This type of resistance is particularly noteworthy in the hierarchical and tradition-bound medical profession, where radical forms of protest have been rare. When activism has emerged, it has usually been around relatively narrow issues, such as the need for better care or more research dollars for AIDS, breast cancer or spinal-cord injuries. But anger at HMOs for interfering with efforts to treat patients has cut through a broad cross section of healthcare professionals, from RNs in city emergency rooms and liberal family doctors to archconservative surgeons.

In 1997 a poll released by Louis Harris and Associates reported that more than half of America's doctors believed the US health system is getting worse. Doctors in states dominated by HMOs were more likely to cite serious problems in caring for patients. Since then, as enraged doctors have drafted recruits, a new generation of medical practitioners has learned that the best way to treat patients may be to ignore the rules.

It is hard to say what impact these brushfires of protest will have or whether they have already contributed to the patients' bill of rights passed by the House in October, which would make it easier for consumers to sue health insurance plans that deny care or provide poor treatment. But in any case, a patients' rights bill will be unlikely to appease managed-care rebels, many of whom want not incremental reform but a universal healthcare system that will insure every American, including the 44 million who are currently uninsured. Some doctors even feel that the patients' bill of rights is a deceptive and cosmetic measure that upholds a system of corporate medicine while masking the profit motive at its heart. "To feign surprise that profits are prioritized over patients' well-being reminds one of the line from Casablanca: 'I'm shocked, shocked, to find that there is gambling at Rick's,'" wrote Dr. Larry Amsel of Columbia University in Tikkun.

A few managed-care companies, including United Health Group, Aetna and several Blue Cross plans, recently appeared to soften their reviewing procedures, offering members the right to appeal denials to an independent panel. But healthcare workers complain that the new policies are still too restrictive, and the phenomenon of medical road rage among patients and practitioners continues unabated.

One result is that some HMOs and hospitals have turned into virtual armed camps. Healthcare has become a booming business for companies that provide on-site security, several of which have even created their own healthcare divisions. In March 1998 the Occupational Safety and Health Administration issued beefed-up guidelines for security in healthcare facilities after its report showed that of all industries, healthcare had the highest incidence of assaults on employees. Joseph Gulinello, executive director of healthcare security at Burns International Security Services, attributes this in part to frustrations caused by managed care. "People have a certain expectation that they're going to go and be treated right away, but they wait a long time, clinics are crowded, they are denied services. It's an environment that leads to violence, and a lot of it has to do with being frustrated with not receiving quality care."

Overt lawbreaking among clinicians is still unusual, but many have used threats and deception to help get procedures covered and claims paid. Some doctors are trying to force accountability on claims reviewers who crouch behind 800 numbers in their industrial parks by threatening, simply, to show up. As one doctor recalled asking, "If you don't give me some indication as to why you've denied this, I will get in my car and I will be coming to the office, and you will give me some explanation." Fifteen minutes later he got a call that his claim had been approved.

In another instance, when the hospitalization of a psychotic patient was denied, a psychiatrist told the reviewer, "I'm going to put her in an ambulance and send her over to you." Claim approved. Bryant Welch, a Washington, DC-based attorney and psychologist who represents psychiatric patients against HMOs, points out that decisions to deny care to the mentally ill may have unforeseen repercussions. "These people are highhanded, and they're hitting people at a time when they are desperate, and being contemptuous of them," he said. "As the decisions become more and more draconian, they do run the risk of denying care to people who are barely holding on, so the danger of violent retaliation is going up."

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