Published on Thursday, December 7, 2000 in the Los Angeles Times
Town Defies HMO, Rallies Around Doctor
Winters, CA, population 5,200, sets up its own clinic to keep physician who calls himself a 'conscientious objector' to the managed care system
by John M. Glionna
WINTERS, Calif. -- Call him old-fashioned, but Dr. Bill Davis likes making house calls.

Carrying his battered black-leather medical bag, he often rides his son's bike along this rural town's leafy streets to visit his patients right where they live, spending an hour or so sitting by the bed or at the kitchen table to get to the bottom of what's ailing them.

But the HMO that employed Davis and the only two other physicians in this Yolo County community didn't agree with his style of country doctoring. While it might be good medicine, they said, it just wasn't good business.

Davis says his bosses at Sutter West Medical Group insisted he see more patients, as many as six an hour. Meanwhile, the 47-year-old doctor, who for eight years had run his own practice before joining the HMO in 1994, bristled at the mountain of paperwork required for even simple procedures.

Calling himself a "conscientious objector" to the managed care system, a frustrated Davis finally quit his $70,000-a-year job this summer. While reluctant to leave medicine, he considered changing careers to teach high school and feared having to move his wife and four college-age sons away from the town where he had spent his entire 14-year career.

"I got tired of watching patients having to wait for oxygen or pain relief" because of HMO requirements, he said. "I became a thorn in their side because their big-city brand of medicine wasn't doing justice to people in this town."

Then the unexpected happened in the tiny farming community of 5,200 residents an hour north of San Francisco--people took a stand against big-business medicine. On the day Davis quit, dozens of his patients lined up outside his old office to cheer him on.

Scores also met at City Hall to try to save this latest in a long tradition of doctors who have made themselves available to townsfolk--from taking late-night calls to doing house calls on holidays.

Their solution was to form a nonprofit health care foundation that would allow Davis to practice medicine as he saw fit. Using volunteer labor, they refurbished an office in the heart of town in what residents proudly refer to as an old-fashioned barn-raising.

HMO Defections Increasing

Davis joined what experts say is a growing number of physicians who have rebelled against what they consider to be the bitter pill of the managed care system.

But rather than quit the profession he loved, this small-town doctor--with the help of his neighbors--created his own alternative brand of grass-roots medicine.

The new Winters Health Care Foundation clinic will mainly treat poor and Medicare patients--charging on a sliding scale based on what they can afford. Among this town's many Latino farm workers, Davis even takes live chickens, fresh vegetables and tamales as barter.

But there's one thing he won't accept: HMO insurance.

Keeping their Sutter coverage for emergencies, 100 people last month saw Davis for their routine care--willing to pay $30 instead of the usual $10 Sutter co-payment.

"Dr. Davis took a stand against that HMO, and we felt that he did it for us, the people of Winters," said clinic organizer Esther Brewer. "And we know that if we lose this type of quality care, we'll never get it back."

For Davis, the split from Sutter forced a difficult choice between his roles as doctor and family provider: Preserving his medical principals would mean less money.

He would have to forgo a salary for a year while launching the clinic. His family would be forced to live on savings and his wife's pay as chief ombudsman with the state Department of Mental Health. He would risk losing his home and could no longer help his children pay for college.

But his wife and sons agreed it was worth the gamble.

"We'll live out of a van if we have to," said Wendy Davis. "It's so liberating to do what you believe in. Now Bill's eyes light up when he talks about his patients. He's become a real doctor again."

The HMO breakaway in Winters has brought some small-town tensions. While Davis says his criticisms are not against Sutter but against managed care in general, his two former partners now rarely speak to him. Sutter managers have resisted releasing medical charts for many patients who wish to see Davis instead.

"From Sutter there has been only silence--they figured my only option was to deliver pizzas," Davis said. "But I thought one of my former colleagues might call to see how I was, at least concerned over whether I could make it or not."

Sutter West Medical Group spokeswoman Nancy Turner said Davis refused to honor his contract. "Sutter West never said he couldn't spend time with patients," she said. "But his contract obligated him to meet its requirements--whether it was filling out paperwork or seeing a certain number of patients in a day."

While statistics on such defections are scarce, Dr. Marie Kuffner, president of the California Medical Assn., says she encounters HMO dropout doctors all over the state.

"They no longer feel conflicted every day--nobody's breathing down their necks saying 'You gotta see the next patient,' " said Kuffner, an anesthesiology professor at UCLA Medical Center. "Most don't care what it costs. They'd rather have their integrity."

Rex Green, who quit practicing medicine after working 12 years with HMOs in Pasadena, said Davis is lucky to have such local support. "What's happening in Winters is a rural solution," said Green, now an administrator at City of Hope Hospital in Duarte.

