Rising costs--particularly in the cost of outside labs and X-rays--has placed upward pressure on the health fee all students are required to pay UHS. Student fees rose 14.8 percent in 1988-89, 11.0 percent in 1989-90 and 8.0 percent in 1990-91.

For the 1992-93 academic year, students paid a $584 user fee and could opt for a $600 insurance plan offered through Blue Cross/Blue Shield. The user fee was up 6 percent from $550 in 1991-92. The cost of the insurance increased less--just eight dollars since 1992.

Janet L. Thompson, manager of insurance programs, says these increases have been less than the rise in the consumer price index and in annual medical costs nationwide. How does UHS do so well? "Management techniques," she says, refusing to specify further.

The new director's focus on money might once have bothered some at the health services. Before Rosenthal was hired in 1989, a group of staff physicians wrote a letter to the Harvard administration urging that the next director be a doctor and not a financial manager. The doctors worried that a new director might be too devoted to the bottom line.

"There certainly is more attention to budget. In the early days of my being here, these things didn't come up," says Dr. Irving Allen of the Mental Health Services. "But Rosenthal clearly lines up to what the group of doctors clearly had been looking for: a clinician."

Rosenthal and other doctors at UHS pitch primary care as a panacea for nearly all of UHS's problems. In a primary care system, patients are matched with physicians who see them as often as scheduling allows and can either treat patients themselves or send them to the appropriate specialist.

Rosenthal, like many health care professionals, believes that primary care makes for better care because physicians are encouraged to treat the same people over and over again, and thus gain familiarity with their patients. But some critics call this "gatekeeping" because student access to specialists is restricted.

Whatever the benefits and drawbacks of "gatekeeping," one major motivation for the policy is indisputable: controlling costs. Specialists are expensive, and while patients may get more direct, appropriate care, patients may go to the wrong specialist.

"I spoke the other day with a specialist--top-notch guy," says Wanzer. "I was talking about the long wait for an appointment with him. He's willing to provide more time to UHS, but the budget does not allow it."

For all the talk of cost containment, doctors and nurse practitioners insist that money does not affect how they treat patients. Care providers on the front lines say they don't know the costs of the different procedures and tests they can perform, and most say they don't want to know.

"In reality, as far as a patient goes, the providers don't know much about the cost of treatment," says nurse practitioner Donna Campbell.

"If a patient needs a CAT scan, I'm not going to not order one," says Dr. Kenneth Gold, an internist at UHS. "You do what's medically necessary...if for no other reason than 'Lawyer's going to sue me the next day.'"

The addition of a UHS referral committee has been one of the most important and effective cost-cutting measures, according to many doctors. Before its advent roughly three years ago, doctors say, the health service would lose track of people sent to specialists outside UHS. In many of these instances, specialists would refer people to other specialists, and UHS would be stuck with the bill for each additional visit.

"What used to happen was...we'd refer the patient outside and lose control," says Dr. Mary Wolfman, who sits on the referral committee. "It's a way of containing costs but it also benefits the care that people have gotten."

UHS also scrutinizes the hospital stays of people for whom it pays the bills. But administrators and doctors say the best way to control costs is to perform expensive procedures only when they're medically necessary and, in purchasing, to be market-wise.