MAIN STORY DAY 1: Collision in Care: Santa Cruz County's looming doctor crisis

Dr. Jennifer Hastings, 53, right, sees patient Judy Hunter, 55, at the Planned Parenthood clinic in Santa Cruz. (Ann Johansson/Center for Health Reporting)

This story first appeared in the Santa Cruz Sentinel.

SANTA CRUZ -- Eighty-three-year-old Gladys Man steered her cherry red electric scooter into the Planned Parenthood clinic in downtown Santa Cruz. Inside the waiting room, nervous-looking teenage girls filled out medical forms; a young couple giggled quietly over a cell phone message.

In preparation for her monthly doctor's appointment, Man had spruced up -- applying bright red lipstick and pinning pink and purple fabric flowers into her fuzzy blond hair.

For about a year now, Man has seen Dr. Jennifer Hastings, the crowded clinic's busy medical director and sole physician, for help with an alphabet of woes, including arthritis, chronic pain, chemical sensitivities, emphysema, heart failure and osteoporosis. Years ago, when Man was pregnant with her children, she'd frequently visited her local Planned Parenthood. Now an elderly woman with complex medical problems, a little clinic better known for providing Pap smears, abortions and birth control struck her as a somewhat unusual place to seek care.

But upon moving to Santa Cruz from San Francisco two Decembers ago, Man found few other local doctors would accept her. Especially once they learned she had Medicare.

In the past two years, many of Santa Cruz County's elderly and disabled patients, like Man, have increasingly been shut out from a primary care system that has no room for them. Many doctors here, for years fed up with the low reimbursement rates paid by the federal insurance program for the elderly and disabled, now refuse to accept new Medicare patients. At the same time, the number of primary care physicians is declining. In the view of some local health care providers, the situation has reached a tipping point.

"Our health care system is breaking," said Dr. Tony Musielewicz, medical director of Dominican Hospital's emergency room. "The fact that the elderly have difficulty finding primary care is something the community, the county, the state and the nation have to work on as a whole."

In the past 18 months, many say, the problem has gotten worse:

* Community clinics like Planned Parenthood, already stretched thin by the swelling ranks of the unemployed and uninsured, are seeing increasing numbers of elderly and disabled patients. One nonprofit community clinic, the Women's Health Center in downtown Santa Cruz, has seen the number of Medicare patients

* The county medical society is being flooded with phone calls from Medicare patients searching for primary care doctors. But of 100 or so primary care physicians who are members of the society, only between three and six are accepting new Medicare patients at any given time, the society's executive director said.

* Hospital emergency rooms are filling with seniors who have nowhere else to go. Lynn Szanto, a case manager for the Dominican Hospital ER, said she sees two to three healthy senior patients every month who move into the area, develop a medical problem and can't find a doctor.

Part of the problem is supply -- these days, there simply aren't enough primary care providers to go around. Nationally, less than 2 percent of graduates are entering general internal medicine; overwhelmingly, new doctors are instead choosing lower stress, better paying specialties like orthopedics or dermatology.

The shortage is even worse locally, because federal rules written half a century ago require that Santa Cruz's primary care doctors get reimbursed at the same rate as their counterparts in Merced and other designated "rural" areas, despite having a cost of living that rivals Silicon Valley's.

The net effect: As the first wave of baby boomers edges closer to 65, fewer and fewer primary care doctors are available to care for them.

With new President Barack Obama promising to enact some sort of universal health care plan, Santa Cruz's inability to provide adequate primary care for its elderly citizens under an already existing universal health care insurance program sounds a disturbing alarm for the rest of the nation.

It's not enough for patients to be insured, after all. Someone must be willing to treat them.

"Santa Cruz is just the tip of the iceberg for the problem," said Larry deGhetaldi, president of the Santa Cruz division of the nonprofit Palo Alto Medical Foundation. "You damn well know it's going to be happening all over the country."

As evidence, deGhetaldi, 53, points to a report published last November by the nonprofit, nonpartisan California HealthCare Foundation. It showed that less than 67 percent of the county's 30,000 Medicare patients get the majority of their care from a primary care doctor -- one of the lowest percentages in the state.

