Doctors Who Lose Patience

Now is the winter of doctors’ discontent. And judging from the grumbling in physicians’ lounges and exam rooms, summer may never come again.

Across California and other regions, doctors are complaining that the era of managed health care has robbed them of autonomy, quality, income, time, prestige--even self-respect.

For this, they wonder aloud, they spent their youths in laboratories and libraries?

“This is life in hell,” said Dr. Rex Greene, a Pasadena oncologist and president of the Los Angeles County Medical Assn.--and he describes himself as an optimist.

Increasingly, physicians are going far beyond grumbling.

A growing minority are rebelling outright--dropping HMO contracts, seeking clout and redress in professional alliances or unions, filing lawsuits, retiring early, going out on disability or moving out of markets colonized by managed care.

Consider the San Diego gastroenterologist who slapped his physicians group with a lawsuit after he was fired for supposedly spending too much time or money on patients. Or the cardiothoracic surgeon from the same city who yanked down his shingle and moved to South Dakota, where managed care is nearly nonexistent. Or the 33-year-old Pasadena internist whose frustration forced him two years ago to cut all ties to HMOs.

“I have been un-neutered, restored to my vigorous self,” said the internist, Dr. Andre Ettinger. “I can finally take care of patients rather than having to punt the ball all the time.”

Nine out of 10 physicians have at least one managed care contract, but recently, hundreds of physicians en masse have rejected contracts in California, Texas, Florida, Georgia and Colorado. Patients have been left to scramble for substitute doctors.

Unions, meanwhile, are competing to capitalize on physicians’ frustrations. Just this week, the nation’s fastest-growing labor organization, the Service Employees International Union, announced it would devote $1 million a year to recruiting salaried doctors--about half of the nation’s 600,000 physicians. Such efforts would not have been contemplated even a few years ago, so strongly did most doctors feel that professionals couldn’t be proletarians.

It is no surprise that California is one of four regions targeted by SEIU organizers. Nowhere, perhaps, is doctor dissatisfaction more pronounced than in this state, where up to 85% of insured adults are covered by managed care plans.

Here, many physicians speak of managed care as though it were a contagious disease. The system is designed to control costs by paying doctors fixed or discounted rates for their services and making them account, both financially and medically, for their decisions. But unhappy physicians lament that they often are forced to take a back seat to bean counters, creating conflicts that compromise their medical mission.

A skeptic might argue that doctors have little to grouse about. Though their incomes have not kept pace with inflation in recent years, physicians still make more money than most Americans--an average of $166,000 in 1996. Some physicians have joined the corporate ranks of managed care as CEOs and medical directors, drawing even heftier compensation.

Proponents of managed care argue that doctors--and patients--should not be so quick to dismiss its benefits, including holding premiums nearly flat in California for five years without demonstrably reducing quality.

But the malaise among doctors persists. One study found that nearly a third of young California physicians wouldn’t go into medicine if they could choose all over again.

“Disgruntled, cranky doctors are not likely to provide outstanding medical care,” warned Dr. Jerome Kassirer, editor in chief of the New England Journal of Medicine, in a November editorial. “Payers, insurers and legislators must recognize this predicament and stop pretending doctor discontent doesn’t matter.”

Pushed to the Breaking Point

Dr. Jerome Lackner, a 72-year-old internist and former health director under Gov. Edmund G. “Jerry” Brown Jr., practiced for 30 years in San Jose and Sacramento. He had planned on working for as long as he was able, which he hoped could be as long as 20 years.

Instead, in September 1997, Lackner poured out his heart in a 10-page, single-spaced letter to patients, explaining why he was closing his doors to become a salaried prison doctor.

“I have not been able to accommodate to this system,” he wrote.

His practice included 24 hours on call, no vacations, late-night exams, free care for the indigent, and hours of counseling for alcoholics and addicts. Meanwhile, the bills piled up, and the pressure mounted to see more patients, turn away the seriously sick, squelch referrals to specialists and spend hours with paper rather than people.

