Health: Medical Costs; A Few Expensive Procedures Are Focus

The coronary bypass operation, developed in the 1960's, was still uncommon 15 years ago. But as techniques improved, more Americans began to demand it and insurance plans began to pay for it. Thousands of lives have been saved by the procedure, in which blood is shunted around clogged portions of an artery to the heart.

Today the nation spends more than $5 billion a year on bypass operations for more than 200,000 people. Many medical experts say doctors use it far more often than necessary. The operation usually costs from $25,000 to $40,000, more than double the price five years ago.

A sharp rise in the use and price of major operations like the bypass is a primary reason that a smaller percentage of people are accounting for an increasing share of health care costs. A common rule of thumb in insurance - that 20 percent of a company's employees account for 80 percent of its medical costs - is being abandoned in favor of an even more extreme comparison. The Ford Motor Company, for example, now figures that 15 percent of its employees account for 90 percent of its health costs. Guidlines Are Sought

While no one is suggesting that patients truly needing a treatment should be denied care, experts say that new attention to the frequency and cost of a relatively small number of particularly expensive procedures will be necessary if the nation's soaring health bill is to be curbed. Many authorities in the field of health economics, medicine and insurance are pushing to establish precise guidelines for when and where certain treatments are performed, arguing that some expensive procedures are overused on people with health insurance yet underused for the 37 million Americans with little or no coverage.

The procedures range from the $250,000 effort to save a premature baby with severe problems to the $175,000 liver transplant.

Figures compiled by the Government for The New York Times show that at least five procedures that did not exist or were not as common a decade ago are now almost routine and annually cost the nation more than $1 billion each. Those five are the bypass; the balloon angioplasty, which opens clogged coronary arteries; the transurethral prostatectomy, which is the prostate operation President Reagan had last year; hip operations, and gall bladder removal.

The coronary bypass looks inexpensive next to organ transplants and care for burn victims and some AIDS and cancer patients. Tests Are Big Cost

The major medical procedures, of course, are not the only reason that health care costs are rising much faster than the inflation rate. The use of far less expensive tests and procedures has also increased dramatically. These and other factors have contributed to a doubling of the nation's medical bill, to $497 billion last year from $248 billion in 1980. Meanwhile, premiums for millions of Americans covered by Government and employer insurance have been raised as much as 70 percent this year.

The benefits manager of one large retailer noted that 2/10ths of 1 percent of his employees now account for 30 percent of the medical costs. He cited a recent liver transplant that had cost $670,000, with the bills still coming in. The patient died.

This manager, who asked that he and his company not be identified, also cited three unsuccessful bone marrow transplants that cost from $150,000 to $500,000 each. $100,000 Claims Are Rising The Wyatt Company, an actuarial and benefits consulting concern, found that the number of claims for more than $100,000 increased 33 percent in 1986 from the previous year in one sample.

Studies have shown that many procedures, such as coronary bypass operations, are often performed on patients who are unlikely to benefit from them. While critics have attributed such overuse to greed, experts in medicine and health economics say it often reflects other factors: a lack of understanding about appropriate use of the procedures, a lack of efficiency, and an insurance system that pays doctors more if they provide more services. The threat of malpractice suits encourages doctors to perform more procedures.

''My belief is that at least a third if not more than half of what we do now is of no benefit or of so marginal a benefit that I think we could agree in society that insurance should not pay for it,'' said Dr. Robert H. Brook, a professor of medicine and public health at the University of California at Los Angeles and the deputy health program director at the Rand Corporation, a research organization. Technology Use a Question

Holding down medical expenses, experts say, requires better guidelines: on when a given procedure is justified and on what prices are reasonable. ''What's missing is the research about what is the appropriate use of technology,'' said Dr. Robert J. Blendon, chairman of the Department of Health Policy and Management at Harvard.

The Congressionally authorized Council on Health Care Technology, which is composed of representatives of medicine, business, insurers and consumers, has taken steps in this direction. Begun two years ago, it plans to issue a Medical Technology Assessment Directory next month aimed at organizations seeking information on the safety, cost effectiveness and social, ethical and legal implications of medical procedures, devices and drugs.

But some health care experts say the council is inadequate and underfinanced. Dr. Brook and other authorities strongly support a group that would provide standards for use of the most common procedures and would compare their efficacy and cost with other procedures.

Uwe E. Reinhardt, a professor of political economy at Princeton University, said any commission on medical procedures should also review fees. Several such efforts are under way.

Whether such guidelines will be adopted is another question. Some experts say that the medical community would conform if given the proper information and if pressured by the Government, insurers, companies and patients. But the American Medical Association, while supporting the development of guidelines, vehemently opposes any mandatory standards or fee schedule. Other Methods Suggested

Other things can be done, says Alain C. Enthoven, a management professor specializing in health economics at the Stanford Business School. He points to the effectiveness of regional centers for major procedures. He cites the example of neurosurgery. Nationally, there are 25 neurosurgeons for every million people, he said, but Kaiser Permanente, a prepaid health care organization, takes care of two million people in Northern California with a team of about seven.

''Those doctors can make a good living at a lower cost per case because they have full operating schedules,'' he said. ''That's good for their proficiency, their quality and also for their economy. What's costly is when you have too many neurosurgeons under economic pressure to charge more because they don't do enough business.''

Some companies agree. Honeywell Inc., for example, has designated six hospitals around the country as ''centers of excellence'' to which it sends employees who need organ transplants. ''That's the model,'' said Dr. John M. Burns, a vice president. ''Then we can begin to carve out other programs.'' THE HIGH COST OF ADVANCED TREATMENTS

Relatively few major procedures and conditions absorb a large and rising share of the nation's medical expenditures. Experts have called for better guidelines on when the expensive treatments are beneficial. At some companies, 15 percent of employees now account for 90 percent of the health costs.

Experts say the $50,000 or $100,000 medical claim is increasingly common. Some of the most expensive procedures, such as those at right, did not exist or were not as common just a few years ago. Other procedures remain relatively rare, but an individual case can require vast expenditures. Liver transplant ... $175,000 Care for premature newborn with severe problem ... $168,000 For eight-month period. Leukemia care with bone marrow transplant ... $161,000 Over five years. Heart transplant ... $83,000 AIDS care ... $50,000 - $150,000 Coronary bypass ... $33,500 Five-year total, assuming no need for reoperation, which is required in about 20 percent of the cases. Mental health care ... $28,000 Over five years, with one hospitalization and outpatient care. (Sources: Healthcare Compare Corporation; Aetna Life and Casualty Company.)

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