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No doctor in the house?

Bankruptcies, strikes, discontent unraveling SLO health care

BY DANIEL BLACKBURN

Each weekday morning as the sun is rising, Vicky Weiss and her teacher husband make the 50-minute daily commute from their North County home to King City, where she happily toils at Mee Memorial Hospital.

In doing so, Weiss joins a daily convoy of nurses who climb into cars or carpool vans, departing homes in San Luis Obispo County and heading for jobs in neighboring counties. They are the quiet personification of a burgeoning talent drain that threatens an already severely compromised state of medical care in this county.

And as if things aren't bad enough already in the world of health care in SLO County, Mee Memorial – as well as hospitals across the nation – woos the ranks of local doctors, nurses and medical technicians with vigorous, well-financed recruiting programs, offering suitcases filled with attractive incentives.

"I feel very appreciated by my employers. They know you as an individual, not just someone they call when they need help," said Weiss.

Her feelings are not isolated. Eighty percent of the King City hospital facility's nursing staff commute from SLO County domiciles. Some drive from as far away as Nipomo and Arroyo Grande, a daily 200-mile round trip.

Contrast these expressions of satisfaction to the insistent tattoo of complaints from medical professionals of all stripes employed by, or utilizing, area institutions:

– Doctors, as well as nurses, are leaving the county in swelling numbers, like energized lemmings searching for a nearby cliff. SLO County currently has fewer than half the physicians it should, according to average standards established by the American Medical Association, and is dramatically bereft in certain critical specialties;

– Primary care physicians are turning away new patients, unable to keep up with a red ink flood created by clinic and hospital bankruptcies and closures;

– Nurses at Sierra Vista Regional Medical Center, upset by stagnant wages, shrunken staffs and back-breaking work loads, have struck twice in recent weeks, been locked out by management, and remain knotted in an intense labor battle with Tenet Healthcare Corp. management;

– County-funded hospitals and clinics are shuttering their doors, strapped by overwhelming costs, foot-dragging HMOs and insurance carriers, and snail-slow pay practices by subsidizing state and federal health coverage programs;

– Specialists such as orthopedic surgeons and pediatricians say they are catapulting toward fiscal insolvency, forced to care for indigents who cannot pay anything for services or whose bills are not adequately covered by private or public supplements. Many threaten to quit seeing Medicare patients;

– Recruitment efforts by SLO County physician practices, clinics and hospitals are falling woefully short of targets, because lower-than-average remuneration is enormously complicated by higher-than-average housing and other living costs. During the past five years, housing costs in most parts of San Luis Obispo County have more than doubled. More than a quarter of all county physicians have left private practice during the past year.

All this is happening as the county grows gray, its population aging by the day, and an ever-greater need for medical care multiplies.

"We are not echoing something that is endemic all over the state. We have a peculiar situation here in this county that is really out of control," said Jo Ann Rogers, a staff ICU nurse at beleaguered Sierra Vista who serves on the nurses' negotiating team currently in discussions with Tenet management.

That "peculiar situation" is one stoked by a variety of factors, not the least of which is money, affecting nurses and doctors alike.

"When the profit motive gets in the way, and the bean counters are involved," said Rogers, "nurses are unable to deliver the kind of care they would like to. That's hugely bad for morale. Nurses didn't get into the business to get rich. They did it because they genuinely like taking care of people."

Rogers said negotiating with Tenet representatives has been difficult.

"Our local administrators are not trying to do anything (positive), even though they are the ones who ultimately have the decision-making power locally," said Rogers. "But we have had six administrators in the past seven years, and as a result they have no ties to the community. No administrators working here today were here two years ago when the last nurses' strike occurred. That may be a corporate strategy, done intentionally so that administrators don't stay long enough to develop local ties."

Dr. Larry Herron, an orthopedic surgeon who is part of the Central Coast Orthopedic Group in San Luis Obispo, agreed that nurses are paid "very poorly" in this county.

"When I left UCLA 20 years ago, nurses there were making what nurses here are making today. It's pathetic," he said.

The current downward spiral in health care is a relatively new phenomenon in this county. Just a few short years ago, San Luis Obispo County, with beehive-active medical facilities dotting the landscape, was an up-and-coming health care Mecca trumpeted from one end of the state to the other. Since then, however, it's been a fast downhill ride.

