Doctors Try to Cure an Ailing Medical System

Patients come into Dr. Joan Bachorik’s acute-care clinic stooped over or feverish, with broken bones or labored breathing.

Above all, they come without health insurance.

The internist, 55, runs a practice for people who might not be able to get care elsewhere. Patients pay $35 for each visit. There are no prior approval forms, no Medicare paperwork and, in Bachorik’s opinion, no bureaucratic barriers for patients who need help.

“You can sense a feeling of relief,” she said of her patients. “They put smiley faces on their checks. One woman came in with quarters. I gave them back.”

Bachorik’s decision to sever her relations with health insurers -- the professional equivalent of going off the grid -- is rare among doctors. But her frustration with the system is not. As the number of uninsured people in the nation nudges toward 46 million, doctors are experimenting with ways to deliver care outside the traditional system.

“Most people in the United States who are not in a coma know that the medical care system is in big trouble,” said Dr. Garrison Bliss of Seattle Medical Associates, a no-insurance practice that charges patients a flat monthly fee. “ ... This is an attempt on the part of our doctors and patients to regain control of medical care.”

Eighty-seven percent of American Medical Assn. doctors say they provide some charity care in a typical week. And in many areas, doctors coordinate with other healthcare providers such as blood labs and imaging companies to streamline care under “Project Access” programs. Started in 1995 around Asheville, N.C., there are now 51 similar programs from Dallas to Danville, Va.

Bachorik practices in Oneonta, a small college city in eastern New York surrounded by farm country. She ran a traditional practice for two decades, gradually becoming frustrated with insurance-driven rules. She got a patient’s-eye view of the system a few years ago after a serious illness forced her to close her office temporarily.

“I realized how frustrating it is to get someone to focus on you,” she said.

Although she had enough money to retire after her recovery, she decided instead to reinvent her practice to serve patients falling through the cracks.

Computers that processed insurance forms went out the door and her staff of four shrank to one. The clinic is open Monday, Wednesday and Friday afternoons; it has served about 500 patients in its first year.

“I’m out of the system because I don’t have enough money to get insurance, “ said Molly Copelan, a patient who stopped by Bachorik’s modest office recently. “She doesn’t stand on rules and regulations.

Bachorik says her fees cover malpractice insurance and other costs of operation. Profits go to buy prescription drugs for patients. The basement practice is no-frills. She answers the phone herself and there’s a sign in the bathroom asking people to please turn off the heater when finished.

Bachorik says about half of her patients come in with the flu or other infections. The rest suffer from everything from sprains to toothaches or psychiatric problems. Bachorik treats what she can and tries to direct patients to other help when she can’t. She says some of her patients have private insurance or Medicare, but they come to see her anyway for the personalized care.

Pleasant with patients, Bachorik turns caustic when talking about a system she describes as dehumanizing. She tells the story of a logger who broke his ankle a week before showing up at her office. Not wanting to pay for an emergency-room visit, he just put his foot in a boot and hoped for the best.

“If you’re staying in the system, you’re failing your patients,” Bachorik said. “ ... You’re perpetuating something that doesn’t work.”

The safety net for the uninsured -- a loose network of public and private funding sources -- is under strain, most agree. The Kaiser Family Foundation recently reported that as the number of uninsured increased by 4.6 million from 2001 to 2004, federal per capita safety-net spending decreased.

Policy-makers have been leery of making wholesale changes to the system since the high-profile failure of the Clinton administration. Absent top-down reform, many doctors have fixed little holes in the safety net on their own.

A growing number of practices have dispensed with per-visit fees in favor of monthly retainers. The Seattle physician, Bliss, said his patients paid $85 a month in return for prompt, personalized service. His practice doesn’t accept insurance, although other monthly service practices do.

Annual fees for these services can top $1,500, leading some to call them “boutique” practices. However, there are also boutique operations that charge patients as little as $420 a year.

But Bachorik’s solution -- forgoing the insurance industry with a fee-for-service -- is rare, industry watchers say.

Doctors say the big problem with the approach is that it does not work well for costly chronic conditions like diabetes or cancer. Dr. Gordon Schiff, past president of Physicians for a National Health Program, said it was a difficult business model to sustain.

“There are many more people who want to do it and a fraction of that number try it, but don’t succeed,” Schiff said.

Schiff’s group advocates for a single-payer system, one of many proposed solutions.

The trade group America’s Health Insurance Plans recommends a series of targeted steps including health savings accounts, government-funded “high risk” pools and enrolling more people in Medicaid. The trade group’s spokesman, Mohit Ghose, said it was wrong to look at a complicated and far-reaching system in need of systemic improvements such as information technology and simply blame insurers.

“For many, many years it’s been very convenient for folks to just say, ‘Oh this is just an insurance problem,’ ” Ghose said. “But the fact is that ... streamlining data systems is not an insurance problem, it’s a systemic problem.”

Bachorik realizes she is limited in what she can do with her one-doctor clinic, but she has no regrets and no plans to change.

“Even if you help one person,” she said, “it’s worth it.”

On the Net:

American Medical Association: https://www.ama-assn.org/The Kaiser Family Foundation: https://www.kff.org/

Physicians for a National Health Program: https://www.pnhp.org/