The endangered private, family doctor

By JEREMY HAY & MARTIN ESPINOZA
http://www.pressdemocrat.com

Tucked away on a wooded slope off Chanate Road is a drab complex of white buildings that houses a medical training jewel that produces some of the best family doctors anywhere.

Many come from the most prestigious medical schools in the country to join the Santa Rosa Family Medicine Residency. And over the years, about half of each graduating class stayed in Sonoma County to practice what Rick Flinders, a graduate himself and today the residency’s chief of adult medicine, calls “cradle-to-grave care.�

Today, about half of the county’s 278 family medicine doctors came out of the residency, according to the Sonoma County Medical Association and the residency program.

But just as the program became a marker of fundamental health in the county’s medical landscape, it now has come to reflect the local and national struggles of a beleaguered health care system.

With each graduating class, an increasing number of talented physicians pack up and leave the county, driven out by the high cost of living, poor government reimbursement for their services and a medical school debt that rivals a home mortgage.

They are joined by established doctors leaving for the same reasons. In 2006, a Sonoma County Medical Association survey found half the county’s doctors were considering retiring or moving away within five years.

Marisha Chilcott, 40, started her second career as a family doctor in Sonoma County in June, joining her 77-year-old ex-father-in-law’s practice. They have begun charging patients an annual fee, the only way they could survive, she said.

“I can think of six doctors, family docs, who left Santa Rosa within six months,� she said. “It really felt like showing up for the last dance on the Titanic.�

This year, only three of 12 residency grads stayed in the county, two as temporary doctors and one as a fellow within the residency program itself.

“I’d love to stay,� said Nicole Mohlman, a second-year resident.

“I just don’t know if it’s feasible.

A full-scope family practice doesn’t seem plausible in Sonoma County—that’s what I’m hearing from my colleagues.�

The graduates who leave the county do so amid a worsening shortage of primary care doctors, defined as family doctors, pediatricians, internists, obstetricians and gynecologists.

And they leave as the public’s points of access to such doctors grow more limited.

Fewer venues available

Although there are more primary care doctors today than there were two years ago, the increase has come at Kaiser Permanente, where services are available only to the nonprofit group’s members.

Kaiser now has 145 primary care doctors, up from 111 in 2006, reflecting the organization’s rapidly growing share of the county’s insured patients.

Meanwhile, the number of non-Kaiser primary care doctors has dropped by 17, from 349 in 2006 to 332.

“The choice of the venues is also shrinking,� said Kirk Pappas, president of the Sonoma County Medical Association and a sports medicine specialist at Kaiser.

“People are coming to the county to join Kaiser, but they’re not coming to hang up their shingle,� Pappas said.

Health-care experts suggest the shortage of family doctors also is driving more people, both insured and uninsured, to seek diagnostic care in hospital emergency rooms.

“We know what happens,� Flinders said. “People delay seeing a physician, and when they see a physician they are sicker.

They get to the emergency room instead — and this more expensive, more inefficient model of health care becomes the default delivery system.�

The roll of Sonoma County family doctors who graduated the residency reveals another fault line: Many are aging, already working part time or getting ready to retire.

“Every time I turn around, I see another family doctor retiring,� said L. Reed Walker, a 1972 graduate of the residency.

Walker was in private practice for most of his career but now works part time for Sutter Medical Group. He closed his private practice in 2006.

“I couldn’t afford to pay formy patients’ care,� he said.

He said the squeeze on his practice was because most of his patients were on Medicare, which reimburses family doctors at lower rates than specialists and Sonoma County physicians as a whole at among the lowest rates in California.

“I was actually borrowing money to keep my practice afloat the last year or so. It was untenable,� he said.

Feeling the squeeze

Access for conventionally insured and government-insured patients is tightening as more family medicine doctors switch to Kaiser to get away from the bureaucratic headache private practice has become.

One of those is Steve Olson, who sat recently in a small, neat office at the residency, which he graduated in 1987. He left Primary Care Associates, once a thriving independent physicians group, for Kaiser in 2006. Now he works once a month at the residency as a preceptor, offering instruction to resident doctors.

What he left behind, he said, was a fragmented and expensive health-care system in which less money was being spent on actual medical services, “patients were getting beat up by their insurance companies� and doctors were pitted against insurers.

“There was such an adversarial relationship between everyone involved,� he said. “It was getting pretty disgusting. I was working for the insurance companies to help increase their profits.�

At Kaiser, Olson said, an institutional emphasis on making care more efficient and effective means that, to his surprise, he works harder, “no question. But the work that you’re doing is all medicine.�

Giving up control

Kaiser assumed a role in the residency last year when Sutter Medical Center, which is obligated to operate the residency program under its health-care agreement with the county, floated the prospect of shutting down.

