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Co-pay or Play

Joining lots of HMOs has become the surefire way for a young doctor to build a thriving practice before bailing out -- leaving patients to pay full fees or switch M.D.'s.

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Six years ago, dermatologic surgeon David Kriegel hit on an enterprising strategy during a stint with a group practice in Queens: The 39-year-old doctor would join any managed-care plan that would have him; he would network, he would meet and greet primary-care doctors in Manhattan to get on their referral lists; he would build up his patient list, work hard, be busy -- very, very busy -- at the office in Queens and his private practice on West 57th Street. And then he would slowly start bailing out of the HMOs (and, eventually, Queens as well).

Alice Furman, 36, had the same idea six years ago, after she completed her medical training and joined an internal-medicine practice in the East Nineties. She'd sign on with a bunch of HMOs ("At the time, no one knew what was going to happen with managed care in New York," she recalls, "and I wanted to keep my options open"), build up her patient base. She'd work hard, be busy -- very, very busy. And then she'd start dropping out of the networks.

Vicki LoPachin, also 36, saw the light five years ago, when she finished her residency and joined Marathon Medical, an internal-medicine practice on the Upper East Side. She'd join every HMO available, build up her patient base, work hard, be busy, and then -- well, you can probably see where I'm heading with all this: The M.O. for many young New York doctors is to use HMOs as a springboard to independence. In this, they're among a select few actually making managed care work for them.

There may still be places where it's possible to wrap up medical training, hang out a shingle, and immediately pack the waiting room. Manhattan, with its high rents, high insurance rates, and high concentration of M.D.'s, is not one of them. Instead, new doctors -- depending on their specialty and the power of their mentors -- join well-established fee-for-service practices on Park or Fifth, where they take the overflow from the senior guys and pray that word of their skill and charisma gets around. Far more often, however, they join managed-care-based practices.

"That's typically what people do," says Roger Platt, a vice-president at Mount Sinai. "The first thing when you go out into practice is that you have to get yourself busy. You may do HMOs for three or four years, may be comfortable and stay with it, or you may try to gradually switch over to fee-for-service mode, where I won't see as many patients but the fees I can generate are so much higher. People have different strategies for doing that over time."

One such strategy is a sort of benign pyramid scheme exemplified by Marathon Medical. Vicki LoPachin was hired by Marathon's solo practitioner, an internist-cardiologist who wanted to do more cardiology. "I joined every plan he was in, plus some additional ones, and then he started to pull out of some plans," LoPachin says. "He pulled out of Aetna, for example, but I still took it, and by five months I had a full daily schedule."

This year, Marathon Medical brought in another internist and "we had him join all the plans, and once he's in everything, the cardiologist will pull out of even a few more plans," says LoPachin, who for her part will start closing panels (industry lingo for bolting the door on new patients) in some plans and will pull out of others completely. In this way, such practices are able to provide continuity of care and build volume while creating a lucrative HMO/fee-for-service hybrid.

But many doctors, punch-drunk from paperwork and fed up with low reimbursements, are jumping ship from managed care altogether. David Kriegel, for example, is dropping out of plans -- Physicians Health Service is one -- that won't cover his costs. And now that she has a full schedule, Alice Furman is becoming more selective. "I've dropped a few plans," she says, "and in the next year I hope to be out of two more."

There is one serious side effect to such fiscal therapy: loss of patients. One Upper East Side fee-for-service practitioner says this is particularly true of younger patients unfamiliar with the quaint custom of paying the full fee for an office visit (especially when they're already tithing a significant chunk of their paycheck to an HMO). "A lot of colleagues who dropped out of their HMOs over the past few years were surprised at the number of patients who left," says Michael Yaker, 35, a pediatrician with Mount Sinai Medical Associates, an Upper West Side HMO-based practice currently weighing the benefits of bailing out of some plans and shifting, in part, to a fee-for-service operation.

"There isn't a lot of loyalty," says Jonathan Lanzkowsky, 35, an OB/GYN who recently left a managed-care office to join a fee-for-service practice. "Your patients are like mercenaries! Even when I had delivered two babies for a couple, they'd leave for the third one if their health coverage changed and I was no longer in their plan. Conversely, I've delivered a third child for women who paid full freight for their first two."

Of course, patients watching their doctors close panels and pare down plans may be forgiven for thinking this talk about "loyalty" and "mercenaries" is not a little hypocritical. "I saw a woman yesterday," says Yaker, "who said, 'Please don't drop our insurance. We don't want to switch pediatricians again.' "

Kriegel confesses that he hasn't vaulted out of plans as rapidly as he'd intended. He could dump 80 percent of them and still be busy, he says, but "I didn't appreciate that within each HMO there would be a good percentage of patients that I wouldn't want to lose because I'd grown attached to them." For the chosen, he has reduced his fees or set up installment plans. But he doesn't plan to hold the line forever.

"The plans that keep cutting their reimbursement will find that doctors who've been out of training five, six, seven years are dropping them," Kriegel says. "The only ones who will join are new doctors."


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