Doctors under the knife

Living in a world of managed care

LOS ANGELES, California (CNN) -- In an age where scientific breakthroughs are pushing physicians and researchers ever closer to finding cures for some of history's most deadly diseases, doctors on the front lines of medicine are also working to resolve another complicated reality of 21st century medicine: managed care.

"We are living in an age where we're no longer valued," complains Cedars-Sinai Medical Center's chief of staff Dr. Paul Hackmeyer.

Hackmeyer is not alone in wondering whether medical expertise and patient care have taken a back seat to a health care system which at times seems to care more about cost than quality.

"As my mother used to say, 'You can't have champagne on beer money,' and that's what I think we are trying to do with our health care system," says Dr. Carol Jordan-Harris, an obstetrician-gynecologist and 16-year veteran of Cedars.

But for many other doctors, especially younger physicians, managed care is just another system to be mastered.

"It's a new ballgame, you have to learn what the rules are," says Dr. Frederico Rossi, a first-year internal medicine resident at Cedars-Sinai.

Growing up managed

"It's just another code, another day," explains Dr. Andreas Kamlot, after rushing to an examination room and running a team of nurses through an emergency procedure to stabilize a patient suffering from pneumonia.

"You have to enjoy a fast-paced working staff," the third-year general surgery resident says. "So far I enjoy what I'm doing. That's why I'm here."

For Rossi, a typical day includes tracking down specific physicians and medical care for patients enrolled in health maintenance organizations.

"I'll be back later with the whole team," Rossi tells a patient complaining of abdominal pain.

But as Rossi later explained, despite that patient's pain, "He's not going to be able to see just any gastroenterologist. It's going to have to be somebody that's on his insurance plan. I don't know who that is. I have to speak to his PMD [preferred medical doctor] and find out."

Rossi and Kamlot represent a new generation of doctors at Cedars-Sinai Medical Center, the largest non-profit hospital in the western United States. As a teaching hospital, residents like Kamlot and Rossi are trained to practice the science of medicine, but they must learn for themselves how to navigate a complicated health care system. For the young residents at Cedars, managed care means spending a third of their time on paperwork or on the phone figuring out which doctor belongs to which insurance plan.

But while they believe managed care may not always feel good, many young doctors see it as necessary and maybe even in all of our best interest.

"The system we live in now is training you to be a better doctor ... because now you really have to think about what you're doing," says Rossi. "There is the so-called shotgun approach ... where you go and you order every lab test, every, every radiological study, run up a $10,000 bill within hours in the emergency room, and then ask the questions, and then take a history, and then find out where the pain is. That is no longer acceptable."

Kamlot agrees. "In the past, the mentality was more is better. I think that's the approach we have and the approach I see in trauma and surgical patients in the emergency room [but on a lesser] level than we were in the past. But a very reasonable level -- so I don't feel pressured not ... to order something which I feel is necessary."

"You have to learn the rules," Rossi says. "And if you do, you'll find out that most managed care providers are reasonable."

Nationwide, some 100 million people are enrolled in some form of managed care, mostly through employer-offered health plans that offer a restricted form of care for a low fixed rate. But is it good care?

Kalmot admits, "At times an operation of somebody who would need it rather quickly is delayed based on the fact that he belongs to a plan -- which is not ideal. Not to the point that it's life threatening, but certainly a delay of therapy."

HMO horror stories attract a lot of media attention today, but a decade ago, when managed care first became a huge force in health care, HMOs were seen as the answer to an industry facing spiraling costs.

"The health care industry was growing at enormous rate in the '80s, so much so that it was growing at three to four times faster than inflation," explains Rossi.

With the advancements of technology came more expensive procedures and higher physician fees. The resulting explosion of costs left many people unable to afford rising insurance premiums.

"The answer was not just cutting physicians' salaries. And HMOs realized that," says Rossi. "It had to do with also the things they ordered."

Kalmot says that ordering many expensive tests and procedures is not more effective medicine than "ordering reasonable and purposeful tests."

