The NewsHour with Jim Lehrer

MR. LEHRER: Good evening. I'm Jim Lehrer. On the NewsHour tonight, the funeral of Ron Brown, Kwame Holman reports [Focus - Farewell]; Labor money in the '96 elections, union leader Gerry McEntee debates Republican House Leader Tom Delay [Focus - Labor & Politics]; our health care cost series continues from Arizona, where Tom Bearden reports, Elizabeth Farnsworth runs a discussion [Series - Changing Times - Quality of Care]; and remembering the specialness of developer James Rouse, Charlayne Hunter-Gault talks to colleague Barton Harvey and architectural critic Robert Campbell [Finally -In Memoriam]. It all follows our summary of the news this Wednesday. NEWS SUMMARY

MR. LEHRER: The U.S. military continued to evacuate Americans and other foreign citizens from Liberia today. The helicopter evacuations began yesterday. Heavy ethnic fighting broke out Saturday in that West African nation. We have more in this report from Lindsay Taylor of Independent Television News.

LINDSAY TAYLOR, ITN: Shaken, exhausted, but safe, the evacuees from Liberia arrive in Freetown Sierra Leona. They carry with them what they can but some escaped with only the clothes they stand in.

UNIDENTIFIED MAN: The only clothes we have is what people has given us since we left there. They got our passports. They got our money. they got--I got away with the car, got the car to the embassy, but it had bullet holes in it.

LINDSAY TAYLOR: From here, they are immediately put aboard transport planes to be flown to Dakhar and Senegal and from there to home. Most are Americans, but the evacuees include some 30 Britons and other nationalities. The scale of the U.S. military operation to evacuate nationals underlines how seriously the situation in Liberia is viewed. Aid agencies have been evacuating their staff. The concern now is for native Liberians who have nowhere to flee to. Tonight, the airlift has been suspended by torrential rain. The evacuation is due to resume in the morning.

MR. LEHRER: At the United Nations today, the U.S. Government expelled a Sudanese diplomat linked to a terrorist conspiracy. The man was identified as Ahmed Yousif Mohamed, a second secretary at the Sudanese mission to the UN. He was given 48 hours to leave the country. Officials said he is suspected of aiding terrorists who plotted to blow up the UN and assassinate Egyptian President Mubarak. In Washington, President Clinton vetoed a bill prohibiting a late-term abortion procedure. Congress sent the President the bill last month. It would have fined or jailed doctors who performed so-called "partial birth" abortions. Congress has never successfully banned any type of abortion since the procedure was legalized by the U.S. Supreme Court in 1973. There were two upsets in yesterday's special run-off elections in Texas. A Democrat turned Republican lost his congressional seat. Four-term incumbent Greg Laughlin switched parties after the 1994 Republican landslide. He lost yesterday's run-off to former Congressman and Libertarian Presidential candidate Ron Paul. Paul will face a Democrat in the Fall. And in the run-off to be the Democratic Senate candidate, high school teacher Victor Morales defeated Congressman John Bryant. Morales will face incumbent Senator Phil Gramm in November. And in Washington today, Commerce Secretary Ron Brown was buried at Arlington National Cemetery. We'll have a full report on the funeral service that proceeded the burial right after this News Summary. After that, a debate about Labor money in the '96 elections, how the changing health care system looks from Arizona, and some words of appreciation about James Rouse. FOCUS - FAREWELL

MR. LEHRER: The funeral of Ron Brown. Kwame Holman has our report.

KWAME HOLMAN: Shortly after noon today, the flag-draped coffin holding the body of Ron Brown was removed from the Commerce Department Building, where it has lain in repose for 24 hours. With full military escort, the coffin was placed in a hearse for the short trip to the funeral service at Washington's National Cathedral. Space inside the cathedral had filled quickly. Only 500 seats were made available to the general public on a first come, first serve basis. Most of the seats were reserved for the family and friends of Ron Brown, government officials, and other dignitaries. The President, Mrs. Clinton, daughter Chelsea, and Vice President and Mrs. Gore were seated in the front row opposite the Brown family. [singing in background] It was a simple ceremony interspersed with prayer and several musical tributes. [singing in background] Ron Brown's son, Michael, was the first to speak. He offered thanks on behalf of the family to all of those who had helped them during the last week. He also recognized the other 32 other Americans who perished in the plane crash, along with his father, and of course, he spoke of his father.

MICHAEL BROWN: You know, Dad, I'm going to miss you, and a lot of other people are going to miss you too. But the thing that made my father real special was that he's going to miss everybody to-- it wasn't a one-way street. He depended on people just like I depend on people, just like everybody else does. And we're all going to miss him. Daddy, I love you.

MR. HOLMAN: President Clinton also spoke, mixing humor and personal remembrances of his Commerce Secretary, the man who helped him attain the Presidency.

PRESIDENT CLINTON: The Bible tells us though we weep through the night, joy will come in the morning. Ron Brown's incredible life force brought us all joy in the morning. No dark night could ever defeat him. And as we remember him, may we always be able to recover his joy, for this man loved life and all the things in it. He loved the big things, his family, his friends, his country, his work, his African-American heritage. He loved the difference he was making in the world, this new and exciting world after the Cold War. And he loved life's little things: the Red Skins and basketball and golf even when it was bad and McDonald's and clothes. And I'm tell you, folks, he would have loved this deal today. I mean, here we are for Ron Brown in the National Cathedral with full military honors, filled with the distinguished citizenry of this country and leaders from around the world in a tribute to him and, as I look around, I see that all of us are dressed almost as well as he would be today. [laughter in crowd] In his letter to the Galatians, St. Paul said, "Let us not grow weary in doing good, for in due season, we shall reap if we do not lose heart." Our friend never grew weary. He never lost heart. He did so much good, and he is now reaping his reward. He left us sooner than we wanted him to leave, but what a legacy of love and life he left behind. Now he's in a place where he doesn't even have to worry about how good he looks, he always will look good. He's in a place where there's always joy in the morning. He's in a place where every good quality he ever had has been rendered perfect. He's in a place he deserves to be because of the way he lived and what he left to those of us who loved him. Let there always be joy in the morning for Ron Brown. Amen.

