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Care Package

anticipation of an uncertain income, we just could not persuade anyone to join us.

After two promising prospects bowed out, the Grace Cottage administration stepped in and hired a doctor—paying a salary and providing benefits, an office, and staff. Once there were four docs in the call schedule, and a guaranteed living wage, working in Townshend became more attractive. Shortly thereafter, the hospital hired a fifth doctor, then a sixth. For one spell, the call schedule included seven physicians, but that didn't last.

By that time, most insurance policies covered some wellness care—a benefit designed, in theory, to encourage better health maintenance. In fact, what these plans did was shift the administration of the benefits to the physician's staff. In our small office, we would submit claims on behalf of our patients in order to be paid by their insurers. The increased expenses associated with this billing—in time and technology—were never reimbursed; they simply took a bigger bite out of every dollar that came in.

At the same time, our patients often didn't understand how their managed-care policies worked. Our staff worked hard both to educate them and to work the system in our patients' favor. But it is not easy arguing with an automated answering system or explaining to a human drone that it's burdensome at best, and sometimes impossible, for patients to get to the company's one networked mammogram site in Burlington, three hours away.

Different insurance companies and different policies also covered different services.Our staff researched the various policies to find out what a given patient's coverage would allow Tim to do. So instead of Tim providing the care his patients' conditions required, he was providing the care his patients' insurers allowed.

We were blessed with employees who worked hard for our patients and were

Above, hands-on care in the office. Below, the $15,542 quote for the office's first computer system.

loyal to Tim and forgiving of me. The "Ladies," as we called them (they were all women), really ran the joint. They knew our patients well and so knew who needed to be seen immediately. They could squeeze 75 minutes into every hour.Working together in a tight space, however, they could also get on each other's nerves. They would complain to me about one another. In the early years, I'd jump in and try to fix things, bruising feelings along the way. Over the years, I learned that all I really had to do was listen.

I also resented our employees' annual raises in the early years. As we worked together, however, I came to appreciate these women, wished I could pay them more, and considered them our allies. Nevertheless, the economic reality was that their hourly wage was only about half the cost of their employment to us. Wages triggered taxes for social security, Medicare, worker's compensation, and unemployment. In addition, they each received six paid holidays and two to three weeks of paid vacation. We also

offered other benefits, such as paid lunches, profit sharing, and health insurance.

Too often, the "Ladies" chose to forgo raises in return for full payment of their health insurance premiums, which rose

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