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FARAI CHIDEYA, host:

From NPR News, this is News & Notes. I'm Farai Chideya.

"What dreams may come when we have shuffled off this mortal coil." It's a line from Shakespeare that refers to the troubles we humans have on the day-to-day and to our physical state. The rules in day-to-day health care are not poetic, though. You can have insurance and end up waiting six hours in an emergency room for basic care. And while health-care consumers might have a - well, bone to pick with the system, so do doctors. We're going to look at how health-care providers are making do with Dr. Thomas Lee, he's a primary care physician in Boston and an associate editor of the New England Journal of Medicine, and Dr. Tanyech Walford, a primary care physician. She just sold her Beverly Hills private practice. Welcome both of you.

Dr. THOMAS LEE (Primary Care Physician; Associate Editor, New England Journal of Medicine): Thanks very much.

Dr. TANYECH WALFORD (Primary Care Physician): Thank you.

CHIDEYA: So Dr. Walford, let me start with you. You had a private practice in Beverly Hills, California until recently, and you sold it to another doctor. So why did you do that? What happened?

Dr. WALFORD: It's been a complicated year. Early on in the year, with the high gas prices and the shift in the economy, a lot of my patients were being downsized from their jobs, and, you know, when you go from full-time to part-time, you lose your insurance benefits, and, you know, things at home are getting tighter, so they would dance around whether or not they needed to keep their appointment. But initially, they would still try to get their prescriptions filled, and so - at least all of the prescriptions. And pretty soon they would miss appointments and not refill prescriptions, and make individual decisions not to come in to the office.

In addition, the ones that did come in started to not pay their outstanding balances, or pay them with checks with insufficient funds, and just ask for a lot of favors. And initially I gave in, but when the numbers started to increase, it started to put my accounts in the red. And that, and a lot of other circumstances, you know, just led me to throw in the towel, so to speak, in primary care - in private practice, anyway, solo practice.

CHIDEYA: So when people go in for health care, some people go in and they just need regular care, but they go to an emergency room because they don't have insurance. Some people have, you know, a private doctor with a private practice like you had, some people go in to, you know, HMOs. Do you think it's harder for people in private practice like the one that you had in this environment?

Dr. WALFORD: Oh, absolutely. Absolutely, because the problem lies in the solo or the small practice in that our books, they need to - you need to get paid in a short interim. You need to get paid in one to three months in order to keep up with the overhead costs, your receptionist, your nurse, the charge - your leasing charges, all your supplies, and not to mention vaccines and all these really, really high-cost items. And what starts to happen is that, you know, people start not paying their bills, or letting their bills go delayed three to six months even. And then you can't pay your bills, because that money needs to come in your accounts receivable, needs to get received.

And for the smaller practitioner, there isn't a lot of - there's no buffer, you know. Whereas a larger group could probably absorb a lot of that. You know, they could probably not be paid for up to a year and still absorb a lot of that. In the small and mid-level practitioner, that's not an option.

CHIDEYA: Well, Dr. Walford, I want to ask in a second kind of what you see in the future, but I want to go to Dr. Lee. Now, Dr. Lee, in November, you wrote an article in the New England Journal of Medicine about the importance of primary care physicians in the health-care system. So given what we've been talking about, what kind of strains do you see?

Dr. LEE: Well, I think we're going through a really messy transition right now, where the health-care system has been paying people like Dr. Walford and people like me for doing transactions, for doing visits, for doing tests and for doing procedures. And that system isn't working so great, it's - costs are going up wildly, and so the payment system responded just by decreasing the amount they paid and taking their time in paying it. The transition that's under way, though, is something new that's not yet formed, but we'll be getting paid in the future for something else, for, like, taking care of people, for producing outcomes, but the payment system isn't there yet, and our office practices aren't there yet. And I think it is very hard for the small, independent practice, like Dr. Walford's former practice was, to handle things during this transition.

CHIDEYA: What do you see ahead, Dr. Lee? I mean, do you see, for example, politics affecting health care? There's a lot of talk about whether or not a new presidential administration is going to really change the game. Do you see the tremendous economic changes creating a system where it's very difficult for anyone but people who provide very specialized services to survive as sole practitioners? What do you see ahead?