Those most affected by the shortage tend to be seniors who have moved to the county recently, or those whose doctors have retired.

For most of the last decade, deGhetaldi, 53, has made it his mission to change the county's low reimbursement rates. Because most commercial insurance companies base their reimbursement formulas on Medicare's, he says the low local rates are hurting access for privately insured patients, as well as for seniors and the disabled.

Mark Beach, a California spokesman for AARP, a nonprofit organization that represents seniors, echoed deGhetaldi's concerns, saying access to care is a national issue that cuts across groups.

"We definitely are aware of it, and we definitely consider it a problem," he said.

Hiram Ward, 75, back row second from right, sits with his care manager Janet Westphal among young patients in the waiting room of the Planned Parenthood clinic in downtown Santa Cruz earlier this month. (Ann Johansson/Center for Health Reporting)

DeGhetaldi's foundation, which contracts with about 30 percent of the county's primary care doctors, stopped accepting new Medicare patients for primary care two years ago, when wait times got too long. With reimbursement rates so low, they simply couldn't recruit enough doctors to meet the need.

"The breaking point," deGhetaldi calls it.

At that time, the organization also closed for primary care to everyone else in Santa Cruz, unless they were family members of existing patients or members of HMOs to which the organization is contractually obligated. Some patients now drive to the foundation's clinics in Mountain View or Palo Alto, which have ample primary care capacity.

Even as those patients commute over the hill, many doctors who live in this county are driving alongside them -- to avail themselves of the Bay Area's better reimbursement rates. Historically, both specialists and primary care doctors who practiced in Santa Clara County earned 25 percent more than their counterparts who practiced in Santa Cruz; that difference is somewhat less now, but it's still significant enough to lure Dr. Nicholas Abidi, an orthopedic surgeon whose main practice is in Santa Cruz, to work in San Jose at least one day a week.

"To have your own practice in Santa Cruz is a huge burden," he said.

That discrepancy makes it virtually impossible to attract new primary care providers to the county. Those who do continue to practice here sometimes refuse to accept new Medicare patients, at least in part, as a form of protest.

Chris O'Grady, 44, a Watsonville-based family practice doctor and president of the county medical society, says many local providers have grown tired of Congress turning a deaf ear to their pleas for better compensation. Instead, O'Grady said, last summer Congress threatened to cut Medicare an additional 10 percent A federal funding formula calls for cutting doctors' pay when Medicare costs grow faster than the national gross domestic product. Congress can override the funding requirement.

O'Grady says some doctors turn patients away partly in the hopes that if those patients get angry enough, Congress might make a change.

"Until the patients complain, nothing's going to happen," he said. "If nobody on Medicare can get in to see a doctor, the politicians have to respond to that."

Last year, O'Grady -- who has special training in geriatrics -- became so overwhelmed with new Medicare patients that he closed his practice to new ones for several months; he reopened again on Jan. 1. But if the reimbursement rates don't change this year, he says, he'll likely close his doors to new Medicare patients again -- this time for good.

The handful of doctors who consistently take on new Medicare patients say they do so out of a sense of moral obligation. Elderly and disabled people, like Gladys Man, are often more difficult to care for than other patients. They have more complex ailments. They need longer and more frequent appointments. Their doctors end up having to leave their offices more often, to make visits to hospitals or nursing homes.

One afternoon last month, a handful of physicians from Family Doctors of Santa Cruz, a small family practice near downtown, gathered for their weekly lunch meeting at a restaurant overlooking DeLaveaga Golf Course. During their years practicing in Santa Cruz, Dr. Stephen Halpern, Dr. Jack Watson and their colleagues have made it a point to always accept new Medicare patients.

"That's what a doctor does," said Halpern, 66. "Part of your duty is taking care of sick people. Otherwise you'd be in Beverly Hills, doing hair transplants."

Patient Jim Struzan, 54, front center, sits in the waiting room at the Planned Parenthood clinic in Santa Cruz on Feb. 5. (Ann Johansson/Center for Health Reporting)

Dr. Hannah Farquharson, 35, agreed, particularly upset that receptionists turn away prospective patients as soon as they hear the word "Medicare."

