trenches

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Chapter 9

To the Trenches

San Diego is a conservative town with a history of slow change. In the early 1980s, when the managed care companies first displayed their might in the city, most physicians failed to understand the situation. That would be the case of Dr. Innocent, a well-trained and well-respected physician who had steady sources of referral, a large number of patients, and a total devotion to her practice.

In the early 1980s the defense industry still was very powerful in San Diego, and employed thousands of people. It was a natural target for the managed care companies, especially those who came in with their own clinics, their own plans for control of medical care, and their characteristic lack of respect for the community or the physicians.

Dr. Innocent had read about the new power of the insurance companies, the emergence of large HMOs, and the HMO view of San Diego as an ideal target. San Diego was an "easy" market because of the relative power of a few employers, its clear boundaries (Camp Pendleton to the North, the Mojave desert to the East, the ocean to the West, and Mexico to the South), its desirability as a place to live (recalcitrant physicians were deemed easy to replace), and the presumed tame nature of the medical community.

Dr. Innocent assumed that the managed care invasion would not affect her patients (well-established and well-educated individuals) or her practice (she had more referrals than she could handle).

Several dozen letters received in two consecutive days in 1983 each brought Dr. Innocent to reality: a managed care company had signed a contract with several employers, had established a clinic with its own physicians, and was requesting Dr. Innocent's records on patients who were transferred to the clinic, overnight and without their consent.

Dr. Innocent talked to her patients (several occupied positions that gave them influence at work), managed to retain most of them, but also knew that her sources of referral had been eliminated by the invading forces.

Events in the following days shook Dr. Innocent's faith in some of her long-term relationships. A lady with schizophrenia suffered an exacerbation of her psychosis. Dr. Innocent referred her to the hospital where she had treated the patient in the past. When Dr. Innocent called to give orders, she was informed that the patient would be seen by a physician assigned by the insurance company. The lady's husband had agreed to this when he was informed of the discounts available to patients treated according to the insurer's protocol.

Soon Dr. Innocent was being invited to sign contracts that would permit her to see patients referred by the insurer. Perusal of the contracts led Dr. Innocent to realize that, should she sign the contracts, she would become a discounted, intensely supervised and belittled line worker for the insurance industry.

The contracts had plenty of warnings about problems to come: uncertainty as to who would make the diagnoses, who would decide on the treatment, which treatments the physician could use, and even whether she would be paid at all (see chapter on "classic" managed care). She was even informed that she was not to talk to the patient about her own ideas.

Dr. Innocent, then in her early forties, with a heavy mortgage on her home, two children in college and no money in the bank, spent many hours thinking about her options. An early retirement, which appeared very desirable, was financially impossible. A surrender to the insurance companies was unthinkable. Keeping the office open without fighting against the invasion was not possible as a long-term strategy.

The hours of doubt and anxiety while evaluating the situation led to anger and determination. Dr. Innocent, who had been a pleasant, quiet, self-effacing clinician, became a militant.

Dr. Innocent decided to join other physicians, her patients, their families, and those in the community who wanted to fight against the new impositions. She, like many others in medicine, decided that many years of her life could be well spent at the trenches.

One of Dr. Innocent's patients came to the same conclusion not long afterwards. Alexander Stoik was an English professor in San Diego at the time of the invasion. He had suffered severe bouts with depression for most of his adult life, had received numerous therapies given by a dozen professionals, had failed to respond to most, and now, after several years of treatment with Dr. Innocent, was almost free of symptoms, working well, and enjoying his life.

Mr. Stoik was surprised to receive notification by the new managed care company that he would be authorized to go to Dr. Innocent for "medication checks". Other treatments would be determined by a "provider" to be selected at a later day. Mr. Stoik decided to insist that his treatment by Dr. Innocent be respected.

Numerous appeals to his employer's "human resources" personnel, to the "benefits analyst", and to the managed care company itself increased Mr. Stoik's determination to be heard. He got in the habit of sending copies of the appeals and the appeals responses to his Board of Education, to his city councilman, to his assembly representative and to his state senator. He also wrote to the California Department of Corporations, then the regulator of the managed care companies.

The managed care company finally proposed that Mr. Stoik be interviewed by a consultant who would make recommendations to the company. Dr. Innocent could not find the consultant on the roster of the San Diego Medical or Psychiatric Society. He was not in the Directory of Board Specialists either.

Mr. Stoik spent two hours with the consultant. He described the interaction as "vigorous". The company has since not interfered with the treatment of Mr. Stoik by Dr. Innocent. Mr. Stoik remains enthusiastically militant about his rights.

The story of Dr. Innocent and Mr. Stoik has been repeated many times and in many places. The unsung martyrs of the struggle are the many patients hurt by managed care decisions. The unsung heroes are the patients and their relatives who rebelled. Many of them have been harnessed by court decisions that prevent them from talking in public about their battles, often won in the face of incredible odds. The insurance companies usually demand that the conditions of settlement be kept strictly confidential, so that the horrors that lead to high monetary awards become closely guarded secrets.

main | table | intro| 1 | 2 | 3| 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | *

©2000 Munoz and Eist, The People v. Managed Care


main \| table \| intro\| 1 \| 2 \| 3\| 4 \| 5 \| 6 \| 7 \| 8 \| 9 \| 10 \| 11 \| 12 \| 13 \| 14 \| 15 \| 16 \| 17 \| 18 \| *

	Chapter 9 To the Trenches

	San Diego is a conservative town with a history of slow change. In the early 1980s, when the managed care companies first displayed their might in the city, most physicians failed to understand the situation. That would be the case of Dr. Innocent, a well-trained and well-respected physician who had steady sources of referral, a large number of patients, and a total devotion to her practice.

