ABC practitioner must read/anyone

ABC practitioner must read/anyone

Jake Wood, CP

I read this articale today. I hope all of you find this interesting. Made me
smile!
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Two years ago, William O. Daniel's doctor adopted a new policy. No longer
would the doctor, Herbert Rubin of Beverly Hills, Calif., accept payments
from health maintenance organizations. No longer would he be on insurance
companies' preferred provider lists. No longer would he even accept Medicare.
From then on, if you wanted to see Dr. Rubin, you paid cash.

That was frightening to me, said Mr. Daniel, a 72-year-old retired
insurance salesman who lives in Hollywood. Reluctantly, he changed doctors.
But, he said, his new doctor's waiting room was always crowded and the doctor
seemed pressed for time. I had to get out my symptoms in about 20 seconds or
he would start interrupting me, Mr. Daniel said. Then I would have to wait
while he saw more patients and then got back to me.

Now Mr. Daniel has returned to Dr. Rubin, one of a growing number of doctors
who have severed their ties to health maintenance organizations and insurance
companies. In return for cash payments, the doctors often offer a lavish
level of service -- uncrowded waiting rooms, long, uninterrupted office
visits, and an office staff that knows the patients.

You always get what you pay for, Dr. Rubin said.

Several years after President Clinton's failed effort to remake health care
in America, the health care market is remaking itself. For those with
insurance or the money to pay for health care, there is evolving a two-tiered
system. One tier is made up of doctors who have cut their prices at the
insistence of health insurers and who make up for the reduced prices by
increasing their volume, seeing more patients per hour. The other tier is
made up of those like Dr. Rubin who offer time and attention -- but at a
cost.

While there are no national figures on how many doctors are joining the new
tier, health care experts agreed that all of a sudden, doctors who never
before dared to abandon health insurance plans were taking the plunge.

They are a different breed from the growing ranks of doctors who are focusing
their practices on cosmetic procedures, like laser eye surgery or
liposuction, that patients pay for out of their own pockets. Instead, these
are doctors like family practitioners and internists who provide basic
medical care as well as specialists, like general surgeons,
gastroenterologists, psychiatrists and psychologists, and cardiologists, who
take care of serious medical problems. These renegade doctors tend to be in
urban areas, where managed care has made the greatest inroads, the doctors
said.

Patients of these doctors can submit the doctors' bills to their insurance
companies, but it is the patient, not the doctor, who must accept whatever
the insurer provides. Some of these doctors accept Medicare payments or
payments from a few other select insurance plans. Others, like Dr. Rubin, do
not. Some doctors are asking patients to give them yearly retainers of
thousands of dollars.

The market is reasserting itself, said Dr. Alan Garber, an economist and
specialist in internal medicine at Stanford University. In characteristic
fashion in America, markets have emerged where they didn't exist.

Health policy experts say there is no proof that patients who see doctors
like Dr. Rubin are buying better health -- although they are buying more of a
doctor's time and attention.

People are buying what to them is very valuable, said Victor R. Fuchs, an
emeritus professor of health economics at Stanford. They are getting instant
attention, instant service. You call the doctor's office and one person is on
the phone and he knows you. Suppose you have a medical test. In some
situations you have to wait a week for the results. Here, it can be two
hours.

What some experts don't realize is that a huge amount of the dissatisfaction
with medical care has to do with the level of service.

Doctors and health policy experts differ on whether the trend is to be
lauded, accepted or deplored. But they agree that it was inevitable, a
consequence of peoples' growing irritation with impersonal medical care by
rushed doctors and a booming economy that allows many people to pay for the
service they want. Dr. Thomas Reardon, a general practitioner who is
president of the American Medical Association, said that his organization had
no policy on the trend, but that he understood why it was occurring.

What the doctors are saying is, 'We're tired of managed care, we're tired of
Medicare, we're tired of the hassle,' Dr. Reardon said. Patients are
equally peeved by much of medical care today, he added.

But some worry about a loss of fundamental equity and justice, that the
affluent are insulating themselves.

We are in an incredibly entrepreneurial climate in medicine, and I think
this kind of tiering undercuts people's thinking about collective solutions
to the health care problems, said Norman Daniels, a professor of philosophy
at Tufts University who specializes in ethics and health care..

Others worry about the effects on patients when their doctors suddenly
announce that they will not accept the patients' insurance.

It is a burden, said Dr. Bernard Katz, a family practitioner who sees
H.M.O. patients and is co-chief executive of SMBP Health Services, a company
in Santa Monica, Calif., that manages doctors like himself.

Dr. Michael Lockshin, a rheumatologist at the Hospital for Special Surgery in
New York, said that in his hospital it is becoming almost impossible to find
surgeons who will accept H.M.O. insurance.

They basically thumb their noses at the H.M.O.'s, Dr. Lockshin said, adding
that he often cannot refer patients to the best surgeons.

I have to deal with patients on a daily basis and it sometimes makes me want
to tear my hair out.

The same thing is happening in west Los Angeles as more and more specialists
refuse payments from H.M.O.'s and most insurance companies, said Dr. Richard
L. Taw Jr., a cardiologist in Santa Monica. Dr. Taw himself has stopped
accepting most insurance payments, but his patients stuck with him. Nobody
left me, not one patient, he said. The economy is so good now that people
want to go to doctors that don't treat them like a number.

Not too long ago it was excruciatingly difficult for an independent doctor to
thrive. One who tried, Dr. Thomas W. LaGrelius, a general practitioner in
Torrance, Calif., said he spent years watching helplessly as his patients
bailed out of his practice, refusing to go to a doctor whose fees were not
covered by their insurance. Dr. LaGrelius had decided as long ago as 1980
that he wanted no part of H.M.O's.

When his partners decided to stay with an H.M.O., Dr. LaGrelius quit the
group and began practicing by himself, but for years he had trouble finding
patients.

Now, Dr. LaGrelius said, the climate has changed and patients seek him out.
He is head of an organization of independent doctors in his area, called
Indoc, which has 104 members and gets inquiries from all over the country.

Some doctors, who once belonged to every H.M.O. in sight, said they recently
decided to drop those contracts. When H.M.O.'s came to the New York area in
the 1990's, doctors like Andrew Weiland, an orthopedic hand and plastic
surgeon at the Hospital for Special Surgery, were afraid that if they did not
join they would have no patients. Everyone jumped on the bandwagon and
joined as many as they could for fear of being left off when the train left
the station, Dr. Weiland said. But, he added: You can only run so fast and
see so many patients and not run an assembly line.

And so Dr. Weiland started to drop his H.M.O. contracts over about three
years. He said he has had no trouble finding patients. Patients sort of
think that if you're out of the plans, you must be good enough to drop out of
the plans, he said.

The independent doctors say they see fewer patients and offer them better
services. The doctors are easy to reach, patients are not kept on hold, and
no one has to wait weeks for an appointment.

Artical had to be cut short, list server limits 176 lines. Jake C.P.