MR. HOLMAN: Trumpeter Wynton Marsalis filled the minutes that followed.

[Trumpet Playing]

MR. HOLMAN: Following the service, Brown's casket was placed back in the hearse for a circuitous procession to Arlington National Cemetery in Virginia. At the request of the Brown family, a two- mile loop was added to the route to include the historic black section of Washington known as Shaw. During the 1950's and early 60's, Shaw earned the nickname "The Black Broadway" because of its many theaters and nightclubs that attracted top entertainers and visitors, many from Ron Brown's hometown, New York City. Today, after three decades of urban decline, the neighborhood is making a comeback. According to his friends, Shaw represented Ron Brown's hopes and interests, particularly during his seven years at the National Urban league. They said he would have wanted the procession to pass through the Shaw neighborhood. The ceremony at Arlington Ceremony was small and mostly silent. The Brown family was joined by the President, the cabinet, and a few friends. Ron Brown, an Army veteran, was laid to rest with full military honors. [rifles firing] FOCUS - LABOR & POLITICS

MR. LEHRER: Now the debate about organized labor's plans for the November elections. The AFL-CIO has, among other things, targeted for defeat many of the 73 freshman Republican House members elected two years ago and will spend $35 million to get it done. That has drawn angry exchanges of fire between Republican and Labor leaders. In a speech today in Colorado Springs, for instance, Speaker Gingrich labeled the labor effort "un-American." We have our own exchange now between the House Majority Whip Congressman Tom Delay of Texas and Gerry McEntee, president of the American Federation of State, County, and Municipal Employees, and chairman of the AFL- CIO Political Action Committee. Mr. McEntee, is what you're doing un-American?

GERALD McENTEE, Chair, AFL-CIO Political Action Committee: Well, I was born here. I don't think it's un-American. What we're trying to do is get as much information to working America, to union members and non-union members alike, about what has happened in this session of the Congress in 1995, in 1996. The attacks that have been made on working people and what they've been able to achieve over the years, the attacks of health and safety in the work place, the attacks that have been made on their pension contributions and the utilization of that money by corporations, the reductions in Medicare, in Medicaid, education in terms of their children, trading money to get new jobs. There's a lot of economic anxiety out there across the country and we want to, we want to be able to bring information to educate American workers about the record of the members of Congress.

MR. LEHRER: And how are you going to go about doing that? What's this money going to be spent doing?

MR. McENTEE: Well, not--you know, I think it's important to note that not one dime will go to a particular candidate, nor to a particular party. We're going to go out and try and get people registered to vote. We're going to try and get people out to vote, and then we're going to run some television ads and some radio ads, and we'll get pamphlets and information out to working America about the records of the members of Congress. We'll sort of in a way copy what Ron Reed has done in terms of--Ralph Reed has done in terms of the Christian Right, bring information, bring education to the people out there, and then they'll vote any way they wish.

MR. LEHRER: Congressman Delay, what's wrong with that?

REP. TOM DELAY, House Majority Whip: [Houston] Well, if he would take a lesson from Ralph Reed, no one would have any problem, but--and what he's done--Mr. McEntee says is--sounds benign. But if you look at what they're actually doing, they are compelling their own rank and file members through their union dues and through taxing them to support political activities that some of them, at least 40 percent of them, do not agree with. And they're doing it in such a way under the guise of education. Well, what they're doing is they're putting ads out there against 75 Republicans. Not one ad has been run against a Democrat to date, and they are misrepresenting what the Republicans are doing in Congress in, in very negative campaign ads. I mean, some of these ads are just outrageous.

MR. LEHRER: All right. Can you give me a--

REP. DELAY: And they mention the name of the Congressman in that particular district.

MR. LEHRER: Can you give me a for instance?

REP. DELAY: Sure. I can even read 'em to you. I've got some of them right here. One of them was a mailing that starts off with "Funeral services for"--the person it's mailed to--"will be held this afternoon at Community Cemetery. The deceased is survived by a loving family, devoted friends," and it goes through, talks about how the Republicans are cutting education, cutting Medicare, cutting Medicaid, and then it finishes with, "Vote labor. Your life depends upon it." During a radio ad they talked about, uh,--and I won't give you the whole ad--but just one quote from it--the announcer says, "That's right, you, ma'am. You can have what's in the box if you know which Georgia congressman voted for a bill that would rob senior citizens of their Social Security." Nathan Deal did that?--a Congressman from Georgia. And then they talk about that--

MR. LEHRER: And he's a Republican, right?

REP. DELAY: A Republican Congressman--

MR. LEHRER: Correct.

REP. DELAY: --from Georgia, and it goes on and on and on.

MR. LEHRER: Okay.

REP. DELAY: This has been going on since last Summer.

MR. LEHRER: So you--

REP. DELAY: That's what we have a problem with. They are making their members pay for this kind of activity and it's not anywhere close to what the Christian Coalition is doing.

MR. LEHRER: Mr. McEntee.

MR. McENTEE: Well, first of all, it's, it's inaccurate to say that we're making our members pay for it. Every labor union in America gives each member the opportunity that if they do not agree with an ideological position and/or a political position of that particular union or the American labor movement, they can get that portion of their dues back that can be returned to them.

REP. DELAY: Oh, sure.

MR. McENTEE: So any member that wishes to do that can do that.

REP. DELAY: Well, Jim--

MR. McENTEE: So we're not forcing any member toparticipate in this who doesn't believe in it. And once again, it's an educational type of message.

MR. LEHRER: Let's stop right there.

MR. McENTEE: I don't know where the--

REP. DELAY: Jim--

MR. McENTEE: --Congressman--

MR. LEHRER: Congressman Delay, you challenge that?

REP. DELAY: Well, that's--what he has just stated is the Beck decision, a decision by the Supreme Court that would allow rank and file members to do that. But the unions fight every request for that to comply with the Beck decision. The rank and file member would have to go to court to make the union do that, and no rank and file member is going to do that.

MR. McENTEE: That's inaccurate.

