It's 7:09 a.m. in the small, windowless office. The back wall displays diplomas from the University of Virginia Medical School and Davidson College. Sitting at his desk is Dr. Richard Lewis Gergoudis, a 52-year-old Richmond native and family practitioner known locally for how well he handles the large number of patients he sees daily.
Dressed in a tie and white lab coat, he snatches another medical file from a tottering stack and starts dictating into his telephone. "Male, age 68. Vascular problems. Also needs to see a neurologist," recites Gergoudis, who is close to the end of the 30 folders that represent yesterday's office work.
Next comes the 34-year-old mother whose bone marrow isn't replacing blood cells fast enough. Gergoudis thinks it's an autoimmune issue, not cancer. To make sure, he'll send her to specialists at Virginia Commonwealth University Medical Center.
The slightly built doctor usually arrives at his office at Commonwealth Primary Care near Glenside Drive around 6:30 a.m., before most of the staff, to dictate files. He needs to clear yesterday's records before today's floodgates open. In the day-long rush of patients, he'll need to listen carefully, win trust, exact tiny but revealing details, make quick judgments and keep meticulous records. The human touch is essential. He needs to be a buddy, a scientist, a detective and an insurance policy counselor.
The family practice specialty is being assaulted on many fronts. These include workdays lasting 14 or more hours, diminishing net income and what experts say could be a dearth of family doctors in coming years. The American Academy of Family Physicians expects a shortage of 40,000 doctors in that specialty by 2019. Meanwhile, during the next seven years, the number of Americans age 65 and older is expected to increase by 36 percent, with millions more added to the patient rolls while the new health care reforms are enacted. Experts predict an overall shortage of 124,400 doctors by 2025.
To get a glimpse of the inner workings of family practice medicine — and its troubling future — Gergoudis has agreed to allow Style Weekly to follow him for a day. The patients he sees have signed privacy statements, and Gergoudis agrees not to reveal their identities for this story.
Patients arrive. Carolyn Rice, a 40-plus-year health-care veteran and chief nurse, keeps the train on track. Gergoudis usually isn't more than 30 minutes behind unless he's derailed by an emergency.
One of the first is a 63-year-old air-conditioning repairman wearing a work shirt and boots. "My back bothers me," says the man, who wears his wedding ring on a gold necklace. The doctor notes gently that the patient had back surgery three years before and has suffered a heart attack. Checks show a healthy blood pressure but low sodium, which concerns Gergoudis. They work out a plan of attack. The man is also hard of hearing after serving in combat in Vietnam 43 years ago.
Rice stops Gergoudis in his office a few minutes later to remind him about a man who needs a chest X-ray, and a cell phone call that needs to be made to arrange end-of-life hospice care. He's back in an examining room with a 69-year-old diabetic for a routine checkup. He and Gergoudis are old friends, and they josh back and forth.
"Dr. Gergoudis is the best doctor I have ever had," he tells the reporter and photographer visiting from Style.
It's 9:37 in the morning at Gergoudis' office. The doctor has been in for three hours. And the day is just beginning.
Family practice is the first line of defense in medicine. It doesn't have the glamour of high-tech robotic surgery or the fascination of Dr. House's TV sleuthing. As the American managed care system enters its fourth decade and health care costs mount, doctors such as Gergoudis play a critical role. They screen patients for dangerous conditions that require more extensive care and treat chronic or minor ailments.
They're the leading edge in other ways, too. Insurance premiums have risen sharply in the past decade. Politicians and think-tank analysts insist that more costs be squeezed and efficiencies be increased. More emphasis is being placed on maintaining health rather than spending precious resources to correct medical issues that could have been caught earlier.
This all may sound like an impressive job description. The reality is that family practitioners are like gerbils on an exercise wheel. Insurance companies and Medicare force them to see more patients each day. They need to generate more revenue to handle the expenses of recordkeeping and malpractice insurance. Getting tests and arranging specialist care requires time-consuming permissions from the bureaucrat gatekeepers stationed throughout managed care.
The gatekeepers are there because four decades ago, physicians were thought to have driven up prices unfairly on procedures not controlled by Medicare. When big corporations were paying most of the insurance bills, the expenses were paid without much controversy. As heath care costs increased, however, that changed.
It became apparent that costs had to be contained as companies such as General Motors ended up with enormous medical bills. GM had built up a medical and insurance obligation to its current and retired employees over the decades that totaled about $5 billion. The money hurt the company while it had to compete against carmakers in Japan and other countries where health care is a government expense. And that meant charging more for their cars.