Lackner felt he would have to change who he was as a person to comply. “I am just unwilling to get a . . . lobotomy in order to achieve success as a doctor under managed care,” he wrote in his letter to patients.

Discontent is rampant among older doctors like Lackner, forced late in life to adapt to what one described as health care’s “industrial revolution.” But many younger physicians, too, confess to uneasiness under aspects of managed care.

A survey of 900 doctors 40 and younger, published by California Physician magazine last August, found that seven in 10 were dissatisfied with their relationships with managed care organizations. Just over half identified “denial of care” by health plans as their greatest ethical concern. More than half also reported that they are making less money than they had expected.

Pasadena internist Ettinger was once among the disaffected.

Just four years into his career, Ettinger, who graduated near the top of his class at UCLA Medical School, found himself fantasizing about early retirement.

With sick patients filing in at an unforgiving rate of one every 12 minutes, the pace--and the lack of gratification--got to him.

Patients were dismayed when he couldn’t visit them in the hospital. He’d treat seriously ill people and never see them again. He had to fight for insurers’ go-ahead on basic procedures. A patient with a slipped disk, in pain so severe he couldn’t work, had to wait six weeks to get approval for a scan that confirmed he needed immediate surgery.

“I was there from 7 in the morning to 7 at night, and I was doing a lousy job,” he recalled.

Then, two years ago, he had what he called an “epiphany.” Others would call it a foolhardy notion, fraught with financial risk, at least in the HMO-heavy California market.

He quit his practice, opened his own office and just said no to HMO contracts. Gradually, he is cutting his ties to other managed care organizations as well.

The result? He’s happy. His income has dropped by a third because fewer patients can afford to see him. But he works fewer hours and has more time for patients, many of whom have traditional indemnity insurance or pay cash up front.

“I’d rather make less money and keep my reputation,” he said.

Other doctors have drawn lines in the sand as well.

Dr. Kenneth Stahl, a 45-year-old cardiothoracic surgeon, didn’t have the luxury of cutting his ties to managed care in San Diego. As a specialist, he was dependent on referrals from cardiologists with managed care contracts.

The problem was, cardiologists effectively sacrificed a portion of their own fixed monthly fees every time they did. Consequently, referrals were drying up or were delayed to the detriment of patients.

So Stahl picked up and moved to Rapid City, S.D.

“There was no way to get ahead [in California],” he said. “For doctors to talk about money is kind of taboo, but I spent a lot of my own money and all my youth training to be a heart surgeon. . . . It’s only fair that I should make a fair income for working hard.”

In Rapid City, where managed care has barely begun, Stahl is making many times what he could in San Diego. But that isn’t all. He now lives in a community where patients still trust doctors to do the right thing for them.

Though he misses San Diego--he still calls it home--”I have a rewarding job,” he said. “I feel like I practice honest medicine.”

Growing Discontent

Doctors’ frustration is surfacing in other ways--ranging from individual resistance to organized action:

* San Diego pediatric gastroenterologist Thomas W. Self drew national attention last year when he sued his medical group, charging they had fired him for spending too much time and money on his young patients. He won a $2.5-million settlement.

Physicians and consumer groups saw Self’s case as sending a strong message that monetary concerns cannot intrude with impunity on the doctor-patient relationship.

* The California Medical Assn., representing 30,000 of the state’s doctors, last year complained to the state Department of Corporations, which regulates HMOs, that many managed care contracts are unfair to doctors and violate state regulations.

The petition asked the agency to prohibit health plans from such acts as stripping doctors of medical decisions, ducking lawsuits, restricting communication between doctors and patients, changing contract terms behind doctors’ backs and failing to disclose how much physicians could expect to be paid. The Department of Corporations denied the petition.

* The traditionally conservative American Medical Assn. is pushing a broad patients-rights agenda in Washington--including the right to sue HMOs--that has rankled some leading Republicans. “If we don’t do anything about this [managed care system], I think we will drive physicians out of practice,” Dr. Nancy Dickey, AMA president, said during a recent trip to California.

