Who Owns The Patient Anyway?

Dr. Don Shuwarger, a Houston obstetrician, used to work six days a week, seeing about 40 patients a day. But on Jan. 1 he lost 2,100 of his 3,000 regular patients when their employers, seven aerospace companies, joined managed-care networks. When he tried to follow most of his patients into the five plans, he was told they had enough obstetricians and did not need him. Of course, his former patients can continue seeing him if they pay higher deductibles, but very few are doing so. "It's almost enough to make a guy paranoid," he says. "The impression in the patients' minds is, 'Nobody wants him. What's wrong with him?' " So these days Dr. Shuwarger is having trouble ; making ends meet: he is living on his savings and may close down his practice. And then? He's thinking of looking for a job as a staff physician in a managed-care plan. If it will have him.

Just a few years ago, doctors like Shuwarger fought managed care mainly by ignoring its steady advance across the country. But now that 7 out of 10 insured patients are enrolled in managed-care plans, these independent practitioners have pulled a classic if-you-can't-fight -them-join-them maneuver -- only this one is turning fierce.

Faced with the prospect of being put out of business, old-fashioned fee-for- service doctors have mounted a campaign to secure their way into managed care and gain some control over it. In Texas, with support from the Texas Medical Association, doctors who were let into Aetna and Prudential managed- care networks and then dropped are suing them, arguing that they are being denied their "right" to serve their patients. In Virginia, doctors are suing a plan that fired them, citing an 11-year-old law called "any willing provider" that guarantees them the opportunity to continue serving their patients even after those patients join managed-care plans. In Massachusetts, doctors who have been accepted into a Blue Cross HMO are chafing under its rules: they are suing the Cambridge-headquartered network for cutting corners on care and endangering patients.

At the same time, through an intense lobbying campaign, the American Medical Association has succeeded in inserting into every health-reform bill produced so far provisions that would require plans to carefully consider applications from fee-for-service doctors like Shuwarger, would make it harder to fire them after they are admitted, and would give them a say in the way the plans are run. "It's really ironic," says Senator Bob Packwood. "For years the A.M.A. and the other medical societies would not even let HMO doctors join them. Now they are fighting to get into HMOs."