Managed-Care Limits Fuel Patients’ Anger

When Dr. Peter Anderson leaves the emergency room at the end of his shift, he can’t help but worry that a disgruntled patient might be lurking in the parking lot of Fountain Valley Regional Hospital.

“You are always wondering if this is the last straw” for an angry patient, he said. Many doctors have come to expect hostility from patients and family members in a world of managed-care medicine and inadequate insurance coverage.

In treating a patient, “you have no clue how violent this person is when you are trying to do the best for him,” said Anderson, who heads an emergency room that handles 35,000 people each year.

Hospitals are places of strong emotion to begin with because of illness, injury and death--along with the accompanying uncertainty and guilt for friends and family. Layer on top of that the unknowns built into rationed health care, and there are plenty of ingredients for despair, wrath and even violence, several experts said.

It was against this background that violence exploded Tuesday at West Anaheim Medical Center. Dung Trinh, 43, apparently was enraged over care his mother had received when he allegedly shot three hospital workers to death.

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The violence was as rare as it was shocking. But many patients and their relatives are angry and frustrated, say doctors, nurses and others in the health care field.

“Rightly or wrongly, there is a great deal of pent-up anger on the part of patients . . . who feel they are being jerked around,” said Dr. Stephen Groth, director of emergency services at Anaheim Memorial Medical Center.

“The for-profit health care system is really straining and there is a lot of unrest and consumer anxiety,” said Sam Roth of the Orange County Medical Assn. “Patients feel they are not receiving the care they think they should be receiving. We obviously don’t believe that as physicians.”

The evolution to managed care has meant it is harder to get into a hospital and stays are shorter. While it can sometimes be easier to see a gatekeeper physician, those visits too are briefer and approval for specialist care often requires third-party consent. In addition, people in hospitals are sicker, and the staff is more hard-pressed to care for patients, say consumer advocates and nursing professionals.

“Overall, there is less attention to the patient, which is causing unprecedented frustration and aggravation and if not dealt with systematically can lead to inappropriate explosions and social alienation,” said Jamie Court of Consumers for Quality Care.

Public disgust is so widespread that managed care medicine has become a major political issue. A week ago, Gov. Gray Davis signed into law major reforms, including giving patients the right to sue their health insurers and appeal coverage denials, and creating the Department of Managed Care to oversee the industry. The measure was supported by both Republicans and Democrats, industry and consumer advocates.

Complaints about care extend literally from cradle to grave, with Congress responding last year to an outcry over so-called “drive-by deliveries” by mandating that insurance companies pay for 48 hours of postpartum care.

Court, whose organization is based in Santa Monica, receives 40 calls and e-mails a week from annoyed patients. He predicted that the shooting in Orange County, where a man acted out of revenge for what he saw as inadequate care of his mother, “is not going to be an isolated instance.”

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Medical schools across the country are responding to the problems, especially the dehumanization of medicine, by increasing emphasis on doctor-patient communication and commitment to compassionate medicine. UCI has a course run in conjunction with PacifiCare Health Systems to better train doctors how to work with managed care providers.

Medical professionals agree that one of the most frustrating settings can be the emergency room, where people often show up hurt, sick or on drugs and often with inadequate insurance. And whether it is in the emergency room or elsewhere, physicians commonly are being asked to be the bearer of bad tidings.

“We have tough situations all day long,” Anderson said. “Obviously, 99.9999% go smoothly, because you have reasonable people who can be made to understand the situation. They are severely distraught and upset but they do not become violent. The question is, what makes people go off the edge?”