The morning’s last patient, a disabled woman on Medicare, trails her doctor into her office and confides that she doesn’t have money for lunch. Tanyech Walford pulls out her billfold and hands her $3. It’s money the doctor really doesn’t have.
“I tell patients I’m broke, and they just chuckle,” she said. “They don’t believe me.”
Walford’s fashionable medical suite in a sleek black-paneled building in Beverly Hills was hiding a grittier reality: She spent much of her lunch hour that day in her office opening mail -- hoping to find payment checks to help fill the gap between her expenses and her revenue.
She hadn’t drawn a paycheck for herself since February. On top of that, her practice has cost her $40,000 in personal savings and left her with $15,000 in credit card debt. Walford, 39, also owes $80,000 in medical school loans. She shops at Ross and other discount retailers, and rarely eats out or takes time off.
“I’m totally stressed out,” Walford said. “How can I take care of my patients when I’m that stressed?”
Walford is not alone in her struggle. Relatively low earnings, rising overhead and overwhelming patient loads are sending veteran primary care physicians into early retirement and driving medical students into better-paying specialties, creating what the New England Journal of Medicine recently called a crisis.
Primary care doctors “should be able to leave work thinking not of their income, or of unanswered phone calls, or of test results that they might have overlooked,” Boston physician and associate journal editor Thomas H. Lee wrote in the Nov. 12 issue. “They should go home thinking, ‘This is what I was meant to do.’ ”
But after five years, Walford couldn’t hang on any longer. She closed her office nine days ago.
“It’s sad,” said Walford, who has shoulder-length wavy black hair, a cherubic smile and a slight lilt that betrays her Jamaican roots. “I worked really hard. It’s a tragedy.”
The loss of a single physician thrusts hundreds of patients into medical limbo. But the effect is far broader. Experts say the pool of primary care physicians is insufficient to meet the needs of an aging population. Already, shortages make it difficult to see physicians in swaths of northern and rural California, as well as neighborhoods in South Central Los Angeles and other urban cores.
Much of the problem lies in an endangered business model: the one- or two-physician general practice. Such practices are particularly difficult for primary care physicians to maintain because of their relatively slim and declining margins.
In her best year, Walford grossed about $360,000, more than enough to cover her overhead and take home a tidy income. That stands in sharp contrast to this year, when her practice slid into the red.
Small general practices afford doctors autonomy to practice medicine as they see fit and can produce strong doctor-patient bonds. But these physicians have little or no clout to leverage better payments with insurers; they have no economy of scale, which makes overhead more burdensome.
“It’s very difficult, even in rich neighborhoods like Beverly Hills, to set up a solo practice,” said Richard Scheffler, an economist at UC Berkeley. “The doctor has to pay rent, a nurse, have a bookkeeper, billing systems, computers. All of those fixed costs are very, very hard for a solo practitioner to have and survive.”
Dr. Jerry Connell kept his family practice going in Santa Rosa for 29 years. But he closed it in October because his income had slipped to $50,000 a year, even though he had 2,600 patients.
“I could make more with my Social Security and investments than I could by staying in practice,” said Connell, 66.
He didn’t bother looking for a buyer because “no one in Sonoma County has been able to find a replacement in five years.”
Connell sold his equipment, but not to doctors. A biofuels company bought his scales and microscope. A veterinarian bought his laboratory equipment. And a tattoo salon bought his autoclave to sterilize needles.
The economic slowdown is making matters worse. Physician revenues nationwide are falling as patients who have lost jobs or homes stop paying their bills and skip appointments.
“As people are tightening their belts, they are deferring things they think are a luxury or not absolutely necessary,” said Long Beach physician Jeffrey Luther, president of the California Assn. of Family Physicians. “We see people putting off physicals and mammograms and blood tests because they just don’t have the cash.”
Walford’s patients began canceling in droves several months ago. Even those who need to monitor chronic conditions like heart disease and diabetes stopped coming in. Of those who did come, many asked to be billed -- even for co-payments as small as $10 -- and then never paid.
“I love medicine,” she said. “But they don’t tell you this stuff in medical school. They tell you there’s a shortage of doctors.”