Since cost containment became goal number one, medical practices must not only treat patients but also help them deal with health care changes that dump more responsibility upon them. The science and economics of the existing system are so complicated and opaque that ordinary consumers are ill-equipped to deal with it. Many of them used to rely on their employers at a reasonable personal cost. But as more companies make cuts, this is no longer the case.
One reason the system is dysfunctional is how payments are made. As one of 18 physician partners who own Commonwealth Primary Care, Gergoudis brings in revenues on a "fee for service" basis. What revenue he generates goes into a pool with his other partners, which they share as profit after overhead costs are subtracted.
To generate income, he must see a patient or order a procedure or test. An office visit at Commonwealth Primary Care, for example, routinely costs $70, says Catherine Cawley, the practice's executive director. Of that, 70 percent, or $49, goes to overhead costs, such as salaries, recordkeeping, rent and utilities. That leaves about $21 per visit for the doctors' revenue base. A decade ago, she notes, the overhead portion was only about 50 percent of an office visit. What's more, Gergoudis and his colleagues don't get paid for helping maintain patients' health by answering phone calls, returning emails or reviewing tests they haven't ordered.
This conundrum has prompted some doctors to seek other payment solutions. Some join "boutique" practices that target higher-income patients and dramatically cut the number of patients but offer more personal service for an extra stipend. Other physicians opt for straight salaries paid by hospitals that have bought medical practices.
Commonwealth Primary Care is a traditional practice, offering more freedom for its health-care professionals. But the deck seems stacked against staying independent. The federal Medicare system, which has been insuring Americans 65 years old and older since 1965, represents about 30 percent of the practice's revenue. Medicare issues an annual list of what percentage of a bill it will pay. And that's been going steadily down while the federal budget deficit grows.
The remaining 70 percent comes from commercial insurance companies, the spearhead of the managed care system that started around 1980. How they pay is even more convoluted than Medicare.
The Richmond market is dominated by a handful of large insurers, including Anthem, Aetna, United Healthcare and Southern Health. Payment schedules depend on what health care groups can negotiate with such insurance companies in contracts that typically last from one to three years. "Mostly, we are at the mercy of the payers," Cawley says.
Critics say that a more market-based health care system is the answer, but how that would work isn't clear. Transparent pricing is essential for any such system, but it simply doesn't exist in the way medicine is practiced in the United States, the only advanced industrialized nation not to use a "single payer" system.
For example, an MRI test that uses magnetic fields to scan a patient's inner organs in great detail can run from $800 to $3,000 in the Richmond area, depending on how and whether the patient is insured. Some hospital companies such as HCA, which operates both the Chippenham and Johnston-Willis hospital campuses of CJW Medical Center, post some prices on their website. The pricing information, however, is stated clearly only for patients without insurance.
For those with insurance, prices vary. A big employer can negotiate a better deal for employees covered by its health plans. As more patients are pawned off as their employers drop them or change plans, they no longer have the muscle to bargain with the insurance companies.
Melinda Hancock, chief financial officer of Bon Secours Richmond Health System, which operates six local hospitals and other satellite facilities, acknowledges that "patients are not well versed" on what their insurers will pay. Bon Secours offers a phone line that will help patients get an estimate of their payment share, but it can be complicated. "My personal vision is to create a kind of TurboTax software where you plug in the information and get your answer," she says.
The pricing conundrum wasn't addressed June 28 when the U.S. Supreme Court upheld most of the Patient Protection and Affordable Care Act, otherwise known as Obamacare. The court upheld the requirement that all Americans buy health insurance, but wasn't required to address the pricing system. Ironically, patients have much better information when they choose which car, smart phone or gas grill to buy.
The paradox puts doctors in a conflicting position of having to weigh expense concerns with patients' health needs, says Dr. Clair Westin, another family practice specialist at Commonwealth Primary Care. "I have a rough idea of what the costs are for a CAT scan," she says, but weighing such things is in itself a problem. "I should never be making my decisions based on costs, but on medical necessity."
Executive director Cawley notes: "The pressure is to keep on the treadmill. The doctors must see 30 patients a day rather than 20. The feds and insurance companies have kind of created a monster."
