Corporate medicine, managed care, and other oxymorons

Last week, our news office received more phone calls about the Berne doctor’s office closing than on any story since Hedy Migden’s practice was being shut down three years ago. Patients depend on their doctors.

Doctors are in short supply throughout the nation, particularly in rural areas. Upstate New York is no exception. Across New York State, 942 doctors are needed, 615 of them upstate, according to a survey by the Healthcare Association of New York; 3 million New Yorkers lack access to primary-care physicians — the doctors on the front lines who, for the most part, aren’t paid as well as the specialists, leading many graduates of medical schools with large debts to choose the more lucrative, less time-consuming practices.

Patients without a primary-care physician lack regular checkups and preventative care.

According to the National Rural Health Association, 20 percent of Americans live in rural areas but only 10 percent of doctors practice there. At the same time, 18 percent of residents in rural communities are 65 or older, compared to 12 percent in urban areas.

Rural residents are also poorer by more than $9,200 a year per capita, and those on Medicare are much less likely to have prescription drug coverage than their urban counterparts.

The combination of rural residents being older, poorer, less well-insured, and with less access to preventative services leads to a higher mortality rate.

Over the last 40 years, the gap in life expectancy between rural and urban populations in the United States has grown, with rural residents living increasingly shorter lives, a 2013 study shows. “Causes of death contributing most to the increasing rural–urban disparity and higher rural mortality include heart disease, unintentional injuries, COPD [Chronic Obstructive Pulmonary Disease], lung cancer, stroke, suicide, diabetes, nephritis, pneumonia/influenza, cirrhosis, and Alzheimer’s disease,” the study found.

Researchers found that improving access to health care could help close the gap.

So last week, when one of the people who called us said, “I think people will die up here if this goes through,” there was truth in what he said.

The caller, Ray Schimmer, is an emergency medical technician who volunteered to be a vitalist, working with Kristin Mack, the doctor of osteopathy who is leaving the practice in Berne this month to practice in Ticonderoga.

Mack got grant money to run the vitalist program, allowing trained volunteers to visit housebound patients to check things like vital signs and communicate with Mack through a computer screen.

The vitalist program is emblematic of the care and effort Mack put into the Hilltown practice since she took it on under the tutelage of Gary Kolanchick, M.D.

We have no quarrel with Mack moving on or with Kolanchick retiring. He grew up in the Helderberg Hilltowns and cares deeply about its people. Kolanchick knew since he was hospitalized as a 10-year-old, with a ruptured appendix, that he wanted to be a doctor.

He told us when he retired, “I promised myself, when I was doing seven days a week, 24/7, carrying a beeper, I’d retire young. I knew I would not be able to retire here. I still have people who drop trou in the Price Chopper,” he said of patients seeking diagnoses.

Before Kolanchick left, he wanted to make sure his practice was in good hands. He had a series of young doctors do internships at his practice. “They would spend a month and say, ‘I love the patients, the staff is great, but I don’t want to run a business. I don’t want to work from seven in the morning to seven at night,’” he recalled.

So Kolalnchick contacted CapitalCare Medical Group, which assumed the practice in 2011; two years later, CapitalCare merged with Community Care Physicians, which now has around 75 different offices. “That January, by the grace of God, Ellis called and said a fourth-year medical student wanted a rural rotation.” Kristin Mack arrived on the scene and, said Kolanchick in 2015, “In two weeks, I knew God sent me my replacement.”

This week, Kolanchick has written us a letter that reads like an allegory about how the beancounters have taken over medicine.

Last week, Joan Hayner, chief operating officer for Community Care Physicians, declined to comment on whether an economic impact was considered when closing the Berne office, as the company attempts to funnel patients to its other offices.

But, even before we received Kolanchick’s letter, we thought economics were key in this decision. That’s why we included in our story the splendid example set by the nearby Hilltown of Westerlo, which was in a similar predicament 11 years ago.

St. Peter’s Hospital had run a clinic in Westerlo after Anna Perkins, M.D., a revered rural physician, died in 1993 and left her home and clinic to serve as a doctor’s office. St. Peter’s closed the clinic in February 2008, saying that the center was losing money and the number of patients had been dwindling.

The Westerlo community formed a committee to find a doctor to use Perkins’s house and her office to keep the practice running; Myria Emeny, M.D. was a good fit.

Emeny was not deterred by St. Peter’s findings. “Their numbers were dwindling in terms of their goal was 25 patients per day,” Emeny said at the time. “They were only getting 11 to 15. My goal is no more than 12 per day.” Because the clinic had a full-time nurse and secretary, it needed bigger numbers to pay for overhead, Emeny said.

Emeny runs a “micro-practice” in Westerlo. We extolled the virtues of a micro-practice in this space in 2008 when Emeny opened her practice. She said at the time, “I’m looking to provide long-term care. I think that medicine needs to be not only an office visit, but a healing relationship.”

Research has shown the importance of continuity for healing.

Another letter-writer this week, Joanna Bull, gives a glowing account of the care provided by Emeny and, as our Hilltown reporter, H. Rose Schneider, noted in last week’s story, “‘End of an Era’: Berne’s doctor’s office to close,” Emeny has openings in her practice.

But there’s no way Emeny could accommodate all of the 1,900 patients Hayner reported in the Berne practice.

So we urge Berne to do what Westerlo did: Form a committee, and search with persistence for a doctor who will work independently of the beancounters, as Kolanchick calls them, a doctor who is willing to do what Emeny does — work on her own, apart from a corporation, to put patients in the center of a practice.

Although Mack, in her message to the community, through our story, said  “I know everyone shares in my sadness for the end of an era of excellent care in the Hilltowns …” she also wrote, “What my patients have taught me is that there’s more to health than prescriptions and office visits — there are relationships, community events, and support from neighbors and familiar faces that make huge impacts on health.”

So, Berne, your work is cut out for you. Resolve that this is not the end of an era of excellent care in the Hilltowns. Find a doctor who cares. It could be a matter of life and death.

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