While most physicians shy away from the political world, Dr. Marie Kuffner embraces it. In March, she will become president of the 34,000-member California Medical Association becoming the chief advocate for the state's doctors on legislation at the state and federal levels. It's a role for which she has been training since medical school; while attending the University of Texas at Houston, Kuffner became the first woman to lead the national branch of the resident division of the American Medical Association.

Kuffner also serves as chairwoman of a physician advocacy group that works with the federal Health Care Financing Administration, a position to which she was appointed by President George Bush in 1992 and re-appointed by President Clinton. She reports to Secretary of Health and Human Services Donna Shalala.

Kuffner still practices and teaches anesthesiology at UCLA, where she was chief of staff in 1995. How does she balance the demands of medicine and advocacy?

"It's a matter of recognizing that the world would go right on if I'm not there, and that no matter how much I'm able to do, it's impossible to do it all."

Question: Much has been made of the disillusionment of doctors with the managed care system. Is managed care here to stay?

Answer: The frustration comes from the fact that physicians can't make medical judgments anymore. You name it, and there are 50 hoops they have to jump through. Everything we do today requires someone else to approve it there's some regulation somewhere, some bureaucrat who decides for you. It's not just Medicare, it's Medi-Cal, it's the Health Care Financing Administration, it's Occupational Safety and Health Administration, it's the Joint Commission on Accreditation of Healthcare Organizations, it's the health plan, it's the formularies. This goes on all day and it comes down to doctors saying, "We don't need this anymore." I see doctors retiring at the age of 50 at the peak of their productivity.

I think managed care in its present form cannot last. There's not enough money to pay for the care that's being demanded. In California, we have the lowest premiums and the lowest level of reimbursement, and you can't ask physicians to continue to see patients for below costs or they'll go bankrupt.

Q: What kind of system could evolve from managed care?

A: It's a very artificial environment that has occurred, where everybody is trying to expand to get market share and that has created a lot of instability in the system. Something has to give. There has already been a resurgence of fee-for-service medicine, albeit a discounted fee-for-service system, where some patients are willing to bypass all the rigmarole and go directly to a physician. Some physicians have found that they can succeed in a market where they are able to compete and have a decent showing in fee-for-service if they have a significant patient population.

Q: What do you think of United Health's announcement that it is going to give doctors the ultimate say in health decisions?

A: We get a big kick out of it. It was the best P.R. move they could have made. Number one, it's open enrollment time, and when people are looking for a new health plan they can say, "Oh! At United my doctor will make the decision! Isn't that nice?" But in any of the procedures where the doctors were under contracts for capitation, they were already taking the responsibility for their patients, not the health plan, so it didn't make any difference anyway. Number two, insurance premiums are going up all over the country and we've gotten to the point where we're cutting muscle, we're not just cutting fat. Now when premiums get raised again, this company can sit back and go, "Gee, the doctors are making the decision, we can't do anything about this." They get to look good at the doctors' expense.

Q: When doctors see a variety of patients from a variety of health plans, doesn't it get confusing?

A: You have groups that are contracting with all kinds of different players who are in all kinds of different arrangements with all kinds of different rules and formularies. It's chaotic trying to figure out who gets what. Doctors are telling me that they have 50 different formularies for any different patient. For instance, a physician writes prescription A for a patient, then when the patient goes to try and fill it, the pharmacy will call the doctor and say that the health plan doesn't allow prescription A, you have to prescribe prescription B. The next patient comes in and the doctor prescribes prescription B, and the pharmacy calls and says, "I'm sorry doctor, his health plan doesn't allow B, you have to prescribe A."

I swear to God, you have this problem all the time with two different patients in two different plans and one prescription is rejected in one and acceptable in the other, and you have doctors pulling their hair out. Doctors are getting second-guessed, and it doesn't take very long before you can see the exasperation. They are angry that they have to practice for health plans that think they can manage care when they manage cost.

Q: Are doctors seeing any impact from all the advertising going on by drug companies on television and magazines?

A: Yes. Patients ask, "Can I look like Joan Lunden if I get the Claritin? I don't even need Claritin, but Joan Lunden looks good taking it." The biggest increase in costs in health care has been in the pharmacy area. Some drug treatments can cost people easily $1,000 a year and who's going to pay for that?

We are working on about 30 years of an entitlement mentality where it's somebody else paying the bill but now that somebody else doesn't want to pay the bill. Insurance doesn't want to pay, businesses don't want to pay for the advanced technology. But particularly in California we are paying more and more on liposuction, Lasix surgery, plastic surgery, things that are not covered by insurance. We are spending billions on this, but if you ask a patient to contribute more co-payment to even out the cost when their doctor gets $16 for a 45-minute office visit, they have the notion that someone else has to pay for it.

Q: But the public perception is, "Why are all these doctors whining when they make $250,000 a year?"

A: It is the public perception, but it only applies to a very few physicians. The number of physicians who make that kind of money work an incredible number of hours, and for the most part they are well deserving of it. They work very hard and they have very little of a real life. But the average doesn't make anywhere near that amount of money. The starting salary leaving our programs at UCLA is $60,000 to $80,000 a year, and that doctor faces $150,000 to $160,000 in debt on average that's the price of a house mortgage just to go through medical school and training and you're 30 and you've finally finished and all your friends have been working since they were 22 or 23 and not accumulating debt, and that's about when you realize that you're very stressed.

Q: So how do you handle it all?

A: I just have to have a very small period of quality time. It doesn't take me a lot of time to renew. I'm intense at work and when it's time to relax, I'm intense at that, too. I don't sleep an average of more than four or five hours a night. But I just need to find some time for some quiet I wouldn't call it meditation but just a quiet separation from whatever else is going on. In California it's easy to get in touch with the beauty of the environment. This morning I just got out of my car in the parking lot after I got to the hospital and I stood out there in the sun and just really took it all in. What it takes is a mindfulness of the really good things, the joy in the environment and in dealing with the patients.

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