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Some Doctors Head to Idaho, a State Without Managed Care

THE HEALTH CARE REVOLUTION. Remaking Medicine in California. One in a series


OROFINO, Ida. — The comfortably cluttered office of neurosurgeon Brad DeLong on the Nez Perce reservation is but a stone's throw from fish hatcheries, forested hillsides and the frothy rapids of the Clearwater River.

Light years away is the life DeLong left in cosmopolitan San Francisco a year ago to establish the first orthopedic practice in Orofino, a tiny, conservative logging town set amid stunning natural beauty.

Why DeLong came to Orofino--and why other California doctors have come before and since to this part of Idaho--is another twist in the evolving story of managed care, California-style.

About a dozen California doctors have landed in the area near the twin cities of Lewiston, Ida., and Clarkston, Wash. Like battlefield refugees, most have come, at least in part, to escape practices that were crumbling under bombardment by health maintenance organizations.

There are no HMOs in this part of Idaho. Although several big employers are making noise about bringing them here, for now a minuscule 1%, or 13,000, Idahoans are members of HMOs, versus 38%, or 12 million, Californians.

And California doctors are not coming just to Idaho. They are also pitching their tents in Arkansas, Montana, Oklahoma, the Carolinas and any place where their services are in demand.

"There is a reverse Oregon Trail occurring, with specialists in covered wagons heading east," said Ian Morrison, president of the Institute for the Future, a Menlo Park think tank.

DeLong and his wife, Irene Lamberti, traded in their "California cars"--a Lexus and a BMW--not for a covered wagon, but for a Jeep and a Chevy truck.

A soft-spoken, thoughtful man, DeLong, 59, was edging toward retirement but was worried about the impact that managed care would have on his plans. A surgeon at the spine clinic at St. Mary's Medical Center in San Francisco, DeLong was experiencing a dip in the number of patients he was seeing--and the future looked grim.

"It wasn't a hard decision to come here, considering how things were going," said DeLong, who now runs the Orofino Spine Center with Lamberti, a former Marin County chiropractor and radio talk show host.

Besides, the couple had long dreamed of escaping the hassles of urban life. They picked Orofino, population 4,000, because Lamberti had grown fond of the area after visiting a close friend who lived here.

"There are trees, creeks and rivers here," DeLong said. "No stoplights, no parking meters or meter maids and no rush hour."

There's also no need for a spinal surgeon in Orofino. For that matter, the Lewiston-Clarkson area has enough neurosurgeons for its population of 40,000, and DeLong decided against competing with them for patients.

Instead, DeLong and Lamberti focus on the decidedly lower-paying practice of basic orthopedic medicine, treating back pain and joint problems through non-surgical methods. Their patients include loggers, retirees, U.S. Forest Service employees and convicts from a nearby prison.

Before his move, DeLong tried to sell the San Francisco practice he started 25 years earlier. But no one wanted to buy in HMO-dominated California, where specialists are in oversupply. To serve his remaining patients, DeLong commutes to San Francisco one week a month to do surgery.

Other former California doctors say they were led to Idaho by a combination of frustration over managed care and family and lifestyle issues.

Warren Ellison, a family doctor, says he came to Lewiston 10 years ago because he and his wife wanted to raise their two children in a more rural setting. Professionally, he had grown frustrated with managed care while working as a "utilization review director" for an Orange County medical group in the early 1980s. It was his job to determine the "medical necessity" of requests by patients or doctors for diagnostic tests and surgical procedures.

"I was the one who said, 'Squeeze the bucks,' " he said, adding that the group was under severe economic pressure to limit services for HMO patients. "It made me feel awful."

Ellison, 48, makes less money now than he did a decade ago in California, but enjoys his job more. "You're closer to the patients," he said, "and you know your colleagues better."

Hugh Haegelin, 62, an internist, says practicing medicine in Lewiston "is like the old days." And it allowed him to realize another dream: "I always wanted to live on a river."

And so he does.

Haegelin left California when his Riverside County practice went into decline as HMOs and large medical groups grew more dominant in the late 1980s and early '90s. As an older solo practitioner, Haegelin found himself locked out of the HMO medical networks and losing patients.

Even in Lewiston, there are rumblings that managed care may be coming soon.

Some of the city's biggest employers--led by Potlach Corp., a San Francisco-based pulp and paper products company whose giant plant sprawls along the Clearwater River--are discussing ways to bring managed care to the city.

"Most of us have a mandate from top management that we do something about managed care," said Carol Schwartz, human resources manager for Blount Inc., an ammunition manufacturer.

Schwartz said medical costs for Blount employees in Lewiston generally have been higher than at other company sites in Minnesota, North Carolina and Oregon, where managed care is more prevalent.

A year ago, Potlatch, Blount and other employers began discussions with doctors and hospitals aimed at setting up a managed care system that would lower costs while preserving quality.

Schwartz said some of the California doctors--recognizing that managed care is inevitable--have been involved in the talks.

"They know managed care is coming," she said, "and they don't want to see something like what they didn't like in California."

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