I was on my own for three years with my practice growing by leaps and bounds and became overwhelmed with patients. I was doing so many deliveries and had to get one of the other groups at the hospital to cover my patients. There were certain situations in which my patients were not comfortable when I did take the occasional vacation. I called up a woman with whom I had overlapped in residency and, after negotiating for a few months she came to join me as an associate. The two of us then were working full time and the practice was growing exponentially.

HMS: We made a decision around 1990 to move our practice away from Northeastern Hospital because new management, a for-profit group from Texas, had taken over the hospital and they really did not have a commitment to doing anything that would update the facilities in the OB/GYN department. We ended up moving our entire practice activities up to Jeanes Hospital in the Fox Chase area. In 1993, after having done obstetrics for 14 years, I decided that I wanted to change my lifestyle. At that point I didn’t know anybody else who was able to make a living just doing GYN, but I figured there was a need for this, and why should I not be a pioneer? In 1994, I went back to solo practice and moved to a small office in northeast Philadelphia. I received a phone call from the Allegheny Health System in late 1994, at a time when it was in a heavy-duty primary care practice acquisition mode. They said, "We will pay you a very nice salary. We will do all of the business. We’ll pay your malpractice, we’ll pay your rent, your overhead, we will pay the salaries of your employees and give them benefits that would be extremely expensive for you. In exchange for that, we will allow you to run your practice as you wish to do." They were associated with JFK Memorial Hospital. I was made chairman of the department and I set up two large women’s health centers. They were very flexible and easy to work with. I changed my hospital affiliation from Jeanes to Elkins Park Hospital, which was without doubt the best community hospital in which I had ever worked.

HMS: Allegheny went bankrupt. It wasn’t my decision. I would have continued on. There were several for-profit companies that came in, in addition to the Temple Health System and some of the other health systems in the city, that were looking at the hospitals and the practices. The one who eventually got the contract of buying the hospitals and selecting which practices they wanted to take over was the Tenet Healthcare Corporation. I then became an employee of that health system. Tenet was very different because it was a for-profit company. It was the first time I’d ever worked in that kind of situation. There was much more accountability. They looked at your billing. They looked at your revenues. They looked at your payroll. They looked at how many employees per doctor, and so on. Basically, you had to earn your keep. There were financial statements that came at least quarterly that told you about every procedure, every office visit, every insurance that you were taking, how many things you were doing in your office, how many surgeries and how much money you were generating, and you basically had to pay your own way. You had to meet your overhead expenses. You had to justify the fact that you needed an additional receptionist because of the volume in your practice.

HMS: Tenet made a corporate decision to divest themselves of all of their practices because the practices were not functioning as profit centers. Mine was one of the last to go. I spoke to an attorney and he said that the Einstein Healthcare System was the only health system that was still in the acquisition mode and were looking to acquire a lot of primary care practices to build a network all around the city. This was the autumn of 2000. They were very interested in acquiring my practice and didn’t have any other practices up in that area that were either OB or GYN or both. And so, we came to an arrangement and I began employment with them.

HMS: It still hadn’t hit me that there were some significant disadvantages in being an employee. I was so involved with other things in addition to seeing patients. I have some very strong ties with pharmaceutical companies for whom I do clinical research. I also do a lot of consulting and a lot speaking for various companies. I do a lot of traveling. I was writing a book and also at one point I had a television show. All these other activities kept my life so diverse and interesting and full. I took this position with the Einstein Community Health Associates and signed a five-year contract with them. This was a very different scenario from any other health system for whom I had worked. It was a break-even scenario: you had to generate, in hard dollars, exactly the amount of all of your overhead expenses, including your malpractice coverage and your salary. We were at the eleventh hour in signing the contract when I suddenly got a call from upper management of the health system and they said they had a problem with my malpractice insurance. PHICO, which had subsequently gone bankrupt, was their insurer and at that point. If you had an open claim and you were someone who had not previously been insured with PHICO, they would not issue a policy. I said, "You’ve got to be kidding" and they said, "No, PHICO’s not issuing any policies. We called around. Nobody is issuing policies." So what I had to do is go to the Pennsylvania Joint Underwriters Association, which was the only institution issuing malpractice policies to "high risk" physicians. Now, I didn’t consider myself to be any higher risk than any other OB/GYN who I knew. However, the quotation that was given to me by the JUA at the end of February 2001 was outrageous. To continue doing major and minor surgeries, office gynecology, to practice in Northeast Philadelphia—it was something like $375,000.

