decision to close the "store." One, ironically, was the cost of providing health insurance for ourselves and our employees. The other was the invisible and intangible cost to our family.

This is the story of what happened, and how it affected us, in the years between 1987 and 2003.

When Tim first arrived in Townshend, he was one of two family physicians covering the emergency room at Grace Cottage Hospital, a 19-bed outpost located an hour and a half southwest of Dartmouth-Hitchcock Medical Center. In addition to being one of two docs on call, Tim also took and developed whatever x-rays his patients needed, drew blood, ran simple lab tests, went on ambulance calls, and served as the regional medical examiner. All of those activities took time—time away from his clinical practice, which was what generated our income.

Back then, the ambulance service was a volunteer affair and the ambulance itself a retired hearse. Tim often rode in back, offering what care he could on the trip up—to either Brattleboro, Vt. (20 miles away), or Dartmouth (60 miles away)—and catching what shut-eye he could in the empty gurney on the way back. In those days, before the widespread use of statins to treat high cholesterol and of clotbusting drugs to interrupt myocardial infarctions, heart attacks—as they used to be called—were a frequent occurrence. Little could be done besides wait them out and then transport the patient to Brattleboro or Dartmouth.

Yet today, heart attacks—and other formerly common emergencies—are rare events at Grace Cottage. Kevlar chaps protect loggers' legs from chainsaw blades, reducing the number who get rushed to the ER. Antibiotics and acidreduction medications prevent bleeding ulcers, another once-popular cause of ER admissions. As a result, the number of hospital procedures Tim does for dramatic illness and injury has

Author Luskin, with Shafer—the doc shop's "Mom" and "Pop"—today.

declined, while the amount of preventive care and disease management he provides in the office has increased—as has the cost of providing that care.

In 1987, few of Tim's patients had health insurance. Those who did were insured only against calamity; they carried major-medical policies that covered traumatic injury or illness after they'd met an annual deductible. Charges for the family doctor's care of injury or illness could be applied to the deductible, but charges for routine wellness care could not. So annual physicals and well-child visits typically had to be paid for out of pocket, setting patients back $17—real money in the 1980s.

From a business point of view, the bookkeeping was fairly simple. As patients left the office, they paid their bill and were given a receipt to send to their insurance company for reimbursement. Except for Blue Cross Blue Shield, Medicare, and Medicaid, our office did not usually interfere in the patient-insurer relationship; we only provided health care. It is this that has dramatically changed.

We had inherited some aging receivables with the practice, so we bought one of the few medical software programs then on the market and became the first computer-users in the local medical community. The computer proved so much more efficient than the old manual system that we began billing insurance companies on behalf of our patients. Before long, we became intermediaries—running between insurer and subscriber in our effort to get paid.

The year we went into business, 1987, was also the year that managed care came to Townshend. Tim signed on to be a provider for the managedcare company, and in the early years our monthly capitation checks—a fixed payment we received for each covered patient—were often what carried us through. We bought this same managed-care plan to cover our employees and ourselves—all of us then under 40 and healthy. The premiums were less expensive than traditionalmajor-medical coverage, and the out-of-pocket copay was just $2.00, a fee all of us could afford.

At first, our business prospered and our family flourished. We quickly had three healthy children and, between the two of us, were earning a comfortable salary by local, if not medical, standards. My job at the office was part-time, but Tim worked 12- to 14-hour days and covered the ER at Grace Cottage Hospital every third night. He also delivered babies. There were days when he didn't see his own babies. As his schedule became increasingly onerous, he yearned for family time. I craved his companionship and partnership in parenting.

Neither of us recalls those years in great detail. We adjusted according to our needs: I learned to sleep through the phone ringing in the night; Tim learned to sleep through the kids' nighttime cries. We were too tired to question this division of labor, though there were times I wondered how I'd ended up as a bookkeeper with a Ph.D. in English.