About a year and a half ago, Dr. Leslie Kernisan, 37, a geriatrician in San Francisco, decided she couldn’t stand her medical practice any longer. Every day, she felt she was shortchanging her older patients.
“What I had in the way of time and resources to meet patients’ needs was so inadequate that it felt almost grotesque,” she told me recently.
At the time, Dr. Kernisan was working at a community clinic filled with caring, committed professionals. They weren’t the problem. What was wrong, she felt, was a dysfunctional system of health care for seniors — and at the center of that was Medicare, the government’s insurance program for seniors.
So Dr. Kernisan did something highly unusual for a geriatrician. She decided to withdraw from Medicare and create a new kind of geriatrics practice.
Today, she spends as much time as her patients want reviewing their medical problems, their prognosis, how their care is being coordinated, and what caregivers can do to help. When people call for help, she calls them back within two hours. E-mails are answered in one business day; a request for a house call generates an appointment in no more than two days.
The price for all of this: $200 an hour, which patients pay out of their own pockets, for anything and everything she does. (Though Medicare doesn’t pay for her services, it does pay for medical tests and services provided to these patients by other physicians.)
Those fees are unaffordable for all but relatively well-off older adults, however. While people didn’t complain, Dr. Kernisan said she felt “terrible” about leaving patients who had relied on her and guilty toward colleagues who shouldered responsibilities she was giving up.
Still, she’d come to a breaking point, and it seemed impossible to go on as things were. “It was so stressful that I felt my own health and well-being were suffering,” Dr. Kernisan said.
Dr. Kernisan described her new geriatrics practice recently in a Hastings Center blog post and spent several hours talking with me about her decision to leave Medicare. Hers is an extreme example of the malaise afflicting geriatricians.
Earlier this year, my colleague Paula Span wrote about the drop in the number of doctors enrolled in fellowship training programs for geriatrics. The number of geriatricians, estimated at 7,222 last year, has fallen from a peak of 8,824 in 1996 and is far short of the estimated 25,000 geriatricians needed to serve the burgeoning population of older adults by 2025.
“Maintaining practice in geriatrics is very difficult unless you have some other form of support,” like an academic position or a medical directorship at a nursing home, said Dr. Peter Hollmann, chairman of the public policy committee of the American Geriatrics Society. “It’s one of the only fields in medicine where additional years of training yields less compensation, not more.”
At doctors’ offices and at the clinic where Dr. Kernisan worked, Medicare paid only for face-to-face visits, not phone calls or consultations with family members; reimbursements didn’t even begin to cover the effort required for thorough medical evaluations of medically complex patients. The only way to stay afloat financially, she found, was to pack in patients back-to-back in 15- to 30-minute slots.
“People would come in with a long list of concerns that they wanted to address, and you’re thinking, ‘How many of these can I follow up on?” Dr. Kernisan said. “And you ended up having to pick just two or three. If you’re conscientious, it’s distressing to feel you can’t do most of what you should be doing.”
Stressed and unable to sleep at night, the young doctor felt pulled between her professional passion for helping older patients and their families and her personal life, with the abundant demands of two small children.
One day, her 3-year-old asked, “Mommy, why are you always mad and always saying no?” At that point, Dr. Kernisan said, she was forced to recognize she was “always cranky at home and miserable going to work.” It was time for a change. In May 2012, she left the clinic where she’d worked part time as a medical director, and in October she opened her own practice.
That move coincides with a growing debate within her profession. Given the small numbers of geriatricians in the United States, should they even try to provide basic medical care? Or should they become consultants, called in on complex cases that require special expertise in the health concerns of older adults?
“A lot of geriatricians feel they might use their time more effectively working in teams with primary care physicians,” said Dr. Gregg Warshaw, a professor of family medicine and geriatrics at the University of Cincinnati.
Today, Dr. Kernisan describes herself as a coach and a consultant. Instead of delivering routine medical care, she conducts comprehensive, specialized geriatric assessments, evaluates care ordered by other doctors, and comes up with plans to fill gaps in care that other medical professionals haven’t addressed.
“I focus on things like pain, physical decline, falls, incontinence, frailty, the management of medical complexity — things that tend to be missed by primary care doctors who lack the time or expertise or both,” she said.
Sometimes, it’s not easy. Though Dr. Kernisan tries to work closely with a patient’s primary care doctor, some haven’t welcomed her input. “It’s a delicate issue,” she said. “The vast majority of the time, it has been a family or a geriatric care manager who calls me up, not a primary care doctor saying, ‘I need help with this older person.’”
Dr. Hollmann said, “I think it is a reasonable option for some number of geriatricians to have this kind of practice, but hopefully it won’t be too many, because we want Medicare patients to have access to care.”
Although there’s a lot of noise about physicians’ unhappiness with Medicare and some evidence of doctors restricting the number of Medicare members they’ll treat, only 3,423 physicians nationwide opted out of the government health program last year, according to the Centers for Medicare and Medicaid Services.
But those numbers aren’t necessarily reliable. When the Office of the Inspector General of the Department of Health and Human Services was asked to evaluate how many physicians were opting out of Medicare, it found that the Centers for Medicare and Medicaid Services and the agency’s contracts were not maintaining “sufficient data” to answer the question.
If you know of other geriatricians who’ve exited Medicare and set up new models of practice for older adults, tell us more in the comments section.
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