HMS: That’s right. Even if I generate $400,000 in revenues, I can’t pay the rest of my overhead expenses. I can’t turn on a light bulb paying this kind of malpractice insurance. We finally went back to JUA and asked what it would cost just to do office GYN. They came back to me with a quote of $72,000, plus change. We figured out that I would still be able to reach that break-even scenario by adding a full day of office hours instead of spending a day in the operating room. However, because my malpractice insurance with Tenet was something like $30,000 and it had gone up to $72,000, what I had to do was take a huge cut in salary. Because I needed to begin working on March 1st and I had a heavy book of patient schedules, I needed to get a policy fast.

HMS: By the time August came, forget the fact that I had taken a huge cut in salary to pay for my increased premium in malpractice, I felt like I was practicing in a black box. There was very little communication over the first six months. I think my expectations of what a practice needs in order to support it, to make it run efficiently, to maximize the cost effectiveness, the billings, the revenues—I really don’t think that my expectations and what Einstein was willing to provide were on the same wavelength. By August I felt that this was not what I wanted to do. I was becoming very disillusioned with the whole practice of medicine. The malpractice situation was getting worse. A lot of my colleagues were not only stopping doing OB, but many of them were taking early retirement. There was a lot of dissatisfaction as our reimbursements from managed care were being cut. I was at a watershed in my career, being mid-life in age and really thinking about what I wanted to do. Maybe I didn’t want to go into private practice. I was thinking about taking a job in industry with a medical insurance company or a pharmaceutical company. One thing was certain: I did not want to stay in the situation in which I was. I was offered some wonderful positions but, after really considering relocating to another city at this point in my life and my husband’s life and having a 13-year-old son in an excellent private school in my neighborhood, in the end I decided that I did not want to relocate. So I thought about it, talked it over with my family and I decided I was ready to go back to private practice.

HMS: With the help of some very good advisors and a good accountant, I found some office space outside of the city to keep my malpractice insurance premium down. I negotiated a separation agreement with Einstein that was satisfactory to both parties and I was able to leave as of March 1st, which was four years before my original contract said I was going to leave. I’m now in the process of going back into private practice, deciding which insurance companies I wish to participate with and I’m going to share office space and expenses with a very well-established physician, a board-certified reproductive endocrinologist and a fantastic surgeon who has been in private practice for 30 years in Elkins Park, Pa. I am still insured for office gynecology only.

HMS: I think the biggest obstacle is that the insurance companies have ratcheted down the reimbursements so severely that, in order to generate enough money to pay the rent, to pay your employees, to pay your phone and your malpractice, you have to see a huge volume of patients and you have to have somebody do your billing who is so compulsive about billing for, and collecting, every penny that you are actually due. And every time a doctor relocates his or her practice there is always going to be some attrition.

HMS: Without a doubt it is absolutely devastating, certainly my specialty. There are so many practitioners who are at the height of their career, the very height of their expertise, knowledge, wisdom, experience, who are in their mid-fifties and who are leaving the specialty in droves or who are moving to Delaware or New Jersey, or moving out to the mid-west. They are so disgusted with the situation that they are leaving Philadelphia and the surrounding areas like rats from a sinking ship. It’s very sad. Those are the times in which we live. That is the price of doing business and being a physician. If insurance companies are looking to have doctors with no malpractice claims, or only one or two in 25 years, I don’t know any doctors, especially in my specialty, who have that kind of record. But that in fact is what the insurance companies want. So the only people really who will be left within the next five years, if things continue on as they have been, are those doctors who are coming right out of residency. They haven’t been in practice long enough to have seen enough patients to have too many malpractice claims. And so what we’re going to be left with in Philadelphia and the surrounding areas are rookie physicians without that much experience who are taking care of patients. Not that they’re not smart or capable, but you cannot substitute intelligence and book smarts for 25 years of experience. There is no substitute for the wisdom and the art that you acquire in practicing medicine when you’ve been in practice for as long as I have, for instance.