"Many places so desperately want the kind of country doctoring their parents enjoyed they'll dream up ways to make good doctors stick around. That's not going to happen in a big urban area."

Winters residents agree the new clinic was a revolt against the fast-lane HMO brand of medicine they call "doc-in-the-box." Said pharmacist Gary Bertagnolli: "It's this small town's way of being rabble-rousers. People are tired of what's being handed to them."

Practicing Grass-Roots Medicine

Davis raised eyebrows soon after arriving in Winters, fresh from medical school, in 1986. He began volunteering at high school football and soccer games to be on hand in case someone was injured.

"Once a week, while other doctors might be out golfing, he visited rest homes to visit the shut-ins," said local farmer Joe Martinez. "There was something spiritual in the way he practiced medicine."

When Esther Brewer's father became ill with a life-threatening intestinal blockage, Davis visited him several times a day. "He'd sit on the floor next to him and hold his hand," she said. "He got into bed with my Dad to comfort him and wipe his forehead. That assurance was so much more valuable than just being told to take a pill."

But tough economic times in the early 1990s made Davis worry over his $40,000 annual earnings. "I was struggling," he said. "I wanted to help my sons go to college, but I was sinking deeper into debt."

His income rose when he joined Sutter, but the work proved even more stressful. In addition to the pressures of mounting paperwork and patient loads, Davis found that red tape often caused needless and painful delays in treatment.

In some cases, the system would require patients to make time-consuming and emotional changes in their approved medicines, only to be required months later to switch back to the original prescriptions.

He saw patients suffering from back pain and stomach ailments go weeks without physical therapy because of paperwork problems. And one desperate woman suffering from sleep apnea paid for an expensive but much-needed test out of her own pocket because the insurance company refused to cover it because of a technicality, Davis recalled.

"Some bean counter who didn't know anything about medicine decided rules were rules," he said. "And so she suffered."

Davis quit after the pressure began affecting his health, making it impossible to concentrate at work. Months later, he says, the swift community reaction has made him feel well again.

Residents collected $50,000 in cash and materials. One woman wrote a $100 check, offering to forgo her diabetes medication. Davis refused her money.

They refurbished a vacant office on Main Street with volunteer masons, electricians and contractors. A local attorney offered free legal advice and a bookkeeper volunteered to do the taxes.

As a nonprofit, the clinic can apply for government grants to defer the costs of treating the poorest patients.

"We're going to try to create comprehensive health care and find a way to pay for it," Davis said. "That's the opposite of what insurance-based medicine does. They only do what's paid for."

Residents hope to raise $500,000 to cover the clinic's $4,000 monthly operating costs and eventually offer Davis a small salary.

"I may be out on a shaky limb, but a lot of hands are reaching out to hold me up," he said. "I don't feel alone. And I don't have to worry about going without food--not in this community."

Treating Patients Out of the Office

While the clinic was being built, Davis continued seeing his patients anywhere he could. He treated them out of his car and at a local park, and held consultations in restaurants. He carried his cell phone to football and soccer games and took calls there.

"People would come up to me at the grocery store, complaining of a problem, and I'd say 'Well, lift up your shirt and let me take a look.' "

At his small clinic, Davis often answers the phone himself, forwarding calls home when he leaves at night. He shows up many weekends, such as the day he treated the daughter of the local newspaper editor after the girl's brother stuffed Play-doh into her ear with a Q-Tip.

"Dr. Davis is a holdover from another era--his style of medicine doesn't exist any more," said Debra Ramos, editor of the weekly Winters Express. "He has an internal clarity of why he loves his profession--and it's not to get rich and it's not to play God."

When a young baseball pitcher complained of arm pain, Davis left the office, taking the boy out to the diamond to throw some balls before diagnosing a rotator cuff problem.

With a woman who lost her ability to speak in a car accident, he waits patiently while she spells out each word on a letter board. "How, in a rushed 10 minutes in some HMO office, do you allow a patient like that the dignity to express things herself?" he said.

But Davis knows he still risks losing his home to save his medical vision. As Winters residents try to raise enough money to keep their favorite doctor in town, he goes about treating his patients as if it were still 1950.

In the living room of 88-year-old Violet Hughes, he leans in close with his stethoscope. Shaking his head, he worries over how pneumonia has cut her weight to a mere 70 pounds.

After nearly 45 minutes, often holding her hand as she sits bundled under a tartan blanket, he stands to leave, offering to pick up her prescription at the nearby pharmacy.

"What's your hurry?" the old woman rasps.

As her country doctor heads for the door, she peeks up shyly.

"Are you coming tomorrow?"

Copyright 2000 Los Angeles Times