MR. LEHRER: Is that--

MR. McENTEE: That's inaccurate.

REP. DELAY: That's happening all over the country.

MR. McENTEE: That's inaccurate.

REP. DELAY: It's happening all over the country.

MR. McENTEE: That's inaccurate. In our particular union, all they have to do is, uh, write a letter in to the union, and they get that portion of their dues back. It's all, it's all regulated. It's regulated by the federal government in terms of portions of money based on not only the Beck decision but also a decision called the Hudson decision.

MR. LEHRER: What about--

MR. McENTEE: And I don't know what they're afraid of in terms of the truth.

MR. LEHRER: What about the Congressman's point that 40 percent of union members disagree with the basic position that organized labor--that the AFL-CIO is taking against the Republican Congress?

MR. McENTEE: I think that's probably based upon the belief that 40 percent of our members are registered as Republicans. First of all, I believe that regardless of registration today, people vote Republican, they vote Democrat, or they vote independent, but all we are doing is providing the facts, providing the truth, providing education to the people, whether it be cuts in OSHA, the reduction in Medicare or Medicaid, we don't control any votes--

REP. DELAY: Well, there you are. The truth--

MR. McENTEE: --anymore. We're not able to do that. They have to make their own decisions which members are making each day.

MR. LEHRER: Congressman.

REP. DELAY: If it were the truth, we wouldn't have a problem. You just heard Mr. McEntee talk about cutting Medicare and, and where have we cut Medicare? We have not cut Medicare. We have reduced the rate of increase. In fact, we've reduced it less than Bill Clinton wanted to reduce it in his government-run health care plan. What is going on here is the Washington union bosses want to protect their Washington power, and they won't debate us on an intellectual level or even a truthful level. What they are doing is running these terribly negative campaigns out there, trying to scare the senior citizens, trying to scare people in America about something that isn't going on, rather than tell the truth; that they're trying to protect the status quo of business, of politics as usual, the old failed welfare state. That's what's going on here. They're trying to protect Washington powers.

MR. LEHRER: Is that what's going on?

MR. McENTEE: No. The Congressman knows, knows well that you can't put ads on television unless there are truth to those ads. And what we have done in terms of--and I use the word reduction in Medicare and reduction in Medicaid--unfortunately, these reductions were so harsh and draconian that the people did react to the ads when they got that information.

REP. DELAY: Now, you're--

MR. McENTEE: All we want to put is the information out there, television, or radio or whatever. All we want to do is talk about the issues, and what the Republican leadership is now doing is centering in in some way on this labor bosses, $35 million, their division from the membership, they don't represent the membership. I mean, we went through this 25 years ago. I mean, all we wanted to do--let's have a debate--

REP. DELAY: Is this a filibuster--

MR. McENTEE: --about the issues.

REP. DELAY: --or do I get to talk?

MR. LEHRER: All right.

MR. McENTEE: An intellectual debate about these issues.

MR. LEHRER: Congressman.

REP. DELAY: This sounds like a Democrat filibuster in the Senate. Let me--when you put on an ad that shows a senior citizen in tears because she is going to be kicked out of her nursing home, and that is an ad that is put on by the AFL-CIO, and they say that the Republicans are going to kick her out of the nursing home to pay for tax cuts for their rich friends, that is not exactly a positive educational process.

MR. LEHRER: Gentlemen, I think we're not going to resolve all this, but you are going to continue these ads, right?

MR. McENTEE: Well, we certainly are. It's the truth. And we want to get the information to the people.

MR. LEHRER: Congressman Delay, can you--do you and your Republican colleagues plan to do anything about it besides this?

REP. DELAY: Yes. We're going to the American people and tell 'em the truth; that the unions are wanting to protect their Washington power. They're saying no to the balanced budget. They're saying no to welfare reform. They're saying no to tax relief for American families. They're saying no to saving Medicare, and they want to continue the structure in Washington that allows them to have their chauffeured limousines and their vacation homes and their fancy offices.

MR. LEHRER: But as a practical matter, you can't stop Mr. McEntee from doing what he's doing, can you?

REP. DELAY: We can--

MR. McENTEE: It's legal.

REP. DELAY: --watch him very, very closely, and when he steps over the line, we will file charges against what they're doing as we have on three different occasions already in the just the last few weeks.

MR. LEHRER: Step over the line?

MR. McENTEE: Well, that's what he says, step over the line. I don't know about these charges. Nobody has stopped us. What we're pursuing is the American way, being truthful in bringing these facts to the American people. Let them be the judge. I don't know what they're afraid of, the leadership in the Republican Party.

REP. DELAY: We're not afraid. We would just like an honest, open debate between you wanting to protect Washington and, and we wanting to return power to American working families. That's--

MR. McENTEE: We're willing--

REP. DELAY: --all we want to do.

MR. McENTEE: I'm willing to debate you, Mr. Congressman, any place in this country at any time on what is best for working America. That's what we stand for.

REP. DELAY: Why don't you answer one question for me? Would you- -

MR. McENTEE: I'd be glad to.

REP. DELAY: Would you as--in Washington--support or oppose a candidate that's supported by one of your locals?

MR. McENTEE: Say that again.

REP. DELAY: Would you oppose a Republican candidate that is supported by one of your locals?

MR. McENTEE: Our locals can make their own decisions in terms of who they support. I'd also like to correct--

REP. DELAY: But do you--

MR. McENTEE: I'd like to correct one--

REP. DELAY: Then you would oppose them--

MR. McENTEE: --statement that you made earlier.

REP. DELAY: --you would oppose their position then?

MR. McENTEE: Yes. Our locals make their own decisions.

REP. DELAY: But you go ahead and oppose their position.

MR. McENTEE: They can make their own decisions. But the one that you mentioned, we have an ad out on minimum wage today and also we are in some Democratic districts as well. I'd like to correct that.

MR. LEHRER: You know what? We're going to have both of you back.

MR. McENTEE: Please.

MR. LEHRER: We're going to continue this sometime.

MR. McENTEE: I'd love it.

MR. LEHRER: Congressman Delay from Houston tonight, thank you very much. Mr. McEntee, thank you.

