"When your lexicon, tools, and theoretical constructs no longer get results, you start casting about," physician Schmitt adds. "You let people whose ways are different have free rein. Practitioners of traditional Chinese medicine, for example, have a totally different way of conceptualizing and diagnosing than the reductionist approach of Western medicine. By addressing a common problem with different languages, you have almost a Rosetta stone."
Caught up in the challenge, the staff treated many patients who didn't have the resources to pay the enormous expenses that accrue to AIDS or HIV-positive patients who try to take the best possible care of themselves. "The reality is that Stratogen subsidized alternative-care services for several years," concedes Dr. Piperato. "It got to the point where it was not a tenable situation. We'll still refer our patients to a massage therapist or acupuncturist. We're still committed to the notion of using alternative care, but the reality is that often they just don't have the income to pay out of pocket when insurance won't pay."
Stratogen patients interviewed for this story all said they would continue seeing the clinic's doctors and psychologist, despite the sometimes difficult adjustments they have had to make, especially if they were patients of Dr. Schmitt (changing physicians is often described by AIDS patients as a wrenching experience). As for continuing their acupuncture or other therapies, they now must go to individual offices and try to work out payment plans. And they no longer have a "case manager," one of the hats worn by Susan Luck, who helped coordinate all therapies and guide patients through the mazes of insurance claims and applications for benefits.
For many the new process is much less convenient. "I have to run around and see [acupuncturist Bell], then fill out my own insurance papers and send them in," says patient Jess Vickelhaupt. "I did see a different chiropractor somewhere else, but I haven't had a massage since all the changes. These people clicked together, there was a chemistry. I don't want to get too esoteric, but there was certainly something happening there."
Another patient, who doesn't want his name published, says he is upset over what he sees as unnecessary and ill-conceived cutbacks. "They could have made it profitable if they'd tried," the patient insists. "The reason I went to Stratogen in the first place was the fact that they embraced not only Western medicine but that the office had [alternative practitioners], and the doctors were able to communicate with them. That and the reputation of Dr. Schmitt. In my opinion, the biggest casualty of the whole situation is that we lost the finest doctor South Beach has to offer, and we can't afford that at this time -- to take him out of practice because a corporation disrupts his whole vision and his ability to practice."
Schmitt stayed on as medical director through July. Leaving Stratogen has been as traumatic for him as for his patients, and at the moment he says he wants only to "step back and ponder" the future of HIV care and how it fits into the business of medicine. "I just can't explain the joy of wrangling with a really complicated problem," he says. "A lot of time has to be spent noodling over each particular situation. There is a tremendous amount of invisible work in taking care of people with complicated conditions. If it were an attorney's office, you could bill by the quarter-hour and get paid. But we were forever being told that what we were doing couldn't be paid because it wasn't an 'approved procedure.'