Faces and Voices

Caesar Julian

Family doctor, HMO pioneer

Simi Valley

Julian, 68, founded one of Ventura County’s first HMOs in the 1970s, then folded it in the early 1980s.

“It didn’t take long to see that it’s almost a pyramid scheme. You bring them in under the guise of doing all these wonderful things, but ultimately the bubble will burst because you can’t give all the things you promised for the price you quote. It has to tumble. There’s no such thing as cut-rate high-quality care.

“Now, I won’t take HMOs. In consultation, I see patients and give an independent second opinion. Kaiser is the best of them. Kaiser allows them to go outside for a second opinion.

“Every week at least I have a patient coming to me from one of the HMO plans that really needs good medicine. We have good doctors under those plans. But they are restricted in tests and labs they can do. They are measured at the end of the year on how much they spend per patient.

“For example, they have a cookbook way of treating pneumonia. And if you don’t have the patients out of the hospital within a prescribed period of time, you’re considered having done a bad job because of the costs.

“I hear the HMO stories every day from my patients. And my skin crawls.”

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Joan E. Baumer

Former clinic director and family doctor

Ventura, Simi Valley

A 1980 graduate of the UCLA family practice residency program at Ventura County Medical Center, Baumer built a private practice and ran public family clinics until she moved to Texas early this month to direct the nation’s largest training program for family doctors.

By mixing private and public practice, Baumer, 48, said she avoided the kind of money crunch that physicians say

low-paying HMO contracts can force on family doctors.

Although she accepted 20 HMO plans, just one-third of her patients were drawn from HMOs, she said. “I don’t know how doctors can make capitation work. You have to see such a volume of patients,” she said.

Baumer gives HMOs a grade of C or D for quality of care. But she likes the concept of managed care, which she grades as a B, because it cuts fat from a wasteful system.

“Managed care is figuring out innovative ways to take care of patients and assure some quality in that care. Some of the early bugs have been worked out.

“But the continuing problems are the patients with unusual diseases or unusual complications or unusual medications. I see maybe 20 of them a year, and those patients have a terrible time getting proper treatment.

“This would be a patient with an unusual eyeball tumor. And the patient sees a specialist locally, and the specialist says, ‘This is out of my experience.’ So he recommends going to [an] eye institute. And the big HMOs just dig their heels in. They’ll have these people go from local doctor to local doctor and delay the necessary treatment.”

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Robert Dodge

Family doctor

Ventura

Dodge, 46, and his four partners were among the first local family doctors to sell their practices to a large HMO and go on salary as employees.

They escaped the administrative red tape of managed care medicine and gave more attention to patients.

But the arrangement ended three years later, in 1997, when Dodge’s practice bought its freedom back after the HMO foundered and sold the practice

to a physicians management group. Dodge says he earns only 65% of what he did four years ago.

“We’ve come back out to the light of day,” Dodge says. “We’re pleased to be out because our reputation is our own again.

“But we left a good salary [approximately $130,000 a year] and walked out to no guarantees. And we’ve re-inherited all the paperwork, all the staffing issues, all the requests [to insurance companies] for utilization. And it’s a very different world than the one we left in 1994.

“In Ventura, of the larger employers, probably 60% to 70% have shifted to managed care with capitated rates. Four years ago, I would say that was less than 30%.

“But we practice medicine exactly the same as we always did. And I don’t recall a test that we’ve wanted for a patient that wasn’t done. We had to ask, and re-ask and write a third letter, but it was done.

“And the reality is that health care is consumer driven. Health-care costs are too expensive in this country. I buy my own insurance, and it was going up $300, $400, $500 a year. But for the first time it hasn’t. And that’s probably because of managed care.

“So now we have to fight and make sure it works.”

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Ronna Jurow

Obstetrician/gynecologist

Ventura

In practice locally since 1984, Jurow was one of the county’s first ob-gyns to sign up with managed care groups. But she now refuses to take any new HMO patients.

She believes HMOs’ capitated payment system turns doctors against their patients because physicians are paid the same small monthly amount regardless of how much care they provide, thus a chronic patient would be a drain on a practice.

Jurow, 48, has seen her income shrink by 75%, partly because of her refusal to take HMO contracts, she says. Married to Oxnard nephrologist John Stevenson, she says she is lucky because she can afford to take a stand against what she sees as substandard medicine.

“There are very few of us left who haven’t totally given in to the HMOs. I don’t think a physician can say they can give the quality of care that should be given under these capitated contracts. I refuse to take them, because you have to compromise your principles or the system will eat you up.

“I had one fight with an HMO [administrator] about one of my patients. He said, ‘She has to understand she’s an HMO patient, and that’s the quality of care she’s going to get.’

“The ‘gatekeepers’ won’t allow patients to get [special] treatment. I wasn’t able to order sonograms or mammograms as they were needed. For example, if there’s a case of abnormal bleeding in menopause, and you want to see what’s going on--whether it can be handled with hormones or does it require surgery--you sit there for weeks or months with a woman bleeding.

