Diagnosis Charlotte

Rising costs, two dominant hospital systems, no medical school—just how healthy is the state of healthcare in the Queen City? We talked to local physicians to find out

 

I was on my way in to start my night shift in the ER. Driving past the main door, I saw groups of people milling about, and the parking lot was full. It looked like it was going to be another hectic night—business as usual. Sure enough, as I walked in, there was shouting, and people were hurrying in all directions.

My first patient of the night was a six-year-old with a sore throat. "Don't you have a primary-care doctor for your son?" I asked his mom.
"No, doctor," she answered. "We can't afford health insurance."

Next up, a forty-one-year-old female who'd twisted her ankle—four days earlier. Same story: no insurance. "Doctor, why did I have to wait four and a half hours to see you?" she wanted to know. Next was a twenty-three-year-old pregnant woman with fever and a cough. So far, every one of these patients could have been seen in a primary-care office—if they could have afforded it.

Just about then, a nurse grabbed me and said, "I think you should go into room eight. Abdominal pain, getting worse." The patient, a twenty-one-year-old male, had been experiencing progressively worsening pain for the last twelve hours. It had just hit a "ten out of ten." After getting history, I put a hand on his belly: Severe tenderness right lower quadrant. Uh-oh. Sure enough, a stat CT revealed a perforated appendix, a true emergency. After immediate surgery and a complicated closure, the young man was all right, but he ended up having to spend a full nine days in the hospital, and has an ugly scar to show for it.

The preceding tale was recounted by Marc R. Lewin. He has since left that area hospital for family practice at Carmel Family Physicians. To Lewin, a native of Toronto who earned his early stripes working in Calcutta with Mother Teresa, no less, America’s insurance crisis came as a culture shock. “We have national healthcare in Canada,” he says. “You can see any doctor you want to see.”
Like many, Lewin found himself frustrated by a growing juggernaut of nonurgent patients overwhelming a system that was never meant to cope with them in the first place. “If that young man hadn’t had to wait so long to be seen by a doctor, we might have been able to prevent the perforation and the complications,” he says. “The fact that a lot of uninsured people need to use the ER for their primary care is a huge problem, but often, they don’t have much choice.”

Of course, overtaxed emergency rooms aren’t endemic to Charlotte. But they are symptomatic of one of the biggest challenges facing Charlotte healthcare: growth. Charlotte’s population has skyrocketed over the past two decades. Current census figures place the population at more than 664,000; by 2017, that number will be at more than 950,000. With that growth has come a high number of uninsured patients, particularly as the city becomes a destination for illegal immigrants.

There are other challenges, too. The lack of a medical school lends too much of a corporate, dollar-driven mentality, say some physicians. Others point out that the competition between Carolinas HealthCare and Presbyterian Healthcare isn’t always healthy.

Still, overall, this is a pretty good place to be if you get sick. With a patient base that boasts a core constituency of high-per-capita income, insured residents, Charlotte has been able to attract and support more than its fair share of physicians and medical practices, including those in high-insurance risk disciplines, such as obstetrics, which in other parts of the country—and even the state—are disappearing faster than you can say lawsuit. 

Double-Edged Healthcare?

Charlotte’s unique medical landscape is dominated by two competing healthcare systems: Carolinas HealthCare System and Presbyterian Healthcare System, the latter a subsidiary of Winston-Salem-based Novant Health. Many physicians claim that Charlotte benefits from the presence of the two systems. But to a vocal contingent, this Godzilla-versus-King Kong scenario fosters an unhealthy competition in which doctor-patient relationships are sacrificed in the name of the bottom line. The result? Out-of-system referrals dry up. Doctors who were once self-sufficient have evolved into employees, now beholden to the employers that own their practices. Less-lucrative specialties have fallen by the wayside—all prescriptions for less than optimum care.

J. Bruce Taylor, an OB-GYN, feels that the rivalry “fractionates the medical community.” Taylor completed his residency in Richmond, Va., and has worked in Charlotte for the past twenty-nine years. His practice has been owned by CHS since 1992. “My perspective has been skewed by that relationship,” he admits, “but since the introduction of managed care, and with the OB liability crisis, more and more practices have been driven into corporate medicine.”

