Angry Poodle
Thursday, July 9, 2009
FOG OR PHAWG? The doctor I saw a few years back about my sleep problem was a scary guy in that gregarious, friendly way really scary people are. After a few tests, he managed to figure out what my trouble was. Because of interruptions in my air flow, I was waking up about 55 times an hour. That’s enough to rearrange the furniture of anybody’s “sleep architecture.” Less clear, as usual, was what to do about it. I left less than enthralled by the prospect of my new trial-and-error future. Almost as disturbing was the perverse delight my sleep doc took in being proven right about his prognostications about something else — the future of healthcare in Santa Barbara. That future was decidedly grim, something he’d predicted — in writing — as long ago as 1986. Those wealthy enough not to need medical insurance would enjoy the solicitous ministrations of doctors who’ve embraced the expanding practice of boutique medicine. Those of us unfortunate enough to still need insurance will find ourselves waiting longer and longer for the opportunity to wait even more in the waiting rooms of our increasingly overworked physicians. And as for the doctors themselves, Dr. Sleep Tight told me, they’re not getting any younger. As the older ones retire — and, he said, they just can’t wait — younger ones won’t replenish their ranks; Santa Barbara’s too damn expensive. In short order, he chortled, Santa Barbara will have the classic two-tiered medical system that defines developing countries: one for the haves, another for the have-nots. He predicted it all, and now it was coming true.
Angry Poodle
That was then; this is now, and the Santa Barbara medical establishment seems intent on making sure this future doesn’t come true. Proposals currently on the table are startling enough in their own right. Under discussion is some sort of mega merger/fusion/consolidation between Sansum Medical Clinic and Cottage Health System. The term used is “realignment.” For the South Coast, these are the King Kong and Godzilla of the medical world, the two signature institutions that truly define healthcare. If these two can’t make it on their own, I don’t want to know what’s out there. While the impatient patient in me might have cause to grumble about either place, my inner sentimentalist is freaking out. Sansum was founded in 1921, a genuinely ahead-of-the-curve experiment in delivering healthcare to the public. Cottage has been here since 1888.
Cottage CEO Ron Werft and Sansum exec Kurt Ransohoff have both assured me there’s no cause for alarm. No deal has been done, everything’s still in the talking phase, and there’s no immediate big, hairy crisis propelling things. Instead, both insisted, they’re exploring ways to make Santa Barbara’s healthcare system even greater than it already is. Naturally, such talk calls to mind people who don’t go to the shrink because they’re depressed, but instead because they haven’t fully maxed out their capacity for bliss. You know the type. The fact is that Sansum has experienced its fair share of financial turbulence during the past few years. And the potentially competitive health giant Kaiser — which provides a unified system of clinics, hospitals, and health insurance — recently has established a beachhead in Ventura. In addition, as both Kurt and Ron will tell you, Santa Barbara is having a tough time recruiting and retaining doctors, especially the frontline, in-the-trenches primary care physicians. In years past, these doctors would have been known as general practitioners; given the realities of managed care, many are now referred to as “gatekeepers.” Either way, Santa Barbara currently has about 10 primary care physicians fewer than it should. According to a recent survey, we’ll be 20 short next year. Part of the problem is that medical schools just aren’t cranking out these docs anymore. If you get paid $442 to insert a colonoscope up someone’s rectum or $86 to hit someone’s knee with the rubber hammer, which field are you going to enter? That young internists have abandoned primary care by the droves makes perfect economic sense. But it makes for bad public health. A recent Johns Hopkins study showed that countries with lots of general practitioners have lower mortality rates; no study exists linking high concentrations of orthopedic surgeons to lower death rates. Obama’s healthcare proposal seeks to redress some of these economic pressures, but lobbying groups representing medical specialists are squawking loud and long. Making matters worse is Santa Barbara’s peculiarly high cost of living. Nor does it help that Medicare’s reimbursement formulas shortchange area doctors something fierce. In Ventura, doctors get paid 7 percent more than those in Santa Barbara for performing the exact same procedure; in L.A., it’s a 10-percent difference.
The thinking is if Sansum is somehow subsumed into Cottage’s all-encompassing health empire, these recruitment and retention problems can be better addressed. By creating a system of “integrated care,” in which the brain synapses of the clinic and the hospital are effectively fused into one giant mind meld, the quality of medical care delivered will be better, more efficient, and a whole lot cheaper. Presumably those savings will allow this new corporate entity to pay more competitive salaries and install the latest state-of-the-art medical gadgets that make young docs drool. Of course, whenever I play musical chairs, my big concern is I won’t have a seat when the music stops. In this scenario, the independent medical groups not currently affiliated with Sansum would need assurances they won’t be left in the cold. And that’s a large community of doctors. Ron and Kurt both insist the independents will be cared for. They talk about creating MSO — management service organizations — in which the new Cottage-Sansum creature could reduce the independents’ overhead costs by buying supplies and insurance at reduced rates, made possible by even grander economies of scale. The group assigned to study the plusses and minuses of this plan is known as Physicians Hospital Alliance Work Group, or PHAWG (pronounced fog, appropriately enough). I have been told that the “W” was inserted at the last minute because otherwise the group’s acronym would have been PHAG, pronounced “fag.” And that could have gotten awkward. This just proves that no matter how serious the subject, silliness will inevitably intrude.
In the meantime, my scary sleep doctor has left town. I’ve been to see his replacement. It turns out I’m now waking up only 42 times an hour. That’s progress. But such problems seem almost irrelevant now. With all these changes going on, who could sleep anyway?