And it's not just nurses who are finding fault with the status quo. Physicians, distressed by slow, low, and no-pay from Medi-Cal, Medicare, and private insurers, are leaving private practices by the droves, seeking the relative simplicity of institutionalized jobs at Atascadero State Hospital, California Men's Colony and other tax-supported facilities in the county. At the same time, huge patient rolls are being abandoned, and people in need of and searching for replacement medical care are finding none.

Orthopedist Herron, who sits on the board of the California Orthopedic Association, sketched the difficulty of finding new physicians.

"We have been looking for another orthopedic surgeon for a couple of years now," he said of his group. "We have interviewed several good prospects, and their wives love the area. Then they start looking around to see what kind of house they can afford given the current (Medicare) reimbursement rates, and we never hear from them again."

And with most insurance companies tying payment schedules to Medicare rates, "it's a double whammy," said Herron.

Many health care providers in the county who are holding firm have been practicing, and have been residents of the county, for many years. Most physicians currently practicing in the county have been doing it for 20 or 30 years. They are simply biding their time until retirement, and no one looms on the horizon to replace them.

But to be sure, the overall malaise in medicine is not limited to San Luis Obispo County.

EFFICIENCY PENALTY

Ironically, it was California's one-time ability to keep hospital costs corralled that sowed the seeds of today's tangled medical circumstances in San Luis Obispo County.

Two decades ago, when the federal government established reimbursement rate schedules for Medicare, this state boasted a relatively solvent medical community. Hospital stays in California averaged nine days, against a national average of 17 days.

As a result, California found itself well down on the list of payout priorities, and in true government fashion, that list might as well have been set in concrete. This state now ranks 47th in the level of supplemental federal payments for medical care assistance.

Compounding this ongoing debacle is an anticipated 5.4 percent reduction in Medicare fees, which likely will take effect this year. The proposed federal funding cutback flies in the face of pleas from the California Medical Association (CMA) to increase Medi-Cal funding.

This hoped-for increase is necessary, says CMA President Dr. Frank Staggers, "to improve health care access for the state's most vulnerable and neediest patients, including children, the disabled, and the elderly in nursing homes."

Four weeks ago, Gov. Gray Davis said the state planned to increase Medi-Cal reimbursement payments by 30 percent, and to pay $175 million for assistance to state medical facilities.

Physicians all over California lose money by treating patients subsidized by federal and state payments, said the CMA's Staggers.

But patients also suffer under the current situation, he added. More than 40 percent of the state's children, for example, are not fully immunized against childhood disease.

Last year, hundreds of physicians marched on the state capital to illustrate their complaints, including:

– a steadily deteriorating emergency care system which has lost 12 percent of emergency rooms statewide since 1990;

– diminishing access to medical care for patients, and longer waits for appointments; and

– a continuing exodus of physicians for greener pastures.

A recent statewide physician poll conducted by the CMA suggested that half of California's entire inventory of doctors plan to leave within three years.

Contributing to the inherent health care quandary facing San Luis Obispo may be the county's unique location – squarely in the middle of two major metropolitan areas, Los Angeles and San Francisco.

Herron said one easy solution to the local problem is for Medicare "to start paying San Francisco or Los Angeles rates. The surgery we do here is just as difficult as it is in Los Angeles."

One Medicare rate consistent throughout the nation would make sense, he said. "If someone breaks their hip in Los Angeles there's no reason it should cost twice as much as it does here. The government calls this a "rural" area. It's not. Things are upside down and backwards."

"We're too close to the sun," said Dr. Rene Bravo metaphorically, "and the sun gets all the attention."

Bravo, a politically active county pediatrician, contends that the biggest overall complicating factor in modern health care is "the middleman."

"The crisis in medical care isn't that people are dying in the streets, and it isn't that people are falling off the edge of the safety net – yet," said Bravo. "But there is a financing crisis, which is driving everything in the wrong direction."

Metamorphosis of the problem was gradual.

"A hundred years ago," said Bravo, "there were doctors, and there were sick people. So what exists today that didn't then? Well, we didn't have Blue Cross, Blue Shield, Health Net, LifeGuard. The 'middle man' is the corporate, economic dynasty of health care – the financiers, and they really only evolved during the last century.

"We have to find a way to deal with that entity that comes between the patients and the physicians. As it stands, instead of focusing on reforming the health care system, we are more concerned with shoring up the safety net."

Concerns about the "safety net" have sufficient merit. Last month, Mission Medical Associates of the Central Coast, the county's largest physicians' group clinic with 30 partners and 55,000 patients, filed for Chapter 11 bankruptcy protection after running up unpaid tabs with virtually every other doctor in the county.