The monster is growling by late morning. Gergoudis sees a man who has an obesity problem and a wife with skin cancer. They have six children and are feeling the stress. Another patient, a woodworker and blues bass player in his 50s, is here for a hypertension checkup. As with all patients, Gergoudis must keep track of lifestyle details. In this case, the man used to consume more than 16 beers on weekends. Now he says he's down to four beers a day. It's still a red flag for Gergoudis, who gently advises him to try to cut down on the alcohol.
This kind of personal touch is essential if the doctor is to know the patient during a period of many years and build up trust. The next patient has been with Gergoudis for 23 years. He and his wife are here to talk about an injury. The retired couple was on vacation in the Caribbean. He fell into an unseen hole while wading in the surf. In his struggle to keep his hearing aids from getting wet, he twisted his hip.
"It hurt something awful on Sunday," says the man, who is worried his hip may be broken. He gets an X-ray, and 35 minutes later imagery shows no fracture. Even better news, the man has a healthy hip joint for his age. Gergoudis prescribes Tylenol and sends him home.
Prescribing and monitoring more powerful drugs are key for the next round of patients. One man is on Lisinopril, a hypertension drug, but his blood pressure has been fluctuating. After some discussion, Gergoudis decides to keep him on the medicine.
A nattily dressed patient in white slacks and a red polo shirt faces a variety of problems. He's recovering from surgery in February and has been snoring loudly. They talk about seeing a specialist for sleep apnea. The patient also complains of not being able to concentrate. They discuss taking the two common drugs for attention deficit disorder, Ritalin and Adderall. Both can help but, because they're related to amphetamines, have their own set of side effects. Gergoudis prescribes Adderall but asks the patient to return in two months for monitoring.
It's lunchtime. The long arm of the pharmaceutical industry doesn't take a break. The doctors' office has a small kitchen with a refrigerator and a table where the staff eat so they don't have to go out. On this day, the menu is takeout pasta and salad with cookies provided by two representatives of a drug company, who ask not to be identified.
Called "detail" people in the trade, the salesmen and saleswomen must abide by strict rules. They can't be in an office with patients. But they can buy lunch while they pitch their company's drugs. The two well-dressed women in business suits chat with staffers, but refrain from much explicit discussion of their products. They leave a fistful of brochures about a blood pressure medicine.
Gergoudis drops by for a bite, but he quickly returns to the job. He has to keep on schedule. Helping him at the practice is a telephone bank with up to four operators sitting in a room loaded with communications gear that looks like something from a submarine war movie. The operators can handle 300 calls a day.
How they perform is critically important because the wrong impression can keep patients from returning. A medical practice is nothing without its patient base. "If we say we can't see them until next February, it may come across as wrong. If they need to be seen, of course we will see them," Gergoudis says.
During a lapse in midafternoon, Gergoudis talks about how essential it is to maintain a personal relationship with his patients. He's prominent in the Richmond community, coming from a large Greek-American family busy with the Sts. Constantine and Helen Greek Orthodox Cathedral, the Malvern Avenue institution famous for its festivals. Both Style and Richmond Magazine reader surveys have named him as one of the area's most popular doctors. Gergoudis says he couldn't do his job without the everyday support of his wife, Elaine.
And the job comes with plenty of surprises. On rare occasions, patients present issues that can't be resolved, and display abusive behavior — cursing or becoming physically threatening. Doctors can legally "dismiss" them, something Gergoudis has done only one or two times, he says. In one case, a woman was angry that he wouldn't give her husband a pass from work without examining him first. She threw a cup of convenience store coffee all over his desk. "I found the Styrofoam cup on my chair," he says. The practice refused to see her again.
Gergoudis and his colleagues are anxious about keeping their physician-run practice going in the face of many uncertainties about medical care and its economics. More medical students, confronting huge tuition bills, are aiming at higher-paying specialties and opting not to go into primary care. Neurosurgeons can make $571,000 a year while family practitioners average about $173,000 a year, only $2,000 a year more than pediatricians, the lowest-paying specialty.
Gergoudis says he isn't sure how Obamacare will affect his group. Many of the regulations haven't been written and full implementation isn't expected until 2014. At that time, uninsured patients must buy policies or face penalties. Companies must offer policies through "exchanges" that will be set up.
The requirement was hotly contested but was upheld by the Supreme Court. Commercial insurers no longer will be able to reject applicants because of pre-existing conditions, as they now do for maladies such as cancer, hypertension or high cholesterol, even if their conditions are under control.
