Despite intense hostility from some of their colleagues -- not to mention a large segment of the general patient population -- a significant number of physicians have become advocates for managed care.
In doing so, they have turned their backs on what many consider to be the essence of traditional doctoring. How -- amid the ongoing blitz of criticism against managed care -- do they maintain their enthusiasm?
Five physician leaders interviewed by Modern Physician provided answers to this question, answers that are strikingly similar despite the varied experiences of the respondents.
All said they were uncomfortable with the waste inherent in the old ways of practicing medicine and with the lack of a systematic approach to healing. In addition, three named a mentor or role model who had helped to shape his vision and had influenced his career.
Lee Newcomer, M.D., is medical director of United HealthCare Corp. in Minneapolis. Previously, when he practiced as a medical oncologist for 10 years, he says he grew increasingly frustrated at how much of a nonsystem the medical system was.
"There were 900 of us on (the hospital) staff," Newcomer says. "We never formally talked to one another about solving problems. We were just like independent tradesmen going into a factory. I never saw care getting systematically improved."
The turning point for Newcomer was enrollment in a managed-care oriented master's program in health administration at the University of Wisconsin. David Kindig, M.D. and director of the clinician program, was an inspiration for Newcomer and several of the other doctors who took his courses. Many have gone on to become medical directors at health plans.
The thrust of the program was very practical, Newcomer says. He and the other doctors had to take assignments back to their clinics and work with them. One example: The doctors simply analyzed what it costs to treat a patient, something they had never done before. Another assignment led to the discovery that they had different approaches to treating patients with stage-two breast cancer.
Newcomer says he realized they weren't "bad doctors," but that the organizations they worked for provided "absolutely zero incentives" to develop a systematic approach to treatment.
Insights like these propelled Newcomer, 45, into his new career. "There's a little of the '60s zealot in me," he says.
What attracted him specifically to United was the company's huge database. Among other uses, it can profile providers to see how they perform against established standards of treatment. In November United began profiling doctors in four cities on six procedures related to heart disease. "We found (the doctors) only got it right about half the time," Newcomer says.
For example, although it is clear that beta blockers and ace inhibitors help patients with certain heart problems, many doctors still weren't prescribing these medications, Newcomer says.
When given the results of the profiles, the doctors consistently replied, "Nobody ever gave me this information before. I had no idea I was doing this (wrong)."
The goal, he says, is to start doctors thinking about improving their performance but not to punish them when they're not up to speed. Doctors have told him, "This is what we hoped managed care would be about: getting information that would help us practice better medicine."
However, in general Newcomer says: "The backlash from physicians has been really severe. (Once at a physician party) they literally would not talk to me.
They literally walked away. . . . Even if what's going wrong is not your fault, you're the target."
Sam Ho, M.D., vice president of quality initiatives for Cypress, Calif.-based PacifiCare Health Systems, says he, too, was "a child of the '60s, when social change and correcting injustice and inequalities were major watchwords." Ho has been with PacifiCare since October 1994; he is responsible for quality programs for all of PacifiCare's 3.8 million enrollees.
Ho's role model was his father, a family physician in a poor urban neighborhood in Honolulu. When Ho was an undergraduate and later in medical school, he started two medical clinics for the underserved in Boston and Chicago. And when he began practicing as a family physician in 1976, he purposely located in the most severely underserved area in San Francisco, he says.
"Seeing all the inconsistencies and variability in American medicine made me that much more committed to making a difference in improving healthcare (for all people)," he says.
"I easily gravitated toward managed care because it represented a more systematic approach and affected much larger populations than I could in my own practice," he says.
In 1983, Ho introduced one of the first HMOs for Medi-Cal recipients, those in California's Medicaid program. "I learned that by developing entire systems of care -- which included expanded benefits, transportation systems, quality improvement, patient education and health promotion -- patients could get better care and better service under prepaid medicine than under fee-for-service," he says.
Ho's relatively small plan was acquired by a larger one and eventually by Maxicare of Northern California, an HMO with 72,000 enrollees, for which he served as medical director for a year. Through his varied experience, Ho was able to see that commercial and Medicare enrollees were also benefiting from systematic medicine.
"There's a total congruence between my personal philosophy and the organizational strategies of managed care," he says. "We're building a healthcare system that really helps doctors and patients achieve better health and service outcomes."
William C. Popik, M.D., medical director at Cigna HealthCare in Hartford, Conn., says he became convinced as a family doctor in Alameda, Calif., that "the healthcare system, in the best light, was very inefficient and, in the worst light, was potentially dangerous."
"For example, a patient would come in with abdominal pain that sounded like dyspepsia," Popik says. Typically, he would put the patient on medicine and later send him to a gastroenterologist. But what he wanted to do, he says, is have another doctor confirm a diagnosis he felt very confident about.
