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The Doctor is Out

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St. Louis psychiatrist Dr. K. Lynne Moritz is watching younger colleagues piece together part-time jobs that require a road-trip commute, just to supplement their therapy-leery managed-care practices. President of the St. Louis Metropolitan Medical Society and director of the St. Louis Psychoanalytic Institute, Moritz decided several years ago not to belong to any managed-care panels. Her patients either carry expensive indemnity insurance or pay out of pocket. But younger psychiatrists, "who don't have a reputation to fall back on for referrals, have great difficulty doing anything except managed care," she notes. "And managed care wants them to do only medication management. It's a very tricky business, because they often pay you more for a 15-minute medication-management visit than they do for 45 minutes of therapy."

One new psychiatrist was doing a fellowship in child psychiatry and was working at a clinic that recommended eight-minute visits. "Twelve minutes were recommended for a new evaluation of a geriatric patient," Moritz exclaims. "You can't even write down the meds they are taking in 12 minutes. This is terrible for physician-patient relationships. And if you don't have a relationship with your patients, they flush the medications down the toilet."

Back to the visit in question: "A 7-year-old girl was telling her grandmother and the psychiatrist -- for the first time -- that an uncle had been using her sexually," recounts Moritz. "All of a sudden there was a banging on the door and a nurse saying, 'Doctor, your time is up -- you must move on."

Brave New World
"Doctors have been seriously well-paid, and they have not stepped up in terms of accountability," observes Dr. Mary Frances Lyons. A board-certified cardiologist at 29, she left clinical practice several years later and now conducts executive-physician searches for Witt/Kieffer, Ford, Hadelman & Lloyd. "Now other entities are giving out the terms of how doctors will do business, and doctors have to accept that." How's it going? "Not well," she says dryly. "You hear a lot of 'We don't get enough input'; 'They are trying to control us'; 'They can't make us do this'; 'Why did I go to med school?'"

Doctors tend to be a bit passive-aggressive, she adds. "They vote with threats -- 'I'll take my patients across town' -- and use maneuvers that can be perceived as vindictive and childish." On the other hand, "their professionalism is totally intact when it comes to decisions about their patients. They will never knowingly make a poor decision about patient care just because they are mad about managed care."(There are indirect consequences, though. Navarro went to see a specialist at Barnes and the physician walked in fiery mad, fresh from a four-hour meeting about restructuring the department and furiously preoccupied.)

"They are not thinking about health-care systems, they are thinking about 'my practice,'" Lyons continues. "One of the most difficult corners for health-care executives to make it around is becoming a company person." All that time learning to hone and trust your own judgment, just to cede it to an organization? Besides, playing well with others isn't part of medical preparation. "Culturally and sociologically, physicians are cloistered during roughly 10 critically formative years," observes Lyons. "You study real hard and make enough good diagnoses, you can be as weird as the day is long, but no one can say you can't practice because you're a geek."

That freedom's changing, though. "Your payer might get a few complaints and take you off the panel, and there goes a third of your practice," notes Lyons. "This is the stuff doctors were protected from when they could just hang out their shingle. Now they are vulnerable to the exact same things the man in the street has been vulnerable to, lo these many years."

Swinging with the Shift
Dr. W.C. Williams, senior vice president of the National Association of Managed Care Physicians, is waiting patiently for his colleagues to get with the program. "They think it's all the managed-care plan's fault," he says. "It's the employers driving the situation. They said, 'The price for insurance is escalating 20-39 percent a year, we're not going to pay it, find an alternative system.' And the physicians just sat back and did nothing."

Williams understands their paralysis: "It's difficult to be in an exam room one minute and behind a negotiating table the next. But when they are moanin' and groanin', it's because they have not gotten up and done something about the business side. I talk all around the country, trying to get them motivated and proactive and back in the delivery system. What they're in is chaos."

Dr. Roger Rathert was a pediatrician for 27 years, working in a large group practice of 170 physicians in Wisconsin and recruiting for their clinic. Then Cejka & Co. recruited him. "I wasn't particularly frustrated with managed care," remarks Rathert. "I just felt I had accomplished a lot and wanted to try something new. The people I deal with have accepted that managed care, done properly, is a good thing, and they are looking for people who value that.

"I think what a lot of physicians object to is what's called 'case management,'" he volunteers. "There's sort of a cookbook for managing a disease, with recommended courses of action. They will say they don't like cookbooks; they want to do things the way they were trained, and they say that's just as valid as a formula provided by someone else. Well, I'll tell you, it may be a cookbook, but it's written by a gourmet chef.

"Medical practice is becoming a business," continues Rathert, "and it has to be managed like a business. You get paid for the number of patients in your panel, not the amount of work you do. One of the hardest things for a procedural specialist, like a surgeon, to understand is that now, if you do lots of procedures, you cost the organization.

"The bottom -- " he catches himself. "The fundamental thing is that managed care is not a bad thing. What it's trying to do is ensure that what is done is appropriate and of the highest quality." What about the gynecologist who hated herself for sending her patient to the ER? "Well, did she enjoy the time she spent with her family?" Rathert retorts. "If the lady got appropriate care that solved her problem, she should feel a little less bad about it."

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