Reflections on the practice of medicine -- then and now Reflections on the practice of medicine -- then and now (September 08, 2004)

Local doctor predicts end of HMOs, suggests changes to medical system

By John Flood
Special to the Almanac

When Dr. Norman Rosenstock looks back on the beginning of his career as a physician nearly 35 years ago, he recalls an era when he was able to spend as much time as he needed with a patient; a time when the focus was on care.

Each day, the Portola Valley resident would treat his patients, tend to their needs and, at the end of the day, he'd go home satisfied that he had done his best.

In those days, he practiced medicine at San Mateo County's general hospital -- called Harold Chope Memorial Hospital at that time, and now, the San Mateo Medical Center.

But as the years went by, the American medical system changed, especially in the way HMOs and government programs defined the rules on the ways he could treat his patients -- rules that frustrated him.

"Intrusive HMOs and government programs, staffed by people who were ill-informed and directed by accountants, made it much more difficult to practice medicine," Dr. Rosenstock explains.

Even more troubling, he was concerned that he could not provide the quality care that his patients needed.

"I had a patient who was bleeding from the rectum who obviously needed a colonoscopy," he recalls. "But a local insurance company told me that I had to perform a barium enema because they did not cover the cost of a colonoscopy."

According to Dr. Rosenstock, because of HMOs and government programs, "the driving force in medicine has become the bottom line." But for him, the bottom line is different. "Providing the best care for my patients has been the guiding principle throughout my career," he says.

And that, he says, is what drove him right out of private practice. In 1997, after practicing medicine for 27 years, his frustrations had come to a boiling point. "I retired at the age of 59, much earlier than I wanted," he says.

A good Samaritan unbound

Wanting to "give something back," Dr. Rosenstock decided to become a volunteer physician at Samaritan House, a nonprofit community agency that offers a range of services for San Mateo County residents who live below the poverty line.

The agency's services include a homeless shelter, free clothing and furniture, a food bank, holiday assistance, and a range of counseling services -- all free.

Dr. Rosenstock was first introduced to the idea of social service when he was a child. "When I was growing up, my family was involved in volunteerism," he says.

"My parents taught us that it is important to give back to the community. This was one of the primary reasons I became a physician."

Today, Dr. Rosenstock practices medicine part time at Samaritan House, seeing up to 50 patients in a week.

"This is medicine without economic aspects," he says. "We are not concerned with payments; all the drugs, all the lab work, and all the X-rays are free."

And best of all, he's free from frustration. "There are no forms to fill out; no approvals to deal with," he says. "This is pure medicine, simple in a way. And we take care of the patients.

"Samaritan provides me a wonderful venue to continue to practice medicine in a way that fulfills my goals."

A failing system

There are big problems with the health-care delivery system in America, Dr. Rosenstock says. "The medical system is failing. It's crumbling at the edges and it will crumble more."

Recent census bureau data indicate that 45 million Americans are uninsured.

But what's the solution? Should the current system be scrapped for a single-payer system like Canada?

"A single-payer system is simplistic. The government doesn't understand the scope of the problem," Dr. Rosenstock says. "If the government provides the solution, it will be a further deterioration similar to the dumbing down of public education."

Under government-sponsored health-care programs, "facilities degrade ... and governments typically under-fund them," he asserts. "They short-change research, care, facilities and insist on low-cost formularies."

The doctor's prescription

"I am in favor of universal coverage," Dr. Rosenstock says. "Health care should be available to everyone in this country.

"There should be a floor for basic health care and for catastrophic events. It should be subsidized through a safety-net system."

The safety net could be funded through a combination of state and federal funds, he suggests. And instead of funding HMOs, employers could make contributions to an "employee medical savings account."

The individual could then purchase insurance based on what he needs and can afford, says Dr. Rosenstock.

The goal, he explains, is for the patient to control more of his medical decisions -- and his dollars -- instead of the insurance company. For example, a patient could be offered a price reduction if, say, he has an elective surgery in the middle of the night, or at a later date.

"Insurance would cover unusual circumstances at less cost," Dr. Rosenstock says. "The patient would pay additional expenses out of his medical savings account, or out of his own pocket."

Drug companies and HMOs

"The drug companies have been unconscionable in what they charge," says Dr. Rosenstock. Drug companies base their pricing on the exclusivity of their patent rights, he says.

"The government needs to rein in drug pricing with input to the duration of patents," he says.

His prognosis for health maintenance organizations is grim.

"The HMO is a failed concept and it will disappear," he predicts. "It doesn't satisfy the employers' need for coverage at low cost; patients feel their medical choices are impaired; and the providers have enormous obstacles in paperwork and costs."

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