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Managed care originated in Southern California, so UCLA has been especially hard hit. Some 40% of its patients are under some kind of plan. Not long ago, UCLA cardiologists routinely charged $400 for an appointment and electrocardiogram. Now they are lucky to get $160 from managed care. In response, UCLA has been forced to cut staff from 4,200 in 1990 to 3,200 today. It has instituted productivity standards for doctors and shortened hospital stays. Unlicensed "care partners" have been hired to take over some of the more routine duties of higher-paid registered nurses. And in a kind of if-you-can't-lick-'em-join-'em move, UCLA is purchasing Santa Monica Hospital in order to launch its own managed-care network. It is also cutting deals with local HMOS -- for example, to perform all transplant surgery for subscribers to the giant Kaiser Permanente plan in Southern California.
But what is clearly the most violent cultural wrench for UCLA is its decision to train fewer specialists and more medical generalists. Late last year, an audience of UCLA specialists listened in shocked silence as Alan Fogelman, chairman of the School of Medicine, outlined a vision of the future: "A tertiary cardiology specialist will be waiting for the phone to ring, but it won't." While it still emphasizes training medical scientists and, in fact, has a new program to attract top-notch students who will commit themselves to research but not practice, UCLA will no longer train students to practice medical "subspecialties," such as cardiology and nephrology. Says Fogelman: "We have told internship applicants during the past two years that UCLA was a great place to be trained as a generalist or a [research] scientist. But if the applicant wanted to practice subspecialty medicine, we stated clearly that ucla was not the place to go."
Other teaching hospitals are following similar strategies, with some variations. The Mayo Clinic in Rochester, Minnesota, saw the managed-care wave coming and hatched a particularly wide array of responses. For one thing, it standardized purchasing of such supplies as knee braces and rods for broken bones. It orders in bulk and demands discounts. Meanwhile, Mayo has a thriving side business in newsletters, books and cd-roms.
Mayo was quicker than many research institutions to build a medical network of its own. It has merged with two other Rochester hospitals, opened clinics in Jacksonville, Florida, and Scottsdale, Arizona, and joined nine other clinics and five hospitals with a total of nearly 1,450 physicians over a wide area of Minnesota and neighboring Wisconsin and Iowa. Like old-time circuit riders, Mayo physicians regularly visit these facilities to provide specialized care and pass on the latest medical developments; they have also begun to consult by computer. And Mayo One, the hospital's emergency medical helicopter, can rush patients from remote clinics to the mother ship.