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Chronic Care in Crisis: Why We Need (And I Chose) a Different System


doi: 10.1097/

Dr. Bowling is clinical associate professor of neurology at University of Colorado-Denver and Health Sciences Center and Rocky Mountain MS Center.

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.

Last July, I converted a busy, high overhead, insurance-based MS practice to one that has lower overhead, is moderately busy, and does not accept any private or government insurance. It is not a “boutique” practice with high patient fees, fancy carpet, and leather couches. But patients get high-quality, personalized, and moderately-priced care with easy access to the neurologist. This change has led me to think differently about neurological practice, physician reimbursement, patient care, and the state of the US health care system.

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The Issues

We all know reimbursement for neurological care to MS patients (and many patients with other chronic diseases) is much lower than that for procedure-based services. MS is a complex, chronic disease with patients who require treatment of ever-changing neurological symptoms, interpretation of MRIs, and regular monitoring of immunomodulating therapy. Perhaps because of the complexity and low reimbursement, some neurologists in the Rocky Mountain area dislike providing care for, or even refuse to see, MS patients, especially on a long-term basis.

I had to change how I was reimbursed or close my MS practice. I am passionate about caring for MS patients — that is the core of my career. However, I am not willing to go bankrupt or have an income that is less than that of a medical assistant in order to provide that care.

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Making the Transition

In spite of much preparation, I was anxious about how to present this transition to my patients. I have spoken individually with about 1,000 patients about health care and the change in my practice. Some patients were not surprised; they have dealt with their own insurance issues for years and assume that physicians face similar challenges. Others were actually surprised that I had not changed my practice sooner.



My current practice does not seem to be “cherry picked.” The patients who stayed with me are not generally wealthy, or “VIPs,” and they span the full range of MS severity. I continue to care for those who live in nursing homes, have advanced disease, are wheelchair-bound, or have severe cognitive impairment, and I am more involved in the details of their care. I now address psychological, social, exercise, and lifestyle issues that I could not deal with previously — this allows me to now provide more comprehensive care.

My patients seem to be more concerned about their health care. Many have commented that their care and their relationship with me have actually been enhanced by the change. They like having a more one-on-one financial relationship with me — in contrast to the previous triad (patient-physician-insurance company) in which I did not know how much patients paid their insurance companies and patients did not know how much insurance companies reimbursed me.

The new patients seem to want to receive the kind of care I can now provide. Some of these patients had actually seen Dr. Corboy in the past. In the hospital-based clinic, where he practiced, these patients say they could not get enough time with or access to clinicians, and they are willing to pay a relatively small amount of additional money for the type of care I can provide. Paradoxically, some patients actually pay less out-of-pocket to see me than Dr. Corboy — because his clinic charges a “facility fee” (which may be a few hundred dollars) for which insurance may only partially reimburse or not reimburse at all.

I am concerned about how my practice change will affect this strained and “unhealthy” US health care system. So I offer a “sliding scale” of payment to some patients. Now that I am more adequately reimbursed for my clinical care, I am more willing and able financially to provide charitable care. Previously, I felt that insurance reimbursement was so low that I was providing some form of “charitable care” to nearly all of my patients. I now provide care at no charge or reduced rates to a considerable number of patients, especially those who are severely affected by MS, have Medicaid, or have limited financial resources.

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Effect on the Profession of Neurology

To me, the core of what a neurologist does is to provide care to people with neurological diseases. But the current system — with its woefully inadequate reimbursement — has hurt our profession and our collective morale; for many of our colleagues, it has quenched their passion and pride in their work, prompting “burnout” and early retirement. These feelings often extend to our staff who also feel the effects of that burnout, causing high turnover, low-quality work, and potentially dangerous administrative errors.

In addition, in a practice observed — but rarely discussed openly — some neurologists may be inappropriately enrolling patients in lucrative clinical trials and benefiting financially by ordering unnecessary diagnostic tests or therapies. These strategies may meet the neurologists' financial needs better than the health care needs of patients. This is especially concerning for younger neurologists who may not be motivated to develop their skills in providing care, and thus may never acquire skills beyond what they learned in residency.

It has become standard practice for neurologists (and other physicians) to accept partial reimbursement for their services. In doing this, are neurologists being fair to themselves and their profession? Most other professions expect that billed services will be paid in full. Within the health care field, there are some who routinely charge extra fees beyond what insurance will pay. For example, many MS patients in my practice routinely pay $200 to $400 per month for injectable MS medications. Also, in the Denver area, nearly all patients pay out-of-pocket fees (which may be several hundred dollars) to radiologists for diagnostic tests, such as MRIs.

Can our chronically “diseased” health care system adequately provide care for a chronic disease, such as MS? No. There are no optimal solutions when one is trying to function in a dysfunctional system.

I made changes that suited my situation and allowed me to continue practicing. Dr. Corboy has a different situation, and he has made his own changes to suit his practice setting. Until the health care system significantly changes, we each need to responsibly and thoughtfully find a way to apply our passions, skills, and interests within our own environment so that we are able to provide useful and valuable professional services.

©2008 American Academy of Neurology