"I think that there are still people who certainly know the past of medical care. But I believe that they're all quite aware of the problems we currently have to fight with in order to provide care to a broader group," he says.

The ideas of containing costs and providing health care to a broader group of people have been around for decades. President Jimmy Carter first proposed universal health care in 1979. But his proposal died in committee. The Clinton administration tried again -- unsuccessfully -- to develop a national health care plan in 1993.

What has emerged instead is a market-driven system with private HMOs that provide affordable health care and profits to shareholders. But critics charged that the primary goal is lower cost at the expense of higher quality.

For the young residents like Rossi and Kamlot, the trade-off between the time spent with patients and the administrative legwork of managed care is all part of their day. Ultimately being a doctor today still means healing the wounded and curing the sick. But for the first time in recent memory, becoming a doctor today does not automatically mean a ticket to prestige, privilege and prosperity.

"The impression of many people that doctors are all very rich and drive fancy cars is not the fact anymore," Kamlot says. "I think the average is that some of them are on 100 to 105 hours a week. So if you break it down by hours, in the worst case, it comes down to $2.60 an hour. And some of these physicians graduating from here, they have about $150,000 of loans to pay back."

Rossi says, "I think physicians in training and the medical students entering the profession now need to realize that there will be salary. Nobody's gonna starve. I mean, we're going to make a living, we're gonna do just fine. However, the super lifestyles that some physicians in the '80s lived are no longer going to be the case."

A difficult transition

For many established doctors, like Cedars' chief of staff Hackmeyer, the transition to a managed care system has been difficult.

"For the young people that are just coming out, they don't know any better. And so if they're going to make only a certain amount of money, they didn't know that it used to be two or three times as much," complains Hackmeyer, an obstetrician-gynecologist. "It's comparable to China in the '60s, this kind of cultural revolution here. We are living in the age where we're no longer valued."

Hackmeyer says he often thinks about whether "to just bag the whole thing," but then he remembers "that I just enjoy what I do so much. I think that if I was doing it just for the money, I probably would have found something else to do."

Dr. Arthur Johnson says in agreement, "It's not about money."

After nearly 21 years in private practice, Johnson has seen the practice of medicine change almost beyond recognition. And like many senior physicians, he is not happy about it.

"It's about how you're being treated," he says. "If I'm not going to change how I'm going to relate to my patients and they're not going to put any more hours in the day, something has got to give."

As a result, Johnson did what a growing number of disgruntled veteran doctors are doing -- abandon their contracts with HMOs.

"I decided to make a move that would allow me to continue the practice in a manner that I felt that the patients deserved," he explains. "It would take me now maybe 30 seconds to order a test. But with a HMO, it may take me 30 minutes to get that permission. Well, 30 minutes is a lot of time away from your clinical practice."

Hackmeyer also has abandoned managed care.

"I don't do managed care at all. It's not worth it. I did it for a year. I thought that my income would stay the same. I thought that what would wind up happening is I would just work harder. I worked harder, doing two or three OBs for the price of one and the income still dropped," he said, adding that the situation made no one happy.

"What I didn't anticipate was the toll that it would take on my office. That is the, the patients were angry, they were more demanding. I now had an unhappy staff," Hackmeyer said. "Patients were just as unhappy as could be because we weren't providing the service that those patients felt that they deserved -- wouldn't necessarily have to pay for --- but they felt they deserved."

Johnson also complained that dealing with the claims staff at the HMO was difficult, saying it was often frustrating and humiliating "to be denied [test approval] by someone who has never even started college."

So far, Hackmeyer and Johnson are managing to survive without managed care: They see only cash-paying patients or those with preferred provider plans, who can see the physician of their choice and seek reimbursement later. But that still is not an option for most physicians who depend on HMOs for their referrals.

Like it or not, all these doctors agree that some form of managed care is here to stay.

"I am sure, without a doubt, I will be involved in managed care with the maturity of my patients. And that's simply the way it is nowadays," Rossi explains. "I don't have a choice and so that has to be fine with me."

NEXT: Finding different ways to overcome the obstacles of managed care-->

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