Primary care doctors struggling to survive

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http://www.latimes.com/business/la-f...228,full.story

From the Los Angeles Times
COLUMN ONE
Primary care doctors struggling to survive
Relatively low earnings, rising overhead and overwhelming patient loads are sending veteran physicians into early retirement and driving medical students into better-paying specialties.
By Lisa Girion

December 15, 2008

The morning's last patient, a disabled woman on Medicare, trails her doctor into her office and confides that she doesn't have money for lunch. Tanyech Walford pulls out her billfold and hands her $3. It's money the doctor really doesn't have.

"I tell patients I'm broke, and they just chuckle," she said. "They don't believe me."

Walford's fashionable medical suite in a sleek black-paneled building in Beverly Hills was hiding a grittier reality: She spent much of her lunch hour that day in her office opening mail -- hoping to find payment checks to help fill the gap between her expenses and her revenue.

She hadn't drawn a paycheck for herself since February. On top of that, her practice has cost her $40,000 in personal savings and left her with $15,000 in credit card debt. Walford, 39, also owes $80,000 in medical school loans. She shops at Ross and other discount retailers, and rarely eats out or takes time off.

"I'm totally stressed out," Walford said. "How can I take care of my patients when I'm that stressed?"

Walford is not alone in her struggle. Relatively low earnings, rising overhead and overwhelming patient loads are sending veteran primary care physicians into early retirement and driving medical students into better-paying specialties, creating what the New England Journal of Medicine recently called a crisis.

Primary care doctors "should be able to leave work thinking not of their income, or of unanswered phone calls, or of test results that they might have overlooked," Boston physician and associate journal editor Thomas H. Lee wrote in the Nov. 12 issue. "They should go home thinking, 'This is what I was meant to do.' "

But after five years, Walford couldn't hang on any longer. She closed her office nine days ago.

"It's sad," said Walford, who has shoulder-length wavy black hair, a cherubic smile and a slight lilt that betrays her Jamaican roots. "I worked really hard. It's a tragedy."

The loss of a single physician thrusts hundreds of patients into medical limbo. But the effect is far broader. Experts say the pool of primary care physicians is insufficient to meet the needs of an aging population. Already, shortages make it difficult to see physicians in swaths of northern and rural California, as well as neighborhoods in South Central Los Angeles and other urban cores.

Much of the problem lies in an endangered business model: the one- or two-physician general practice. Such practices are particularly difficult for primary care physicians to maintain because of their relatively slim and declining margins.

In her best year, Walford grossed about $360,000, more than enough to cover her overhead and take home a tidy income. That stands in sharp contrast to this year, when her practice slid into the red.

Small general practices afford doctors autonomy to practice medicine as they see fit and can produce strong doctor-patient bonds. But these physicians have little or no clout to leverage better payments with insurers; they have no economy of scale, which makes overhead more burdensome.

"It's very difficult, even in rich neighborhoods like Beverly Hills, to set up a solo practice," said Richard Scheffler, an economist at UC Berkeley. "The doctor has to pay rent, a nurse, have a bookkeeper, billing systems, computers. All of those fixed costs are very, very hard for a solo practitioner to have and survive."

Dr. Jerry Connell kept his family practice going in Santa Rosa for 29 years. But he closed it in October because his income had slipped to $50,000 a year, even though he had 2,600 patients.

"I could make more with my Social Security and investments than I could by staying in practice," said Connell, 66.

He didn't bother looking for a buyer because "no one in Sonoma County has been able to find a replacement in five years."

Connell sold his equipment, but not to doctors. A biofuels company bought his scales and microscope. A veterinarian bought his laboratory equipment. And a tattoo salon bought his autoclave to sterilize needles.

The economic slowdown is making matters worse. Physician revenues nationwide are falling as patients who have lost jobs or homes stop paying their bills and skip appointments.

"As people are tightening their belts, they are deferring things they think are a luxury or not absolutely necessary," said Long Beach physician Jeffrey Luther, president of the California Assn. of Family Physicians. "We see people putting off physicals and mammograms and blood tests because they just don't have the cash."

Walford's patients began canceling in droves several months ago. Even those who need to monitor chronic conditions like heart disease and diabetes stopped coming in. Of those who did come, many asked to be billed -- even for co-payments as small as $10 -- and then never paid.

"I love medicine," she said. "But they don't tell you this stuff in medical school. They tell you there's a shortage of doctors."

Walford's 1,950-square-foot office, down the hall from the Armenian Consulate, was in a professional building on La Cienega Boulevard. Framed modern art and historic photographs lined the walls. Oriental rugs were scattered over blond wood floors, and table lamps cast a cozy glow.

The office had four examination rooms and two waiting rooms -- one in the front and one in the back, for overflow. A couple of years ago, the space might have made sense. Walford was seeing 30 patients a day. In recent months, her patient load dropped to about 15; on bad days, 12.

