Still in exile

ROBERT BERRY'S CRITICS CALL HIM AN ALARMIST. He's a very bright man, they say (and they are right), but the system he's dropped out of needs his insights and skills.

But don't try that line of argument with the 30 people or so who come every day to see Dr. Berry at his PATMOS Emergiclinic. Don't try to persuade the 3,000 different patients who have used his services in the last 18 months that Robert Berry M.D. is some kind of wacko. They see him instead as one of the most reasonable, sensible, and practical people they know. After all, he made it easy for them to find basic medical help in an era when that has sometimes become desperately difficult and expensive.

For Dr. Berry, PATMOS has at least three meanings-but only two of them were intentional. It is an acronym for Payment At TiMe Of Service, suggesting the cash-and-carry approach of Dr. Berry's unusual clinic. It also refers to the Aegean island where John was exiled to write the book of Revelation-and is a not-so-subtle reminder how many folks in today's society are exiles from traditional medical care. Their lack of insurance sends them out like nomads seeking whatever helping hand they can find.

But sometimes, Robert Berry feels like an exile himself, shunned and marginalized by a profession and system of which he could easily be a leader-if he would only cooperate.

Note this well: Robert Berry is not a promoter of alternative medicine. By training, by conviction, and by practice, he is a traditional M.D. It's with reference to the delivery system of that medical care that he's become a rebel. He doesn't like managed care, arguing that it compromises the doctor-patient relationship. He doesn't like the paperwork and insurance hassles. He doesn't like the high costs. He doesn't like patients' impatient experiences in waiting rooms. What's different about Robert Berry is that he has put his whole career at risk to do something about issues so many others just complain about.

PATMOS Emergiclinic in Greeneville, Tenn., is not even Robert Berry's final model of what he'd like to see happen in the world of primary medical care. It is a slightly scruffy work in transition. At PATMOS, patients will find a lawn that needs mowing and a modestly cluttered office. "Most doctors aren't very good business people or administrators," Dr. Berry told me, "and I'm among the worst. I'm trying to learn along the way."

What patients do find at PATMOS is prompt, caring, professional attention. Precisely because most patients don't have insurance, they see a doctor only when they really have to. At PATMOS, the whole process has been stripped down to bare essentials. Every patient has a chart, with Dr. Berry's terse, handwritten notes summarizing any previous visits. Because his background is in emergency medicine, he's used to a wide variety of ailments. And, as most primary care physicians will affirm, 90 percent of those ailments can be treated right there in fairly quick fashion. A few must be referred to specialists or facilities with more equipment. A small dispensary allows Dr. Berry not just to prescribe medication but to provide it-at low cost-on the spot.

Up front, there are no appointments, but little waiting. On the back end, there's no fuss with insurance-because PATMOS doesn't accept insurance payments. (Dr. Berry isn't anti-insurance. He just thinks it's inappropriate for primary care-the sort of treatment all of us know we'll need from time to time and ought to budget for. He especially favors medical savings accounts.) "That'll be $35," Dr. Berry told the first man I saw him treat. He was a self-employed contractor, typical of thousands in America who-for a great variety of reasons-don't carry health insurance. The man fished some bills out of his pocket and settled up on the spot. A surprising number of PATMOS clients have insurance, but pay out of their own pockets just because it's fast and simple. Most procedures cost a fraction of what they would at the emergency room or at insurance-based clinics-but Dr. Berry insists that, other things being equal, he can make a decent living with the PATMOS approach.

But other things aren't equal. Because he won't take Medicare payments, Dr. Berry is not allowed to accept any payment at all from patients enrolled in Medicare-or to admit patients to the local hospital. That puts him in a serious bind. He's not sure how long he can continue in a small town like Greeneville, where the population is under 15,000. You can't escape the sense that for all its modesty, PATMOS is what millions of health-care users are looking for. You also can't escape the sense that if the 40 million uninsured Americans were given a chance to vote between PATMOS and the nationalized, Canadian-style system we're all too likely to get, Dr. Berry would have nothing to worry about. PATMOS-style clinics would be everywhere.