Good Work, Now You're Fired

The name of the place -- Stratogen Health -- sounds like a high-tech diagnostic center, or maybe a medical consulting firm. Definitely streamlined and corporate. In reality, for the past five years the name was a front of sorts for something quite different: a pioneering HIV/AIDS treatment center, and the antithesis of the kind of corporate medical operations that are taking over the world of health care.

Patients, especially those who were treated even if they couldn't afford it, loved Stratogen, housed in an unassuming office building just off Arthur Godfrey Road in Miami Beach. But everyone knows love can't pay the bills, and Stratogen was a money loser for years. Now, ironically, its name fits much better. Ten months ago a fast-growing New York corporation became the clinic's new owner and began performing financial triage. In the process, most of what made Stratogen unique and innovative has been sliced out.

The surgery no doubt is saving Stratogen as a viable business, but it has also had potentially serious consequences for the lives of many of Stratogen's couple of hundred patients. More broadly, the South Florida HIV/AIDS community, one of the nation's largest, has lost an important resource.

By all accounts Stratogen was the first HIV clinic in South Florida to integrate traditional Western medicine with a range of vastly different approaches to treating the complex problem of AIDS: acupuncture, herbal medicine, massage, chiropractic, nutrition and vitamin therapy. Even five years ago the concept wasn't new; similar multidisciplinary programs existed in other cities, and alternative therapies have long been used to one degree or another in HIV and AIDS treatment.

Locally, though, nothing quite as ambitious had been combined under one roof. And the timing was propitious. Today a growing body of medical literature is noting positive results of alternative medicines on various AIDS-related conditions, and hospitals and clinics across the U.S. are establishing more integrated (or "complementary") HIV programs. Also, more insurance companies are beginning to pay for at least some alternative therapies, although many insurers remain skeptical.

"What we put together was a really important model [for HIV care]," says Susan Luck, a nurse and nutrition educator who was part of Stratogen's diverse staff. "We each came from different directions, but we all were always looking at the whole person. And just when this care was being documented in mainstream medical literature, these business people came into a community sophisticated enough to know what they're getting and didn't allow the clinicians to have any input."

Adds Dr. David Schmitt, one of Stratogen's founders and its recently departed medical director: "It was an extemporaneous experiment that I think was really dazzling. And now it has burned out."

When Total Physician Services, Inc. (TPS) bought Stratogen this past October from a corporation called Pro Health, the operation had been "hemorrhaging money," according to another Stratogen physician, Dr. Joseph Piperato. No one, however, claims to know exactly how much money it was losing, and TPS isn't releasing financial data.

With other recent acquisitions in Dade, Broward, and Palm Beach counties, TPS now employs a total of 33 doctors, says president and CEO Andrea Benko. (The two-year-old corporation also owns HIV practices in New York and California.) "We're putting together a network of physicians specializing in HIV and AIDS," Benko elaborates. "We see this as an opportunity to really improve patient care, since right now HIV patients are usually seen by doctors who are not specialists in the field."

Stratogen has merged with another Miami Beach medical practice purchased by TPS, giving the clinic four physicians instead of the three it used to have. A new in-house laboratory performs the latest highly sophisticated diagnostic tests -- all aimed at taking advantage of recent technological and pharmaceutical advances in HIV care. Both the tests and the drugs are very expensive but are generally covered by insurance.

Many doctors believe the ideal arrangement is a combination of the powerful new anti-HIV drugs and alternative therapies. But a critical mass of physicians and insurance companies has not yet formed to endorse the holistic approaches, so insurance reimbursement remains troublesome.

Stratogen's new owners couldn't figure out a way to make money by keeping a massage therapist, an acupuncturist, a chiropractor, and a nutrition counselor in the office. So this past spring the alternative practitioners on staff began leaving the clinic. First the contracts of the massage therapist and chiropractor were not renewed. Then one Friday afternoon in June acupuncturist Lori Bell and nutrition educator Susan Luck (both of whom had already taken pay cuts) were told not to come back the following Monday. They had the weekend to cancel their upcoming patient appointments.

No one disputes the great dedication and competence of the past and remaining medical staff -- one reason, Benko says, that TPS was interested in buying Stratogen. But patients and co-workers say it was the doctors' willingness to seek input from outside their disciplines that made Stratogen important. "We worked with very open-minded doctors," relates acupuncturist Bell, who now has her own Miami Beach practice and also works at the Alternative Medicine Center in South Miami. "It really was integrated. They'd pull me into a room and ask if I'd noticed anything out of the ordinary with a patient's liver, for instance."

"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.'


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