Power shifts in health care as public demands voice.

The health care industry is changing fast - and nowhere is the pace of that change more feverish than in Los Angeles.

For more than a decade, the region has been in the vanguard of the managed care revolution, which has transformed the way American consumers receive their health care. Now, L.A. is at the center of what might be called a managed care "counter-revolution" - with patients, consumer advocates, physicians and legislators increasingly demanding a place at the table.

"As a result of the massive growth in managed care, people have recognized that they no longer have control of their health care," said California Assemblyman Martin Gallegos, D-Irwindale, who has led the charge in Sacramento for HMO reform. "They have become more visible politically. Their voices are becoming much louder."

Gallegos, a chiropractor who was elected to the Assembly in 1994, is one of the many new faces in the Business Journal's 1997 Who's Who in Health Care.

Indeed, there are only a handful of returnees from last year's Business Journal Who's Who - evidence of the highly dynamic state of the region's health care industry.

In addition to physicians, hospital administrators, HMO executives and consultants, this year's Who's Who includes an unprecedented number of attorneys, consumer advocates, politicians and regulatory officials.

Besides Gallegos, those newcomers include Peter Kezerian, general counsel of the state Department of Corporations, the state agency responsible for regulating health maintenance organizations; Jamie Court, director of Consumers for Quality Care; and Mandy Johnson, executive director of the Los Angeles Community Clinics Association.

The emergence of advocates and regulators as major players in the health care field constitutes a significant change from years past, when the agenda was set primarily by large purchasers and insurers seeking to scale back the excessive costs of fee-for-service medicine by instituting the new, often intensely cost-conscious model known as managed care.

"Twenty years ago, a 'who's who in health care' would have been all doctors; 10 years ago it would have been all too many accountants," said Peter Lee, director of the Center for Health Care Rights HMO Consumer Protection Project.

"Today, we're moving towards a better mix of doctors, providers, purchasers, consumers - a whole range of people wrestling together with the need to balance access, quality and cost of health care," he said.

In the midst of this cacophony, the various industry participants - health plans, hospitals and doctors' offices - are continuing to merge with one another to increase the efficiency and cash flow demanded by managed care.

There are two major factors driving the consolidation trend: first, physician groups and hospitals need geographic coverage throughout an entire region if they hope to secure contracts with large health plans.

At the same time, those health plans especially publicly traded HMOs - need sustained growth to fatten profits and cut costs.

Those factors have remade L.A.'s health care landscape, according to Jim Lott, senior vice president of the Healthcare Association of Southern California, a group that represents hospitals and physician groups.

"With managed care, the competition suddenly has become someone to form an alliance with," said Lott. "Your opponents of yesterday have become you strategic partners of the future. People have stopped growling at each other and started smiling."

With increasingly vocal patient advocates and regulators on one side, and intense market pressures on the other, the effective health care executive will be the person who can successfully negotiate a minefield of competing interests, said Steve Valentine, president of Camden Group, an El Segundo-based consulting firm that works with hospitals and doctors' groups.

"You have to find a person who is very good at relationships, yet has a good, strong analytical orientation because of the complexities of managing in this kind of environment," said Valentine.

Added Lott: "The health care leader needed for tomorrow is someone who can think outside of the box."

That kind of thinking will be needed in a hurry. A flurry of managed care-related legislation is pending in Sacramento - which, among other things, would require HMOs to disclose within five days their rationale of denying treatment to a patient.

This grassroots push to reform HMOs has propelled consumer advocates to the fore of the health care debate, and will likely keep them there in the years to come.

Already, HMOs have begun responding to pressure from patient advocates like Lee, Court and Johnson by giving consumers more power to choose their own doctors through such features as point-of-service plans.

"HMOs are beginning to see that they have to respond to what consumers are asking for," said Lott. "The question is, Is it too little too late? There seems to be a steamroller effort towards regulating HMOs - or even destroying managed care."

How We Compiled The '97 Who's Who

Selecting the health care professionals to include in this year's Who's Who in Health Care was an especially difficult job, considering the dynamic state of the industry.

Just a few years ago, health maintenance organizations were Goliaths dominating the local scene, and the Business Journal's Who's Who reflected that dominance.

But times have changed, with the playing field leveling as physicians, hospitals and patients gain back some of the clout they had initially lost in the shift to managed care. This year's Who's Who reflects that dramatic field-leveling. Fewer than 25 percent of the people featured in last year's Who's Who in Health Care reappear this year.

Our initial research effort began with a review of major health care news stories from the past year, from general readership publications as well as health care trade publications.

Additional candidates were brought to our attention by industry analysts, prominent health care veterans and local industry observers.

The original field of candidates was whittled down by the Business Journal's news team from more than 200 names to a short list of about 65 candidates. Of those, 50 were selected for the Who's Who report.