This concept of doctors being “owned” by the hospitals that employ them is a recurring theme among physicians. “It’s the way things are moving,” says surgical oncologist Peter Turk, who practices out of the independent Carolinas Surgical Clinic. “It’s definitely an evolution.” Turk admits that if you are not “owned” by one of the major hospital groups, you can sometimes find yourself out in the cold. As a specialist, Turk notes that his referral base has changed over time. “I’ve been in Charlotte fourteen years,” says the Brown University-trained surgeon, “and I’ve always enjoyed a good referral system and interaction with referring doctors. With this splitting between one hospital and another, I’m not seeing the same referrals [as I used to], because now that they own more surgeons, there is a pressure within the hospitals to refer inside their own group.”

“We now have two healthcare systems,” Taylor says (see sidebar for a side-by-side comparison), “which I guess is good for the patients who have the opportunity to pick and choose what they feel is the best from each, but the negative is that you end up with physicians who have historically been very collegial in this environment [who no longer know one another]. When I started practicing medicine here, I knew physicians all over the community because I interacted with them. That does not occur anymore. Basically, the Presbyterian doctors refer to their colleagues, and the CHS doctors refer to colleagues at CHS. The few folks who are independent get what’s left over. Patient care can sometimes suffer as a result of this lack of communication.”

Psychiatrist V. Sagar Sethi, author of Solving Psychiatric Puzzles, was born in India. He received his undergraduate and master’s degrees in pharmacy from Banaras Hindu University, India, and went on to earn his PhD in pharmaceutical sciences from Munich University in Germany, where he graduated magna cum laude. At fifty, he received his medical degree while in Mexico, followed by four years of residency training in psychiatry at Creighton and Nebraska universities in Omaha and the University of North Carolina at Chapel Hill. Sethi has been in Charlotte for more than sixteen years. While he says he loves the town and feels blessed to be here, he says he has found maintaining an independent practice difficult. “We only have two camps that compete pretty fiercely, and they always want to use their own people,” he says. “When you are an independent, your name doesn’t come up, no one invites you to lecture. It’s all very politically motivated. At least, that’s my impression.”

 

 

Many physicians, however, such as Lewin and Kaiser (whose practice is owned by CHS) don’t see a conflict in keeping things close to home. “In any healthcare system, you are going to try to stay in your own [network],” Kaiser says. “For one thing, it’s easier to be in touch with people; it’s easier to get records for patients. It’s unfortunate, but it can take a few weeks to get records for someone who has been working with another system. You have to jump through a lot of hoops. Plus, CHS has got a lot of great specialists. I trust those opinions because I know them.”

General internist Greg Collins (“We’re the pediatricians for adults,” he jokes”), completed his residency at the University of Oklahoma and moved to Charlotte in 1985. Collins has worked for CHS and Presbyterian. “The reality is that if you don’t have at least two competing systems, then a single dominant system is going to get too happy with itself, and the quality of that system will likely not be pushed forward to greater levels of excellence,” he says. “I think competition is the catalyst for improvement. If there were only one major employer, there would be a monopoly, and everyone knows what happens then. Lack of competition results in abuse.”

Glenn B. Perry, an orthopedist who specializes in sports medicine, trained at Temple University and has served as team physician for the Charlotte Hornets, the Charlotte Bobcats, and the 2000 Olympic basketball Dream Team in Sydney, Australia. He also sees Charlotte’s healthcare à deux arrangement as a positive force. Perry believes that having two competing hospitals forges a healthy rivalry that creates a climate of not only achievement but of shared commitment to the greater good of the Charlotte population.

“Yes, the hospitals are kind of competitive,” he says. “Both want the best for the city, and both want to be able to boast that they have the best this or that. Both systems are proud, but never have I seen it be a detriment to the patients. I’ve dealt with both. The Hornets were associated with CHS; the Bobcats are with Presbyterian. Both have delivered very high-quality care. In fact, the healthcare-delivery system that the Bobcats have is the envy of the NBA.”

Practicing Independence

Octavia Cannon, of Arboretum Obstetrics & Gynecology, believes that staying independent in Charlotte may not be as difficult as some of her colleagues would have you believe. Cannon, a native of East Lansing, Mich., landed a full four-year scholarship to Johnson C. Smith’s undergraduate honors program here in Charlotte. After attending medical school in Miami and serving her residency in Detroit, in 1999 Cannon landed a job as director of women’s health for the Gaston County Health Department. Six years later, she was ready for private practice. “I think we may be the only OB practice in Charlotte that isn’t owned by one of the hospitals,” she says with a laugh. “We would like to stay independent for as long as possible.”