The point of forcing all citizens to have insurance is to prevent people, notably healthy, young ones, from skimping on paying and then expecting to be treated when they're sick or injured. Hospital emergency rooms, for example, are required by law to treat anyone who walks in the door if they're in serious trouble. But in doing so, they simply pass their costs along to insured patients or taxpayers.
Nurse Rice says that the biggest change she's seen in years of experience was the flood of paperwork that was required after Medicaid, the federal plan to pay for the poor, took effect in the 1960s. "Doctors often treated the poor for free. A visit was normally $7," Rice says. "But after Medicaid, you had to fill out more paperwork, then you had to hire more people to handle it. It just sort of snowballed."
In the Supreme Court ruling, the only hit Obamacare took involved paying for the poor. Its plan to expand Medicaid to everyone younger than 65 whose income is under 133 percent of the poverty line was struck down. (The Obama administration's intention was to extend more government-paid coverage to more lower-income people.) States, which administer the Medicaid program, now can choose whether they want to expand Medicaid coverage. The federal government cannot refuse to pay Medicaid funds if states refuse to cover more poor people.
Making health care more convenient for the well-to-do is no problem — something "boutique" practices provide. One such operation locally is Concierge Medicine, run by PartnerMD, which advertises "better-than-average medical care." Its website contends that a shortage of primary care physicians means that such doctors "see thousands of patients per year and spend less than ten minutes with each of them." The site quotes a 2009 Washington Post study showing that Virginia has 88 primary care physicians per 100,000 residents. It doesn't state that that this figure is the national average, according to the same survey.
Linda Nash, chief executive officer of PartnerMD, defines her service as "membership medicine." Since 2003, it's grown to 4,300 participants. They're covered by 10 physicians who work on a straight salary basis, providing appointments lasting 30 minutes and including a three-hour annual physical exam. The service costs from $1,700 to $1,900 a year, but prices drop when spouses and children are added, she says. Most clients have other insurance, but Nash says they aren't all high-income. Some are postal workers or teachers whose family income is about $75,000.
Gergoudis says that the "boutique" idea has its limits. "You may pay $1,700 for it, but out of 3,000 patients you might see, only about 500 would be able to afford it," he says. "My worry is what happens to the other 2,500? Where do they go?"
For the vast middle sector of patients, he sees much greater use of walk-in clinics that can handle minor emergencies but "should not be used as family practices," he says, because patients can't develop a personal relationship with their doctors.
Another idea is the so-called "medical home" concept that's designed to make patients feel that they have the support of physicians' assistants, nurse practitioners and family practice doctors, who are the first ones they approach with a problem. This team-based health maintenance approach could cut costs as much as nay-saying insurance company gatekeepers. More house calls could be involved.
Still unsettled is the payment system. Cawley says that technically, "it is the responsibility of the patient" to learn what their health insurance will pay for. At Commonwealth Primary Care, for instance, prices for tests run by in-house labs are available if a patient asks. But the price listed may not be what a patient pays. A simple office visit is listed as $110. But how much the patient pays, such as $40, depends on their insurance policies.
For now, the treadmill continues. Gergoudis will finish up at his office around 5:30 p.m. but then must answer phone messages and fax data. Commonwealth Primary Care is developing its electronic records system, which some say could do much to improve efficiency and cost savings.
But the system has bugs. Doctors find that entering information into an iPad or other device while talking with patients is disruptive. Talking with them in a positive, trusting way is critical, says Gergoudis, who teaches a class on clinical interviewing to first-year medical students at VCU. One afternoon a week, he visits Lakewood Manor Baptist Retirement Community in the West End, where he serves as medical director. Some Saturdays he works at one of his practice's satellite offices. It's difficult to take vacations, he says, because all the recordkeeping often requires adding an extra workday at either end of his time off.
Yet he believes in what he's been doing for the past 26 years. He's determined to keep his practice independent, and says it's the best way to keep doctors motivated to heal the sick. "I try to get students excited about it," says Gergoudis, who, as always, will be back in his office about 6:30 the next morning. S
Thousands of patients' paper files, now being digitized, are the lifeblood of Dr. Rick Gergoudis's family practice.
Chief nurse Carolyn Rice, a 46-year medical veteran, keeps Dr. Gergoudis' crammed day on track.
Basic examinations of ears, heart and blood pressure, performed endlessly, are the starting points of any diagnosis.
Gergoudis checks a retiree who slipped in the Caribbean surf and hurt his hip.