Walford was forced to cut her staff from three medical assistants to one. In the end, the two of them did it all -- answering telephones, scheduling appointments and filing charts.

A naturalized citizen who emigrated from Jamaica as a girl, Walford grew up in Hyattsville, Md. She was inspired by a missionary doctor she heard speak while at the University of Maryland. The first member of her family to finish college, she attended medical school at the University of Virginia. A residency at Harbor-UCLA hospital brought her west.

Many of her patients were very attached to her. Some, like Catherine Ingram, cried when they learned Walford was leaving. A retired nurse, Ingram, 65, had been coming to Walford for four years.

"I was just getting used to her . . . trusting her," Ingram said. "She's wonderful."

In one of her last days in her practice, Walford saw Vincent and Eloise Hall, Malibu residents who own an auto parts distribution business in Compton. She checked Eloise's blood pressure, noted that she had lost 5 pounds and reminded her that she was due for a mammogram.

After giving Vincent, 74, a flu shot, Walford noticed that his blood pressure was up. As they went through the medications he is on, she learned that he had stopped taking his blood pressure pills. She reminded him of their importance and lectured him about getting more exercise.

Said Eloise Hall, 80: "She reminds me of our daughter."

Angela Russ couldn't get a doctor to see her until she found Walford. The 54-year-old airline customer service representative has insurance, but other physicians demanded that she pay her annual $600 deductible upfront. Walford gave her a pay-as-you-go option.

"I love her," Russ said.

Beverly Hills medical offices, near the prestigious Cedars-Sinai Medical Center, command some of the highest rents in the nation. Walford's suite ran $7,900 a month. It cost her an additional $6,700 or so for payroll, workers' compensation, taxes, medical and liability insurance, utilities, continuing medical education fees and other expenses.

But in the last few months, many patients failed to pay their bills. In September, she sent invoices to Medicare, Medi-Cal, private insurers and patients for $70,000. With negotiated discounts and government fee schedules, Walford, as a rule of thumb, expected to collect two-thirds of her billings, or about $45,000, that month. Instead, she got $14,000 -- less than her overhead. Walford fell behind on her rent. But she didn't bother dunning her patients.

"I can send patients to collections until the cows come home," she said. "I will never see that money."

Many primary care physicians boost their income by offering Botox injections and other cosmetic procedures for cash. Walford couldn't afford the training.

Others have abandoned poor and working-class patients altogether, opening so-called concierge practices that require clients to pay an annual retainer of $1,500 or more and to submit their own insurance claims. Her patients would not have supported that sort of practice.

With debt mounting each month, Walford was forced to explore other options. She set her sights on large, stable practices near where she grew up. She sought a job -- one with a steady paycheck -- that would allow her to take vacations without worrying about who would cover for her. She longed to concentrate on patients rather than on billing and collections. And she wanted to live in a place where she could afford to buy a home in a couple of years.

Early next month, Walford will join 200 physicians in a multi-office practice affiliated with Johns Hopkins Medical Center in Prince George's County, Md. Her base salary will be $115,000, plus bonuses based on the complexity and quality of care she delivers. Benefits include vacations, health insurance, a pension plan and paid continuing medical education.

Walford couldn't find anyone to buy her practice and is still searching for someone to take over her lease. Dr. Peiman Berdjis, a friend with an office nearby on Wilshire, agreed to take the charts of the 2,000 patients she had seen over the years. Her patients can start seeing Berdjis or find another doctor.

Walford said she sold her equipment for "pennies on the dollar" and gave her furniture to a couple who lost their home in the Sylmar wildfire. She stayed up until 4 one morning putting stamps on farewell letters to her patients.

"This is a relief," Walford said from her cellphone as she drove east toward her new practice. "I've been spent emotionally, financially, physically, and now I need to have someone else worry about the finances."

Girion is a Times staff writer.

lisa.girion@latimes.com

[Sol Invictus]

"As people are tightening their belts, they are deferring things they think are a luxury or not absolutely necessary," said Long Beach physician Jeffrey Luther, president of the California Assn. of Family Physicians. "We see people putting off physicals and mammograms and blood tests because they just don't have the cash."

Holy absolute ####!

Putting off physicals and mammos because of being a luxury......



Just......

Originally Posted by Sol Invictus

Holy absolute ####!

Putting off physicals and mammos because of being a luxury......



Just......

You know it is rough when you have to let one of the children go come time
to cut costs.

In America under the HMO system, they have already placed a monetary value on human life. It is your insurance that made this judgement.
Soylent Green cannot be far behind.

[Sol Invictus]

Soylent Green.

That movie gave me the creeps. People laughed at me for saying 'you know, thats going to come true one day because they need us as slaves'.

