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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."
"My father and grandfather were both physicians in rural Wisconsin," he says later. "I went to engineering school a couple years first, but with a background like that, it's hard to avoid medicine. And it's a great line to be in; it's a great business." Yet for his dad and grandfather, it wasn't a business. "I'm sure my grandfather would have disliked managed care," Rathert admits freely. "He was his own person. And my dad practiced until he was 90; he'd see anybody that came in the door. On the other hand, they had (bill) collections of 50-60 percent. The benchmark for a good practice is above 90 percent."
Isn't something being lost in the switch to a punched-clock, cookbook-regulated system? "Medicine's much too complex now to be done that way," replies Rathert. "What is available is astounding, in terms of the ability to prevent, diagnose and treat disease. There is still a lot of caring, but there are also fabulous technologies, and it's necessary to manage all that more tightly. You can't continue losing money in a medical practice -- you don't stay in business."
Younger doctors know that better than their elders, he adds. "I identified myself by my job; I'd say, 'I am a pediatrician.' They are lifestyle-oriented. They want to have regular hours, time off, vacations with their families. My dad was on call 24 hours a day, seven days a week, and the phone would ring all hours of the day and night. That's not what people want."
Unfortunately, it's still what their patients want.
The Call of the Tame
The field of medical executives is rising fast: The American College of Physician Executives now has 13,600 members, more than double the 5,711 they had in 1990. "The group of wannabes is huge," sighs search consultant Lyons. "When health care was in its time of largesse, peaking 7 to 10 years ago, being CEO of a health-care system was like being Ike when he was president: You just had to be smart enough to not do anything stupid. Now, on the health-care-executive side, the adults are being separated from the children as we speak."
The move into management isn't all peaches and perks, though. "You lose collegiality with other physicians," says cardiologist Palank. "They see you as a suit, not a white coat. We have lived medicine all our lives as clinicians. There is an emptiness, a void." There's also a lot of maddeningly protracted committee work. "Seeing patients is terrific," sighs Palank. "Diagnosing and correcting a problem. Projects I'm in now may take a year to complete."
If Palank were suffering with chronic pain or disability, he might not bother adjusting. Now that they're mere mortals, physicians have begun claiming disability so freely their insurers have lost money on the payouts. "Physicians used to be like Marcus Welby, delivering a baby that morning and dying that afternoon and enjoying the profession right up to that minute," remarks James D. Johnson, spokesman for Provident Life and Accident Insurance Co., one of the disability biggies. "But with managed care and large group practices, physicians are feeling and acting much more like employees than professionals. Starting in the '80s, we saw an increase in their disability claims. They went from being the best risk to being average. Plus, they had policies to fall back on that became more windfall than safety net."