The second in a five-part series.
Lindsay Mangum, NPR
Between 1995 and 2003, average physician net income declined 7 percent, after adjusting for inflation. Physician income data are based on reported net income, after expenses and before taxes.
Between 1995 and 2003, average physician net income declined 7 percent, after adjusting for inflation. Physician income data are based on reported net income, after expenses and before taxes. Lindsay Mangum, NPR
Lindsay Mangum, NPR
Physician participation in managed care (health insurance, HMO and PPO) sharply increased between the late 1980s and the late 1990s. In that same time, the percentage of physician income from health insurance providers more than doubled.
Physician participation in managed care (health insurance, HMO and PPO) sharply increased between the late 1980s and the late 1990s. In that same time, the percentage of physician income from health insurance providers more than doubled. Lindsay Mangum, NPR
Behind Dr. Rebecca Jaffe's desk hangs a large black-and-white framed photo.
"That's me on my third birthday, sitting on my grandmother's step," Jaffe says, "with my junior doctor kit."
When she was younger, Jaffe says, she wanted to grow up to be just like the doctor who took care of her family.
She didn't know that her life would be very different from that of her family's doctor. She is a family physician, practicing in Wilmington, Del. But she increasingly struggles to spend quality time with her patients as disputes with insurance companies demand more of her attention.
For the first time in nearly two decades, efforts to improve the health care system are back on the national agenda. But even since former President Bill Clinton tried to overhaul the system, practicing medicine has greatly changed.
As Jaffe sees it, "insurance hopes to keep people well until they're 65 and on Medicare." After that, she says, it becomes somebody else's problem.
Because insurance companies watch costs aggressively, Jaffe says she has to fight to get her patients the care they need. On two occasions, insurers told her they would pay less for an immunization than it would cost her to buy the vaccine, let alone administer it.The insurance company told her to make up the cost by seeing more patients.
"I just felt that was so wrong," Jaffe says. She believes that good medical care takes time.
These days, Jaffe feels like every patient with a health problem also has an insurance problem.
Jaffe describes the daughter of an elderly woman who came in to say her that mother's Medicare drug coverage wouldn't pay for prescriptions any more. She had gone through $2,250 of subsidized drugs included in the plan, and was now on her own.
"This is a woman who has had multiple strokes," Jaffe says, "She was on four anti-hypertensive drugs, plus blood-thinning drugs."
Jaffe helped her patient obtain as much medicine for as little cost as possible. Finally, once she had exhausted all other options, Jaffe pared down some of the elderly patient's medications.
"It made me extremely nervous," Jaffe says.
Despite her best efforts, sometimes Jaffe is unable to help. She has one low-income patient with no health insurance. His father, two uncles and a cousin all had colon cancer. Jaffe knew the patient needed a colonoscopy so that any early cancer could be removed.
"I called a few of the gastroenterologists, all of whom were willing to do the colonoscopy for free," Jaffe says, "[but] unfortunately there's a facility fee."
For months, Jaffe spent hours on the phone, researching places for free care.
"That is the crime of what's going on in America today," says Jaffe. "I can't believe he didn't get his colonoscopy a year ago."
'Somebody's Got to Do It'
Jaffe says she wishes she could be practicing medicine, rather than searching for ways to pay for it. At the end of the day, once her patients have gone home, she is left with mounds of paperwork. Yet Jaffe feels strongly that her patients need someone to hunt down lower-cost options, negotiate with insurers, and find other ways to help them to get the medical care she thinks they need.
"Somebody's got to do it," Jaffe says, "Who else is going to advocate for these people? I'm stuck being a secretary more than a doctor sometimes."
Jaffe says that the time that she spends on paperwork is time that could have been spent with patients. Instead, she's filling out forms and sending in requests to insurers.
Despite the added responsibilities, Jaffe is also making 7 percent less this year than last. Compared to medical specialists, her salary is already low, hovering around $140,000.
"Maybe I should have done something different," Jaffe says, "but I love what I do. It's just sad the way the system is set up — the compensation is skewed."
But her patients' finances worry Jaffe more than her own. As time goes on, their out-of-pocket costs are going up. An increasing number of them are losing insurance entirely.
"It's a broken system for part of the population," Jaffe says. "It's a bumpy system for others."
Jaffe wanted the system to change in the early 1990s and she still hopes for change today. She would like a system where she doesn't have to wrestle with insurers so much, and where everyone could get a basic level of care. But how to get there? Jaffe says she doesn't know.