What You’ll Learn

A pediatrician devoted to children’s well being for 30 years shares a powerful look at the clinical frustrations and financial challenges of providing primary care in an era of cuts to reimbursement and Medicaid. Her patients aren’t getting the care they need and, after private practice led to her going deep into debt, she’s living in a trailer park barely making ends meet.¬†

Interviewee: I am a pediatrician. I’ve been in private practice since 1994, so 30 years now. Currently I am in California since December. Prior to that, I was in Arizona for 12 years. And prior to that I was in New Jersey. I was in the mountains of Arizona, so we had four seasons, and it could get quite cold. It was a very nice area, but it did have its moments of getting very cold and it never got hot like the valley. This is hot here. I’m in central California in the Central Valley.

VIVO: What type of practice are you in? Is it private? Are you in the hospital setting or community setting?

Interviewee: Currently I am in a rural health clinic, which is a community outpatient setting that deals with a lot of the indigent population. It’s not a federally qualified health care center, but it’s just the other side of it.

VIVO: How large is the practice, and about how many patients are you seeing in a given week, month, whatever the case may be?

Interviewee: The practice is huge. I couldn’t even begin to tell you how many providers we have. As far as pediatrics is concerned, we currently have three and a half physicians, three nurse practitioners. I think that’s how many we have here at this location. There’s more than one location. Most of our providers are nurse practitioners or PAs, especially on the family health area. We do have some subspecialties that come into the clinic on a semi-regular basis. I moved here in December, so I am still getting my feet wet in terms of all of the details. But that’ll give you some idea. In Arizona, I was a single practitioner since 2015. Prior to that I was with a hospital system. I’ve done it all.

VIVO: Do you have a preference?

Interviewee: I like having the control of being on my own and making decisions, but currently I like getting a paycheck better.

VIVO: Fair enough.

Interviewee: I left my practice in Arizona. I closed it deeply in debt because we weren’t getting paid.

VIVO: Before we get into the day-to-day and your patient load, when was the last time that something new inspired you at work?

Interviewee: I guess I get inspired every day when I’m seeing different things with the kids. And since moving to California, it’s a different group that I’m dealing with. It’s a very migrant population. So some of the diseases are different, some of the problems are different. And I’ve gotten to learn a bunch of new things even after 30 years, helping the kids. You run into times where there’s a disease state or something that you find, I was running a little late because I had a patient that had a rash that I was not that familiar with. It was this X-linked genetic big deal, something that I hadn’t seen before in 30 years. So, it’s that kind of thing. Pretty much every day I still see stuff where I can help these kids out.

I dealt a lot with Native Americans in Arizona, although it was not my whole group. But I do see a lot of Mexicans, a lot of immigrants from Mexico coming through. And a lot of the workers like the farm workers, that kind of thing.

VIVO: Why did you become a pediatrician?

Interviewee: You think a lot about this, and what would you do if you didn’t do pediatrics? And that’s a hard call because pediatrics is a true calling. I’m 59 years old and I dabbled with thinking about, when I was a kid, becoming a ballerina. I don’t have the body type or the coordination for that. All of the things that you think you might do. But pediatrics, dealing with kids, I love kids. I love kids, I love babies. And being able to help them and take care of them, it’s a calling. It’s literally, I can’t imagine myself doing anything else.

VIVO: Has it been what you expected? 

Interviewee: It’s changed so much over the years. It’s hard to imagine what I expected way back when, but I guess my thought process was probably along the lines of what my own doctor that I’d gone to way back when, a hundred years ago. And I think initially when I started practice, it was probably similar to that, but better. Because I knew what I was doing and I’m good at it. And then, when I started practice in 1994, the insurance companies were just getting a toehold in, and they really destroyed medicine. And now it’s totally not what I had envisioned. There’s still a lot of good parts to it, but the insurance companies have really destroyed healthcare.

VIVO: Do you think that’s changed tremendously over the years?¬†

Interviewee: Over the 30 years? Absolutely. We used to have some control over finances, you used to be able to do what was best for the patient. Now you’ve got this person, this entity paying for a service that they’re not using. It’s a middleman, and the middleman gets the biggest cut and nobody else is winning. Everybody else is losing the game.

VIVO:  What wisdom have you learned from pediatrics?