"Instead, the patient would come back having had numerous x-rays and invasive procedures that have potential consequences. And after spending all that money and putting the patient through all that risk, guess what the diagnosis was? Dyspepsia.
"I started to believe there were other ways to improve care while reducing costs," he says.
Popik's point of view kept him open to new healthcare possibilities. "I always considered myself to be more interested in people than in the diseases they had. I found myself asking, `How is this going to benefit the patient?' " That line of thinking was diametrically opposed to the prevailing belief that more procedures equal better quality care.
Popik took a job as medical director of a small HMO in Oakland, Calif., which led to a job with healthcare giant Cigna, managing and encouraging doctors to think in new ways.
"I'm now in the great position of helping to hire 100 medical directors," Popik says. As overall medical director, Popik urges Cigna medical directors across the country to "manage for quality," which means, to him, doing the right procedure in the right setting the first time and "taking it very personally."
Paul Lairson, M.D., is acting chief medical officer at Prudential Healthcare, Western Division, which has 744,000 enrollees. Before moving to Prudential five years ago, Lairson spent 25 years at Kaiser Permanente.
When he first started practicing medicine as a general internist in 1966, he was disillusioned by what he saw. "It shocked me how many resources were wasted in medicine," Lairson says. "In county hospitals, patients were turning moldy before we discharged them. There was no concept of why we should order a test or not. The more you did the more money you made."
A few years later, when he interviewed with Kaiser Permanente in Oregon for an internist position, he says: "It was for me like coming home. The people I talked to had a clear concept of using resources wisely, of having a responsibility to use the membership's money well."
Early in his career, Lairson was also involved at Kaiser's Center for Health Research in Portland, which does clinical and health systems research. "We were looking into why people sought care the way they did, he says, looking into quality assurance and the development of a unit medical record, in lieu of a record being kept in a doctor's bottom drawer. All of those elements of "systematic medicine" appealed to him, he says.
Although Lairson is officially retired now and doesn't have to work, he stays at Prudential, he says, because the company "puts a value on quality and gives doctors an important role."
He believes that doctors who recognize the perverse economic incentives of the fee-for-service system will gravitate toward managed care. Many doctors also recognize that managed-care plans assist them in practicing better medicine, by "watching over their shoulders" and encouraging them to consider whole populations and not just individual patients.
If doctors can be comfortable with that role and not need to be grand authorities, they will accept managed care, Lairson says.
Dan Fishbein, M.D., 36, president of NYLCare Health Plans of Maine, followed a path to managed care that is unlike that of others interviewed for this article. Fishbein was doing a clinical rotation at Boston University School of Medicine when he decided that, though he wanted to be involved in healthcare, he did not want to be a clinician. Instead, he chose to work with a mentor to set up and run managed-care systems.
"I was fortunate enough to hook up with Dr. Richard Egdahl, vice president of BU's Medical Center," Fishbein says. Egdahl was also director of the BU Health Policy Institute at that time. "He was really one of the pioneers in developing managed care for private industry," Fishbein says. He had worked on early projects in the 1970s for Caterpillar, developing one of the first managed-care products for a large employer.
After graduating from medical school in 1985, Fishbein went to Massachusetts Mutual Life Insurance Co. in Springfield, Mass., whose health operations were later acquired by Wellpoint Health Networks. Fishbein was part of the first round of people they hired to develop networks and products, he says.
He joined New York Life in 1990, where he was responsible for managed-care network and product development. When the insurer created NYLCare for its managed-care products, Fishbein asked for the job of developing its New England region, which has 95,000 enrollees.
Currently, he holds simultaneous positions with NYLCare -- developing the Northeast region, which is headquartered in Portland, Maine, and heading the company's Maine division. HMO activity so far is focused in Maine; the remainder is PPO and indemnity business.
"I wanted the opportunity to run a health plan . . . being responsible for everything within a defined region. It's a great experience," Fishbein says.
Since he first came to Maine, he has seen HMO penetration "probably double" to about 30%.
Fishbein says that as a physician leader he doesn't encounter the kind of hostility to managed care the media says is prevalent. "The reality is nowhere near as extreme. There certainly is a backlash, but the vast majority of interactions (with physicians) are not negative and are generally positive," he says.
He doesn't think the criticism of the system will ever go away, however.
"Healthcare will always be controversial," he says. He also believes that in 10 years healthcare will look different in ways no one can predict today. "I definitely see managed care evolving, and much more towards provider partnerships and emphasizing more and more the interest of the member," he says.
Louise Kertesz is the Los Angeles bureau chief for Modern Healthcare, sister publication of Modern Physician.