Dr. LEE: Well, I'm an optimistic guy, and I think that the combination of politics and the economy are going to lead to big change, which will ultimately make health care much better and financially sustainable. But the realistic side is that the transition that's upon us is going to be brutal, and it's going to be very hard on everyone.

But the two big forces, politically and economically, are, we've got to cover people. We have to find a way of getting health-care insurance for everyone. It's just not sustainable when 47 million people don't have insurance, and it's going to become 50 million with the economic downturn. And then the economic downturn also affects companies, taxpayers, by really making it imperative that we move to some different way of paying people than diminishing fees for every visit, so that doctors like Dr. Walford just are working harder and harder and falling farther and farther behind.

CHIDEYA: Dr. Walford, before I ask you what lies ahead for you, just give me an example of what you think this is doing to patients. Give me an example of - of course, you don't have to use a name - but someone who had been a patient of yours, who - and what's going to happen to that person now that you're leaving private practice.

Dr. WALFORD: I've actually had some significant feedback from some of my patients through the physician that purchased my practice. And the biggest concern that I have is for some of the patients that had developed a significant trust relationship with me, and had really committed with me to improve their health. And in really drastic ways, like smoking cessation, you know, like complete dietary changes after heart attacks, and cholesterol lowering, and massive weight loss with Type II diabetes. And those people I would see on a regular basis, even accepting the smaller reimbursement form from the insurance company, because they needed more emotional support to actually accomplish the goals that we had set together. And my biggest concern right now is that, it took them years to develop that rapport with me, and I would hate for them to slip through the cracks, and for them to not achieve their goals or not even be able to continue in that same - in that same venue without the support.

CHIDEYA: And what's ahead for you?

Dr. WALFORD: For myself?

CHIDEYA: Mhmm.

Dr. WALFORD: For myself, I'm heading towards a large group practice that can absorb all of these extra costs, and they can have the staffing that can support all the needs that primary care patients require.

CHIDEYA: Dr. Lee, do you - when you think about what options people will have, do you see a lot of what are, you know, what might have been called family doctors just, you know, throwing in the towel, and either joining large practices, HMOs, leaving the profession? I mean, what's going to happen to people who have been caregivers who really know the name of all of their patients and have a long relationship with them?

Dr. LEE: Well, you know, I think that the standalone solo for this in practice, it is going to be very tough for it to survive. And I actually don't think it's worth spending too much time mourning it, because it's inevitable. You - at this day and age, you don't care of sick patients by yourself. You know, there's just too much to know, too much to do. No one can know everything, and you have to work with groups, and you have to have electronic medical records so that the other people know what you've done. And it's very tough for solo docs to do this. Now. what I do think is imperative is that big organized groups in medicine have to adopt, you know, systems and approaches where they give warm, personalized care to people. I don't think you should have to choose between, you know, friendly, personalized care and getting it from a well-coordinated, you know, financially viable group. But, you know, there is a challenge there.

CHIDEYA: Dr. Walford.

Dr. WALFORD: Yes.

CHIDEYA: If you have one piece of advice for a patient, you know, what would it be in terms of advocating for themselves in the health-care system, finding a doctor?

Dr. WALFORD: That's a difficult question. But I guess, they need to find a practitioner, a physician, that will be honest with them, even when it really hurts. They need to find someone that they trust enough that when they hear honesty, they can respond appropriately to it.

CHIDEYA: So you mean, when you have a diagnosis that's negative, or you just tell them, you know, lose weight or die, or stop smoking or die, that they listen to you?

Dr. WALFORD: Yeah, but it doesn't have to come across like, you know, like a billboard ad, you know, driving in and then you drive past and it's gone. But someone that will give you that information, but also guide you to achieve results. So that would be the best situation.

CHIDEYA: Well, Dr. Walford, Dr. Lee, appreciate talking to you. Thank you.

Dr. LEE: My pleasure.

Dr. WALFORD: Likewise. Thank you.

CHIDEYA: We were speaking with Dr. Tanyech Walford, a primary care physician who just sold her Beverly Hills private practice, and she joined us from NPR headquarters in Washington, D.C. We also spoke with Dr. Thomas Lee, a primary care physician in Boston, and associate editor of the New England Journal of Medicine.

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