* Labor unions, though still anathema to many doctors, are stepping up their organizing efforts and seeing remarkable success. The SEIU’s is only the latest--and biggest--endeavor. Even the AMA has started a collective bargaining unit, though it draws the line at strikes. Membership is concentrated among salaried physicians in HMOs or hospitals. But some unions are picking up membership among independent doctors who hope to negotiate better HMO contracts.

* Doctors, once in the work-till-they-drop category, increasingly are filing disability claims, delaying their return to work after injury, or simply not going back. Insurers say the overwhelming reason is dismay with managed care.

* Physicians are becoming more outspoken in their critiques of HMOs. One physicians’ network in Long Island, N.Y., drew scrutiny from federal regulators after it warned Medicare patients against joining HMOs.

In some cases, patients have been caught in the cross-fire. During a recent contract dispute in Texas, for example, hundreds of specialists temporarily pulled out of one of Aetna U.S. Health Care’s HMOs. Aetna, the nation’s largest health care insurer, responded by refusing to authorize the doctors to treat any of the thousands of patients in Aetna’s various plans. The dispute was ultimately resolved, but patients paid a price in delayed or disrupted care.

Coming Up With a Cure

For all their grumbling, physicians are not of one mind about how to respond to managed care.

Some doctors have made their peace with the system; others have jumped in with both feet. Those who have taken top positions at managed care companies argue that the system is better directed by MDs, with their background in patient care, than MBAs.

Managed care “is a fact of life, and the question is, how can you make it better or worse? A lot of doctors are in the crying-over-spilt-milk phase,” said Dr. Jeff Mason, medical director and chief medical officer of ProMed Health Care, a physician-directed, for-profit company in Pomona. In taking leadership positions, “We have some opportunity to regain some control.”

“If I had wanted to be a business person, I would have gone to Harvard Business School,” countered Santa Monica pediatrician Victoria Paterno. “Business is about trying to maximize profit and physicians are . . . trying to maximize what is best for the patient. Those are two very different things. Very often, they are in conflict.”

At the same time, critics note that doctor-directed companies have presided over some of managed care’s worst debacles such as the bankruptcy of FPA Medical Management in San Diego, which the California Medical Assn. says owes doctors statewide $60 million in fees, and the demise last year of California Advantage, the HMO launched by the medical association.

Often ornery individualists, doctors have not--until recently--been adept at organized opposition to managed care, either.

Said Dr. Stuart Fischbein, a Century City obstetrician-gynecologist, “We’re suspicious of other physicians. I think it’s always been true, but it’s more true when the money gets tight.”

Managed care advocates say unhappy doctors unfairly reduce the HMO debate to “cost control versus quality.” In fact, says Walter Zelman, president of the California Assn. of Health Plans, one major UC San Francisco analysis found that quality hasn’t been significantly affected by managed care. And despite recent predictions of rising costs, premiums in California have held fairly steady.

Yet many doctors feel they’ve lost something, and many patients as well--something, perhaps, not easy to measure.

One specialist, who asked not to be identified, said he struggles not to let his exasperation affect his treatment. He recalled, with some embarrassment, how he had once refused to remove a mole of a managed care patient who’d come in for something else because the insurer wouldn’t cover it. He would gladly have done the procedure in the old days.

Some doctors blame patients for choosing the cheapest health plans offered by their employers, saying “You get what you pay for.” And patients sense their rage.

One of Lackner’s former patients, Amy Griffith, 37, was astonished recently to be “screamed at” by her new doctor, whom she described as tense and overworked. She doesn’t doubt his ability, but she misses Lackner and can’t help but question the system that weeded him out.

“The best part of what made [him] who he was,” Griffith said, “ran him out of business. His whole life was about being of maximum service to other people, and he was required to sever that cord for financial reasons. It seemed blasphemous.”