Photograph by Kathy De La Torre
Neurologist Harmeet Sachdev, director of Good Samaritan Hospital's stroke program, struggles within the current medical system, in large part, because he is deeply committed to the successful stroke program he created in 1996. Sachdev spent many days and hours of his own time without reimbursement, while trying to get this treatment established. 'Insurance companies don't cover new procedures,' he says.
Code Blue: Fighting to save medical care
Medical associations say the exodus of California doctors is an epidemic
The second of two-parts
By Sandy Sims
Many doctors say it's when the HMOs became for-profit organizations, that the focus shifted from taking care of patients to taking care of profits for the stockholder. Dr. J. C. Pickett, an orthopedist and the immediate past president of the CMA, says medical care is being run by Wall Street now instead of Main Street.
Eventually, government and HMOs began setting fees, completely leaving doctors out of the loop.
Obstitrician Curtis Montgomery says large businesses negotiated for lower employee insurance premiums and drove reimbursement rates down even more. Doctors, banding together in medical groups
to survive the cost of running their practices, wound up competing with each other and drove the rates down even more.
Montgomery, who knows of 11 ob-gyn specialists who have recently left Santa Clara County, says he tried not to let this affect the quality of his medical care. But when he would call for a pre-authorization, he would have to "rant and rave," and the HMO still wouldn't give authorization to him. "And these weren't doctors I'd be talking to;" he says. "They'd be some kid out of high school." He recalls an orthopedic surgeon who wanted to get an MRI for a patient with chronic knee pain. The HMO said no and recommended anti-inflammatories.
"God forbid you see a patient without a referral," Montgomery says.
If the treatment could be done in his office, he often went ahead and performed the procedure without pay. But the out-of-office procedures didn't get done.
"It's hard to practice medicine in that system," Montgomery says, "because all you do is take care of the minutia."
"People don't realize what this is all about," San Jose cardiac surgeon Gary Silver says. "They are being jerked around by insurance companies who are screwing doctors' reimbursement down tighter and tighter while doctors' costs are going up. Somewhere," Silver says, "the curve will cross."
It seems the curve has already crossed. Under the current system of reimbursement, doctors are losing money if they practice in California.
For example, in August of last year, the CMA released a study that shows pediatricians receive a capitation rate of about $24.24 per child, while the average cost--including mandatory immunizations--are about $47 per month.
Capitation rate is the per-patient amount a health maintenance organization pays a primary care physician monthly to treat the HMO's members. The rate is paid whether the doctor sees the patient or not.
The study shows the overall capitation payments have dropped 35 percent, from $45 down to $29 per patient. Santa Clara County's rates go even lower because of a complex system of competition between business groups for the lowest insurance premiums and between medical groups for the insurance dollar.
It isn't just the money, though.
Silver, who at 59 years old is a highly esteemed heart surgeon with a 27-year practice, says doctors of his vintage are leaving. He retired last year.
"The practice of medicine is no fun now," Silver, says. He knew he wouldn't stay in medicine till late in life. But he thinks the struggle to practice medicine today helped his decision along a little sooner. "It's the hassles with insurance companies, people telling you who, when and what you can do," Silver says.
He remembers what it used to be like. Twenty years ago, if Silver needed to perform surgery on a patient, he simply called the hospital and told them when to admit his patient. Then he called the doctors he wanted to work with. "The whole thing took 10 minutes," Silver says. "We also got fee-for-service."
Fee-for-service means the patient pays the doctor directly and then sends the bill to the insurance company for reimbursement.
"There's no good guys and bad guys in this," San Jose obstetrician Margaret Mahoney, insists. Mahoney says, "We all agreed that HMOs were a good idea. But we've tried that idea, and it's not working."
Photograph by Kathy De La Torre
Dr. Richard Sieve, a sole practitioner, sorts through records in his office. He has hired one person for 30 hours a week just to follow up with insurance companies on unpaid claims.
Now no one is happy, Mahoney says. She says, "Doctors no longer like practicing medicine; nurses are leaving the hospitals, and patients are no longer at the center of medical care. Even the HMOs are running into financial trouble, she says. "No one ever expected us to get to this place."
Mahoney went through a soul searching after hearing herself say to her patients too many times, "It's out of my hands." The result is her book Saving the Soul of Medicine, which chronicles her and her patients' experiences and thoughts for one year as she practiced medicine under the current system. Her book brings to light HMO practices such as utilization reviews, which is the HMO system of monitoring a doctor's use of certain medical procedures. URs are set up solely for the purpose of cost containment, with the underlying threat of dropping a physician from the HMO.