Interviewee: Wisdom? I don’t know. I don’t have any wisdom anymore. I guess really looking through the eyes of a child, seeing the world through the eyes of a child is an amazing thing. And then having a baby is making a decision to walk around with your heart outside of your body. And nobody does it right. No parent does it right. No pediatrician does it right. We just do the best we can and go with the flow.

VIVO: What do you think pediatrics will be like in 10 years?

Interviewee: God knows. I think if the whole thing doesn’t implode, we’re all going to… It’s terrible right now. More and more we’re using nurse practitioners and PAs as opposed to physicians. Your physicians aren’t going to be… We’re sitting here paying for medical school and paying that off, and I’m making less than I did 30 years ago. It’s a tremendous insight when you’re thinking, the cost of living has gone up so dramatically in those 30 years, and yet I’m making less than I was making then. I’m living in a trailer. I’m living in a box in a hot trailer park where the people across the way from me deal drugs. I’ve got neighbors who are living in extreme poverty. I’m living in a trailer where I’m not even sure how I am making ends meet because now I’m so far in debt from my private practice, because we couldn’t get paid.

I think we are being asked to do more and more and more for less and less and less. We’re constantly being asked to add more things, do more. So I do so much more for my patients today than I did 30 years ago, because I know more now. There’s new things to do. There’s developmental screenings that we do. There’s depression screenings. I do a lot of mental health, so much mental health. Which is not what I wanted to be doing with my life. COVID just destroyed us. There’s so many things and it’s going to get worse because they are paying less and less for everything we do and they’re not reimbursing… They say they reimburse for quality, bullshit. Sorry, I call bullshit. They don’t. They don’t care about quality, they care about volume. And California is 10 times worse than any other state I’ve been in.

VIVO: Really? And why do you think that is?

Interviewee: It’s an insurance issue. In New Jersey, I was not dealing as much with a Medicaid population because of the practice that I had joined 30 years ago. It was in an affluent area. They didn’t take Medicaid because they didn’t pay. When I left New Jersey, and again, for financial reasons, we couldn’t get paid for love nor money. And I started working in Arizona. Most of my population was Medicaid, but it was a fee-for-service type of Medicaid. So if you performed certain services, you got paid more based on your coding, you got paid more… If I did a strep test, I get paid for the strep test. If I did a urine, I get paid for the urine.

And the insurance companies started requiring us to separate out everything. It used to be one set fee. And then you started having to carve out all of your things, charge separate for vision and hearing and strep and all of these things. Well, I’m in a practice in California where they get paid a flat rate no matter what you do. According to my boss, you could perform an appendectomy versus seeing a kid on a phone visit and you get the same amount of money. And that doesn’t make sense.

So the quality of care suffers a great deal because nobody’s incentivized to provide better care. We don’t do strep tests here, which is to me is ludicrous because to not be able to get a rapid strep, I’ve never in my life not had a rapid strep in my office to be able to do until I moved to this practice. And their feeling is, who cares? You’re going to give them antibiotics anyway, which means our whole antibiotic stewardship is out the window. Because strep tests cost too much money and they don’t get reimbursed for them. And everything I do, and I do a lot, none of it gets reimbursed over the flat fee per patient. So we are disincentivized to do quality care, and incentivized to run a Medicaid mill.

In and out fast as you can. Every phone call gets charged the same. And since COVID, now you charge for every single phone call. I don’t care if I call them, tell them their labs are normal, it’s a charge. So all of that used to be just part of the cost of what you did. But because we can’t get paid enough for what we do, everybody’s trying to find a way to make ends meet.

And it’s going to get worse.

VIVO: Do some states do that better than others? In your experience?

Interviewee: I’ve been in different states. So yeah. When I was in Arizona, the Medicaid population, it was a fee for service. Way back when, a hundred years ago… I’m going to tell you a story. I know that our time is not always, but this is a story. Way back when, I started practice, I got pregnant. I had my baby nine months into starting practice, I had my second child. And we attended, we had an insurance company called HMO Blue, which was going to give us a spiel about what they were going to do for us. They introduced capitation to us where it was a flat fee per life that you had per month for all of their care, with the exception of a few carve outs. Things like vaccines or whatever you could carve out. But you weren’t getting extra for them, you were barely scraping by.

