"I think there are several issues our society's going to have to look at. How much are we willing to pay," for health care? asks Dr. Kathryn Medearis, an independent physician until this month when she joined the Menlo Clinic. "Doctors will always make the choice to take care of the patients. We will spend what it takes . . . until society says `You can't do this (procedure), and we won't sue you for not doing it.'"
Medearis has had to make similar choices, to find ways to spend more time with patients, and maintain her quality of life without getting mired in bureaucracy.
Until joining the Menlo Clinic, she was in independent practice for nearly five years. Like many doctors, she faces the changing nature of medicine, a field that is receiving intense scrutiny by the government, and where many feel that less control is left in the hands of physicians where it should be while more is being taken over by insurance companies in the name of efficiency and cost-cutting.
Medearis, a 37-year-old mother of two young sons, began her practice in 1989. She and her partner practiced in Palo Alto, splitting the overhead of their office fifty-fifty. Yet Medearis found she was wearing hats she didn't want to wear and handling too much of the business end of things, at the same time trying to keep up with her patients and changes in the medical field.
"When you're in private practice, there are two parts to your job. You are a doctor, and then you run this small business, do the hiring, the firing, have to be up to date on regulations for employee taxes and benefits," she said. "I don't like being the human resource person, the employer."
Beyond that, she had to keep up with rules and regulations about insurance, and Medicare. "Literally at home I have three garbage bags full of bulletins from Medicare," she said. "It's hard enough to keep up with the work of taking care of patients and to keep up with the reading in your field and the last thing you want to do is read a Medicare bulletin."
Then there were the Cal OSHA requirements and the strict rules for doing any lab work.
"There's nothing intrinsically bad about that," said Medearis. "It's just I'd rather spend my time reading medical journals and taking care of patients and playing with my kids."
For independent physicians, it is also financially prohibitive to cope with myriad insurance plans. Medearis and her partner didn't belong to an HMO (health maintenance organization) or a PPO (preferred provider organization).
"So what would happen is many of my patients would have to pay more to come and see me than they would if they went to somebody on their list. I, however, did not make more money than other doctors. My overhead was the first thing that got paid.
"The busier my practice got, the more successful, the worse my life was," she said, laughing at the irony. "I wasn't getting home until 7 o'clock at night, and I was exhausted."
Deciding to chuck the independence along with the business hassles, Medearis chose to join the Menlo Clinic, where she shares an office with another woman doctor, who is also a mother. They are both able to cut their hours yet still cover their patients.
But while some of the administrative headaches have been taken away, and the convenience of having access to X-rays and labs and high tech equipment has eased her burden, Medearis still cannot escape the impact of changes in health care.
"This insurance thing has really been disruptive, and it's upsetting for patients," she said. She recounted the story of a longtime patient who called to tell her that her employer had switched to an HMO that did not include Medearis. The woman's human resources department told her she could go to another doctor on the plan and ask them to refer her to Medearis.
But Medearis, an internist, sees problems with such a scheme.
"If I had a patient come in who basically said `I'm coming to you because you're on the list, but I want you to refer me to another internist,' I can't just refer them out to another doctor who's trained to do exactly what I can in good conscience.
"It puts doctors and patients in really a bad kind of relationship. It used to be that patients came to me because their friend had told them I was a good doctor and there was (an) assumption of trust, that we had kind of chosen each other. Now we're getting patients who, if they had their druthers, they'd go to somebody else. Well, that doesn't feel good."
The way President Clinton's proposed health reform plan is outlined, many doctors, including Medearis, see it as price fixing.
"As a private doctor, if the government fixes your costs, it basically means you are at the mercy of your suppliers because there's nothing you can do to make it profitable. Now, Clinton may say `You've got to be more efficient,' or 'Doctors make too much money,' but that's a very difficult thing to determine. A lot of doctors work 60, 70, 80 hours a week.
"We basically believe in free enterprise. I really feel it's out of the role of government to tell doctors what they can charge for their services.
"I went into practice in 1989. I was 33 years old when I started to make money in my profession. Nobody in their right mind who wants to make a ton of money goes into medicine. It asks too much of you."
Beyond that, she says, health care employs many people. "Frankly, taking care of sick people is a noble human endeavor and it may not be so bad that it takes a good deal of our GNP. The reality is, in time we're going to have to start making some choices because it isn't free and you can't buy everything." A recent court case illustrates this. Nelene Fox, a southern California woman in the last stage of breast cancer, sued Health Net after it refused to pay for a bone marrow transplant that was deemed experimental. Fox died, and the court later ruled in her favor, awarding $12 million to her estate.
"I have total empathy for this family. You are talking a lot of money. If we say, okay, insurance is going to cover bone marrow transplants for women in advanced stage breast cancer, you have to ask what you're going to do without."
Medearis notes that if she has to spend 15 minutes on the telephone talking to an insurance company to get approval for a test, that's 15 minutes she can't spend with patients.
"The quality of a patient-doctor interaction is affected on some level by how much time you can spend.
It is more than just a health issue, Medearis feels.
"Politicians are talking about it, business people are talking about it. We need to have a social dialogue on this. This is not a medical issue. This is really an economic issue, a political issue. I kind of felt like there's not a whole lot I can do, I'm kind of at the mercy of the politicians and health care administrators. (But) I've come to see it in a different way. If you're my patient, I have more influence on your health care than anybody else.
"You can't just look at a thing and say `oh, it's terrible an insurance company won't pay for bone marrow transplants.' You have to say `Am I willing to have my insurance rates go up $200 a year so that insurance companies will pay for bone marrow transplants?' These are not medical issues. These are really how does our society value things?"
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