This was the case in Dallas, Texas, where a group of doctors--widely described in the media as medical rebels--told Aetna that they were decamping from the HMO system and dropping 8,000 patients unless they chose to stay on voluntarily. While the doctors complained of patient-care problems, the dispute centered ultimately on money. According to Dr. Ralph Turner, chairman and president of the Genesis Physicians Practice Association, Aetna had agreed to provide the group with centralized data, like patient hospital days and prescription drug information, crucial for managing costs. When Aetna failed to do so, leaving the group in the dark and "financially responsible," said Turner, the doctors rebelled.

The group ultimately dropped Aetna, which then used a provision in its contract to block Genesis from treating 300,000 additional patients in other plans and threatened the doctors with a price-fixing lawsuit. "We weren't trying to blow up managed care," said Turner. "We have managed-care companies that really want to work with us."

The group's concern over money is made visible to patients in the office of one Genesis doctor, Evan Bates. Three different signs stuck to the sliding door of the reception area say: "Payment is expected at the time services are rendered." "$15 service charge on all returned checks." "Sorry, we do not validate parking."

By contrast, Johnathon Ross of Ohio has studiously removed every mention of payment from his office so that he won't discourage patients from seeking care. But he also relies on a strange rapport with the system he detests. He uses the drug-company representatives for their samples, for instance, at the same time that he keeps a folder of every "bribe" they send him: offers of cruises and elegant dinners, golfing outings and family trips to amusement parks, in exchange for learning about or using some of their products. He sent this file, including the one about an evening of beef tenderloin and carrot cake to talk about advances in cholesterol-reducing drugs, to the Ohio Attorney General for investigation. He received no response.

On a recent day a drug representative wandered into his office, and Ross bristled with hostility as she unloaded a jar of candies bearing her company slogan and a bagful of samples. But when his patient, Wanda Williams, came in to get medication for a seizure disorder, her baby daughter in tow, the samples were crucial. "Welfare needs to know the gross of my husband's income," she said. "But if I don't get my dilantin, I'll die."

In 1992 the St. Vincent Medical Center Auxiliary Foundation invited various medical practices to compete for a $50,000 grant to purchase medications. Most of the competitors showed up with a fancy presentation and glossy slides. Ross simply showed blank slides, to illustrate his empty medicine cabinets. He won the grant.

Ross seems a rare kind of doctor--for now. But as healthcare professionals grow angrier about scraping together care from a threadbare system, they are increasingly ready to defy the bureaucrats and insurers who get in their way.

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