“I tear my hair out. But the patient was unaware her care was being compromised. I would say to her, ‘You call your insurance company and agitate. It’s the squeaky wheel that gets the care. Not the patient who needs it the most, but the crankiest.’ ”

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Gary Nishida

Obstetrician/gynecologist

President

California Women’s Health Care

Oxnard

Nishida heads a group of 18 doctors--all obstetricians and gynecologists--who pooled their efforts in 1994 to try to gain some bargaining power with HMOs.

This single-specialty group contracts with five large Ventura County IPAs, which are large, loosely knit independent physician associations that contract with HMOs.

Increasingly, subcontracts offered by IPAs to Nishida’s group--and to other physician specialty groups--have been based on a capitated payment system.

Although critics say capitation encourages doctors to undertreat patients, Nishida thinks capitation has one big plus. It shifts responsibility for controlling the costs of ob-gyn care from HMO “gatekeeper” family doctors to his group of specialists.

But Nishida is no fan of HMO medicine. He figures it has cut his income 50% in recent years.

“I’m just trying to survive in this world,” he said. “Capitation is something that none of us physicians feel particularly comfortable with.

“They set up systems to decide whether a procedure or operation is medically necessary. The problem is the premiums paid by employers have gone down. So the amount of money to play with has decreased. Therefore, what is medically necessary has unfortunately had to change.

“Clearly, that’s not a situation that’s good for the patient, and it doesn’t sit well with physicians. And, frankly, a lot of decisions about what is medically necessary are made frequently by nonspecialists.

“One of the things we’ve been able to do under capitation is control utilization. Now we choose which corner to cut. No, really, we’re not interested in cutting care. We’re interested in providing care more efficiently at a lower cost.

“We do not tell our physicians they cannot do something because it’s unnecessary. But if you have two or three ways of dealing with a problem and the outcome is equal with all three, we encourage the physician to pick the least costly alternative. And they’re rewarded for it.”

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Brenda Perry

Nurse

Newbury Park

Perry became a nurse 34 years ago at age 17 in her native England. She left front-line nursing last month, frustrated by changes that she thinks are working nurses to exhaustion and jeopardizing the health of patients.

A nurse at Los Robles Regional Medical Center for 16 years, she served her last 11 in the emergency room. In June she took a job as a case manager for Blue Cross in Newbury Park.

“I left Los Robles a week and a half ago. I was a good nurse. But I just couldn’t do it any more.

“It’s constant work, constant stress. Long hours. People coming in sicker and angrier. Nobody ever turns around and says ‘thank you’ any more. Sometimes I’d come home in the evening and just sit down and cry.

“I really liked taking care of patients. But I had to leave. And a lot of nurses are leaving the profession, too, some of the best ones, because of these reasons.

“When I started here I probably carried six to eight patients a night on a pretty acute unit. Now, they’re carrying huge loads. And the patients are sicker because HMO patients are held out of the hospital longer.

“The HMOs have given us a lot more work in the emergency room, because we have to get authorization for every step we take.

“But I really feel sorry for the patients, because they’re the losers--they’re losing good nurses, and they’re not getting the staffing because of health-care changes. It’s a sad situation.

“At Blue Cross, I work in the managed care division with their preferred provider plan, not the HMO. I do authorizations. Working here is so nice I can’t believe it. It’s like another world.”

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Susan Brooks

Nurse practitioner

Ventura

Brooks, 45, works for Ventura County’s oldest HMO-contract provider groups as a family doctor.

Hired by the Buenaventura Medical Group 2 1/2 years ago, Brooks represents a trend in HMO medicine in which patients see highly trained “physician extenders” instead of doctors on routine office visits.

Although critics say this represents a lessening of care, Brooks says the hiring of nurse practitioners and physician assistants allows medical groups to stretch insurance premiums and give patients same-day appointments.

“If you came to see me, you would be treated just like the patient of a physician. I would diagnose you, give you a prescription and schedule your follow-up. If you need to be referred out to a specialist, I’d refer you out if your treatment was within the Buenaventura system. If it’s outside the system, it would need to be approved by a utilization committee. On my referrals, I have always gotten what I’ve asked for. Medications are another story. On those you’re dealing directly with the insurance company, and they only cover certain drugs for certain conditions.

“[Nurse practitioners] are more in demand these days because we cost less than a physician and we can do just about anything they can do. If we get a patient that’s over our heads, we’ve always got a physician who will help us through it.

“Managed care has its glitches. It’s not the best thing in the world. But it’s what we’re working under right now. I think it’s pretty good, and I can see it getting better.”

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Samuel Edwards

Hospital administrator

Ventura

A Ventura County doctor for three decades, Edwards was medical director at Ventura County Medical Center before he was named top administrator in 1995. He views managed care as a physician, administrator and longtime student of the national health-care scene.

He thinks managed care--though disorienting for patients and frustrating for doctors--has great potential. Local hospitals have adjusted, he said.

“There’s no question that managed care imposed some challenges. Doctors are irritated and angry. They used to be the seat of all power. Now they’re told what to do. And hospitals have to get patients out quicker, and they don’t have the frills they did before.