She writes about having to send specimens to inferior labs HMOs have contracted with for lower fees. She writes about patients having to go to a primary care physician (PCP) for all referrals, which means patients can wait in pain for days, or longer, before getting to see a specialist. And she tells how PCPs are burdened with patient loads that often number in the thousands. Which, Mahoney says, is why finding a new primary care doctor is so difficult.
Practicing medicine under the current system became unbearable to her.
Three years ago Mahoney took what she says was a radical step at that time. She left the medical group she'd been with for years and opened a sole practice specializing in post-menopausal care. She refuses to deal with insurance companies altogether by charging fee-for-service.
"It's wonderful," Mahoney says. She takes one hour or more with her patients. She is able to practice what she calls the most fundamental elements of good medical care--continuity, careful attention to detail, and long-term follow-up. She can order tests from labs of her own choosing and refer to the specialists she has faith in. Her practice is thriving. Mahoney has been speaking in the community to educate the public and to promote public debate about where medicine should go from here.
Three years later, more and more doctors are dropping out of the HMO system.
Established doctors can do fee-for-service, says Mathew Mingrone, an ear, nose and throat specialist in Saratoga. "But if more than 50 percent of your patients are with HMOs, it will kill your practice to leave. You can't just hang up your shingle and start practicing like in the old days," he says.
Mingrone, who spent a year in Beverly Hills training in facial plastic and reconstructive surgery, grew up in the area and has returned after 15 years of medical training. If his and his wife's family weren't living here, he doubts he would have returned. An inheritance from the death of his father enabled him to buy a home and take over an established practice.
Mingrone says he is the first ENT specialist to come into the southwest valley in five years. And he knows of four or five ENT specialists in the West Valley who will retire in the next three years. He also knows one ENT who is leaving the state to practice elsewhere.
"This area is the bottom feeders, as far as insurance reimbursement," Mingrone says. "In the past, taking over a solid practice was a gold mine," Mingrone says. Patients were loyal. Now they have no physician loyalty because of changing insurance plans. Some Medicare patients continue with Mingrone, and some longtime patients who are used to paying out-of-pocket are still coming.
Mingrone says younger doctors who are hungry need more patients to come in the door. Insurance companies know new doctors will take lower reimbursements. He didn't sign up with HMOs, but he has contracted with some of the large medical groups as a specialist.
Fresh out of residency at Santa Clara County Medical Center, Nina Jaki found a way to practice in the area. Jaki, a Willow Glen resident, also grew up here and wants to stay. After finishing a four-year residency in obstetrics and gynecology, she accepted a salaried position four months ago with a highly thought of medical group in Los Gatos. Jaki says she was actually offered $30,000 more to work in Auburn and $40,000 more for a position at Clear Lake. Though the cost of living is high here and she can't afford to buy a house, she likes her current arrangement.
Some well-established doctors are staying around, but it isn't easy.
Neurologist Harmeet Sachdev, director of Good Samaritan Hospital's stroke program, is watching his colleagues leave. He knows six doctors under the age of 60 who have recently retired. Still, Sachdev struggles within the current medical system, in large part, because he is deeply committed to the successful stroke program he created in 1996. Sachdev spent many days and hours of his own time without reimbursement, while trying to get this treatment established. "Insurance companies don't cover new procedures," he says.
The stroke treatment includes the expensive medication dubbed TPA that must be administered within a three-hour period after a stroke. The medication gives a patient a 50 percent chance of complete recovery with no paralysis. "Good Samaritan has been very supportive of this program," Sachdev says. And HMOs are covering it now that they understand that it saves money in the long run.
However, the HMO system of requiring patients to get a referral from their primary care physician is a major problem. Sachdev says, "We tell the patient to call 911, but the HMO says the patient must go to his PCP for a referral before coming to us." He says he knows of three patients who became paralyzed in the waiting room of their PCPs six or so hours after their strokes occurred.
Many Californians have begun to suspect that the healthcare system isn't healthy, but those who are on the front line--the doctors the hospital administrators, the nurses, the technicians--say the situation is far beyond "not healthy." Those in the medical field in California--and especially in Silicon Valley--say it's nothing short of a crisis.
Sunnyvale, California Since 1994
