Disenchanted doc goes "off the grid"

ONEONTA, N.Y. — Patients come into Dr. Joan Bachorik's acute-care clinic stooped over or feverish, with broken bones or labored breathing.

Above all, they come in without health insurance.

There are no prior approval forms, no Medicare paperwork and, in Bachorik's opinion, no bureaucratic barriers for patients who need help.

The 55-year-old internist's decision to sever her relations with health insurers — the professional equivalent of going "off the grid" — is rare. But her frustration with the system is not.

As the number of uninsured Americans nudges toward 46 million, doctors are experimenting with different ways to deliver care outside the traditional system.

It's a noble effort, said Dr. Asha Gupta, president of the Broome County Medical Society. Eliminating the cost of dealing with insurance companies would save a lot of money for health providers — savings that could be passed on to patients. But running a practice primarily on income from uninsured patients is not feasible in most fields of medicine.

"Expecting them to pay out-of-pocket for costs would not be realistic," she said. For that reason, fee-for-service practices such as Bachorik's will probably remain rare.

But efforts to provide charity care for uninsured patients is becoming more and more routine through other avenues. Free clinics are proliferating, and sometimes other doctors find themselves footing the bill when patients just can't come up with the money.

Eighty-seven percent of American Medical Association doctors say they provide some level of charity care in a typical week. And in many areas, doctors coordinate with other health-care providers such as blood labs and imaging companies to streamline care under so-called Project Access programs. Started in 1995 around Asheville, N.C., there are now 51 similar programs from Dallas to Danville, Va.

Bachorik ran a traditional practice for two decades, gradually becoming frustrated with insurance-driven rules. She got a patient's-eye view of the system a few years ago after a serious illness forced her to temporarily close her office.

While she had enough money to retire after her recovery, she decided to reinvent her practice to serve patients falling through the cracks.

Computers used to process insurance forms went out the door and her staff of four shrank to one. The clinic is open Monday, Wednesday and Friday afternoons; it served 500 patients in its first year.

"I'm out of the system because I don't have enough money to get insurance," said Molly Copelan, a patient who stopped by Bachorik's modest office recently. "She doesn't stand on rules and regulations. ... She just tries to help people out."

Bachorik said her fees cover malpractice insurance and other costs of operation. Profits go to buy prescription drugs for patients.

She said about half her patients come in with the flu or other infections. The rest suffer from sprains to toothaches to psychiatric problems. She treats what she can and tries to direct patients to help when she can't.

Pleasant with patients, Bachorik turns caustic when talking about a system she describes as dehumanizing. She tells the story of a logger who broke his ankle a week before showing up at her office. Not wanting to pay for an emergency-room visit, he just put his foot in a boot and hoped for the best.

"If you're staying in the system, you're failing your patients," she said. "... You're perpetuating something that doesn't work."

There is wide agreement that the safety net for the uninsured — a loose network of public and private funding sources — is under strain.

Doctors say the big problem with Bachorik's approach is it does not work well for costly chronic conditions like diabetes or cancer. Dr. Gordon Schiff, past president of Physicians for a National Health Program, said it's a difficult business model to sustain.

"There are many more people who want to do it, and a fraction of that number try it but don't succeed," Schiff said.

Bachorik realizes she is limited in what she can do with her one-doctor clinic, but she has no regrets and no plans to change.

"Even if you help one person," she said, "it's worth it."

Associated Press writer Michael Hill and staff writer Tom Wilber contributed to this story.