familiarly GHA -- is one of the oldest names on the Washington health scene. It is an organization that has had an "up" period and a "down" period and is now in a new "up" that could, if it continues, make GHA one of the nation's exciting medical names again.
This is good news for its patients -- and anyone who considers joining it.
GHA was one of the world's first prepaid health plans, founded almost 50 years ago by federal workers fed up with the unpredictable costs of their medical care.
They succeeded magnificently. They won a war with organized medicine, which denied medical society membership to GHA doctors, thereby keeping those doctors off hospital staffs. By the 1970s GHA had 100,000 members paying a set sum for virtually all their medical and hospital care.
It then bogged down. For 10 years it essentially stopped growing, while in the West Kaiser prepaid health centers flourished, and elsewhere new and vigorous prepaid plans -- now called health maintenance organizations, or HMOs -- were being created.
GHA's doctors became dissatisfied and wanted a stronger voice. They sought to form an independent medical group to serve GHA by contract, just as Permanente Medical Groups contract with the Kaiser plan to care for Kaiser subscribers.
"We wanted to share both the risks and the benefits," says Dr. Donald Mitchell, a GHA dermatologist chosen by GHA doctors to lead their fight.
"Benefits" to some extent meant profits, if any. But the larger issue was how to share both income and management.
"You can't really divorce doctors from the management of a medical plan," says a health administrator not connected with GHA. "They decide when to treat, when to hospitalize. They spend the money."
Mitchell says: "We thought some injection of a free enterprise system, some sharing, would improve both the quality and efficiency of care. We were part of GHA, and we were worried about its future."
The members' board of trustees argued that GHA had been founded on the principle of member control and should remain in members' hands.
The doctors, stymied, formed a union, the Capital Alliance of Physicians. In 1977 they struck for 11 days, treating only emergency and hospital patients.
The result, as in most labor disputes, was a compromise. But the doctors, says Mitchell, the union president, now have a say in matters from compensation to how many patients they should see.
Soon afterwards, GHA started sinking into the red. In April 1982 its nurses went on strike for a month. GHA's deficit that year was $4 million.
An even greater deficit was in spirit. For a time, Mitchell says, the doctors had been "thoroughly demoralized." Their own union contract helped, but many had left.
In June 1982 GHA hired a new medical director, Dr. Robert Rosenberg, a Tufts and Harvard-trained pediatrician.
"I found GHA had a lot of good leadership and high-quality doctors," he says. "But the organization had just gone through the very dispirited and traumatic nurses' strike when it still hadn't really recovered from its problems with its doctors. "The doctors were not really practicing as a group. The amenities, like appointments, were suffering. There were grave financial problems and substantial member turnover, 11 percent a year 'voluntary' turnover alone, not counting those who left because they changed jobs or cities . And no growth, in an industry with explosive growth."
Rosenberg, a sobered board and Dr. Edward Hinman, then executive director, began changing things. GHA stopped using George Washington University as its main hospital. Care at a university hospital is expensive, vital often for the critically ill but not the most economical care for many lesser problems.
Doctors' "productivity" was stepped up, meaning they now see more patients.
Is this good for the patients?
The heart of good care can be enough time for a doctor to spot real problems. Yet there is a new fact of life for every medical plan, not just GHA: high costs and competition, and the need to limit fees to meet competition force care-givers to be more "productive."
Rosenberg says GHA uses a mix of practitioners -- physicians, nurse-practitioners, physicians' assistants and, for uncomplicated deliveries and obstetric care, well-trained nurse-midwives -- to give "care we can be proud of." There are few non-MDs in some GHA centers, more in others, but "I'm very proud of adding more," Rosenberg says, "and I'd like more still. They add a dimension -- of excellent primary care, of time, of working with you on chronic problems, of recognizing quickly when a physician is needed.
"You have a choice. You can always see a physician. But one of our members is a Washington executive who keeps referring to his nurse-practitioner as his doctor. He won't go to his doctor."
Rosenberg said the "anticipated work load" for GHA's primary care doctors, almost all of them board-certified internists, is "15 to 20 patients a day," not an unusual number in any practice. But the number can vary greatly by luck of the day or type of patient or the doctor.
At GHA's Annandale center last week, patients -- I asked several -- said they liked their care. The sample was hardly representative. Any who had quit, dissatisfied, were not present.
But Edwin Anuswith, a 71-year-old retired federal worker, said: "You have your own doctor. I like the one I've got. My wife likes hers. We don't have any bills to pay. We're completely covered."
Elizabeth Corson, a former nurse who is the center's administrator, said: "We book 21 15-minute appointments for each of our primary care physicians. But a lot are double appointments -- for people over 65, consultations about emotional problems, other things. They probably see 17 or 18 people a day on average.
"And we have one physician who's always slow, but she's excellent. She spends a lot of time with people. And she has a lot of Medicare people."
Dr. Barbara Carson of the Annandale staff said: "Sometimes I see 17 patients in a day, once in a while 26. I don't feel overloaded unless it's 26."
Dermatologist Mitchell says: "When I came with Group Health in 1966, I saw 18 patients a day. Now, by our contract, I see 30, plus extras, so it's often 30 to 40."
Would he like to see fewer patients? "Certainly."
How does his load compare with private-practice dermatologists'? "I know some that would be happy to see 30!" esponsive," he says. "The first word that comes to my mind when I talk about a good doctor is 'conscientious.' I mean a doctor who is both competent and caring, who is working for you. I think we have doctors like that."
If you're a Group Health member and do not, ask to change doctors -- or change to some other type of care.