The regional controversy between physicians, hospitals and managed care administrators has done two things.

It has brought into the open tensions between provider groups. That’s a significant accomplishment.

Those who participate in this dialogue provide a service to the public and their communities by speaking candidly about areas of disagreement and professional conflict. It is impossible to make decent public policy decisions if profound underlying problems are unexposed.

This dialogue has been necessary, but it has shifted the focus of the health care debate away from where it ultimately belongs: the need for unity.

Northeastern Maine is small in population and limited in economic resources. If people here, patients and providers, want to control the future of health care delivery, they must combine forces and pool their energy. End the conflict within. Prepare for the one coming from without, the large health maintenance organziations (HMOs) that will capitalize on a weak and fragmented market.

At stake is the patient-physician relationship, treatment choice and the financial base that supports the pool of medical talent from Bangor to Calais to Caribou.

Regional physician groups, hospital trustees and representatives of employers and patients need to meet at a neutral site and agree to find ways to work together. There’s plenty of shared self-interest and common ground.

Ethics and choice

In a recent issue of “Complications in Orthopedics,” its editor-in-chief, Dr. Harry Gossling, examined the complex social, political and economic forces tearing at the patient-physician relationship.

Dr. Gossling, professor emeritus in the Department of Orthopedic Surgery at the University of Connecticut Health Center School of Medicine, considered the potential impact of HMOs, capitation and diminished resources at the level of care delivery. He described a dynamic, unpredictable environment. He had profound ethical concerns as he considered its future:

“… The question to be answered is whether the changes in the health care system can be made without significantly lowering quality of care as it affects individual outcome, comfort and dignity.”

No panaceas from this doctor. His advice, directed at surgeons, is valuable for everyone, and is germane to the health care debate in northeastern Maine. Be better informed, said Gossling, as laymen and physicians. Communicate and be aware of changes in the health care system. Monitor outcomes of insurance-driven practices on patients.

Costs and profits

This debate is about numbers, and Dr. Gossling shared some of those as well. He points out that the $54 million saved statewide in Connecticut through new discounts offered by hospitals since deregulation began there more than a year ago is equal to the increased profits reported by its HMOs last year. Higher HMO enrollments were part of the reason for the 15 percent jump in profits, said Gossling, but “some of the money simply moved from hospitals’ coffers to those of insurers.”

There would be similar consequences in the northern two-thirds of the state with a large outside HMO entering the health care market. It would function like a huge conveyor, removing local resources. For example, an HMO signing up 35,000 Greater Bangor area residents at $2,000 per member per year would expect a 20 percent profit margin. That would siphon $14 million annually out of the economy while squeezing physician practices and limiting patient choice.

The challenge in this region is to keep the money here, invested in quality medical care — including facilities and reasonable compensation for physician services — and expanded health care opportunities for the working poor.

Interests and an alliance

Northeastern Maine can prevent these dollars from flowing out of the region if in a short time it can overcome years of distrust and rivalry.

The new system empowers primary care physicians, and eventually will strike a closer balance between their incomes and those of specialists. In the meantime, however, they share common interest in keeping medical decision-making where it is now, right here. They need to get together, align themselves professionally and politically.

There always will be tension in Maine between rural and urban perspectives, whether they are hospitals or physician groups. Somehow, these differences must be subordinated to the pursuit of the common good, and regional economic self-interest.

Put aside, not resolved or forgotten, these rivalries should be seen for what they are: unproductive, debilitating. They sap political and economic strength.

Medical centers must cooperate. Administrators and their boards need to talk publicly about their investments in physical plant. The region can’t afford, for example, duplication of expensive facilities at St. Joseph and Eastern Maine Medical Center.

Maintaining rough parity in key functions of local institutions may provide the semblance of competition, a comfort level and a fall-back for physicians who continue to distrust the medical center, but it’s plain dumb as medical economics. If aministrators, physicians and the public don’t work together to eliminate redundancy and waste in the region’s medical care delivery system, it eventually becomes an opportunity for someone else’s profit. The savings, the money, all of it local dollars, will flow out of the region. Better to economize and keep it here.

Threatening to send local patients to specialists outside the region is similarly shortsighted and economically self-destructive. Most costs here reflect a comparatively lower standard of living. Someone outside will offer to do something more cheaply only until the region’s capacity to compete to perform the same service is sufficiently diminished. Then, watch prices go up and power shift.

The solution is simple but difficult. The major players in this region must get together and agree to work collaboratively in an alliance.

The objective should be a single system that is large enough to include everyone in the region and strong enough to be competitive. It must acknowledge such rural hospital concerns about losing control or identity.

It should demand efficiency, but place a premium on people, care-givers and receivers. The debate has been useful. Now it’s time for the region to unify.