Primary concerns

WICHITA, Kan.-Politicians and policy experts continue to debate Obamacare, but we don't hear enough from frontline family doctors: How difficult is it for them to practice medicine in the current healthcare climate? Six Wichita physicians told me that they struggle to take care of their patients without drowning financially-and they don't have much hope in the government making things better anytime soon. Here's a look at three of them:

Dr. Timothy Wolff opened Rock Ridge Family Medicine four years ago with dreams of running an old-fashioned doctor's office. Inspired by his own boyhood physician in Nebraska's Elkhorn River Valley, Wolff wanted his practice to be a home away from home for his patients. His wife, Christine, manages the practice while their 5-year-old daughter is at school. A poster-sized picture of their daughter in a dance recital outfit hangs behind the reception desk.

Wolff found that owning and managing a medical practice was much more difficult than simply taking care of patients. The meager reimbursement from patients' insurance-especially the government-based programs Medicare and Medicaid-barely covered the business' bills, and he stopped seeing Medicaid patients two years ago. He says, "I didn't realize there was going to be so much governmental involvement-that people were going to tell me how much money I could make. ... I've been forced into a point where we have to see at least 20 patients a day just to break even to cover my expenses."

In the center of Wichita, Dr. Ronald Ferris has developed a business model that allows him to take care of the Medicaid patients that many doctors refuse to treat. He founded Holy Family Medicine with another doctor right after Ferris completed his medical training. Many physicians seek more stable income in the first few years of their careers, but Ferris believed owning his own practice would give him the freedom to incorporate his Catholic faith into his work. As a fresh graduate of residency, he had to have his parents co-sign his business loan using their home as collateral.

Now, after 11 years of practice, Ferris says God's grace and the sheer volume of patients he sees at the clinic have allowed him to stay in business. About 55 percent of the practice's patients are on Medicaid, and many more are uninsured and pay out of pocket on a sliding scale. He accepts all patients regardless of ability to pay and employs a staff of three nurse practitioners and one physician assistant who, with his supervision, can perform many of the duties of a doctor. Those mid-level providers do not require as high a salary as physicians. Together the staff can treat up to 100 patients a day. They receive between $30 and $60 per patient visit, depending on the patient's insurance.

Ferris' office is decorated with prints of antique icons depicting Mary, Joseph, and a small but not infantile Jesus. Ferris had an opportunity to change locations over a year ago when he decided to purchase a building rather than rent his office space. He moved just a mile and a half north and opened a combination doctor's office and urgent care center. Where some physicians see low-income patients as a burden, Ferris sees them as a gift from God: "I was privileged by these families coming to us and seeing us, and that's what helped as far as my continuing because otherwise I'd be burned out. ... If it was about money, you won't last very long. You'll be disgruntled and bitter."

It's not about the money either for Dr. Scott Bledsoe, another Wichita doctor who left a job managing mergers and acquisitions for the Case Corporation to become a family physician. Bledsoe says he is amused when people he meets assume he is rich because he is a doctor: "In previous careers, I've made more money than I make now." His wife Patricia, who was a high-ranking executive at a medical technology company, is now also a doctor and his only partner in their medical practice. They conceived their dream of a joint practice shortly after their marriage, taking turns going to medical school, and finally started practicing together in 2009.

The Bledsoes treat both Medicare and Medicaid patients, but they are selective about which Medicaid patients they take. The ideal Medicaid patient for them is a child or a young parent who is just starting out and has the potential to get a better job with increasingly better insurance over the years. "We tend to focus more on having good people-people who take care of their families," Scott Bledsoe explains. Patricia Bledsoe works three days a week at the practice, he works four plus one day a week at a local emergency room, and they have two children, ages 11 and 7.

Scott Bledsoe is quick to emphasize that their medical practice provides plenty for their family's needs, including private school for their children. Their lifestyle is comfortable, but not as lucrative as it could have been if he and his wife had stayed in their previous careers. For Bledsoe, medicine is intellectually challenging and personally rewarding: "We could probably make a lot more money in medicine than we do. That's just who we are."

Other doctors I spoke with gave me more information on how they make money. Family physicians are paid less than most other doctors. Medicare uses a relative value scale to determine how much to pay for medical services, and primary care visits are near the bottom of the scale. A 25-minute office visit with a primary care doctor has one-tenth the relative value of services such as cosmetic surgery on the forehead or repairing a broken upper arm.

Medicare's reimbursement scheme is important because most private insurance companies apply the same principle of paying less for primary care than other services. Reimbursement rates for Medicaid, the government insurance program for people with low incomes, are set by state governments. On average, Medicaid reimbursement is 66 percent of what Medicare pays, though Medicaid rates are nearly equal to Medicare in the state of Kansas, according to the Kansas Health Institute.

While primary care doctors don't get much respect from Medicare, they can save the healthcare system money by applying the right preventive care at the right time. A 2004 study published in the journal Health Affairs found that the more primary care physicians a state had, the lower its healthcare spending. Adding one primary care physician to a population of 10,000 people reduced that population's Medicare spending by $684 per patient.