[Anchor]

Big pharma doesnt want solo or independant doctors. They will all be squeezed till thier pips come out.

This is quite sad for now, but hopefully will precipitate a tipping point that forces people to discover "real" health care and the truth behind modern medicine.

A..

[Dantheman62]

The funny thing about it is the whole insurance thing here in America is a scam, for example when I had kidney stones( OUCH! ) the urologist I went to asked if I had insurance, and I said no, so he said he'll discount everything since I'm paying cash and he'll give me the pain meds out of his sample packs that he gets from his drug co. reps. So about $4,000 dollars later I was fine, but I thought if I just paid around 4 grand for everything than what would he have charged the insurance company if I did have insurance? probably twice as much!=scam!

[Sol Invictus]

$ 4000 ????????????????????????????????????????????

For kidney stones??????????????????????????????


THATS A FECKING RIP OFF!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

A quick ultra sound blast to fragment them and they pass through as small little grains... job done in eight minutes tops!

[Dantheman62]

Nope, ultrasound to find the stone,then x-rays to pinpoint it and determine size, then a thing called Lithotripsy(spelling?) to crush the stone up,which they put you out cold for, then tests and drugs and check ups, and lions and tigers and bears, oh my!

[Sol Invictus]

Originally Posted by Dantheman62

Nope, ultrasound to find the stone,then x-rays to pinpoint it and determine size, then a thing called Lithotripsy(spelling?) to crush the stone up,which they put you out cold for, then tests and drugs and check ups, and lions and tigers and bears, oh my!

................ thats not Kidney stones, thats kidney mountains!

[Dantheman62]

HaHaHa, I wasn't even going to go to the doctor but I got real tired of leaning over my bed, feeling like somebody was stabbing me in the left side of my back and twisting the knife, the funny thing is that the pain would leave about every 15 minutes, for about 15 minutes, so everytime that happened I would eat or drink or smoke or do whatever I had to do knowing that I had about 15 minutes before it came on again! phew I wouldn't wish that on my worst enemy, hmmm, well maybe

[Humble Janitor]

No love for the U.S Healthcare System here. It's one of the greatest frauds ever perpetuated upon Americans. I do not feel sorry for doctors. Some of them are clearly only in the business to make money. They should be blaming the insurance industry, which profits off of YOUR pain and suffering.

I still have medical bills that I haven't paid and again, the insurance industry is made up of crooks. All you do is spend money for them to insure you and when you get sick and really need the money, where are they? They're sending you constant bills, harassing you over the phone and charging you interest on YOUR medical bills once they pass them over to collection agencies.

Again, no love lost. Boo ****ing hoo.

Originally Posted by Humble Janitor

No love for the U.S Healthcare System here. It's one of the greatest frauds ever perpetuated upon Americans. I do not feel sorry for doctors. Some of them are clearly only in the business to make money. They should be blaming the insurance industry, which profits off of YOUR pain and suffering.

I still have medical bills that I haven't paid and again, the insurance industry is made up of crooks. All you do is spend money for them to insure you and when you get sick and really need the money, where are they? They're sending you constant bills, harassing you over the phone and charging you interest on YOUR medical bills once they pass them over to collection agencies.

Again, no love lost. Boo ****ing hoo.

The medical community wears their share of it. But so do you. During the eighties west texas obstreticians
were forced out of business by the high cost of malpractice insurance. This caused women to drive as far as four hours to be seen.

Here in Washington State lack of access to care has caused a backlash response. Much of the primary care
is handled by nurse practitioners and physicians assistants. Everyone and his dog are allowed to write a prescription. Trust me when I say that there is
a difference. The other than physician provider groups
have a much wider variation in quality than physcians.
Let me just say that they require close watching for
wierdness even though most are very good.

Of course there is always socialized medicine. I work in the prototype of the socialized health care system. Services are free if you don't count your time. You may wait 3-6 months for an appointment and the standard wait time for my services is 2-4 hours. They drive up to eight hours to come see me and then bitch about the wait. Never mind that my pharmacy fills 5,000 prescriptions a day. Never mind that the fool doing the bitching drove two hours and waited three to pick up a bottle of enteric coated aspirin for free that cost him 18 dollars in gasoline. Most of the **** I throw out the door
is unnecessary because the average american can't cope with life unless they are medicated into a stupor. But they get upset if they wait six months and walk out with a pat on the head and a word of encouragement. They don't feel treated unless they walk out with a fist full of prescriptions, and they're not shy about voicing their opinion about it.

Heal thyself pilgrim!

Where my wife comes from they don't have insurance and they don't go to doctors. One fellow she knows fell face down in his garden with a heart attack. Got up went in the house and sucked it up. He's still with us btw and never did see a doc about it. That was over three years ago.

Root hog or die!