I may be many things, but a health care economist is not one of them. Unencumbered by arcane theory and impenetrable jargon, I live in a murk-free zone, which lets me cast a blissfully naive eye on the Harvard Pilgrim Health Care crisis in Massachusetts and on the health care mess in the rest of America as well., ufbitelabel Dr. Steffie Woolhandler has been calling for a single-payer health care system for years.

Quality not measured by profit

And the way I see it, the pols and the money guys have made our health care system unnecessarily complicated. The real problem is philosophic, not economic: If we run health care like a business, not a public service, we put profits above people.

OK, it sounds like a bumper sticker from the Sixties. But treating sick people is not like making widgets. MBAs don't know what's best for your health. And patients aren't the real consumers (for many of us, our employers are). If we were, it would be easier to take our "business" elsewhere.

And how can any organization that's legally bound first and foremost to its stockholders also put patients' needs first?

At the moment, one of people's worst fears is that Harvard Pilgrim, now in state receivership because it lost as much as $177 million last year, will morph into a for-profit outfit.

I know (because I've been spun all week by the HMO folks) that an organization's dismal balance sheet or tax status may not automatically reflect the quality of the care it provides.

I also know that the for-profit tidal wave seems unstoppable. Elsewhere in the country, millions of people are already in for-profit HMOs. In fact, most HMOs nationwide - between 60 and 80 percent - are for-profit or "investor-owned."

But what happens to quality of care when profits come first?

To be honest, nobody knows for sure because there's only one study, published last summer in the Journal of the American Medical Association, and its conclusions - though not the data used to arrive at them - are controversial.

The study was done by four doctors with a powerful bias in favor of a single payer health care system. They are Drs. David U. Himmelstein and Steffie Woolhandler of Harvard Medical School, Dr. Ida Hellander of the Chicago-based Physicians for a National Health Program, and Dr. Sidney M. Wolfe, director of the Washington, D.C.-based Public Citizen Health Research Group.

When their study came out last July, they were denounced by the HMO industry. The American Association of Health Plans said they confused "ideology and analysis" and noted - using data not included in the study - that both for-profit and not-for-profit HMOs score better on quality-of-care measures than the old fee-for-service plans.

The National Committee for Quality Assurance, a group that accredits HMOs and actually supplied the raw data to the JAMA researchers, said it felt "uncomfortable" with the authors' sweeping conclusions. But it did not challenge their findings.

Here's what the JAMA researchers did. They looked at 1996 data on 14 quality control measures supplied by the HMOs themselves - 248 investor-owned HMOs and 81 not-for-profits - and found that, compared with the not-for-profits, the investor-owned plans scored worse on all 14 quality-of-care measures.

The differences were sobering, and were greatest for the sickest patients. Among heart attack patients discharged from hospitals, 59 percent of those in investor-owned HMOs were given beta-blockers, drugs that can control blood pressure and heart rhythms. By contrast, more than 70 percent of similar patients in not-for-profit plans got the potentially life-saving drugs.

Among diabetics taking medications to control their disease, 35 percent in investor-owned plans received an eye exam to check for diabetes-related vision problems in the past year, compared to nearly 48 percent in not-for-profit plans.

And on it goes. Seventy-two percent of 2-year-olds finished their immunizations in not-for-profit HMOs, versus 64 percent in the for-profits. Sixty-nine percent of women in investor-owned HMOs got mammograms within the past two years, compared to 75 percent in not-for-profits.

Granted, assessing quality of care is still in its infancy. "We have the feeling" that care is better in not-for-profit HMOs, "but the data on quality measurement is not so well-honed that we can be sure," says Dr. Jerome Kassirer, editor-in-chief emeritus of the New England Journal of Medicine.

Still, Kassirer argues, "health care should not be a business and it shouldn't be considered a commodity but a basic right of all Americans. It's quite amazing that we have done so poorly compared to other countries."

Investor-owned HMOs, he adds, spend more of their premium dollars on advertising, administrators' salaries, and profits for stockholders than not-for-profits.

Investor-own HMOs are also more likely to go out of business when times get tough or dump patients who need care most, argues Wolfe of Public Citizen. "If your care is interrupted because your HMO goes out of business, you can't have good quality of care if you keep changing doctors."

"In the marketplace," adds Woolhandler, "you can say `Buyer Beware.' But when you are sick, you have to trust the doctor, the nursing home, the hospital to take care of you. . .If you have an institution whose officers have a fiduciary responsibility to shareholders to make as much money as possible, then it is an unfair contest."

Dr. Harris Berman, the CEO of Tufts Health Plan (which, like Harvard Pilgrim, is a not-for-profit), puts it this way: "For-profit HMOs need to make a 4 to 5 percent profit to satisfy stockholders. The not-for-profits are perfectly content to make 1 to 2 percent a year. And the difference between those two is substantial and comes out of medical care."

Obviously, the "marketeers," as former Gov. Michael Dukakis, now a professor at Northeastern University, calls the health care-as-business proponents, see things differently.

Robert Hughes, president of the Massachusetts Association of HMOs, argues there's no difference between health care and any other business: "Health care is subject to the same economic forces as any other industry. People are exchanging goods and services for money."

Sorry, but I'm not buying. If I have to choose between the government running my health care and some CEO, the lesser evil seems to be the government. After all, I trust government with fire-fighting, police protection, and health research. Why not health care delivery, too? Perhaps something based on the Medicare model? At least I can vote those government guys out of office. And while any system has to live within a budget and make choices, at least there'd be less incentive to deny care.

Judy Foreman is a member of the Globe staff. Her e-mail address is: foreman@globe.com.

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