With inflation and practice costs rising faster than reimbursement, physicians have had to get creative to keep their businesses profitable. At Galichia Medical Group in Wichita, a practice with more than 20 primary care doctors and specialists, Dr. Chris Meyer, CEO of the group, treats most of the practice's Medicaid patients himself. "The docs are on a production salary; I am not," Meyer says. "I choose to do that so they don't have to."

One of Wichita's largest family practices, the Wichita Clinic, recently sold to local hospital system Via Christi Health. Dr. Kevin Hoppock said the more than 160 physicians of the clinic decided after the advent of Obamacare to hand over management to a larger corporation in hopes Via Christi could help bear the burdens of government regulation. Via Christi's Chief Finance Officer David Hadley said the hospital system hopes owning the practice will help it experiment with newer, more cost-effective models of care.

As family physicians look to the future, they have gloomy predictions about how much the current healthcare legislation can improve their situations. Obamacare would make more people eligible for Medicaid, as well as require states to close the gap between Medicaid and Medicare reimbursement. The most controversial portion of the act, requiring Americans to have health insurance or pay a penalty, would also likely lead to more people on Medicaid or Medicaid-like programs. The act does nothing to change the system for calculating payments, which puts primary care physicians at the bottom of the payment barrel.

In the meantime, Congress is considering cutting Medicare reimbursement by 27 percent. The cut is part of a formula called the Sustainable Growth Rate, which is supposed to make up for Medicare overspending. So far Congress has delayed the SGR cuts, but hasn't announced a plan to cover the costs of that delay, which runs out March 1.

Dr. Dee Ann Stults treats patients at a Wichita clinic primarily for uninsured and underinsured patients. She said she has access to more charitable resources for patients with no insurance than patients who have state-based insurance: Obamacare, she worries, "might create a large population of people who are underinsured or people who have some semblance of coverage but it doesn't really get them very far."

Just how large will the population of underinsured patients be, and how will that affect access to healthcare for all patients? One healthcare administrator I spoke with said a "tsunami of demand" is headed toward primary care clinics. Physicians would have to hire more mid-level providers to handle the demand, and longer wait times are likely.

The Supreme Court is set to hear arguments on the constitutionality of the law in March. If the law stands, officials who oversee Medicare have called the Patient Protection and Affordable Care Act unsustainable financially. One way the act proposes to fund the increase in Medicaid is by "substantially reducing the growth of Medicare payment rates for most services," according to the Congressional Budget Office. Healthcare providers will supposedly respond to lower increases in payment over time by becoming more efficient and cost effective.

In the annual report for Medicare's trust fund, trustees predict that if physicians stop getting adequate raises from Medicare, they are likely to just stop accepting those patients altogether. The report states, "Many experts doubt the feasibility of such sustained improvements and anticipate that over time the Medicare price constraints would become unworkable and that Congress would likely override them."

Family medicine as mission

As the pay and prestige of family physicians has declined, family medicine as a discipline has transformed into a mission field.

"When I was in medical school and I decided to go into family medicine, I think a lot of people were like, 'Why?'" said Dee Ann Stults, a 31-year-old family physician who works at a clinic for low-income patients in Wichita, Kan. "I think primary care is sort of considered lesser than in some ways."

Stults says her decision to enter family medicine was God-led: "When I first went into medicine I considered it something that was going to lead me into a mission field for Christ. I never really thought of it as, 'This will get me fame and fortune or whatever.'"

Benjamin Anderson is counting on doctors with Stults' same attitude to staff his hospital in rural Kansas. Anderson started as CEO of Ashland Health Center three years ago, and the hospital's only physician resigned soon after. The hospital relied on a physician assistant and a nurse practitioner to care for patients. Ashland has 855 people and is a two-hour drive from the nearest Starbucks.

"A lot of people want to work in a suburban area with great schools and affluent people," Anderson says. Stymied by traditional recruiting efforts, Anderson decided to look for physicians who shared his sense of calling to serve the underprivileged. He offered eight weeks of paid time off to physicians who would come to Ashland to serve. Though the physicians can use the time off however they choose, the package was designed to allow for overseas mission trips. Every employee gets four to eight weeks.

Anderson has spread the word about his open positions through the Christian Medical and Dental Association. He said that the candidates he interviews are "not interested in huge lavish homes. ... They want to know, 'Where's my opportunity to serve?'" He has received six inquiries about the jobs in the past year and hired one physician.

Anderson has also worked with leaders from the family medicine residency program at Via Christi Health in Wichita, the same program where Stults trained. He said the Via Christi residency program tends to draw mission-minded physicians. Dave Sanford is the CEO of Grace Med in Wichita, a nonprofit organization that owns the clinic where Stults works. He said he can easily recruit residents from the local program to serve in the low-income clinics: "Young people aren't so much money-driven, that's what I'm finding out. ... There's so many of them that have a desire to serve, which is refreshing."