MR. McENTEE: Thank you. SERIES - CHANGING TIMES - QUALITY OF CARE

MR. LEHRER: Now, part three of our week-long look at the changing face of health care in America. Tonight and tomorrow we'll be in Phoenix, Arizona, to focus on managed care. An estimated 100 million Americans now receive medical treatment through managed care plans. Arizona has a particularly high rate of participation. Tonight, Elizabeth Farnsworth is at the Good Samaritan Regional Medical Center in Phoenix.

ELIZABETH FARNSWORTH: 80 percent of the patients who come to Good Samaritan are in some sort of managed care program. Whether they're treated here in the emergency room or somewhere else in the hospital, their relationship to their physician is quite different than before. We're going to talk to a group of doctors about those changes, but first a report from Correspondent Tom Bearden. He recently spent a day in a local physician's office.

WOMAN: [talking to patient] And is the insurance through your employer or through your husband's?

PATIENT: Mine.

WOMAN: Yours.

TOM BEARDEN: Mindy Edwards belongs to a managed health care plan, a plan which sets policies and procedures for controlling the cost and the delivery of her health care. A few years ago, that kind of plan would have been something of a rarity. Today, the majority of patients at this Phoenix area practice are in managed care.

UNIDENTIFIED WOMAN: How are you feeling?

UNIDENTIFIED PATIENT: About the same.

MR. BEARDEN: Enrollment in health maintenance organizations in Arizona has doubled since 1988, from 740,000 to nearly 1.5 million today.

YOUNG WOMAN ANSWERING PHONE: Desert Valley Family Medicine. This is Anna.

MR. BEARDEN: The tremendous growth of all forms of managed care has dramatically changed the way health care is delivered in Arizona. for Mindy Edwards, it meant choosing a doctor from an approved list.

MINDY EDWARDS, Patient: Finding a doctor was real hard off the insurance list. Umm, I called a lot of them. A lot of them had denied the insurance so far. A lot of them weren't taking new patients. So I only found two doctors out of probably twenty in this area that would take a new patient or take this insurance.

MR. BEARDEN: Finally, she found room here at Desert Valley Family Medicine, located in a suburb of Phoenix. But there were more problems when the doctor's staff tried to verify her insurance coverage.

WOMAN AT RECEPTION WINDOW: We called your number, and they gave us a different number, and those people gave us a fourth number. So we called four places. The fourth place was the real one, and they're closed for the day, which means, umm, that we're unable to verify your insurance at this point.

MR. BEARDEN: Staffers say this is a common problem. Edwards had just changed jobs, and the paper work for her new insurance apparently hadn't yet been processed. They say insurance companies are sometimes overwhelmed by paper work because many employers change insurers every year. In the end, Edwards didn't see a doctor, but, rather, nurse practitioner Lois Henderson.

LOIS HENDERSON, Nurse Practitioner: [speaking to Mindy] Hi. I'm Lois Henderson, nurse practitioner. Nice to meet you.

MR. BEARDEN: This too is an increasingly common experience for managed care patients. As a cost containment measure, some insurers now require people to see nurse practitioners and physicians' assistants for minor ailments that don't require the expertise of a doctor.

LOIS HENDERSON: They are similar to physicians, but there are also limitations because the fact that we haven't gone to medical school, so it's important, I think, as a nurse practitioner, I work within my limitations, but I also draw on my experience and my education to manage a patient's health care.

MR. BEARDEN: If patients are allowed to see a doctor, managed care has also changed the kind of doctor they're initially allowed to see.

DR. HOWARD WERNICK, Primary Care Physician: [talking to patient] I'm going to ask you to take a deep breath in and out through your mouth.

MR. BEARDEN: Dr. Howard Wernick is a family practitioner, one of two at this clinic. In managed care circles, he's known as a primary care physician. For many plans, he must serve as a gatekeeper. He must give his approval before a patient can consult a specialist.

DR. HOWARD WERNICK: When patients are used to specialists where they go to a dermatologist for their skin problem, a gynecologist for their gynecological problems, a pediatrician for their children's problems, and they're used to that, one has to really make those patients aware that a family physician that's trained can do all that. And it's a matter of educating the patients. Most patients accept it; some don't.

MR. BEARDEN: If Dr. Wernick has to refer a patient to a specialist, he also has to turn to a list, a list that may not have any names he recognizes.

DR. HOWARD WERNICK: Tell the girls at the front desk that I said it was okay for you to be referred to Dr. Bankatesh for your colonoscopy, and then you set up a time that's mutually for you and him.

MR. BEARDEN: Under some HMO plans, doctors are given financial bonuses if they limit their referrals for hospitalization or specialist care. There are also capitated plans in which primary care physicians are paid a flat monthly fee per patient regardless of how many times they see them. Dr. Wernick says no matter what the payment incentives, he thinks first as a doctor.

DR. HOWARD WERNICK: I personally feel I will treat my capitated patients the way I treat my private care patients; that there should not be a different mode of handling my medical care.

MR. BEARDEN: Dr. Wernick deals with some 18 different managed care plans.

DR. HOWARD WERNICK: [on phone] I'm not on that particular access list of insurance companies, that's correct.

MR. BEARDEN: Each of them requires different procedures, laboratories, and medications. Accountant Diane May says all the rules have changed the work load for the staff and have led to a substantial increase in red tape.

DIANE MAY, Accountant: Oh, immense. We have so much paper work, we--you know, the amount of filing that has probably increased tenfold just in the last two years, just in one month's time we can have, uh, say eight, ten different insurance companies send us updates on their provider manuals with new rules and regulations before we've had a chance to memorize the last ones.

MR. BEARDEN: Dr. Wernick says he's had to hire several full-time staffers to cope with the requirements. That's substantially raised his overhead.

DR. HOWARD WERNICK: Well, I can tell you that our practice, our overhead, is probably 55 to 60 percent of our gross income. I would think perhaps it may have been 45 to 50 percent before this occurred.

LOIS HENDERSON: [taking Mindy's blood pressure] Okay. 100 over 64--real good.

