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Once a physician, now merely a "provider'

I was a physician for more than 20 years. Now I am a provider. "Provider" is the term used by health maintenance organizations to refer to physicians and other health care professionals. They attempt to suppress the very word "physician," and for good reason: It has connotations of expertise, authority and respect, which are incompatible with the managed care agenda.

Being a provider is a limited and discouraging job. There is, for example, the problem of prescribing medications. I treat many patients for hypertension, high cholesterol, heart disease and diabetes. Some of these patients are on complicated regimens of multiple drugs that have been carefully adjusted over months or years. I am now expected to discontinue many of these medicines and substitute others that happen to be on the drug formularies of the health maintenance organizations. These formularies are selected largely on the basis of which drug of a particular class the HMO can obtain most cheaply.

This means, for example, that a patient whose high blood pressure is well controlled on a medication that is well tolerated is to be arbitrarily switched to a formulary drug. The patient will therefore be exposed to the small but real risk of an adverse reaction to the new medicine. He will be exposed to this risk for no possible benefit, in violation of the most basic principles of therapeutics. If it is tolerated, the new medication may or may not be effective. If it does work, the patient will need one or several extra office visits, wasting his time and my own, to adjust the dose and re-establish blood pressure control. He will then be back where he started.

However, HMOs negotiate with pharmaceutical companies continuously; if the patient's health plan obtains a better deal on yet another drug next year, the whole process will need to be repeated _ all for no purpose other than to minimize the expenses of the insurance company.

The provider faces many other frustrations. There is relentless pressure to discharge patients from the hospital whether or not they are ready. It is sometimes difficult or impossible to refer patients to the appropriate specialist. A good deal of time is wasted debating medical care with representatives of managed care companies. These individuals generally have no medical training, and their primary concern is not the patient but the financial well-being of their company.

I have noticed something about these "managers": They all want a piece of my authority, but they want no part of my responsibility. If I cut corners in an attempt to satisfy them, and the patient suffers as a result, it is the patient's problem and my own.

Good medical care is threatened not only by the above constraints but by the capitated system of reimbursement. Under this system, the physician is paid a small monthly stipend for each patient assigned to him, regardless of what, if any, services he provides to that individual. In my community, this typically amounts to $12 or $13 paid monthly to the primary physician of a middle-aged patient.

Capitation not only fails to reward quality care but effectively penalizes it. Quality takes time, and the doctor who devotes time to his managed care patients will suffer for it financially. The physician whose reputation is such that sicker patients are attracted or referred to him is in particular trouble. There is a problem with a system that makes the sick patient a financial threat to his own doctor.

The provider's final problem, then, is simply making a living. I have a busy and previously successful internal medicine practice. An hour of my time is now worth approximately 60 percent of its value several years ago. I work more than 60 hours a week. My current personal income, after office expenses, works out to less than $35 per hour. I know many internists who are doing no better. I find myself very discouraged and sometimes rather angry. Every physician I know feels the same way.

It is the apparent intent of those who drive managed care that medicine be reduced to a commodity, and a cheap commodity at that, to be bought, sold and manipulated solely for the financial benefit of their industry. In the San Francisco Bay area, these goals have already largely been achieved. I believe this portends very serious problems ahead, not only for the profession but for the future of patient care and the well-being of the population at large.

Richard G. Williams practices internal medicine in the San Francisco Bay area.

Special to the Washington Post