The Republican-controlled Senate yesterday rejected most major Democratic proposals to strengthen the rights of patients in managed-care plans, including an initiative that would have given physicians, rather than insurance companies, the final say over patients' treatment.

On five votes that were relatively close and largely along party lines, the Senate also brushed aside Democrats' hopes of imposing federal powers that would have given new protections to every American with private insurance. It defeated their efforts to give women more freedom to pick their doctors, to guarantee payments for emergency room visits and to set up grievance procedures when health maintenance organizations deny care. A Republican proposal to allow self-employed people to deduct the full cost of health insurance from their taxes was approved.

Despite defeat of the broader proposals, the Senate signaled that it is prepared to take more modest, Republican-sponsored steps that would grant new rights to patients in certain kinds of health plans.

After the voting ended last night, Assistant Majority Leader Don Nickles (R-Okla.) reiterated the GOP's contention that the Democratic approach would drive up medical costs and said Republicans plan today and Thursday to offer proposals on many of the same issues. "I think we had a very productive day," he added.

The votes reflected formidable unity among Republicans only a few weeks after they fractured over the issue of gun control, losing to the Democrats on key votes.

Yesterday's votes were a bad omen for the rest of the Democratic proposals, especially a contentious one -- favored by doctors and consumer groups but adamantly opposed by the insurance industry and most Republicans -- that would allow patients to sue their health plans for malpractice.

Even though they lost the votes, Democrats believe they scored at least a partial political victory in framing the issue for next year's elections. Complaints about HMOs and other forms of managed care have increased in recent years, giving the Democrats what they see as an opening to take an aggressive consumer protection posture.

Earlier in the day, President Clinton was on the attack, slamming the Republicans' narrower and less stringent approach, charging that it offered "merely toothless and half-hearted protections."

"The people deserve a bill that protects them, not the insurance companies," he said. Clinton's advisers said this week they would recommend a veto if the Republican bill is approved by Congress.

The significance of the women's health initiative, in particular, was political as well as substantive. Medically, it had two main goals: to let women in HMOs pick an obstetrician-gynecologist as their primary care doctor and ensure that doctors and patients, not health plans, have the final say on how long women can stay in the hospital after surgery for breast cancer.

This has been a relatively tangential part of the battle over managed care, but Democrats chose the initiative for their first vote, showing how deeply political considerations lie at the heart of the debate. In essence, the minority party was trying to force the GOP onto the unpopular side of an issue Democratic senators feel will play well with women.

"Today we saw what `compassionate conservatism' pretends to be," said Sen. Barbara A. Mikulski (D-Md.), referring to the campaign theme of Republican presidential front-runner George W. Bush. "It isn't compassionate, but it is conservative."

Republicans appeared to understand the political stakes too. Before yesterday's vote, GOP leaders made clear they would have a more narrowly drawn proposal on women's health care that would not allow women to pick an OB-GYN as their main doctor, but would allow them longer hospital stays after mastectomies. And unlike the Democrats' plan, it would guarantee that both men and women can get a second opinion after any type of cancer is diagnosed.

GOP leaders said last night they also will offer alternative proposals on access to emergency rooms and clinical trials along with their own way of defining what kinds of treatment are medically necessary.

Given the lack of support for the initial Democratic proposals, it was hard to see where Democrats could pick up additional GOP backing before additional votes on amendments and the final votes on the two parties' rival bills, scheduled for Thursday. Minority Leader Thomas A. Daschle (D-S.D.) had described these early roll calls as critical "test votes."

In yesterday's votes, which were either 52 to 48 or 53 to 47, Democrats drew the support of no more than two or three Republicans on any of the five disputed proposals. Sens. John H. Chafee (R.I.) and Arlen Specter (Pa.) were among the most consistent Republican crossovers, but were joined by several others on at least one vote.

Among them was Sen. John W. Warner (Va.), who voted with the Democrats on the women's health care issue, which was sponsored by his Virginia Democratic colleague, Sen. Charles S. Robb. Warner voted with his party on the other proposals. The other Washington area senators, all Democrats, voted with their party.

In what was probably yesterday's key vote, the Senate scuttled a leading Democratic initiative that would have substantially weakened the leverage of HMOs by guaranteeing that doctors, not health plans, could dictate what kinds of treatment patients need. Democrats had argued that profit-minded HMOs are cheating patients of care, while the GOP has contended that giving doctors more clout would drive up medical costs and, ultimately, cause more Americans to become uninsured.

In beating back the Democratic plan, Senate Republicans left intact a proposed grievance procedure in which patients who believe they have improperly been denied care would be able to appeal within their HMO and, if necessary, to an outside appeals panel. But the measure would not go as far as Democrats want, because the health plans could pick the outside reviewers and charge patients for pursuing complaints.

The women's health amendment dealt with two issues that many states have addressed over the last few years.

Currently, about one-third of the nation's OB-GYNs say they are not allowed to be primary care doctors in the biggest HMO for which they work, according to a survey last year by the American College of Obstetricians and Gynecologists. The group's latest figures, based on a 1993 survey, suggest that nearly three-fourths of women consider their OB-GYN to be their main doctor.

The Democratic proposal would have overlapped a trend in state legislatures, 37 of which have adopted laws in recent years to try to make it easier for women to visit OB-GYNs. Most, however, have not gone as far as Senate Democrats wanted.

States also have stepped lately into the other issue in the Democrats' women's initiative: guaranteeing longer stays after mastectomies to remove breast cancers. There is little research evidence documenting how many women are having such surgery on an outpatient basis or suggesting that women have been harmed by going home too soon. And some politicians have started to decry what has become known as "legislation by body part."

Nevertheless, the issue has become such a rallying cry recently that laws guaranteeing a minimum of two days in the hospital -- or giving patients and doctors final say over when women go home -- have been enacted in 19 states.

CAPTION: At the White House, President Clinton said the GOP's health care measure offered "merely toothless and half-hearted protections." At right is Sen. Edward M. Kennedy (D-Mass.).

CAPTION: Sen. Bill Frist (R-Tenn.), a transplant surgeon, goes online with to promote the GOP view on health care. Jennifer Coxe of Senate Republican Conference staff stands behind him. His press secretary Margaret Camp is at left.