"To close the door at the phone call," she said, "it's just unethical."

As a result of this open door policy, Watson says, their practice has, at times, been overrun with requests from patients with nowhere else to turn.

For many, the search for a doctor willing to take on new Medicare patients can seem nightmarishly frustrating. Marcus Kwan, executive director of the Santa Cruz County Medical Society, said more than two-thirds of the calls he's received in the past 18 months are from Medicare patients requesting help finding a primary care doctor willing to see them.

A small fraction of those patients end up choosing one of the Medicare HMO plans, which are accepted by the larger medical groups. But critics say those come with their own problems, including unexpected co-pays that patients on fixed incomes may struggle to afford.

Seniors are "really confused," trying to decide which plan to choose, said Sally NeSmith, the program manager at the local Health Insurance Counseling and Advocacy Program, which helps seniors search for care.

"This provider will take that one and not this one... It's just madness, really," she said.

Two years ago, 49-year-old Irene Tsouprake convinced her father, Peter, to move to Santa Cruz to live with her. Peter Tsouprake, now 81, was a highly decorated Air Force veteran. He'd recently undergone heart and back surgery in Massachusetts. Irene wanted to find him a doctor quickly.

But call after call yielded the same answer -- "Oh, I'm sorry. Our office doesn't take Medicare."

"It's appalling for any American," Irene says now. "But for someone who's put themselves in the line of fire, it's absolutely unconscionable."

Says her father, Peter: "I was flabbergasted."

Eventually, after a few months of searching, someone suggested Irene contact Dr. Jack Watson. But the experience has left her wondering -- what happens to the elderly who don't have daughters or sons who will advocate for them?

"It's just such a difficult, broken system," she said.

Peter Tsouprake, 81, right, sits with his daughter, Irene Tsouprake, 49, by the piano in her home in Santa Cruz on Feb. 5. Peter moved in with his daughter and her family so she could care for him. It took her months to find a primary care doctor willing to accept him. (Ann Johansson/Center for Health Reporting)

Eventually, growing numbers of elderly and disabled patients end up seeking care at the network of nonprofit community clinics, county clinics and hospital emergency rooms known as the "safety net."

Because their very mission is to catch those who fall through the medical system's abundant cracks, the nonprofit clinics are reluctant to refuse any patient, even though Medicare reimburses them at the same low rates as everyone else. The emergency rooms are legally prohibited from turning patients away.

With the economy in disarray, the ranks of the uninsured swelling and the county slicing its clinics' budgets close to the bone, the safety net is stretched perilously thin. And more and more people are leaning on it for help.

"Every month is the most patients ever," said Dr. Jose Chibras, chief medical officer of Salud Para La Gente, a large nonprofit community clinic in Watsonville.

At the Women's Health Center in downtown Santa Cruz, where the number of Medicare patients has nearly doubled since 2004, Medicare patients now make up 9 percent of the clinic's clientele -- despite its traditional focus on women and children's health.

When current patients started having a hard time getting in to see their doctors, the nonprofit decided it had to turn away new patients for a six-week period, starting in late December. But they couldn't find it in their hearts to refuse the Medicare patients.

"They couldn't find anywhere else to go," said Dr. Patrick Meehan, the center's executive director.

A few blocks away, the downtown Santa Cruz Planned Parenthood has seen a 12.5 percent year-over-year increase in patients these past seven months. In January, the clinic staff considered refusing new Medicare patients to ease the crowding. Ultimately, they decided the idea went against the organization's mission.

They do their best to squeeze in as many patients as possible; they're determined not to turn away anyone who needs them.

Dr. Hastings, the medical director, is well-loved by her patients. But as the clinic's sole physician, she knows there's a limit to how many complex cases she can juggle while also handling a regular workload that includes abortions, transgender support and prenatal care.

At least some of her patients, she says, "should be in other medical homes."

Gladys Man agrees with her. She describes Dr. Hastings as a kind-hearted woman and a wonderful doctor. But the clinic is just so busy all the time, and Man doesn't want to be a constant bother.

"If I knew who else to go to," she says, "I would."

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