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Chronic Care in Crisis: Why We Need A New System


doi: 10.1097/

Dr. Corboy is director of the University of Colorado Mutiple Sclerosis Center and professor of neurology at the University of Colorado School of Medicine in Aurora, CO.

TWO APPROACHES TO THE SAME PROBLEM Dr. Bowling has a "cash-only" private neurology practice, while Dr. Corboy accepts "third-party" insurance in a clinic at an academic medical center. Both are dissatisfied with the current reimbursement and health care system, but offer different perspectives here on the problems.

It is getting harder to provide high quality care to patients with chronic diseases such as multiple sclerosis (MS) and maintain a reasonable income. Overhead for comprehensive services is substantial, reimbursement is low relative to time spent, and there are few procedures available that might boost income.

In the last five years three Denver-area physicians who specialize in MS care either left MS care entirely, or no longer accept third-party insurance, which means they have gone “cash only” with minimal office staff. One general neurologist further south closed his practice to new and established MS patients. Nationally, the National Multiple Sclerosis Society found that 64 percent of surveyed neurologists do not want to take on more MS patients. This is a crisis.

Dr. Allen Bowling is the latest to go “cash only” in Denver. As a friend with intimate knowledge of the complexities and challenges he faces in his daily practice, I am sympathetic and am rooting for him to succeed. I believe him when he says this change frees him from the financial burden of high overhead costs, and allows him to spend quality time with each patient with no ambiguity about whether and how much he will be paid for his time.

Although I schedule 75 minutes for a new patient visit, and frequently exceed this time limit, I am sure there are some patients who need even more time. His approach is really no different from the practice model of many psychiatrists, who run small offices with little overhead and accept cash only.

But I wonder if he will offer anywhere near the comprehensive services needed by so many MS patients. We have a full-time nurse practitioner, with over 15 years of experience with spinal cord injury and MS patients, available to respond to emergencies, and a full-time nurse to respond daily to the many clinical and administrative needs of these complex patients. The patients need this assistance on a routine basis, and primary care physicians do not have the expertise to handle many of these issues.



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Narrowing Population of MS Patients

Perhaps more importantly, I believe Dr. Bowling is limiting his practice to a narrow population of MS patients. From my point of view, a provider's unwillingness to accept third-party payments is another example of cherry picking within the health care system, and is no different from surgeons setting up their own “surgi-centers” and siphoning off well-insured patients while the local charity hospital acts as a safety net for poorly insured patients.

I believe Dr. Bowling when he says he sees a spectrum of MS patients, including some with minimal ability to pay. I volunteer and regularly see MS patients for free at our city hospital. But how many of the patients who remain in Dr. Bowling's practice have Medicare or Medicaid as primary insurance, are uninsured, are on disability, or live in nursing homes with minimal family support? I suspect this is a low percentage.

In our academic MS practice, about 40 percent of our patients rely on Medicare, Medicaid, or Tricare (federal insurance for retired military which, by law, may not exceed Medicare payments) to cover most if not all of their health costs. It is true that a small percentage of our patients may have minimal insurance coverage for the facility fee requested by our University hospital, but most see little additional cost in their out-of-pocket expenses.

Each time a neurologist in Colorado no longer accepts third-party payments or closes a practice to MS, we at the University of Colorado feel the impact with an upsurge in patients, many of whom are seriously impaired and have Medicare as primary insurance, and most of whom remain as long-term patients. This is happening again. I have spoken to many patients who have sought care with us after leaving Dr. Bowling's practice, and even to a few who have remained with him.

All are sympathetic to the difficulties we face in our practices, but quite a few who have moved to our practice, especially those who have been in Dr. Bowling's practice for many years, have expressed unhappiness at being released by a physician on financial grounds — especially when all of them have insurance. The vast majority have expressed that the primary motivation for leaving Dr. Bowling's practice was financial; that is, they simply did not have the extra disposable income required to continue to see him. Of course, others who have stayed with Dr. Bowling have accepted the costs, likely because they appreciate his fine care.

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What Are the Answers?

I don't know how to fix all the problems we face in our health care “system,” but I do not think the exit of physicians who care for patients with chronic illness from the insurance-based system of care in the US is the answer. In a larger sense, this is what we already have when comparing those with and without insurance. Ultimately this approach will accelerate the failure of the system as a whole, and further accentuate the disparities among patients by putting greater strains on physicians who continue to see a wide range of patients.

What America needs is a system that offers true health care access to all Americans, affordable cost to patients, and reasonable compensation with low administrative burdens for physicians. To obtain this will require a change in mindset for physicians, patients, and politicians, because many Americans desire Cadillacs but want to pay for Chevrolets. What remains to be seen is whether, in this election year, any of the current presidential candidates will offer an operational solution to this crisis, and whether the American public is finally fed up enough to vote for meaningful change.

©2008 American Academy of Neurology