While Sutter, under pressure to honor its contract, reversed course, it’s given up control of the residency to a consortium that includes Kaiser and Santa Rosa Memorial Hospital, community health clinics and the county government.

One of the consortium’s goals is to recruit talent from the program. The crisis also paved the way for non-Sutter doctors, such as Olson, to participate as teaching staff.

Family practice doctors and pediatricians are the lowest paid of all physicians, said Lauren Spieler, a third-year resident at the Chanate Family Practice Center.

“People don’t go into family practice to become rich doctors,� Spieler said. “We do it because we’re passionate about the health of our community.�

Spieler, who grew up in Los Angeles and refers to herself as a Southern California expatriate, said she’d love to stay in Sonoma County. She lives in Sebastopol and has a 3-year-old son cared for by her husband.

Whether Spieler stays likely will depend on where her husband finds work because it will require two incomes to pay for the house they want and the $220,000 “career mortgage� hanging over her.

Sonoma County’s designation by the federal government as a rural area where medical costs are deemed relatively low is part of the reason young doctors like Spieler often are forced to leave the county.

The rural designation brings low reimbursements from Medicare, which in turn triggers lower reimbursements from private insurers. Changing it has been the focus of an all-out lobbying effort that encounters stiff resistance, Flinders said.

“To change our designation, we’ve got to take it away from some other county, and what county wants to give it up?� he said.

Leaving the county

Novato, just a few miles south of Petaluma, get’s a higher Medicare reimbursement.

“You go down to Marin County and you make more money. It just doesn’t make sense,� said Joe Matel, a third-year resident physician.

Matel, a tall, bearded redhead with a big smile and calm voice, went to medical school at the University of Minnesota.

He will have to leave Sonoma County next year.

The National Health Service Corps paid for three years of his medical school studies, a $100,000 tab. In return, however, Matel must give back three years of service in federally designated areas that suffer severe shortages of primary care.

There are none in Sonoma County, he said.

Recently, Matel juggled rounds at the Chanate clinic, going in and out of small examining rooms where young patients and their mothers waited for him. They didn’t have to wait long.

“I love him ’cause he’s honest and he doesn’t hide anything.

He’s the first doctor I fully trust,� said Brittany Nikol, 26, of Santa Rosa, as Matel performed a checkup on Nikol’s 7-month-old baby, Harper.

The high cost of living, low government reimbursements and insurance company hassles are causing family doctors to seek refuge with large institutions: One of several community clinics in the area, Kaiser or expanding medical groups, such as Sutter Medical Group of the Redwoods.

One such outfit, Annadel Medical Group, will open Oct. 1. It is formed, tellingly, from a private practice, Primary Care Associates, that had shrunk dramatically under financial pressures and decided it could no longer survive.

Annadel Medical Group will be managed by St. Joseph Health Heritage Healthcare, a part of the St. Joseph Health System that also owns Santa Rosa Memorial Hospital.

Essentially, Heritage provides the Annadel group doctors with back office, records and equipment systems and administrative support, as well as nursing and office staff, said C.R. Burke, president and CEO of Heritage, which operates a similar model in Southern California.

A national problem

The goal is to retain primary care doctors in the county and attract new practitioners, said Katy Hillenmeyer, St. Joseph’s Sonoma County spokeswoman.

Working for such groups relieves physicians of what is known as practice hassle.

Trina Bowen, a family doctor at the Occidental Area Health Center, said that when she finished her residency in 1983, about half or more of the graduates stayed in the area.

Bowen said the things that ail the county’s health-care system are national in scope and unlikely to change without an overhaul of the system.

“Many of us, if not all of us, are absolutely being pushed to the limit by managed care or prior authorization for any medication, test or referral,� said Bowen, who favors a single-payer system.

The national shortage of primary care physicians is expected to be 85,000 doctors by 2020, said Walt Mills, associate program director of the Santa Rosa residency.

“Family medicine is the main, largest specialty generating primary care physicians, of which there’s just not enough,� Mills said.

Half of all the people going into primary care in the United States are foreign medical graduates, he said. However, he said,

this trend is not likely to continue as global economics change.

Matel is among 30 percent of residency grads who must leave the county because they are obligated to work in one of the federal government’s nearly 6,000 health professional shortage areas, or HPSAs.

Matel can easily go from English to Spanish, depending on who is sitting in the examining room waiting for him.

“I love Sonoma County,� Matel said. “I like the people. I love my patient population . . . if they got an HPSA in Sonoma County, I’d definitely stay.�

Contact Staff Writer Jeremy Hay at 521-5212 or jeremy.hay@pressdemocrat.com.

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