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ical Building. Whether he'll be
able to maintain his indepen-
dence is a question he can't an-
swer, but he's satisfied with his
choice.
"I can run the practice exactly
as I want to. If there's a particu-
larly good way of managing my
patients and my office, I have that
privilege. If I'm working for an
HMO, I've got to do it their way,"
he explained.
He acknowledged he's part of

•• • • • • • • • • • • • • • • • • •

66 Economically,

it's almost
impossible to make it."

— Dr. Frederick Minkow

HEALTHY WAYS NUTRITION COUNSELING

31513 Northwestern Highway
Farmington Hills, Ml
810-855-4558

Gail Posner, M.S.
Registered Dietitian

Providing Professional
Nutrition Advice For Over
Ten Years

14 4-

Sensible Eating Guidance
By Registered Dietitians

a dying breed.
"It's going to be a thing of the
past soon. Private practice as we
know it will disappear," Dr.
Schare said plainly.
Managed care organizations,
like HMOs and PPOs, are part of
the problem, he said. Their fees
are dropping, they tend to dis-
courage doctors from referring out
patients or performing procedures
they deem unnecessary, and they
often place authorization obsta-
cles in the way so that a lot of time
is spent on the phone.
Yet, Dr. Schare's expenses —
including rent, support staff and
supplies —continue to climb, and
patients who are frustrated when
they can't get immediate ap-
pointments or swift authorization
for a procedure will go elsewhere.

"You come into conflict with
what their insurance companies
think is accepted protocol and
what you as her physician thinks
is proper. As reimbursements go
down and doctor's expenses go up,
you've got to see more patients.
So what's compromised is you
spend less time with patients," he
said.
Worse than the reduced fees
are the restrictions and penalties
a managed care organization will
impose if it decides a doctor has
or is about to perform a costly pro-
cedure.
In one of his cases, Dr. Schare,
43, was denied permission to use
a culposcope to evaluate the
progress of a cancerous lesion he
found in a young patient.
"They said I could use a hand-
held magnifying glass; or I could
do a culposcopy, but they would-
n't pay," he recalled.
In another case, he wanted to
order an ultrasound to see if a
pelvic mass was cystic or solid.
The patient's primary care physi-
cian refused to approve it and told
Dr. Schare to send the patient to
him in a month and he would
check on the status of the mass.
"On a young girl it was doubt-
ful it would've been a cancer, but
God forbid it was. I couldn't spend
time on the phone convincing the
doctor (that the ultrasound was
necessary)," he said.
Ophthalmologist Alan Mindlin,
a self-described "poster child" of
solo practitioners, said he's lost 10
percent of his patients because of
managed care, which also requires
patients to see only the doctors
who are part of their plans.
He complained, too, that man-

aged care organizations withhold
fees from doctors if they believe
the doctor is performing too many
procedures of a certain kind. Dr.
Mindlin, 48, says he was finan-
cially penalized for taking too
many patients who needed tear-
duct blockages removed. He'll do
the surgery while many other
ophthalmologists won't, either be-
cause reimbursement is too low
or they consider it tedious, he ex-
plained.
Lower Medicare reimburse-
ment is also a burden. Half of Dr.
Mindlin's income is generated by
Medicare patients, many of whom
have been with him for his 20-
some years in practice.
"The good news of being in
practice for over 20 years is, if
they like you, they grow old with
you. The bad news is, they grow
old," he said.
The government has "target-
ed" specialists like ophthalmolo-
gists, radiologists and, lately,
anesthesiologists, Dr. Mindlin
said. It will distribute available
health care dollars among doc-
tors, but the lion's share goes to
primary care physicians whose
services are cheaper. The cruel
paradox is that for specialists who
treat older adults — a costlier
population — fees are declining.
Dr. Mindlin, the new chief of
staff at North Oakland Medical
Centers in Pontiac and the pres-
ident of lernple Shir Shalom, said
he stays the course by economiz-
ing where he can. He buys sup-
plies cooperatively and is "a lot
more careful about where I'm
willing to allocate funds in the
practice." He just stopped using
a private company to transport
patients to and from their ap-
pointments because the compa-
ny's charges became prohibitive.
Dr. Mindlin's wife, Blanche,
schedules for him and four full-
time employees staff his South-
field and Pontiac offices. Last year
he laid off a fifth employee, but
doesn't plan to make any more
staff cuts.
When Dr. Frederick Minkow,
56, finished a two-year stint as an
Army doctor, he couldn't wait to
start his own practice as an or-
thopedic surgeon. He actually
looked forward to the long hours
because he saw the building of a
practice as a noble and challeng-
ing endeavor.
Twenty-three years later, he is
part of a two-man practice in
Bloomfield Hills that specializes
in hand surgery and is a founder
of Physicians in Transition, a task
force of the Michigan State Med-
ical Society that helps older pri-
vate practitioners, many of them
specialists, make decisions about

