The Year Past and Those to Come

                           By James R. Missett, M.D., Ph.D.

This year has been an important one for the physicians of San Mateo County. During the course of the last 12 months, Sutter Health announced its intention to build a full-service hospital in San Carlos, the California Legislature passed the California Health Insurance Act of 2003 (SB 2) mandating employer health care contributions for employees, and newly elected Governor Arnold Schwarzenegger appointed two competent and tough-minded women to serve as administrators for the state’s two most important health-related offices: S. Kimberly Belshe as director of the Department of Health Services, and Lucinda “Cindy” Ehners to run the Department of Managed Health Care.

The events of the past year also illustrate how, as physicians, we benefit by paying attention to the potential impact on medicine and medical care from national, state, and local events.

On the national level, the fighting in Iraq has meant the hemorrhaging of lives and money. Indeed, the burgeoning national debt can be expected eventually to affect the life of every citizen. For physicians, it will most likely come in the form of decreased Medicare and Medicaid benefits and in fewer federal dollars for medical education and research. Doctors seldom reflect on how the advent of Medicare in 1964 was followed by a perceptible improvement in the income and lifestyle of the average physician. Indeed, the medical profession as a whole gradually rose from the 1960s through the 1990s from a generally middle-class to a generally upper-middle-class standard of living. This improvement in the standard of living of doctors has been temporally associated with Medicare and the spread of insurance-based care. However, in the intervening decades, many physicians have become dissatisfied with Medicare reimbursement rates; this situation will likely worsen with big budget deficits.

On the state level, California saw the enactment of SB 2. This law requires large-sized employers (in 2006) and eventually medium-sized employers (in 2007) to provide health care coverage for employees and their dependents (employers are mandated to pay 80 percent; employees 20 percent). From the perspective of physicians, SB 2 is an important law that will reduce the extent to which lack of adequate health insurance keeps individuals from seeking appropriate and timely medical care. This has been a divisive issue even among physicians, and business interests are seeking to repeal SB 2 through the initiative process this fall. In my view, their efforts deserve the opposition of the medical community.

On the local level, the fact that the membership boundaries of the SMCMA are co-terminus with those of the county of San Mateo provides its physicians with unique access to local, county, and state elected officials. An example this year of how common geographical boundaries can work to the mutual benefit of doctors and their patients was the county task force on hospitals and hospital beds. After the announcement by Sutter Health last summer of its intention to build a full-service hospital in the southern portion of San Mateo County, the SMCMA leadership approached Supervisor Jerry Hill to ascertain whether he and his fellow board members fully understood the dynamics of either increasing or decreasing hospital facilities and the impact on the medical community at large. Hospital services for the San Mateo County population always have been a priority of Supervisor Hill, who sits on the Board of Directors of the San Mateo Medical Center. Subsequent to our meeting, Supervisor Hill set up and chaired a task force, which sponsored a series of public meetings with presentations by all the leading hospital providers in the county, to examine the balance of inpatient hospital beds and hospital-based care throughout the county. The result of Supervisor Hill and the task force’s efforts was evidence of the uniqueness and distinctness of the differing missions and populations served by each of the hospitals in the county. Although the various hospitals might theoretically be in competition for providing services to the overall population, each hospital has its own unique set of services and appears to be in competition with other hospitals only for a defined subset of the overall patient population. From the perspective of the interests of SMCMA, this uniqueness and only partial overlapping of services by the various hospitals means that it is especially important for all physicians to work to preserve the openness and independence of hospital medical staffs, access to such hospital services by the widest number of doctors and patients, continued services by hospitals and physicians to the poor and disadvantaged, and an equal distribution of full-time and full-service emergency rooms.

The physicians of the SMCMA, who range in age from 29 to 93 years, are representatives of large groups (such as the Permanente Medical Group and Sutter Health), of small groups, and of solo practitioners. The membership reflects practitioners of many specialties and sub-

specialties. Such diversity of background and interests serves as the source of strength and influence for this Association, much as in any family. The joining of doctors from such varied backgrounds and interests results in SMCMA being the one local organization that represents the interests of all physicians and derivatively the health care interests of every citizen of San Mateo County.

In recent conversations with the most senior SMCMA members who continue to be actively involved in medical practice or research, they commented again and again about the gratification they enjoy from their association with their patients and the extent to which these satisfactions are balanced by the financial stresses of continuing to provide such care in the face of dwindling levels of compensation. With the exception of two physicians who maintain teaching positions with UCSF and Stanford University School of Medicine, all of these physicians are in private practice. As such, their practices represent the running of community-oriented small businesses. Indeed, for all these doctors, who have reached the age of 80 years and who continue their active involvement in medical care, the universal complaint involves the extent to which decreasing levels of reimbursement make it increasingly difficult to maintain adequate levels of staffing and patient care. These pressures can be expected to intensify in the coming years.

Although it may not be possible to alter the direction of upcoming governmental changes and budget reductions, it should be possible, through concerted and united effort, to blunt their impact on individual physicians and patients. This will be best accomplished by all physicians working toward commonly held ideals and goals through organizations such as SMCMA and CMA. The power of the individual doctor is multiplied many times when allied with one’s brother and sister physicians. This is one of the reasons why I should like, in closing, to thank all of you, the physician members of the San Mateo County Medical Association, for having afforded me the honor of serving this past year as the president of our county medical organization.