BEDFORD, INDIANA: WHOSE AMBULANCE WILL GET THERE FIRST?

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Dunn doctors boast that they are not tied to the controversial drug "formularies" used in managed-care to rein in doctors' drug choices. Cardiologist Ganapathy Ramanathan says he regularly prescribes a very expensive heart-attack drug called TPA, at thousands of dollars a dose, rather than the drug streptokinase, which is available for a fraction of the cost but has been found less effective in some studies. "I'm sure the hospital has lost a lot of money on many of my patients, but they've never told me about it," he says. Dunn contends it is more willing to refer patients to expensive specialists. Dr. Theresa Travis, a Dunn nephrologist who spends about 20% of her time at Bedford Regional, says she often sees patients with traditional insurance months ahead of HMO patients with similar conditions. "Managed-care patients are always referred very late," she says, in some cases making kidney failure more likely.

As a result, health care is costlier at Dunn: the average charge for heart-failure and shock treatment is $7,892, for example, compared with Bedford Regional's $4,817. But Bedford Regional, which gets about a quarter of its revenue from managed care, vigorously disputes the notion that its treatment style is any less effective. "Just because you can stay twice as long at Dunn doesn't mean it's better health care," Birdzell says. He adds that Bedford Regional's drug-selection policies are not cost-driven. It prescribes both TPA and streptokinase, for instance, depending on the specifics of the patient's condition. As for specialists, Bedford Regional says its HMO patients see them when appropriate, even though their use is carefully monitored. Actually, Bedford Regional argues, its more modern approach can be better. For example, the hospital is starting up a teleradiology laboratory that takes advantage of the fact that it is owned by Clarion, a statewide hospital network. Radiologists will be able to send images to colleagues in Indianapolis, drawing on greater expertise than is usually found in a small town.

But Bedford's strongest argument is that the whole nation is moving in its direction: critics say Dunn has been able to snub managed care only because Indiana has been among the states slowest to require it. Its economic good fortune will change, they say, when the two automobile companies with large plants in Bedford start requiring employees to shift to managed care and when Medicaid and Medicare begin pushing recipients into HMOs. At that point, if Dunn is to survive, it may have to sell out to a large for-profit chain. Should that happen, Bedford's medical civil war will simply rage on with even greater firepower.