San Francisco: Changes at Conant Medical Group

A confusing series of disputes, caused ultimately by changes in the business of medicine, has led to the disbanding of the Conant Medical Group [Dr. Conant's dermatology practice has not been affected]. To assure continuity of care, some patients will need to decide whom they want to stay with, arrange for the transfer of their medical records, and perhaps also change their designation of primary care provider at their HMO. In case of doubt, contact your provider's office to learn what actions, if any, you need to take.

An August 7 letter to patients provided new contact information for some of the providers formerly with the Conant Medical Group. Virginia Cafaro, M.D., Jon Kaiser, M.D., Lisa Lewis, M.D., Martin Kramer, PA-C, Pat Sanders, FNP, and Gordon Sanford, PA-C., can now be reached through a message number, 437-5433, fax 437-5434. They are located in a new office at Davies Medical Center, Castro at Duboce, in San Francisco.

Mark Illeman, FNP, is with Drs. Stephen Becker, Alison LaVoy, Jeremy Berge, and Lawrence Goldyn at 923-6560, fax 922-0263, in the Potrero Hill Medical Group, 2300 California St., Suite 306.

Medical records for all former Conant Medical Group patients are at the Potrero Hill Medical Group. Patients can obtain copies of their records, or have them sent to the physician of their choice. In case of questions, contact the Potrero Hill Medical Group at 923-6560.

Note re Quest: Confusion has occurred because two different HIV medical organizations in San Francisco are named Quest. Margaret Poscher, M.D., asked us to clarify that "Quest, a primary care group," which is owned by her, is entirely separate from "Quest Comprehensive Health Care Systems," which purchased the Conant Medical Group. Dr. Poscher told us that she has supported the concept of Quest Comprehensive Health Care Systems creating a national HIV practice network, but that it has no role in the management of her practice.


Comment: Managed Care

These difficulties at one of the leading HIV medical practices in the country highlight the need for more public and professional attention to issues of managed care and other changes in medicine today. California is ahead of most of the U.S. in the use of managed care -- so what happens here, for better or for worse, has national importance.

Traditionally, physicians were usually paid for the services they performed; a drawback of this system was the financial incentive to overtreat, since the more procedures and tests they used, the more the doctors got paid. To control the resulting inflation of health-insurance costs, employers started shifting to HMOs (health maintenance organizations), which usually pay doctors a fixed amount per patient to provide whatever care is necessary -- a system called capitation. The drawback here is a financial incentive to undertreat, and to avoid expensive patients.

Unless other arrangements are negotiated, capitation rates are often the same for a patient with a serious condition like HIV or cancer, as for a healthy person who needs little medical care. This makes it impossible for an HIV specialty practice to survive, since they will lose money on almost every patient.

This is the pressure which is forcing specialists in HIV, cancer, and some other fields to combine into large groups of physicians. These physician groups can negotiate with HMOs to handle the care of their HIV infected patients -- with or without capitation -- at a rate which covers the cost of care. Large groups can also cut costs and generate income in ways which individual practitioners and small groups usually cannot -- from economies of scale, to developing standard protocols for both quality and efficiency, to running clinical trials, to vertical integration with their own laboratory, pharmacy, and other services (which individual physicians or small groups are usually forbidden to do).

Few patients, physicians, or others involved think that these changes are all bad, or all good. Clearly there are potentials for kinds of abuses which particularly harm persons who are seriously ill. Until we have workable healthcare reform, public vigilance, advocacy, and sometimes aggressive pressure will be required.