And so again, that was disincentivizing you to see the patient, because the more frequently you saw the patient, the smaller and smaller your remittance per visit became. It was a disincentivization to provide care. That was the first of these things that we got introduced to. My partner came out to me and said, “Are you pregnant?” I just had a baby. So, yeah, what? I don’t understand. I was totally clueless. He’s like, “are you pregnant?” He says, “’cause you’ve just been fucked.” Because that’s what he meant. Those were his exact words, because that’s what that insurance company wanted to do. They were disincentivizing you to see the patient because they wanted you to take on all of that liability for a very, very small amount. And that’s what’s gone on.

Since then, when I went to Arizona, we would get a fee for service depending upon what we did. It was never enough. It was never the fee that we should have gotten, but they stopped thinking that… What we got paid didn’t go into our pockets. It went to overhead and staffing. And then we had to hire more staffing. You have to hire more staff if you want to do insurances and referrals and getting meds covered and all of the things that go along with having to deal with insurance companies and not being able to provide direct care to the patient. So you were hiring more staff, your overhead was higher, your supplies were costing more. None of this was going into our pockets. And so our cut became so much smaller.

VIVO: What’s something that’s not being said in pediatrics that needs to be said that is not being talked about?

Interviewee: It’s all of that. We have to do too much. We are not getting reimbursed for all of the things that we’re doing. And then, so there are people that aren’t doing them. I can tell you here, so many people slipped through the cracks early on that should be getting developmental services. There are no services here. These kids are falling through the cracks. I’m seeing autistic kids, older kids who have never gotten services. They’re low functioning nonverbal kids who don’t get social security and don’t get any of the services they’re supposed to be getting because the parents don’t know how to navigate the system to get them the services they need. The services just aren’t available up here.

And I’ve only been here a short period of time, so I’m still learning the ropes. But I had so much more available in Arizona where I was, and I knew how to navigate the system. But even then, it was hard for the parents to navigate the system. COVID killed everybody. It took these kids, and it is being talked about to a certain extent where these kids now, they don’t go to school and not going to school is what they’re used to. Instead, they do online, which is crap. They don’t have the resources, especially the kids in poverty. People are making decisions about how to give care without taking into account that some of these kids in poverty just can’t, there’s a lot more barriers that come in play there.

Now we have the schools, I don’t know if this is universal, but the schools here get paid by the amount of students that are there on a daily basis. So if the kids are missing school, then the schools aren’t getting paid. So the schools are insisting on doctor’s notes. So the kids are coming in for a doctor’s note for, “I was sick three days ago, I’m better now.” What the hell do you want me to do? “I need a doctor’s note. That’s what I need.” All right, now you need a doctor’s note. And again, it’s not good care. It’s all based on these stupid rules that people are putting into place. With COVID, you sneezed wrong and they were like, go home. Now. They’re like, oh no, don’t go home. Now we’ve got an online doctor in the school which interferes with quality of care and continuity. So that’s a whole other thing. I could talk forever.

VIVO: Can you tell me about one of your most challenging patients and why they were so challenging?

Interviewee: That is a long and hard question because there are so many different kinds of challenges. My most challenging patient, I don’t know, I’ve been doing this for 30 years. Today, my most challenging patient was the kid with the rash that I’d never seen that I need to now look up and figure that out. But earlier, there was a teenager who didn’t want to have her more private parts exposed, because nobody here does genital exams. Nobody here does breast exams. And I find kids, I’ve diagnosed kids with cancer who nobody else has… I saw a kid with cancer, he was 15 months, something like that. And his face was bulging out, and we were about to hit a snowstorm, this was in Arizona. And I had to get them… I knew he had a tumor. It was the only thing that would cause it. But the prior doctor thought it was normal, it was a sinus infection. That kind of challenge blows my mind.

Right now obesity is a challenge. Getting these kids to understand that they’re already diabetic, they’re pre-diabetic, how to get them to eat healthy, especially when poverty… Getting kids to eat healthy and poverty is ridiculous because everybody wants to feed them cheap shit.

One challenging patient? I have a million challenging patients. I’ve been doing this for 30 years. I just had one, my last one was a kid… A kid, he’s now 18. He’s dizzy, a headache, no other symptoms. And I’ve done every test. Now I’ve got to start doing other tests and try to figure out that puzzle. That’s what I do best is figuring out puzzles. But some of them take longer.

VIVO: Tell me about one of your most rewarding patients and why they were so rewarding.