Walford’s 1,950-square-foot office, down the hall from the Armenian Consulate, was in a professional building on La Cienega Boulevard. Framed modern art and historic photographs lined the walls. Oriental rugs were scattered over blond wood floors, and table lamps cast a cozy glow.
The office had four examination rooms and two waiting rooms -- one in the front and one in the back, for overflow. A couple of years ago, the space might have made sense. Walford was seeing 30 patients a day. In recent months, her patient load dropped to about 15; on bad days, 12.
Walford was forced to cut her staff from three medical assistants to one. In the end, the two of them did it all -- answering telephones, scheduling appointments and filing charts.
A naturalized citizen who emigrated from Jamaica as a girl, Walford grew up in Hyattsville, Md. She was inspired by a missionary doctor she heard speak while at the University of Maryland. The first member of her family to finish college, she attended medical school at the University of Virginia. A residency at Harbor-UCLA hospital brought her west.
Many of her patients were very attached to her. Some, like Catherine Ingram, cried when they learned Walford was leaving. A retired nurse, Ingram, 65, had been coming to Walford for four years.
“I was just getting used to her . . . trusting her,” Ingram said. “She’s wonderful.”
In one of her last days in her practice, Walford saw Vincent and Eloise Hall, Malibu residents who own an auto parts distribution business in Compton. She checked Eloise’s blood pressure, noted that she had lost 5 pounds and reminded her that she was due for a mammogram.
After giving Vincent, 74, a flu shot, Walford noticed that his blood pressure was up. As they went through the medications he is on, she learned that he had stopped taking his blood pressure pills. She reminded him of their importance and lectured him about getting more exercise.
Said Eloise Hall, 80: “She reminds me of our daughter.”
Angela Russ couldn’t get a doctor to see her until she found Walford. The 54-year-old airline customer service representative has insurance, but other physicians demanded that she pay her annual $600 deductible upfront. Walford gave her a pay-as-you-go option.
“I love her,” Russ said.
Beverly Hills medical offices, near the prestigious Cedars-Sinai Medical Center, command some of the highest rents in the nation. Walford’s suite ran $7,900 a month. It cost her an additional $6,700 or so for payroll, workers’ compensation, taxes, medical and liability insurance, utilities, continuing medical education fees and other expenses.
But in the last few months, many patients failed to pay their bills. In September, she sent invoices to Medicare, Medi-Cal, private insurers and patients for $70,000. With negotiated discounts and government fee schedules, Walford, as a rule of thumb, expected to collect two-thirds of her billings, or about $45,000, that month. Instead, she got $14,000 -- less than her overhead. Walford fell behind on her rent. But she didn’t bother dunning her patients.
“I can send patients to collections until the cows come home,” she said. “I will never see that money.”
Many primary care physicians boost their income by offering Botox injections and other cosmetic procedures for cash. Walford couldn’t afford the training.
Others have abandoned poor and working-class patients altogether, opening so-called concierge practices that require clients to pay an annual retainer of $1,500 or more and to submit their own insurance claims. Her patients would not have supported that sort of practice.
With debt mounting each month, Walford was forced to explore other options. She set her sights on large, stable practices near where she grew up. She sought a job -- one with a steady paycheck -- that would allow her to take vacations without worrying about who would cover for her. She longed to concentrate on patients rather than on billing and collections. And she wanted to live in a place where she could afford to buy a home in a couple of years.
Early next month, Walford will join 200 physicians in a multi-office practice affiliated with Johns Hopkins Medical Center in Prince George’s County, Md. Her base salary will be $115,000, plus bonuses based on the complexity and quality of care she delivers. Benefits include vacations, health insurance, a pension plan and paid continuing medical education.
Walford couldn’t find anyone to buy her practice and is still searching for someone to take over her lease. Dr. Peiman Berdjis, a friend with an office nearby on Wilshire, agreed to take the charts of the 2,000 patients she had seen over the years. Her patients can start seeing Berdjis or find another doctor.
Walford said she sold her equipment for “pennies on the dollar” and gave her furniture to a couple who lost their home in the Sylmar wildfire. She stayed up until 4 one morning putting stamps on farewell letters to her patients.
“This is a relief,” Walford said from her cellphone as she drove east toward her new practice. “I’ve been spent emotionally, financially, physically, and now I need to have someone else worry about the finances.”