MR. BEARDEN: But Nurse Henderson is glad that managed care has returned the family care physician to a prominent role in medicine.

LOIS HENDERSON: So it brings back the old concept of a family doctor.

MR. BEARDEN: And that can save a lot of money.

LOIS HENDERSON: That's great! I think it helps you, plus the whole family can be seen in one office and it's really nice to develop that rapport with people.

MR. BEARDEN: But Henderson is still bothered by the fact that insurance companies have the last word.

LOIS HENDERSON: I think that's always been like a thorn in the flesh for a lot of health care people, that somebody non-medical has sometimes more of a say or is supervising the actual manipulation of numbers when we're talking about people's lives or people's health.

MR. BEARDEN: Mindy Edwards also has some concerns.

MINDY EDWARDS: It might be saving money for, for me in the long run, but I might not be getting the best health care either.

MS. FARNSWORTH: Now we turn to six doctors, all of whom see patients in HMO's, health maintenance organizations, or other managed care plans. Joining us are General Surgeon Robert Stephens, who's in private practice; Pediatrician Mark Morales, a staff physician at CIGNA Health Care; Obstetrician/Gynecologist Marilyn Laughead, president of the Arizona Medical Association; Michael Gray, a rural primary care physician now in private practice who previously spent time working on staff at an HMO; Debra Jamison, an internist who also used to work on staff at an HMO; and Todd Taylor, an emergency physician here at Good Samaritan. Thank you all for taking time from your busy practices to be with us. You heard what Mindy Edwards, the patient in that piece, said, and you all have been trained to give the best care possible to your patient. Can you do this in this new managed care world, Dr. Stephens?

DR. ROBERT STEPHENS, General Surgeon: I don't think there's any doubt we do. Notice Mindy did get seen. Unfortunately, you know, there are different insurance policies out there, and the buyer beware. There are some which are very good. There are some which are very inadequate. And that's the problem. It's choosing which ones where they have the better coverage.

MS. FARNSWORTH: But you're not worried that your ability to, to treat your patient as well as possible is compromised by an HMO?

DR. ROBERT STEPHENS: No. Once that patient gets in my office, I have no guidelines that's any different taking care of that HMO managed patient than anybody else. Once they get in the office, the treatment's equal.

MS. FARNSWORTH: Dr. Taylor, what do you think?

DR. TODD TAYLOR, Emergency Room Physician: I think Mindy's concern really speaks to the heart of managed care, and that is that there is some loss of control once you join a managed care plan. And so perceptions may be different. If you have ultimate control over what--selecting your physician or your hospital or your treatment, you feel better about it, versus in a managed care plan, where maybe somebody else is making a lot of those decisions. And whether it's different or not, you may feel that it is different.

MS. FARNSWORTH: Well, I would think that control issue would be especially hard because you were all trained to think that you had to make these decisions. Is this an issue for you, Dr. Laughead?

DR. MARILYN LAUGHEAD, Obstetrician/Gynecologist: One of the problems in my practice in order to get the appropriate testing done for a patient, for example, the mammograms as I see of patients that are women is that it has to be pre-certified, and sometimes it may slow down the process in terms of trying to get patient care done.

DR. MICHAEL GRAY, Internist: Right. I think that the operative clause in Dr. Stephens' comment was once the patient gets to your office. In our situation as primary care physicians, we fight the battle to try to get the authorization to get that patient to your office, and certainly many times it goes smoothly, but at other times there are significant delays, there can be hours spent on the telephone for our staff in our office, trying to get through to the proper person to get authorization and so on and so forth. I mean, I've had to put a person on full-time, doing nothing but getting prior authorization for, for needed patient care.

DR. MARK MORALES, CIGNA Staff Pediatrician: But this speaks, I think of the benefit of a staff model, which we are networked ahead of time. I do not have a problem.

MS. FARNSWORTH: Explain what you mean there.

DR. MARK MORALES: Well, basically, we are self-contained. We are staff model--

MS. FARNSWORTH: This is your pediatric practice?

DR. MARK MORALES: Pediatric practice.

MS. FARNSWORTH: Uh-huh.

DR. MARK MORALES: And I have exclusive rights in determining where the care is delivered. I like to look at my relationship with the family as a partnership, and we, together, will decide what their child needs. And I've had no barriers, and, in fact, I'm encouraged to practice the standard of care which is not only here locally but nationally.

MS. FARNSWORTH: You think that you can give actually better care this way?

DR. MARK MORALES: Through this networking, I have statistics to prove it, our asthma education program has prevented days lost from school, has decreased emergency room visits, has decreased hospitalization. Our immunization rate now is 90 percent for children under 35 months of age. It's increased 20 percent for children under two years of age.

MS. FARNSWORTH: So the prevent aspects are working in your case.

DR. MARK MORALES: Again, it's really encouraged, I think, and our founding fathers based this whole concept on looking at populations based on a budget, finding out where people need their care, how they get sick, and to proactively work with it.

MS. FARNSWORTH: Uh-huh. Dr. Jamison, you've done both. What do you think? You've been both in the managed care situation and now you're in private practice.

DR. DEBRA JAMISON, Internist: Right. Umm, that's all I know. I started working for a managed care right out of residency, and I worked for a big HMO here in Arizona for the first five years. After five years, myself and two of my colleagues who also worked at an HMO decided to start our own private practice. So HMO, managed care is all I know. I really don't have a problem with providing adequate care for my patients. I have a problem with getting those procedures done in a timely fashion, and all the other things that all the other physicians have mentioned here. Umm, I think that one of the problems is the ton of paper work. Like my colleague here has said, I've had to hire a person who actually--I mean, I just can't pick up the phone and say I want this test done, I have to get that authorized. I just can't pick up the phone and schedule a patient to see one of my colleagues that's a specialist. I have to get that authorized. Plus, I have to hire a person to do that, I have to work more hours so I can pay that person, so I have to spend less time with my patient.

MS. FARNSWORTH: Do some of the plans that you work with give you a bonus if you don't refer to specialists, or if you don't put somebody in the hospital? I mean, does any of that affect you?

