Doctors Are Saying ‘Enough’ for a Reason

Stories have appeared in the press recently about patients in California being denied medical care. In the most recent example, The Times reported on how some on-call medical specialists refused to respond when called to the emergency room to treat inadequately insured patients.

We adamantly believe that physicians should never refuse to provide emergency care to a patient, regardless of the circumstances. It is the fundamental responsibility of every physician to treat patients in need. Period.

The California Medical Assn. and the California chapter of the American College of Emergency Physicians have been aware of the complex problem of emergency medical services backup for some time. Last summer, these groups brought together specialists, emergency physicians and hospital representatives to address this critical issue. (Health plans were invited to participate but declined.) The task force’s report is due later this summer. But participants quickly agreed that lack of enforcement of existing laws intended to regulate the managed care industry and the continuing defunding of the state’s health care system have combined to create a climate in which those dedicated to caring for patients are almost penalized for doing so.

Why are some physicians refusing to be available for on-call backup? Because health plan and government standard operating procedure has devolved to the point where emergency physicians--in fact, all physicians--are being paid only a fraction of the cost of patient care, if anything at all.

California physicians already bear a tremendous financial burden in our state’s ongoing experiment to see just how little it can spend on health care. California’s Medi-Cal managed care program, which ranks 49th out of 50 states in per-capita funding, is sitting on 30,000 claims physicians have submitted for patient care. HMOs, meanwhile, currently owe physicians associated with FPA and MedPartners (two large physician groups that went bankrupt in the past year) more than $150 million in unpaid claims. As a result of these bankruptcies, more than 4,500 California physicians have provided more than $150 million in care to 1.5 million Californians without getting a penny in return.

And we must emphasize that these physicians continue to serve these patients--those on Medi-Cal and those with insurance--every day, knowing full well that the chances of ever getting paid are remote.

Physicians who treat cancer patients have testified before the state Legislature about how lack of payment forces them to pay hundreds of dollars a day out of their own pockets for their patients’ life-saving medications. Others have mortgaged their futures to keep their office doors open or have been forced to leave the state and practice elsewhere. More than 200 physician groups have gone bankrupt in the past several years. These physician groups served millions of patients who now have had their care interrupted or degraded.

It will be up to society as a whole to figure out how to reverse the current shrinking of access to care. But as our organizations’ Emergency On-Call Task Force has already concluded, California has the power to do at least two things to improve physician on-call participation in emergency medical services. First, it must enforce existing laws and close all the loopholes that allow health plans to deny payment to on-call physicians who treat the plans’ own enrollees. Second, with the number of uninsured Californians growing at the rate of 50,000 per month, the state must allocate more resources toward the provision of emergency care for those who do not have and cannot afford health insurance.

Beginning in 2000, California is due to receive $1.7 billion annually in tobacco industry dollars for 20 years. This money should be spent to improve health and health care, not for sidewalks and potholes. Apparently, the continued collapse of major medical groups across the state has not sent a strong enough signal to state regulators. Nor has the fact that the state’s emergency medical system, once the envy of the nation, is in tatters.

The HMO industry and the government continue to play a dangerous game of seeing just how few resources they can provide physicians and hospitals and still have them care for patients. We are now seeing that some physicians, against every instinct and all their training, are saying “enough.”