Mission Medical has been around since 1941, beginning its tenure as San Luis Medical Clinic until it was purchased by the Tenet Corp. in 1996. Four years later, the clinic was purchased by the physicians' coalition.

Today, the clinic has not paid its contracted physicians for six months, and officials of the group have said no further payments will be made for another 90 days. Mission Medical, sadly, has plenty of company. Over the past two years, 347 physician groups in California have filed for bankruptcy protection.

Complicating the local medical picture is county supervisors' recent decision to finally close San Luis Obispo General Hospital, which has been integral to the local health care scene since 1879. If this should proceed as planned, hundreds more patients, most of whom can't pay medical bills, will be cast adrift.

LOOKING FOR ANSWERS

So who is the villain in this pending health care crisis? Who pays when the patient can't – or won't? There's actually plenty of blame to go around, but generally speaking, the culprit is simply more hands in the shrinking money pool.

In some instances, it is a matter of poor management on the part of individual physicians. After all, medicine is a business like any other enterprise, and if a doctor is unable to adequately handle business affairs, that doctor likely will endure some degree of financial failure. The fact that some doctors in this county are doing well financially is evidence that effective professional management plays a key role in the success or failure of a physician.

Sloth-like payments from insurance companies, however, often arbitrarily reduced in amount, cause grief for physician and patient alike. But insurance companies and health management organizations (HMOs) are in business to make a profit, and to stay viable. Despite a reputation to the contrary, these entities play only a contributing role in the broad scenario.

The reasons for the problem seem myriad and complex. But it's really all about money.

Nurses at Sierra Vista, who walked out for a second time this month on Monday and are not expected to be on duty until today, claim to have encountered an intractable opponent in Tenet.

At least with Tenet, money to pay the bills is not a major problem. Three months ago, the corporation reported its strongest quarterly earnings ever, and boosted its fiscal 2002 outlook.

Tenet's second-quarter operating profit rose 47 percent, attributed largely to increased patient load and higher prices.

Tenet owns both Sierra Vista, in San Luis Obispo, and Twin Cities Community Hospital, in Templeton, employing more than 1,200 people locally. Overall, the company owns and operates 116 hospitals in 17 states, making it one of the nation's largest hospital management enterprises.

The company has been described as tough-minded, with an analytical approach to business that mirrors changes in the health care system nationwide. Its practices have helped generate double-digit expansion in health care costs for employers. Those costs more often than not are simply passed on to the employee.

Many doctors today dream of the way it once was.

"The complexity of the health care culture is partly to blame," said pediatrician Bravo. "Life used to be simpler. Once, when people couldn't pay for medical services, they might barter with a doctor ... pay in chickens, as it were. But I can tell you that most of us went into medicine thinking that we would be battling sickness and death – not these insurance companies. The fear is that the situation is driving the best and the brightest out of medicine."

The government has shown that it doesn't want to be in the medical business, said Bravo.

"So what happens when you have a county that doesn't want to be in the health care business but is mandated by law to do it?" he asked. "That has precipitated all this current situation – we have had a fundamental shift in attitude at the government level."

Raye Burkhardt, nursing administrator at Mee Memorial in King City, thinks that treating people fairly is key to hiring and keeping good people. Mee, she said, is a not-for-profit institution with a "positive bottom line."

As a result, she said, "We are sitting a lot better than most facilities."

Burkhardt, who also lives in San Luis Obispo County, readily agrees that part of the overall medical problem lies with state and federal subsidies. These diminish, while at the same time "we are being asked to do more and more."

Mee Memorial, in an effort to attract nurses from surrounding areas, is advertising widely and offering a bag full of incentives in an effort to fill out nursing ranks by an additional 20 percent.

"We offer a sign-on bonus, travel expenses, relocation packages, tuition for advanced studies, loan repayment plans. We are also recruiting at the graduate level, something we haven't normally done," said Burkhardt.

But despite the current situation, there remains some optimism among the San Luis Obispo County medical fraternity.

"The thing we know for sure is that people will always get ill, and there always will be people who want to care for them," said Bravo. "That's human nature. Good people will still be drawn to medicine. In the meantime, we need to make sure the medical system doesn't crumble."

Eventually, said orthopedist Herron, the government probably will take a more proactive role.

"We will have a crisis, though," he said. "People will be dying needlessly. And you know politics. There is no reaction unless there is a crisis."

But Herron, too, hopes for the best.

"Because," he noted, "all of this ought to be about what's best for the patient.

Freelancer Daniel Blackburn can be reached for comments through the editor at [email protected].




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