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The merger also promised a more personal benefit. Under the old medicine, says Dr. Hasan, "the idea was, you don't go into the health-care business to get rich. But that system was very inefficient." Now the reverse is true, he argues. When he took his company public, his holdings became worth $150 million. "We all got very rich," he says, his delight bubbling out in a chuckle. The prospect of such wealth, Dr. Hasan argues, helped managed-care companies draw the best executives, who in turn applied corporate stratagems to compel doctors to become more efficient. "It's no longer a gentleman's club," he says. "And I see that as a very positive development." A merger with QualMed would make Greaves a very wealthy man.
Christy deMeurers at last won approval to see a new oncologist, Stanley Schinke, and met him for the first time on June 21, 1993. She liked him instantly. "He and Dr. Jones were the only physicians up to this point who made us feel welcome," Alan deMeurers says.
Like virtually every doctor in California, Dr. Schinke has seen his practice change rapidly. In 1990 he didn't have a single capitated contract with an HMO. Today capitation governs half his practice. So far, he says, he has not felt pressed to scrimp on care but is worried that managed care is eroding satisfaction with the process of medicine, especially among patients with complex and emotionally wrenching diseases such as cancer. The inability to get things done quickly can be "horrendous," he says. Recently he needed three or four weeks of effort--"I'm calling every few days, my receptionist is calling, the family is getting nervous"--just to get a leukemia patient an evaluation at an advanced research center. "That's a big difference now," he says. "Patients five years ago didn't have to jump up and down and scream and say, 'I really want this treatment, please get me this referral, what's taking so long?' That never happened. You had a patient advocate in your doctor when you hit the doctor's door."
Dr. Schinke examined Christy and agreed she ought to consider a bone-marrow transplant. At the least it might provide a period free of disease and debilitating chemotherapy. He suggested she get an evaluation at the UCLA Medical Center. To Dr. Schinke, whether Health Net would pay was a side issue. "When the patient comes to me, I'm still going to tell them about what I think may help," he says. "That's the ethical thing to do."
Health Net's Dr. Ho called Dr. Schinke, who in a deposition and interview says he found the call coercive. "I didn't understand an administrator calling up and in an abrupt tone saying, 'Why in the world, what was your thinking, why are you recommending this patient consider such an option?'" But Dr. Ho, now with another HMO, says the call was "simply to remind him" that a transplant in a case like deMeurers' "is not indicated."
The deMeurerses, meanwhile, had grown so distrustful that they decided not to tell UCLA that Christy was a Health Net subscriber. Says Alan: "We wanted to find out what your average citizen would learn without insurance." Christy got an appointment to see Dr. John Glaspy, an oncologist who prides himself on being a fierce patient advocate. "They were suspicious, and they were in pain. Psychic pain," says Dr. Glaspy. Still, he says, "the first step in our relationship was a lie. There really isn't any other way to put it."
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