DR. DEBRA JAMISON: Now that I'm in private practice, no.

MS. FARNSWORTH: Uh-huh. How about any of the rest of you?

DR. MICHAEL GRAY: Yes, it does. There are incentives that are operative in many of the contracts. It depends which managed care program you're talking about, but there certainly are incentives that relate to your profile, the physician profile, which is maintained by the managed care systems in terms of the percentage of patients who refer to specialists, the, the cost of in-patient care, and so on. And it's not always clear to the provider really what it is that the parameters are that are being looked at. You often don't have any access to the data. You just know that you did or didn't get the bonus and so on and so forth.

DR. MARK MORALES: And then ironically, though, using that same information, we as a department set our goal, and we as a department are judged on how efficiently we work at it, but, again, we are encouraged for quality of care, and, in fact, when statistics are gathered for us, we look at it as an opportunity to improve care, specifically kind of basically standardizing care. Though the art of medicine is wonderful and individual style practices, for certain disease entities, sometimes you can get a wide range on how you approach that, and to really affect a good outcome, usually a standardization or a bringing in of the mean on how you approach a particular problem is most helpful in primary care and pediatrics.

MS. FARNSWORTH: And you're a specialist. Are people referring their patients to you in the same way that they used to?

DR. ROBERT STEPHENS: I think always, and I don't think there's any--been delay in transfer to a requested general surgeon to see a patient, but I want to pick up on something that Mark said earlier. We also in the private practice mode have the same requirements for the testing, annual exams, mammograms, that the private or the staff model uses.

MS. FARNSWORTH: By requirements, you mean you have to convince the--

DR. ROBERT STEPHENS: Patient care, our charts are audited, we must provide the same follow-up that they do in their staff model, and so I don't think that the care is rendered differently but maybe we have a bigger paper work mountain that we have to go through. But the patients are getting the same care.

MS. FARNSWORTH: But would you go--you would not want to go back to the way that it used to be, right, the way it was say 15 years ago, or would you?

DR. ROBERT STEPHENS: I'd love to, but that's not--that's not a fact of life. I mean, there's been--

MS. FARNSWORTH: This is inevitable, you think?

DR. ROBERT STEPHENS: And I think for the most part the change has been good. I think the patients are getting better care, they're being better followed up, lab works are being appropriately followed up. They're getting appropriate testing. They're getting to the specialists in a timely fashion. The preventive medicine especially, I mean, mammogram rates have gone from 38 to almost 80 percent. Our asthma program, which is the same as the private mode, we've got programs now trying to identify the male between 20 and 40 who doesn't access this system, trying to get them in to the doctor so we can pick up hypertension, obesity, all these other hidden things which before were never looked at.

DR. TODD TAYLOR: I'm going to take a little different aspect here, because in the emergency room where I work, I many times see the failures of managed care. In other words, once they weren't able to get to see their doctor, many times they come to me for help that they were not able to receive, uh, elsewhere, many times after hours, on weekends. I think the promises of the HMO, which was initially health maintenance organization, has been lost. It's been lost and become a health management organization or a health cost containment organization, and, umm, Dr. Morales, I think his points are well taken. In certain types of managed care, the health maintenance is still a major factor; however, as time goes along, many other organizations have seen opportunity really to save money rather than maintain health and have taken that to the extreme. And that's where sometimes legislation or regulation needs to rein these plans back in to get back to our original premise, and that is to maintain health and keep people healthy.

MS. FARNSWORTH: But do you think maybe we're just in a certain stage here, where the cost containment aspects were foremost and now we have to move to some, to much more concern with quality?

DR. TODD TAYLOR: Certainly it's an evolutionary process, and in Arizona, we've had in our Medicaid system managed care for sixteen or seventeen years. In the early years, it was terrible, and then it over the years became better and better, and now I believe in Arizona, we probably have the best Medicaid system bar none in the whole United States primarily due to managed care.

MS. FARNSWORTH: Because are Medicaid patients--go ahead, sorry, Dr. Gray.

DR. MICHAEL GRAY: I think we have the best plan for those who qualify and get into the plan. The fact is the state of Arizona is not a leading state in terms of the number of patients that are covered in relation to the poverty level. There are about--you know, if you're at 30 percent of the poverty level or above, or maybe 35 percent, you don't qualify for that plan, $400 a month, you're not in it. Your concept of the staff model is really not at issue from our perspective. I certainly had no problem practicing the staff model setting. The problem is that there is more and more incentive for managed care programs to get away from staff models. Everything is showing us that the economics is pushing them away from the staff model, even though the staff model might well work better for primary care purposes.

DR. MARK MORALES: But that's all part of our societal evolution. The bottom line is there is a bottom line. The bottom line is there is a budget at some point. We don't have a bottomless pit of finances for health care, and who pays for that as part of this evolution and how that's affected is part of our responsibility too. As Todd pointed out, there are plenty of glitches, but part of the positive changes that have happened have been the hard work that he's put in, his staff, in terms of alerting certain payers, what is right and what's wrong. And as long as we continue that evolution--

MS. FARNSWORTH: Dr. Laughead, do you feel like your relationship with your patient has changed? I mean, you, you have been in medicine long enough to have been through this transition. Do you feel like your--the fundamental relationship has changed?

DR. MARILYN LAUGHEAD: It's definitely changed in some circumstances. What happens is, is that now the employers will go from one plan and next year to another plan. And so consequently, there's no continuity of care. And this greatly interferes with the relationship that I as a physician have with my particular patients. And you can't really follow through. Now, if it's an obstetrical patient because we're caring for them for nine months, that's a little bit different situation. We do have the rapport and the continuity of care with obstetrical patients. But with the gynecological patients, we've lost that, because now next year they have to go see another physician.

MS. FARNSWORTH: Do you think this is the way it's going to be, or do you think there are still changes that will come that will allow you to stay with somebody longer?

DR. MARILYN LAUGHEAD: What we're hoping is that the managed care associations, that the health plans realize that it's important that there is some way of maintaining continuity of care because that really makes care better for the patient, not only for the so important physician-patient relationship but just in terms of getting general care for the patient. And so hopefully, they will be able to see some way of being able to maintain that. I'm not sure how they're going to do this, but there should be some way so that patients don't have to, to every year to see a new physician.

