Up on the hill, across the road from the signs advertising snowplows, water pipes and animal feed, Dr. Joseph Jensen is somewhat grimly contemplating the future of his rural medical practice.
In his small, crowded office, between bites of a tuna sandwich made with homemade bread, the 53-year-old physician is telling a story he doesn’t like: How it came to be that he’s seeing more patients at his Methow Valley Family Practice in Twisp, Wash., but is losing money.
Once, he was a well-off doctor to rich people, working in an Atlanta practice. Now he’s nearer the other end of the scale in a town that’s three blocks long and has fewer than 1,000 year-round residents.
This has been a particularly bad year, with unusual expenses. But Jensen believes the trend is clear.
Rural medical practices such as his are struggling for survival in eastern Washington, where insurance providers have stopped selling individual policies, state reimbursement has dwindled, and one of the state’s largest insurers–Premera Blue Cross — has assumed so much clout that doctors complain its “negotiations” really come down to a “take it or leave it” deal.
A preacher’s son, Jensen always knew he wanted to do something that helped people and made him feel needed. So in 1990, after being wowed by the Methow Valley’s spectacular scenery and wooed with home cooking, he bought this little country practice from Dr. William Henry. “Doc Henry” was retiring after 30 years, many of them as the valley’s only doctor.
On this day, after Jensen finishes lunch at 2 p.m., he’ll see a man with mysterious intestinal problems; a guide for a local outfitter who says she’s had a lump on her hand “ever since the cattle drive”; a young mom with a face rash; a tiny, tough 98-year-old woman who lives by herself in a log house and is complaining of a bad headache; a 13-year-old boy with an eye infection; and a 23-year-old hiker whose 10-foot fall smashed bones in his now badly swollen hand.
At 4:15 p.m., there are nine patients in the waiting room.
Jensen is needed, no doubt about it. But his psychological satisfaction has come at a cost–the cold cash kind. So far this year, he has put more money into the practice than he has taken out.
Like his predecessor, Jensen has never made gobs of money from this practice, but the bottom line has always been black.
This year has been different.
In part, that’s due to unusual costs. Computer expenses to keep billing systems alive through the transition to the year 2000 took a toll, for example. Last month, after hiring a second doctor to help expand the practice, he laid off two popular physician’s assistants–much to the dismay of the surrounding community. He didn’t want to do it, but he couldn’t afford to keep them; by July, he had paid himself a total of $5,000 and dumped nearly $30,000 into the practice just to keep it afloat.
But Jensen’s most serious financial troubles–the ones he and others believe are just the start of a worrisome trend–involve the special problems rural residents face in getting, and paying for, health care.
Rural areas have taken the hardest hit from the health-insurance crisis affecting individuals and employees of small businesses. With fewer large employers in their region providing group policies, and with new individual-insurance plans no longer available, more rural residents resort to state-subsidized insurance, less-than adequate coverage, or just do without.
Clinics in rural areas, with their small, scattered populations, can’t benefit from the large number of patients available to urban clinics, and they’re also much more vulnerable to the impact of costly single cases.
Insurers, both private and government, have reduced the level of reimbursements to health-care providers. Some plans pay a flat fee–per patient per month–for the doctor to provide all regular health care.
Often, says Linda Dennis, the clinic’s practice manager, that fee isn’t enough to cover the clinic’s costs.
In the worst case, the clinic receives only $3.86 per month for some children covered under the state’s subsidized Basic Health Plan. For less than $47 a year, the clinic must provide all routine care–including an annual exam.
At the same time, Jensen says, he has had to cope with more paperwork requirements–for example, he had to hire a nurse just to negotiate with insurers about referrals to specialists.
Ann Diamond, the new doctor at the clinic, says she just wishes she could make enough money to pay her child’s health-insurance premiums. She also wishes she could see patients who can’t pay.
She knows she can’t do it now, that the clinic is struggling; but she’s struggling, too–for a different reason.
“I’m not a businesswoman,” she says. “I’m a physician.”
After lunch, the patients stack up again in the clinic’s waiting room. Diamond dashes by, heading for an examining room. Flashing a smile, she grabs a chart. “I gotta keep moving.”
