Seen from the extremes: Uninsureds' effect on medicine

The sky is darkening outside the office of Terry Eska, MD. The rural Texas internist's appointments are finished, but his work isn't. A new nursing home patient needs inpatient dialysis, which isn't available at the local hospital, so Dr. Eska calls a hospital an hour away.

The hospitalist at the other end of the line is reluctant about accepting a Medicare patient who may need critical care, and this man might be "at death's door" anyway, as Dr. Eska puts it. But the hospital's kidney specialist believes the man has a chance and the patient's daughter isn't ready to give up, so the hospitalist relents -- after venting to Dr. Eska about the hospital's finances.

"He finally agreed to accept him after I got my lecture," Dr. Eska said.

These types of negotiations are a regular part of Dr. Eska's work life in Gonzales, a town of 7,500 people about 65 miles south of Austin.

A recent journal article concluded that some of the professional tribulations experienced by physicians such as Dr. Eska are related to practicing in places with many uninsured people. Texas has the highest average percentage of uninsured in the U.S. at 24.1%.

The article found that physicians working in areas where many people lack coverage have lower career satisfaction, more difficulty communicating with specialists and less ability to provide high-quality care without making financial sacrifices, compared with their counterparts in areas with few uninsured people. The analysis, "Physicians' Career Satisfaction, Quality of Care and Patients' Trust: The Role of Community Uninsurance," was published in the October 2007 Health Economics, Policy and Law.

Visits with Dr. Eska and Denny Peterson, MD, a family physician in rural Willmar, Minn. -- the state with the lowest average percentage of uninsured at 8.5% -- show that the findings are true in some ways but don't account for the myriad influences on doctors' professional lives.

Drs. Eska and Peterson typify small-town physicians in their states in a few ways. They are part of relatively small independent physician practices located next to their city's only hospital. Both grew up in rural towns no more than a few hours from where they work.

The two also have some differences. Dr. Eska relies on six cabinets full of manila folders; Dr. Peterson's clinic has an electronic medical records system. Also, Rice Memorial Hospital in Willmar operates 90 beds, compared with 28 beds at Gonzales Memorial Hospital.

Patients worry about costs

One day in mid-November, Dr. Eska is busier than usual. He begins at 8 a.m. with rounds at Gonzales Memorial, a two-minute drive from his practice. He has five patients to visit -- about twice as many as normal.

Dr. Eska, in his 34th year as a physician and 31st in private practice, moves quickly, despite a limp. Polio permanently damaged his right leg in 1950 when he was 3 years old.

His hospital patients today have problems ranging from intestinal bleeding to signs of dementia to failing kidneys. One elderly man, who lives alone, fell into a hole in his backyard while emptying a bucket that serves as his indoor toilet.

Back at his office, Dr. Eska is running about 15 minutes late because of the busy start at the hospital. Shuffling between his exam room and his adjacent office, Dr. Eska sees several patients before lunch and several more in the afternoon. In between visits he returns phone calls, dictates case notes into a voice recorder and approves prescription drug refills by signing forms faxed to him.

Dr. Eska doesn't see that many uninsured patients, considering there are so many in his area. Many of Gonzales' uninsured residents visit one of the two federally qualified health centers in town. "That's a buffer for me." He might see several uninsured people each week in his office and a few at the hospital. This care reduces his personal income by 5% or more, he estimates.

Many of his other patients still have financial worries. Of the 80 to 90 people he sees each week, 80% are on Medicare. Most have supplemental coverage, but several each week can't afford the prescription drugs they need for their cholesterol, blood pressure or depression, for example. Boxes of drug samples line the shelves on his office's back wall. Dr. Eska has the local Wal-Mart pharmacy number on speed dial.

Some of his patients are reluctant to go to the hospital for screenings, diagnostic procedures or treatment, for fear of medical bills. Others are simply too stoic. One of his patients today is an 84-year-old man who six days ago had bloody diarrhea. His blood also was losing its ability to clot. Dr. Eska had to sternly persuade him to go to the hospital. Now, back in Dr. Eska's office and escorted by his daughter, the man downplays her concerns. "I'm on the road to recovery," he says, smiling.

Like many other Gonzales physicians, Dr. Eska takes call five or six times a month at the emergency department, where uninsured patients often show up. "If they get sick and need specialty care, then you have a problem," he said.