Even so, she sees the pros and cons to taking a solo approach. “Malpractice is a huge issue,” she admits (obstetrics-gynecology has one of the highest malpractice-insurance rates in the country, although North Carolina’s are more modest than most states), “and being owned by a hospital would definitely cut down on overhead, but the other side of it is that if you want to try something new and innovative [such as digital mammography, which is not covered by some HMOs], you can do that without having to go through a lot of red tape.”

At the end of the day, Turk, who notes that many of his patients come to him via word of mouth, believes that even though the system is stacked in the hospitals’ favor, running a successful independent practice boils down to maintaining personal contact between the physicians and their patients. “We have to realize how hard it can be for patients to get in touch with their physicians at times. We all have our gatekeepers,” he admits. “When you call a doctor’s office, you often get a machine, and then you have to push a button and wait. It can be difficult for a patient to get follow-up, or even the answer to a question. [You have to be sensitive to that], but more important, is to have patients who are satisfied with your care. Patients still have the final say. Often times, they want a completely independent second opinion outside the hospital system. If they have a preference for a certain specialist, that’s where they’ll go.”

“There’s nothing to prevent an independent physician from applying for privileges at any hospital here,” adds Collins. “Anyone with proper credentials shouldn’t have a problem. In fact, individual hospitals like having doctors apply for privileges because it’s a conduit for more patients.” 

The Missing University System

While Charlotte does have major-league hospital systems, it is also the largest city in America that lacks a historically well-entrenched medical university. While some physicians pooh-pooh this missing link, others fret that without an academic facility supporting research, Charlotte’s medical care will increasingly be dictated by the concerns of CEOs, without any grounding in the pursuit of academic advancement. “A doctor may be absolutely brilliant, but if he’s not bringing patients in, then the hospital or practice administrator can very easily shunt that doctor off, which does not happen with a learned, tenured professor,” says Sethi.

Because of this lack of an academic sector where specialties such as psychiatry and genetics typically prosper through research, these same specialties tend to fail here, he says, simply because they’re not profitable. For example: Since moving to Charlotte, Dr. Sethi has seen five independent psychiatric facilities bought up by the powers of managed care, only to be closed as unprofitable. “If a member of your family needs to be admitted for substance abuse, or any kind of real psychiatric care, there is not a decent facility in the entire Mecklenburg area,” Dr. Sethi laments. “I think it’s all very money driven, as opposed to being driven by the needs of the people.”

“I have found that psychiatry is the toughest referral,” admits Kaiser. “What ends up happening is that we [primary physicians] are seeing quite a lot of patients who aren’t able to get to psychiatrists. We are diagnosing depression and even bipolar disorder. For me, putting somebody on those medications is still very new, and I’m somewhat uncomfortable with it, but trying to find a psychiatrist can take two to three months. In the eyes of managed care, procedures are more lucrative—sitting and talking with somebody, not so much. Mental-health coverage has been slashed left and right, and that’s so sad because it’s so incredibly important.”

Rx for the Future: Prevention Is the Best Medicine

Ironically, many who practice medicine worry that even as technological advances make an increasing number of modern-day miracles possible, the quality of patient care may be in jeopardy. Whether they pin their concerns on dwindling reimbursements from insurance companies, the skyrocketing cost of malpractice, or interference by HMOs and other managed-care entities in the prescription and treatment options they can offer, many physicians agree on one thing: The crisis in the American healthcare system is critical, and without intervention, we are facing disaster.

Every year, the cost of care and the number of uninsured and underinsured goes up. “We have all these excellent diagnostic and therapeutic options,” says Collins. “The question is: How do we pay for them? The answer is: We can’t.” In 1900, Collins points out, the average life expectancy was forty-eight; in 2000, it was seventy-six. “So the public, as a whole, benefits from the new technology—even the expensive aspects.” In addition to finding a cure for medicine’s financial ills, Collins believes what American society could really use to improve its well-being is a very basic “apple a day” prescription.

“The answer,” he says, “is learning how to use the inexpensive things that really make a difference to maximize people’s health and longevity, and prevent the need for expensive intervention.”

Judy Cole is a freelance writer who lives in Gastonia. For the April issue of this magazine, she profiled local playwright Tonya Shuffler.

 

 

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