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Care Package

and Medicaid reimbursements—if we were willing to take on the added work of becoming a Rural Health Clinic (RHC). The RHC program had been established in 1977 to address an inadequate supply of physicians serving Medicare and Medicaid beneficiaries in rural areas. Like the National Health Service, which brings physicians to medically underserved areas, Rural Health Clinics aimto keep them there. After considering our options—most of which included packing up and moving—we hired consultants, borrowed money to pay them, and applied to be an RHC.

Though it was a program designed for small, struggling, rural practices, we had to write a policies and proceduremanual befitting a Fortune 500 company and draw up an organizational chart. Every function had to have a job title and a job description. With only five employees, several of us had more than one. Tim was Owner, Medical Director and Laboratory Director, Trash Hauler, and Snow Remover. I was Practice Manager, Head of Human Resources and Information Technology, Director of Facilities, and Safety Officer. I even had to conduct an annual fire drill—and document it.

Over time, we learned how to fulfill the often redundant, sometimes opaque reporting requirements of being an RHC. We also learned that though we had strict deadlines for our reports—with interest and penalties if we failed to meet them—Medicare and Medicaid could take forever to audit our reports and always did. Nevertheless, for several years we were able to pay our bills, pay an office cleaner, pay ourselves, raise wages, and fund a profit-sharing plan for retirement.

We became an RHC in 1994, a watershed year for two other reasons: Timstopped delivering babies and a fourth doctor came to town. Unlike the three other local family practitioners, however, this physician was not in private practice but was an employee of the hospital.

Shafer today, making rounds on inpatients at the 19-bed Grace Cottage Hospital in Townshend, Vt.

When I met Tim in 1984, he was one of just two doctors covering the ER at Grace Cottage. When he asked me to marry him, I said, "Yes—when there's a third doctor in town." The third doctor miraculously materialized the following year, and the three of them had shared call since then.

There had been room for a fourth for some time, but it was a tough sell. Sometimes physicians would stumble across Grace Cottage when they were vacationing in southern Vermont; others heard about this tiny hospital through the medical grapevine. Whenever doctors expressed interest in setting up shop in town, we'd have them over for dinner—one couple trying to seduce another to join an unquestionably good life, which would be so much better if only there was one more doc with whom to share call.

The way Tim practiced medicine was very appealing: he was his own boss, he treated whole families, he made house calls, and he was part of the social fabric

In 1990, our expenses soared and our income plunged. In addition to keeping the books, I now cleaned the office at night, and Tim took the trash to the dump.

of the town that he served. Other bonuses included a two-mile commute and casual dress every day of the week. Our small-town life was bucolic: we lived in an antique cape, grew lots of vegetables, tended a flock of chickens, kept bees, and even raised our own pig.We were part of a community. We also lived smack in the midst of New England's beauty and could snowshoe out our back door or be in the GreenMountain National Forest within minutes.

These dinners were always a great success, followed by the inevitable morning-after of financial truth.We could barely pay ourselves, let alone hire another physician. Short of finding a doctor with enough savings to be self-sustaining for an indefinite time, in

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