Interviewee: I guess that one of the most rewarding was the kid with the tumor in his head. That I sent him down to the valley, which is three hours away from the office I was working in, right before a snowstorm. I’d already gotten him a CAT scan, we knew we had a tumor. Sent him down and they didn’t come back because they had to relocate three hours away. But I followed him on Facebook and the parents, they had to move down there to get him treatment. So that’s the only reason they didn’t come back to me. We were still in contact and after he started getting treatments his face looked so much better. This kid survived cancer because I got him down to the valley in time. He had a neuroblastoma and he had in his abdomen and his head, and the parents had another baby while they were down there. It’s was rewarding. That kind of thing, it makes my heart swell when I can figure something out and get a kid to treatment and save their life.

VIVO: How do you think taking care of patients in particular, children, will be different in the next 10 years?

Interviewee: Unfortunately, I’m seeing so many people who don’t care anymore and they miss a lot. Since coming from the east coast… On the east coast, when I was over there, doing a full exam was part of what you did. It was how we were trained. It was part of what we did. Since coming further west in Arizona and here, people aren’t doing them and they’re missing a lot. There are things that are going to get missed. They’re going to get missed until it’s too late. And that’s what I’m seeing a lot of, because nobody cares anymore to do a good job because we’re not getting paid to do a good job. But it’s even that where doing a good job takes time. Time that we don’t have. Not when you’re trying to push them in, push them out.

I’ve seen a lot of families, I saw a family immigrated from Mexico, and Mexico that the care over there is less than adequate. But this was a teenager, 15 or 16. He didn’t know he was supposed to have two testicles. He only had one. And I can only tell you about the personal hygiene that was not happening either. But the thing is, you’re supposed to have two testicles, and if you don’t have two testicles, you got to find the other one because there’s an increased risk of testicular cancer and an increased risk of infertility if the testicle is not brought down by, before two years of age. And this kid was already in his later teens. That’s the kind of stuff that gets missed because nobody does genital exams. Because everybody’s like, oh my God, I don’t want to…

People aren’t doing full exams. They’re not having them take their clothes off. They’re not looking at… I’ve seen bad scoliosis that’s been missed. I’ve seen so much, so much in, I’ve been here since December, and so much that has been missed because nobody’s looked for it. And it’s going to get worse because nobody cares. Nobody cares anymore. There’s no incentive to do a good job.

And if you can catch things early, you can save kids’ lives, you can make their lives better. You can help fix them. That’s the idea is, did you ever hear the allegory about you’re walking along a river and you keep seeing these people drowning and you pull them out, then another guy comes by and he’s drowning and you pull him out and another guy comes by and you pull him out. You keep trying to pull people out of the water, you got to go upstream and figure out why they keep falling into the river and you got to fix the bridge where they’re falling through the hole and this way…

That’s pediatrics. Pediatrics is, we got to look at the beginning and fix things in the beginning so they don’t become problems later on. Especially with the abuse and neglect that’s happening out there. There’s ACEs, which is adverse childhood events, which we know cause long-term problems, heart disease, asthma, drug and alcohol abuse. Huge, huge abuse. Addiction starts in childhood. It doesn’t start with drugs and alcohol, it starts with sugar and other things that come up that if we can help those kids early on, we help them to overcome things that are going to cause worse health problems later. This is where we need to start. But nobody cares. They want to fix the things, they want to pull the people out of the river, but they don’t want to fix the bridge.

And we do everything we can. We vaccinate to the best of our ability, but then there’s all that crap that’s out on the internet, “Don’t vaccinate your kids,” blah, blah, blah. Whatever. So I spent a lot of time talking about that. It’s challenging.

VIVO: Thank you. I really appreciate your time and talking through some of what you’re seeing out there.¬†

Interviewee: I’ve been doing it for 30 years, I can talk all day about all the problems.

Participant Profile:

• Female pediatrician with 30 years of experience (since 1994)
• Currently practices in Central California (since December 2023)
• Previously practiced in Arizona (12 years) and New Jersey
• Works in a rural health clinic serving predominantly indigent population
• Practice includes migrant farmworkers and Mexican immigrants
• Previously ran her own practice in Arizona (2015-2023)
• Currently works in a large multi-provider clinic with 3.5 physicians and 3 nurse practitioners in pediatrics
• Faces significant challenges with California’s Medicaid reimbursement system