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?

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