Doctors Lying Low Regarding Props. 214, 216

A group of doctors and their spouses gathered recently at a tastefully decorated home in Sherman Oaks to snack on cookies and punch and write campaign checks in support of Proposition 214, one of two health-care regulatory measures on Tuesday’s ballot.

The next morning, the dermatologist who hosted the gathering--and invited a reporter to attend--left a halting message on the reporter’s telephone answering machine.

“Please do not identify me by name,” the dermatologist asks. “There is still fear of retribution from HMOs . . . should they find out my involvement.”

At first glance, Propositions 214 and 216 would seem to be music to California doctors’ ears. They seek to address a host of thorny ethical and economic issues that are generating lots of angst among the state’s doctors these days.

Many doctors complain bitterly that HMO policies are interfering with doctors’ autonomy and creating a conflict between their own best interests and that of their patients. Among other things, the competing ballot measures would restrict so-called physician gag orders and ban certain financial incentives said to discourage medical treatment.

Yet, except for quietly writing checks, the state’s physicians by and large have been profoundly silent on the political front.

Indeed, the state’s major medical group, the 34,000-member California Medical Assn., is officially sitting on the sidelines. In August, the CMA’s board of directors--after a lengthy, contentious meeting--voted to take a neutral stance on Propositions 214 and 216.

(The only physicians’ group to take a stand--the California Academy of Family Physicians--came out Thursday against both measures. Family doctors have thrived under managed care, at the expense of specialists.)

CMA officials say that they oppose details “in the fine print” that impose taxes on hospitals, regulate physician group practices and protect union health-care jobs.

But the reasons for the doctors’ reticence are more complex. And they say a great deal about how the medical profession, like medicine itself, is changing.

With more than 60% of all Californians enrolled in HMOs, doctors are increasingly dependent on HMOs to deliver patients to their offices--and reluctant to cross them. Said the Sherman Oaks dermatologist: “There were actually physicians who were afraid to come to my house. . . . It is terrible to have to work in fear.”

Explains Jack Lewin, executive vice president of the CMA: “Other than a handful of doctors in Beverly Hills who take cash for plastic surgery, managed care is the total environment in California. There are no patients if you’re not in managed care.”

Moreover, many California doctors, especially younger ones, are generally supportive of managed care. Though not all doctors who work for these groups are enthusiastic about HMO policies, many believe that managed care has more strengths than weaknesses--especially the emphasis on preventive health, better information on doctor performance and less over-treatment.

“Doctors don’t know whether to bite the managed-care carrot or be fearful of the managed-care stick,” said Jamie Court of Consumers for Quality Care, a Santa Monica group that is backing Proposition 216.

So although doctors may bad-mouth HMO policies at cocktail parties or in the hospital doctors’ lounge, they often are loath to speak publicly.

The concerns of the Sherman Oaks dermatologist--that he might be disciplined by his doctor group for criticizing managed care--are not as unusual as they might sound. Indeed, some health plans have explicitly banned participating doctors from making negative comments about an HMO--one form of the so-called gag orders.

“People are afraid they will be fired or dropped from the health plans, or that they will no longer get patient referrals from the [medical group] if they speak out on the issue,” says Jennifer Reifel, 30, a chief resident of medicine at UCLA Medical Center who has been campaigning on behalf of Proposition 214.

In the spring, a doctor showed up at a Proposition 214 news conference in downtown Los Angeles wearing sunglasses and a black fedora. He feared that with TV news cameras at the event, colleagues might recognize him on the local news, Reifel said.

Ron Bronow, a West Los Angeles dermatologist who refuses to take HMO contracts, bemoans the fact that doctors seem largely apathetic about the ballot measures.

“Doctors have very little idea what these propositions are about, despite the fact this is their careers,” said Bronow, who is campaigning for Proposition 214. “These guys are convinced they better shut up and do what they’re told.”

Although reluctant to speak out, doctors have been willing to write checks. The Proposition 214 campaign, for example, estimates that individual doctors have contributed about $50,000, mostly in donations of $100 and $200.

Some see the CMA’s vote as more than a predictable thumbs-down to government regulation. To them, it signals the waning influence of the medical society itself as its membership changes and the organization struggles to redefine its role at a time when managed-care executives, not doctors, are calling many of the shots in medicine.

In California, the solo-practice doctor, once revered in medicine, is nearing extinction. Now the vast majority of doctors practice in ever-larger groups, some with several hundred physicians. And these groups are typically formed to give doctors a better crack at landing HMO contracts.

“Group practice is a rising influence, so it stands to reason that the attitudes, concerns and preferences of these doctors are more and more affecting [the CMA’s] legislative policy,” Lewin said.

Indeed, the medical society itself recently created a managed-care company that may seek state licensure to form its own HMO.

And some contend that the medical society’s policies are increasingly influenced by Kaiser Permanente, the state’s largest HMO, which has paid the membership fees for several hundred Kaiser doctors to join the CMA in recent years. The influx of Kaiser doctors has helped stabilize the CMA’s membership--and finances--after about a decade of declining membership.

But CMA officials insist the board’s neutral vote was in no way an act of submission to Kaiser or other managed-care interests.

Lewin notes that Kaiser doctors account for only about 2,000 of the CMA’s 34,000 members. And Kaiser has only two doctors on the CMA’s 48-member board. “I’d like to see all Kaiser doctors join the CMA,” Lewin said. “They are a great group of doctors.”

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