians, who limit expensive, sometimes unnecessary visits to specialists.
More changes ahead
But that means huge numbers of patients are switching into managed care plans -- often forcibly -- and many must find new physicians. Once in managed care, many must change again because their employer switches health plans to get the cheapest buy.
Doctors are moving too. In order to survive in the new system, they're joining with physician groups, health maintenance organizations and hospitals.
A recent national survey by the Commonwealth Fund found that nearly half of the 3,000 insured adults interviewed had to change health plans. Of those, three-quarters had to change involuntarily, primarily because their employer decided to switch plans.
The survey also found that 41 percent of managed care members who changed plans in the last three years said they had to switch doctors. That compares with 12 percent of those enrolled in fee-for-service plans, in which doctors are paid for each service and patients have little restriction on which doctors they can see.
Still, others say the new system will be better over the long term, because people can pick a primary care doctor whom they know the managed care plan has screened for quality and credentials. Managed care advocates also say their system helps link up many people who never had family doctors.
"One of the advantages of an integrated system is getting people connected with a family physician and setting up appointments when the person is well, so you can establish a rapport," said Geni Dunnells, former director of the Maryland Association of HMOs.
But others contend the opposite is happening.
Celeste Dunstan started out with Dr. Joseph Zebley 13 years ago when her husband, Bert, had to practically carry her into his office. Several other physicians had failed to diagnose her illness even though she had lost 15 pounds and couldn't keep down food or even water.
"As soon as I was there, all of a sudden, I felt like OK, I'm at the right place," said Mrs. Dunstan. Dr. Zebley was soothing and determined. He told her: "We're going to take care of you. We're going to find out what it is." He diagnosed colitis.
Since then, the family has experienced what's called "rebounding," where patients move in and out of doctor practices every few years as their companies switch health plans. The Dunstans saw Dr. Zebley for years, until her husband's company switched to a different plan, and they had to find another doctor. Two years later, the company switched back, and they rejoined Dr. Zebley's practice. When the company changed plans a third time, they found yet another doctor.
After the company's latest switch, Mrs. Dunstan and her husband pulled out the plan's list of doctors and rejoiced: Dr. Zebley's name was there.
Some feel it's a life-and-death situation.
Four years ago, when Joseph Marchand's employer switched health plans, the Marchands lost their physician of 16 years, Dr. Joseph Deckelbaum, a man Mrs. Marchand considered like family.
Gradually, though, the Baltimore couple found confidence in their new physician, Dr. Leonard Lichtenfeld, an internist who monitored Mrs. Marchand's angina, high cholesterol and diabetes, and helped keep the conditions under control. He also discovered her husband's arterial blockages.
"Dr. Lichtenfeld saved his life," said Mrs. Marchand, 60. "When I was younger, I never cared which doctor I went to. But today, I want confidence in who I'm using."
But in September, Dr. Lichtenfeld left his solo practice to join a group. To stay with him, the Marchands would have had to switch to another physician group and lose many of her specialists. They also would have had to go to a distant hospital. They are just two of 130 patients Dr. Lichtenfeld lost in one day.
Recently, the Baltimore couple met their new physician, their third choice after the first two said they had no room for additional patients.
"It's so sad," Mrs. Marchand said, describing the feeling she had for a longtime physician as being "like an old shoe. You just feel comfortable and safe."
But those values aren't at the heart of what's happening. Money is forcing the changes.
With managed care, businesses are reporting savings of anywhere from 3 percent to 25 percent. BGE, for instance, saw health care costs rise about 12 percent annually, until the last few years in managed care plans, where costs have remained flat.
Already, roughly 40 percent of insured Marylanders are in HMOs, with another 20 percent in some form of managed care. That's comparable to managed care enrollment nationwide, which is about two-thirds, an increase from just one third in 1988.
Studies have found that effective communication and collaboration between patient and physician leads to improved control of diabetes and hypertension, fewer symptoms from chemotherapy and fewer limitations from peptic ulcers.
A bond of trust
"It's a bond of trust and respect between a patient and physician," said Dr. Zebley. "There is a power to that sense of trust. That's the extra grain of magic that makes therapies work better."
Now many say the revolution in health care means people are treated like property, shifted from one health plan to the next. Picking a physician will no longer mean asking friends or nurses and doctors for recommendations.
"In the future, people will be picking a physician off the list like you pick a Whopper off the menu," said Dr. Howard M. Klein, a local pediatrician. "They don't choose you by relationship. They choose you by insurance."
Physicians also say that they have less incentive to go to extreme lengths to stabilize patients with chronic illnesses. "In the back of my mind, I'm wondering why should I get everything straightened out, because most likely, this patient will be moving in a year or two," said Dr. Joseph Adams, an internist who spends many evenings reading new patients' medical histories.
But some say the public must make certain sacrifices if society is to rein in the high cost of health care. Being able to choose your own physician costs roughly 10 percent more than being in a restricted system.
Bob Blendon, a Harvard University professor who has studied health care and public opinion, says choice of physician was one of the public's top priorities during last year's health reform debate -- and it still remains near the top.
"What's happening is that the health care system is being changed from the top down by employers, and if President Clinton was doing what many employers are doing to their employees, he'd be voted out of office," Dr. Blendon said. "But people don't want to lose their jobs."