MS. FARNSWORTH: Dr. Gray.

DR. MICHAEL GRAY: The issue of bottom line, I agree with you, is very important but it also has to be looked at from a national perspective. The United States spends 15 percent of its Gross National Product for health care services and are not providing services to almost 63 million or 1/4 of our population. There are terrible contradictions here, and the question of whether or not managed care is going to provide the model that will take care of these problems is very much at issue because currently your managed care programs, unlike Kaiser when it was first established which basically was a health maintenance organization that encouraged utilization, encouraged preventive services--

MS. FARNSWORTH: And was non-profit.

DR. MICHAEL GRAY: And was non-profit--we are now dealing with profit, insurance carriers that are for profit, that are driven totally by the profit motive. You and I and all of us sitting at this conference are committed to providing care and serving as advocates for our patients. Service is our primary concern, and I think we should take a perspective that says that health care is a right and not a privilege.

DR. MARK MORALES: But let's not bad-mouth the idea of profit. Let us say that none of us are here truly as altruists; that there at some level there is a, an area of profit that needs to be addressed. It can be a positive incentive. If you do it better, more efficiently, you do it well, why should you not be rewarded for it? The questions that you're bringing up are grander societal issues.

DR. DEBRA JAMISON: Right.

DR. MARK MORALES: That we are not going to necessarily--or look at managed care--the consumer needs to be more active in this as well.

MS. FARNSWORTH: Dr. Jamison, would you go into medicine today knowing everything you know about how the practice has changed?

DR. DEBRA JAMISON: Quite honestly, probably not. You know, I grew up in a time where we were looking at TV stations, you watched programs on Marcus Welby, you'd say, oh, great, I wish I can practice medicine like that, and, and you begin to believe that that's what you'll be able to do, but now that I'm in the real world, it's not fun. If I can just take care of patients, that would be great, but I'd say 30 to 40 to 50 percent of my time is not with patients.

MS. FARNSWORTH: Anybody else on whether they would go into medicine now?

DR. MARK MORALES: There was a time where I would have answered the same way as Debra did, but I'm having way fun now. Umm, I'm having fun--

MS. FARNSWORTH: What's made the difference?

DR. MARK MORALES: Umm, I must say that it's actually the organization that I'm presently involved with, plus the fact my close ties and encouragement with close ties in the community, the medical community that is, the opportunity to network, the opportunity to practice the way I was trained. It can be fun. There are those moments, and there are those moments I wish I was selling cars, I guess, but nonetheless, I am having fun.

DR. ROBERT STEPHENS: I love what I do. I would do it for nothing if somebody would take care of my bad investments, my kids in college, hold up my house that's too big, but I don't know anything else that I would do. I enjoy what I do. I think I do it well, and I love my relationship with the patients, and that's what drives me every morning when I get up--and have fun with my patients.

MS. FARNSWORTH: But I do know doctors who have left the practice because of having to deal with the insurance companies just did 'em in.

DR. ROBERT STEPHENS: There's been a tremendous downsizing in reimbursements. Who would have thought four years ago that we would love to work for what Medicare pays? Now Medicare has become the gold standard, and now all these contracts are coming Medicare minus.

MS. FARNSWORTH: I don't want to embarrass you, but has your income actually gone down?

DR. ROBERT STEPHENS: Oh, I'm down a third, as I think most physicians, the specialists that I know.

MS. FARNSWORTH: Are you all down?

DR. MARK MORALES: No, I'm up.

MS. FARNSWORTH: You're up.

DR. MICHAEL GRAY: I'm at a par.

DR. DEBRA JAMISON: I'm down.

DR. TODD TAYLOR: Down.

DR. MARILYN LAUGHEAD: Talking to physicians around the state, it appears that income pretty well generally is down. We're talking about as much as 40 percent.

DR. TODD TAYLOR: Let's not lose sight of what we're talking about, though, get off on to physician pay. In the emergency room every day, I fight for patients' rights under their health plan, and at the worst possible time all, of all time, when they are ill, many times their health plan fails them.

DR. MARK MORALES: I accept the situation in the community that there are situations like that. I tend to look at it, though, again, as an evolutionary process, and we just need to be continually involved in that.

MS. FARNSWORTH: I'm sorry, that's all we have time for. Thank you all very much for being with us.

MR. LEHRER: Tomorrow, Elizabeth will examine the Arizona legislature's plans to regulate HMO's. FINALLY - IN MEMORIAM

MR. LEHRER: Finally tonight, remembering James Rouse. Charlayne Hunter-Gault has that.

MS. HUNTER-GAULT: James W. Rouse, the visionary developer who died yesterday at age 81, was awarded the Presidential Medal of Freedom last Fall for his achievements in changing the way Americans live. In the 1950's, Rouse pioneered indoor shopping malls. In the 1960's, disappointed with the sterility of suburbs, he used the model of the colonial village to build the planned community of Columbia, Maryland. In the 1970's, Rouse worked to rejuvenate dying downtowns by introducing so-called festival marketplaces, Fanueil Hall in Boston, Harbor Place in Baltimore, and the South Street Sea Port in Manhattan. In the 1980's, he retired from the Rouse Company and created a foundation to focus on affordable housing forthe poor. In 1985, Rouse was a guest on the NewsHour on the subject of urban decay.

JAMES W. ROUSE: [1985] All over this country at the heart of our cities, we have people, citizens of this country, living in, in condition that hardly exists anywhere else in the world. We need to launch a massive campaign in this country to find fit, decent places for people to live in fit and decent neighborhoods, with adequate opportunity to get jobs. And that can be done.

MR. LEHRER: Is it the federal government's responsibility to do it?

JAMES W. ROUSE: We need to build. We need to work from the neighborhoods, from the bottom up to build new systems of, of dealing with these neighborhood community problems of the desperate poor.