	In the early 1980s the defense industry still was very powerful in San Diego, and employed thousands of people. It was a natural target for the managed care companies, especially those who came in with their own clinics, their own plans for control of medical care, and their characteristic lack of respect for the community or the physicians.

	Dr. Innocent had read about the new power of the insurance companies, the emergence of large HMOs, and the HMO view of San Diego as an ideal target. San Diego was an "easy" market because of the relative power of a few employers, its clear boundaries (Camp Pendleton to the North, the Mojave desert to the East, the ocean to the West, and Mexico to the South), its desirability as a place to live (recalcitrant physicians were deemed easy to replace), and the presumed tame nature of the medical community.

	Dr. Innocent assumed that the managed care invasion would not affect her patients (well-established and well-educated individuals) or her practice (she had more referrals than she could handle).

	Several dozen letters received in two consecutive days in 1983 each brought Dr. Innocent to reality: a managed care company had signed a contract with several employers, had established a clinic with its own physicians, and was requesting Dr. Innocent's records on patients who were transferred to the clinic, overnight and without their consent.

	Dr. Innocent talked to her patients (several occupied positions that gave them influence at work), managed to retain most of them, but also knew that her sources of referral had been eliminated by the invading forces.

	Events in the following days shook Dr. Innocent's faith in some of her long-term relationships. A lady with schizophrenia suffered an exacerbation of her psychosis. Dr. Innocent referred her to the hospital where she had treated the patient in the past. When Dr. Innocent called to give orders, she was informed that the patient would be seen by a physician assigned by the insurance company. The lady's husband had agreed to this when he was informed of the discounts available to patients treated according to the insurer's protocol.

	Soon Dr. Innocent was being invited to sign contracts that would permit her to see patients referred by the insurer. Perusal of the contracts led Dr. Innocent to realize that, should she sign the contracts, she would become a discounted, intensely supervised and belittled line worker for the insurance industry.

	The contracts had plenty of warnings about problems to come: uncertainty as to who would make the diagnoses, who would decide on the treatment, which treatments the physician could use, and even whether she would be paid at all (see chapter on "classic" managed care). She was even informed that she was not to talk to the patient about her own ideas.

	Dr. Innocent, then in her early forties, with a heavy mortgage on her home, two children in college and no money in the bank, spent many hours thinking about her options. An early retirement, which appeared very desirable, was financially impossible. A surrender to the insurance companies was unthinkable. Keeping the office open without fighting against the invasion was not possible as a long-term strategy.

	The hours of doubt and anxiety while evaluating the situation led to anger and determination. Dr. Innocent, who had been a pleasant, quiet, self-effacing clinician, became a militant.

	Dr. Innocent decided to join other physicians, her patients, their families, and those in the community who wanted to fight against the new impositions. She, like many others in medicine, decided that many years of her life could be well spent at the trenches.

	One of Dr. Innocent's patients came to the same conclusion not long afterwards. Alexander Stoik was an English professor in San Diego at the time of the invasion. He had suffered severe bouts with depression for most of his adult life, had received numerous therapies given by a dozen professionals, had failed to respond to most, and now, after several years of treatment with Dr. Innocent, was almost free of symptoms, working well, and enjoying his life.

	Mr. Stoik was surprised to receive notification by the new managed care company that he would be authorized to go to Dr. Innocent for "medication checks". Other treatments would be determined by a "provider" to be selected at a later day. Mr. Stoik decided to insist that his treatment by Dr. Innocent be respected.

	Numerous appeals to his employer's "human resources" personnel, to the "benefits analyst", and to the managed care company itself increased Mr. Stoik's determination to be heard. He got in the habit of sending copies of the appeals and the appeals responses to his Board of Education, to his city councilman, to his assembly representative and to his state senator. He also wrote to the California Department of Corporations, then the regulator of the managed care companies.

	The managed care company finally proposed that Mr. Stoik be interviewed by a consultant who would make recommendations to the company. Dr. Innocent could not find the consultant on the roster of the San Diego Medical or Psychiatric Society. He was not in the Directory of Board Specialists either.

	Mr. Stoik spent two hours with the consultant. He described the interaction as "vigorous". The company has since not interfered with the treatment of Mr. Stoik by Dr. Innocent. Mr. Stoik remains enthusiastically militant about his rights.

	The story of Dr. Innocent and Mr. Stoik has been repeated many times and in many places. The unsung martyrs of the struggle are the many patients hurt by managed care decisions. The unsung heroes are the patients and their relatives who rebelled. Many of them have been harnessed by court decisions that prevent them from talking in public about their battles, often won in the face of incredible odds. The insurance companies usually demand that the conditions of settlement be kept strictly confidential, so that the horrors that lead to high monetary awards become closely guarded secrets.