“But overall, the condition of hospitals in Ventura County has improved in the last two or three years. Hospitals have become more efficient. Middle management is out the door. We’re sending employees home when the wards are empty. And suddenly hospitals are using that same razor blade a couple of times before they throw it away.

“When you can charge anything you want by running up the tab, there’s not much incentive to save. But General Motors--the big companies--finally said we’re not going to pay for everything you’re doing any more.

“Don’t forget that managed care is a mixed bag.

“It has brought down the cost inflation. However, managed care rations care, and people don’t like it. They want to be able to self-refer to a neurosurgeon, and they can’t.”

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Moustapha Abu-Samra

Neurosurgeon

Ventura

Past president of the Ventura County Medical Society, Abu-Samra, 51, is one of a handful of neurosurgeons in western Ventura County. Because his specialty is so rare, he said he has fared better financially than most doctors under the cost-cutting of HMOs.

But he says managed care can be harmful to patients, since it has delayed necessary treatment and turns over key medical decisions to generalists.

“We’ve seen a patient with tumor to the spine that was diagnosed later than necessary. You go to your doctor in an HMO setting and his inclination is not to send patients to specialists right away. In the old days, we would have seen this patient the same weekend, but that’s not the way it works anymore. The referral comes two or three months down the line.

“And once we get the patient, that doesn’t mean we can do what we need to do. We have to get approved all the way along.

“Managed care has set us back in a lot of fashions. When I started my schooling and training, from 1972-80, the emphasis was on specialties. Now, because of political or financial reasons, we’re told that it’s best to be cared for by physicians with no specialty.

“So the best care is available, but people in HMOs don’t get it right away. From that standpoint, we’re not on the right track. And we’re not honest about it either. I see patients all the time who wait until their insurance expires, then come to me with new insurance with problems they’ve had for two years. How can that be? Because they’ve not been told the truth.

“I’ve seen patients with chronic back pain who’ve needed surgery for two years. But the patient was not given the option of surgery. That may be what happens in a Third World country, but we’re not a Third World country.”

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Siegfried Storz

Cardiologist

Ventura

Storz, 57, thinks the quality of health care has improved over the last 10 years--that managed care has made doctors and hospitals more accountable and more careful about how they spend their time and resources.

But he also sees an erosion of relationships among doctors, and between doctors and patients as medicine becomes more of a competitive industry.

“The hardest thing for me to deal with is to see collegiality and professionalism being replaced by commercialism and competition. What’s hard for a lot of physicians is the difference between medical ethics and business ethics. It happens almost every day in any other industry, but it didn’t happen in ours.

“In the past, physicians were just kindly old professionals who would do what they wanted to do. Now they’re forced to be businessmen. And it changes the relationship between the doctor and the patient. They talk about providers and clients, not doctors and patients.

“Patients are frustrated. Their expectations are continuing to increase. They see things happen in five minutes on programs like ‘E.R.’ that take five hours. Some people are very demanding and blunt. And they do well with HMOs. They want what they get for the least amount of cost. They want a Mercedes, but they’re paying for a Yugo.

“HMOs know they need to differentiate themselves on the basis of quality. And there’s definitely a trend where they’re trying to document what they’re doing so they can show the big corporations what their patient satisfaction is.

“We’re seeing more patients and people are having to wait longer [for an appointment], and that’s a by-product of the HMOs. But I think we’re still delivering better care than ever before.”

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Jess Wagner

Family doctor, HMO-contract clinic

Ventura

Wagner, 48, spent his first 12 years of private practice in the tiny town of Smith River, as the northernmost physician in California.

But he never netted more than $75,000 a year. He moved to Ventura in 1992 for a sunnier climate, fewer worries and a hefty increase in salary as a staff physician for the Buenaventura Medical Group at its Ashwood Street clinic.

“I considered my time up there a mission of idealism. But it got worrisome being a small business and having to run an office. So I was happy to start working for someone else.

“And I really feel as if I treat my patients here as I always have. I think the quality of medicine in our group is excellent.

“It is frustrating because I have to ask for approval for tests I normally would have just ordered. I have to convince a panel to let me proceed. But I have never had a situation where the patient was denied care that was absolutely needed.

“The critical word here is need. And there are disagreements about need. One of the most troublesome things to get are MRIs. Your colleagues may think it’s unnecessary. So it might not go through. It’s a soft call. So you say to your patient, ‘It’s been denied, and I’ll watch you closely.’

“The same is true of referrals to specialists. It often falls into these gray areas.

“But if there’s clear-cut need and benefit, it’s approved without a second thought. We send people for bone-marrow transplants, for transplants of kidneys and hearts, for very expensive treatments of Hepatitis C and multiple sclerosis and treatment of AIDS.

“And I have to say that patients are different today. Instead of coming in and saying, ‘Doctor, I’ve got a headache, what do you think?’ They say, ‘Doctor, I’ve got a headache, I need an MRI of my brain.’ ”