The journal article highlighted communication with specialists as a particular problem for physicians in areas with many uninsured people. Dr. Eska agreed, and said practicing in a small town is also a factor. Getting care for the uninsured is easier if one also sends paying patients to the same physician. "Usually the specialists, they'll take the good with the bad. Sometimes the hospitals they work for won't do that."

Dr. Eska has the most difficulty finding a rheumatologist or gastroenterologist -- none work in his town.

The maneuvering and negotiating sometimes make Dr. Eska feel as if his primary job is finding a way for patients to afford care rather than treating them. Would his professional life be better if Gonzales had fewer uninsured residents? "Having never worked in a highly insured population, it's hard to know. I wouldn't mind trying it, though."

Fewer uninsured, more specialists

In Willmar, a town of 18,000 people about 95 miles west of Minneapolis -- and 1,200 miles north of Gonzales -- it's an average day for Dr. Peterson, a family physician. He checks today's appointment schedule on his PC. It's just after 8 a.m. and the temperature outside is in the 20s, reasonable for November in Willmar.

Dr. Peterson deals with many of the same issues Dr. Eska does, including hospital patients who need home care or a nursing home stay but who are reluctant to consider these options, sometimes because of the expense. He also has a small mountain of paperwork, some of which is procedure authorizations. "My day is full of signing papers."

Today he sees two patients in the hospital: an elderly man with terminal prostate cancer who just wants to be kept as comfortable as possible, and an elderly breast cancer survivor who's having a little hip pain.

Back in his clinic, Dr. Peterson covers three exam rooms, each with a computer on which he updates patient files and orders prescriptions. One room has an oval fish tank in the wall. Young patients like to feed the fish.

Dr. Peterson sees a typical mix of people: a boy with a rash, a farmer with a sore neck, a woman with lots of questions about a skin condition that could be lupus, and an older man with a growing lung mass that looks like a tumor.

"You never know what's going to be behind the door, which is how I like it," said Dr. Peterson, who has been in private practice for 15 years.

But Dr. Peterson's work life differs from Dr. Eska's in that he seems to see fewer uninsured patients, and fewer who openly fret about costs. About 2% of Dr. Peterson's practice charges are billed to self-pay patients, a gauge of how many patients who come in are uninsured. Nearly 60% of charges are to private health plans, with the rest to Medicare, Medicaid or other public programs.

His practice doesn't offer drug samples. It stopped accepting them more than three years ago, in part because state law required the practice to inventory samples. Now the practice is more likely to prescribe generic drugs, and patients are less likely to ask for brand-name medications.

Getting specialty care for patients seems less difficult for Dr. Peterson as well. Cardiologists, neurosurgeons and rheumatologists visit Willmar. Specialists likely are more available because the town has another group practice with about 70 doctors.

Willmar doesn't have a federally qualified health center, so uninsured residents rely on both the hospital and private practices. "For the most part, there's an awful lot of benevolent care that's given on behalf of the uninsured and the poor," Dr. Peterson said.

It's difficult to calculate the impact of uninsured patients on his practice, because he doesn't always know if a patient lacks coverage. But Dr. Peterson believes the effect is negligible. "I don't think there's a financial burden on the clinic yet." That picture could change if payments by Medicare and Medicaid fail to keep pace with costs, he added.

Minnesota has relatively fewer uninsured people partly because of its broader health care safety net -- and higher taxes. While Texas does not tax individuals or physicians, Minnesota has both a 7% personal income tax and a 2% gross revenue tax on doctors, hospitals and drug distributors. The latter tax covers 92% of the cost of MinnesotaCare, a sliding-scale health insurance program for residents who don't qualify for Medicaid or whose employer covers less than half the cost of a private health plan. Monthly MinnesotaCare enrollment averaged 129,000 in 2006. The Minnesota Medical Assn. supports the program but opposes the physician tax, preferring a broader-based funding source.

Minnesota's Medicaid program was ranked seventh-best in the U.S. in April by the consumer organization Public Citizen, based on eligibility, scope of services, quality of care and physician payment. Public Citizen ranked Texas' program 48th.

Both physicians said they're satisfied with their careers. Dr Eska said he can devote the time his practice demands now that his two children are grown. "This is the best time in my life to be a doctor."

Said Dr. Peterson: "I feel blessed to do what I get to do every day."