MS. HUNTER-GAULT: For more on James Rouse and his accomplishments, we turn to Robert Campbell, architecture critic for the "Boston Globe." Yesterday, he was awarded the Pulitzer Prize for criticism for his writing on architecture. And Barton Harvey, chairman and CEO of The Enterprise Foundation, which was founded by Rouse. And, Mr. Harvey, describe for us James Rouse, the passionate man we just heard. Who was he, and how did he accomplish so much?

BARTON HARVEY, The Enterprise Foundation: [Owings Mills, Maryland] Well, he was an extraordinary person and he was marked by optimism, a positive point of view, and ability to lead and attract people and most of all, by his ability to hold out for what is best and what ought to be and what ought to happen, and, and not to compromise.

MS. HUNTER-GAULT: We just talked about the four decades, where each decade he came up with something new, and I read today where he saw the future and made it his. How did he become a visionary?

MR. HARVEY: Well, I think he--where other people saw problems, he saw opportunities. He really believed this, this creed, and these are his words, that what ought to be can be when you have the will to make it so. And he had the will to make it so.

MS. HUNTER-GAULT: Where did that will come from, because he was born poor and he achieved a lot and made a lot of money so he got rich at a certain point, you know, but what motivated him?

MR. HARVEY: Well, I think he had a unique blend. He had a blend of the, of the optimism and belief that he could do something, he individually could make a difference. He was a deeply religious individual, never wore it on his coat sleeves, but he took great solace in, in that, and he really put that to work in his life. His belief was his life as well, and those two combinations, along with the ability to attract people to good cause, umm, really spurred him forward and got him over obstacle after obstacle.

MS. HUNTER-GAULT: How did he see his work?

MR. HARVEY: He, umm, he really saw his work as a blend of what he believed in and, umm, and what could be accomplished. He, he once said in setting up the Rouse Company that the purpose of business is to serve a legitimate human need and that if you did that well and helped people reach their potential in an organization, profits would result. But it went in that order.

MS. HUNTER-GAULT: So he was the kind of person who could--what do they say--make--do good and do well at the same time?

MR. HARVEY: He certainly did. But I think at every turn those beliefs really served him well and whatever he made, he put back and gave back and felt that obligation to put it back. He believed deeply in the free enterprise system, but he also believed that, that each of us, umm, had the responsibility to help out those that didn't have the same opportunity.

MS. HUNTER-GAULT: Mr. Campbell, you're sitting in Boston, where Fanueil Hall was created by James Rouse, the first of his so-called festival marketplaces. How has this kind of urban rebuilding stood the test of time?

ROBERT CAMPBELL, Boston Globe: [Boston] I think it made just a tremendous difference. You have to remember Boston and other American cities, but particularly Boston was coming out of a 40- year recession. There was no belief in the investment in downtown. He came in and with others that worked with him created something I think that was kind of--of reinvigorated the idea of what was local. They moved into a building that was 150 years old, an historic structure, and tried to create a sense of the region. This was an era when Americans were buying their food wrapped in plastic and shipped from California to supermarkets, and here's a guy saying no, come on downtown, buy fish, this is Boston, and buy it from local merchants and regain a sense of the local place.

MS. HUNTER-GAULT: What exactly was a festival marketplace? I mean, what was festive about--

MR. CAMPBELL: As far as I know, he invented the term, and went on to do it in other cities, and I think the idea was that shopping you'd come to a place that was so much fun to come to that you didn't just come with the goal of buying something, you came because it would be such a wonderful experience to be there. And so the, the festive life of the place, the way you might visit an Italian hill town for the festive sense of the place and then buy something I think was the concept.

MS. HUNTER-GAULT: How would you describe Rouse's impact on Americans, the way they lived in both cities and suburbs?

MR. CAMPBELL: Well, it was an unbelievable impact. He had a belief in himself, a messianic zeal that was just amazing, and once he bought a concept, he never lost faith in it. It was very difficult to pull the Fanueil Hall Marketplace in Boston. The bankers didn't believe in it. The politicians didn't believe in it. It was a tremendous struggle. The day it opened, the whole world seemed to show up at once and want to shop there. And by the way, a funny story about Rouse is that one of his ideas was that you set small businesses in motion. That's one of the good things you do in life. So they invented the idea of push carts, and they filled the marketplace with push carts where people could generate new businesses, but they didn't have any new businesses the day they opened. Jim sat there at a push cart, himself, selling baskets the whole first day the Fanueil Hall Marketplace opened.

MS. HUNTER-GAULT: And how is this standing the test of time? I mean, is it having an impact today on building and--

MR. CAMPBELL: I think that it's a tremendous success economically. I think that we here in Boston believe that some of his original vision has been lost, that sense of a unique place. In the original Fanueil Hall marketplace, there weren't to be any national franchise businesses. There were to be local merchants, which is what had always been there. Now we find Disney there, Warner there, all kinds of national clothing chains and things like that there, so that it's becoming more like other places, and that vision of a place that was for--that a tourist would come to because it was a local Boston place and something different from home has maybe been killed by the very touristic culture that, that came to it.

MS. HUNTER-GAULT: Mr. Harvey, how do you see his legacy?

MR. HARVEY: I think a lot of people would say that he touched the urban landscape in a major way, not only in Fanueil Hall and Harbor Place but in the city of Columbia, that he, he helped build from scratch. But I would say that he touched the human landscape of America, that everywhere he went, he connected in very human terms with individuals and he spurred people on, and he talked about his vision of what could be for America, and it's a wonderful vision. There are millions of Jim Rouse stories that are out there. There are people that were touched and inspired and moved by him.

MS. HUNTER-GAULT: Gentlemen, thank you so much.

MR. HARVEY: Thank you.

MR. CAMPBELL: Thank you very much. RECAP

MR. LEHRER: Again, the major stories of this Wednesday, the U.S. military evacuated Americans and other foreign citizens from Liberia for a second day. Fighting continued in the capital of Monrovia. At the United Nations, the U.S. Government expelled a Sudanese diplomat linked to a terrorist conspiracy, and President Clinton vetoed a bill prohibiting a--prohibiting a late-term abortion procedure. We'll see you tomorrow night. I'm Jim Lehrer. Thank you and good night.