When we read that 47 million Americans are uninsured, a lot of us think that’s awful. Then when you lose your job and your health insurance, you start to understand what "awful" really means.
When we read that Big Insurance is making it harder for traditional small family practices to make a go of it, we wonder when America’s policy elites will begin to care about something other than the stock prices of giant corporations. But when the only private practice physician in your small town (and entire rural area) announces she’s closing her practice, it’s a total gut-punch. You feel like puking.
Dr. Molly Bourne, who is positively beloved in my local community and for good reason, is being forced out of business by the big insurance companies. Here’s the link to the story that ran yesterday in our kind-of-local paper: Insurance costs could doom West Marin Medical Center. I say kind-of-local because it is the paper from the nearest urbanized area, which is in turn a suburb of San Francisco.
Couple of quotes from the article:
"She's never not been there for us. She even gave me her cell phone number," said Joannie Kwit, owner of Point Reyes' Pine Cone Diner. "Other doctors just don't do that."
"I like running my own business, and I don't like being told by an insurance company what drugs to prescribe or what protocols to follow. The insurance companies pick and choose what they'll pay for, and it's not enough to be able to sustain my practice. I've bounced a lot of checks in the last year because I haven't been able to pay myself." [Molly speaking]
Let that last statement sink in for a minute. She hasn’t been able to pay herself. Who has she been paying? Well, she’s been paying the purchase price of the practice, the mortgage on the building she practices in, assorted other bills, and the wages of her small staff. A big share of that small staff, and of her own time, goes to trying to get the insurance companies to pay for services rendered to patients who needed her care.
Imagine that. She provides needed care to her patients, and then she needs to be paid for it so she can continue to provide needed care. Seems reasonable to me. I don't have a good explanation for why our for-profit insurance system can't seem to meet this need.
In effect, Dr. Bourne Molly has personally taken it upon herself, for the last 8 years, to make it seem to her approximately 4000 patients like our broken health care system works pretty well. For her patients, it was a convincing illusion. For Molly, it has finally become an intolerable burden. She has come to a point in her life where she just can’t carry the load any more. She cannot any longer, through her own personal heroic sacrifice, continue to make a broken system seem like it works.
While I’m ranting, let me also note the effect of the real estate bubble on health care at the local level. When I came to this community in 1973, a handyman and a waitress (that was me and my former wife) could buy a house, albeit a fixer-upper. Today, houses that come on the market are bought by wealthy professionals and dot.com millionaires to be razed and replaced by a bigger, fancier place for occasional weekend visits. Today, if Molly’s site goes to the general commercial market, it will probably become sophisticated retail, or perhaps another fancy restaurant catering to people from out of town. It will be lost to the local health care network.
Now for the plot twist. Molly is the only private practice in the area, but she is not the only practice of any kind. There is also a small local organization of community health clinics, called the Coastal Health Alliance. (Full disclosure: I am the board president of the Coastal Health Alliance, which I will call CHA henceforth.)
CHA serves anyone who comes in the door, regardless of their insurance or financial status. We are a fully bilingual operation, and a good percentage of our patients are Latino immigrants, including a lot of ranch workers and their families.
Our organization was founded about 25 years ago, so many families who have been here longer than that are established with Molly and her predecessors' practice. But now Molly is leaving, and she is not likely to be replaced by another private practice, for the same reasons that she herself is being driven out of business. What will her patients do? Some will go "over the hill" to the urban areas, but private practices are closing over there too, from the same causes. Those who are Kaiser enrollees (both she and CHA accept Kaiser, an unusual arrangement that I won’t go into here) will do OK, but the others will find it difficult or impossible, especially those in the lower income ranges. For the frail elderly, traveling a long distance for needed care will be a severe hardship, to say the least.
Some of the long-time local families of means formed a committee to explore their options. Could Molly be induced to stay? Would money help? Could they set up their own practice, perhaps a boutique practice? Well, all that’s a longer discussion, but here’s the conclusion they came to: No to all of these questions. Is there some other way to preserve health care in our area? Yes. It’s the Coastal Health Alliance.
How about that, folks. Our local community health clinics, set up to serve everyone including the Latino population and those of lesser means, may turn out to be the infrastructure best suited to address the needs of the established, the insured, and the well off.
How is CHA suited to serve all sectors of our rural community? Because we are a non-profit corporation, governed by a board of community members, a majority of whom are patients of the clinics, and our only mission is to provide care to this community. Our by-laws stipulate all of the above, and strictly prohibit any type of conflict of interest for directors. As a non-profit, we draw over $1 million a year in government and foundation grants, which helps defray overhead and allows us to also serve our non-indigent patients. The magnificent Dr. Bourne, for all her heartfelt resolve, was unable to withstand the brutal pressures of the for-profit system. She had to bail, despite the loyalty and affection she truly feels for all her patients. CHA, however, cannot "bail"—we exist only to do what we do, which is to serve this community. Individual doctors or nurse practitioners may decide to move on for their own personal reasons, but our organization remains. We will miss them, but we can (with great effort) replace them. We are not portable, we are rooted.
This community has the resources and, I think, the will to respond to the loss of Molly’s practice. Those are essential parts of the puzzle, but they have to be put together in a sustainable way. That is our challenge, and I think we can do it.
Having given this somewhat optimistic report, I should also say that the horse is not back in the stall just yet. CHA has a lot of work to do in this community to ensure that there is adequate health care capacity to provide for everyone who needs care. CHA may be that provider, or perhaps another entity will come forward (unlikely but not impossible). Our real mission is not to be the sole provider of care, it is to see that the community is well cared for, so if that happens we would be fully supportive. In the more likely scenario where CHA needs to expand our capacity to absorb many of Molly’s patients, we will have to work to include all stakeholders, to draw on all available resources, and perhaps to change aspects of our culture so that new patients are comfortable and feel confident in the quality of care that they receive.
This blog tends to look at the largest-scale happenings and issues. But all of us live somewhere, and the wisdom we gain from visiting here must have some application in our local lives. For me personally, the logic goes like this: The big challenge we face in this century is global sustainability. To deal with that, we will need to increase cooperation and sharing. Health care is a powerful, ready-made issue that clearly demonstrates the advantages of cooperation and sharing for certain types of challenges. A national single-payer system is urgently needed, but so is local infrastructure to deliver health care. I can work on that right where I live. Therefore, helping Molly Bourne’s patients find a new medical home in their own community IS what I’m doing about global warming (along with some other stuff, of course).
One of the interesting things about Molly closing her practice is that it touches demographic segments of our community that typically are more conservative, perhaps believing that their wealth will protect them, or that problems are best solved through self-reliance. In saying this I mean no disrespect, a lot of them are my friends, but I think it's a fair description. This crisis reveals some of the limits of those strategies. For certain aspects of our lives, we really are dependent on well-functioning social institutions, of which for-profit health care is more and more NOT an example. It turns out, however, that a locally controlled non-profit community health center has a lot to offer that even the wealthy, the strong, and the self-reliant may sometimes find good to have locally available.
Together, we really are stronger.
In closing, I want to again thank Dr. Molly Bourne, for her years of compassionate dedication to her patients and this community. She and her predecessors have done good things here, and that is something to build on. Her dedication to people who depended on her, people we know and love, should be our inspiration to create the best possible outcome for our small community in the present health care environment.
UPDATE: For more on this developing issue, you can visit Molly's website here.