The Doctors' Bill: Salary guarantee adds up for this recruit

"When Dr. Georgia Heisterkamp considered moving her general surgery practice from Ohio to Whidbey Island, Whidbey’s wooded hills and quiet beaches were some of the factors she weighed.So was making a living.After 17 years spent learning and financing her profession — eight years of college and med school, five years of residency and four establishing her own practice — Heisterkamp knew the costs of operating a solo general surgery practice were considerable.Factoring in rent, state fees, licenses, insurance, equipment, staff payroll and other costs, the 35-year-old Colorado native figured running a practice cost about $110,000 to $120,000 a year in Ohio.That’s why Heisterkamp sought, and got, a salary guarantee before she decided to move to Whidbey.Heisterkamp, who opened her general surgery practice in Coupeville on July 1, exemplifies the reasons why Whidbey General Hospital has agreed to open its coffers to bring new doctors to the island.Since January 1999, the hospital has committed itself to spending up to $860,000 to subsidize the practice of eight new doctors.The goal, said hospital director Scott Rhine, is to attract more doctors, providing a more complete range of specialties to serve the island’s residents.“This has been one of our primary focuses this year,” Rhine said. “Filling in the slots, or gaps, in health care on the island.”In Heisterkamp’s case, a salary guarantee was the key factor that influenced her decision to move to Whidbey.Without the guarantees, “it would not have been possible for me to do this,’’ she said recently. “I could not afford it.’’Many doctors begin their professional careers deeply in debt, and only start making money after years of investing in their careers, Heisterkamp said.SCHOOLING & DEBTHeisterkamp said her medical school tuition was about $8,000 a year, excluding living expenses, for four years. She had classmates who were $90,000 to $100,000 in debt by the end of medical school.While some people may still believe that doctors simply graduate medical school, then start raking in the bucks in between afternoons on the golf course, Heisterkamp said the realty is different. For most, establishing a profitable medical practice is a long-term investment in which, for years, outlay exceeds income. Before new doctors can build a practice and a client base — before the referrals come in and various health insurance plans start to reimburse them — doctors like Heisterkamp have to pay for equipping and maintaining a practice. And keep current on the student loan payments for eight years of post-secondary schooling.“This is not a field you go into to make money,” Heisterkamp said. “Because if you do, you’ll be disappointed.” After medical school, Heisterkamp completed her five-year residency program at Dartmouth-Hitchcock Medical Center in New Hampshire. There, she worked impressively long hours, staying over at the hospital every second or third night, for an unimpressive salary: In the mid-$20,000 to low $30,000-a-year range.“One of my peers figured out their hourly wage there,” she said. “It worked out to a little over a dollar an hour. You have to laugh, but you’re thankful you’re getting paid.”After residency, she said, doctors typically join a hospital staff, an existing practice or start a practice of their own, often with little preparation to run a business.“My attendings (supervising physicians) were not real helpful in that area,” she said. “They’d only known the academic side.“They don’t prepare you for the real world,” she said. “Don’t teach you the business aspect of the practice of medicine.” Heisterkamp opened her first general surgery practice in Lancaster, Ohio, and learned as she went.“I didn’t know how to run a practice, buy equipment, hire staff or even write up a contract,” she said.So Heisterkamp contracted with a professional health care consultant, who helped her set up a practice in which she eventually prospered.LIFESTYLE CHANGEBut after three-and-a-half years in Ohio, she decided to leave. The hospital Heisterkamp worked at was undergoing changes - being negatively affected by changes in managed care and competition from other medical providers. Heisterkamp had also grown weary of the grind.“Lifestyle became a priority,’’ she said. “I didn’t want to be on call 24 hours a day, seven days a week anymore. I wanted a little more out of life and to be in a town where I could share being on call. I was also looking for other surgeons who were reliable, well-trained and easy to get along with.”A recruiter pointed Heisterkamp toward Whidbey Island and Heisterkamp ended her search.“This place seemed perfect,” she said. “I’d visited the Northwest before and liked it. It seemed like a place where I could enjoy hiking and biking and gardening.”Although the move to Whidbey has provided the quality of life she sought, Heisterkamp said it has also brought a whole new round of expenses. Among them: hiring a staff, furnishing the office, paying the various fees and licenses to practice in a different state and meeting payroll while she waits for her practice to build.Liability insurance alone costs the surgeon about $30,000 annually. As in Ohio, she figured the annual tab for operating her practice in Coupeville will range $110,000 and $120,000. “You have to be able to bill twice that much, and you’re lucky if you recoup twice that much,’’ she said.Meanwhile, insurance compensation is more complicated and cumbersome, while less equitable.“Most surgeons set their own fees based on standards in the areas they practice,” she said. “Regardless of those fees, when you agree to participate with an insurance plan, you agree to accept their fees.” Fees that sometimes don’t equal hers. Still, Heisterkamp is steadily building another practice and, thanks to the salary guarantee she negotiated with the hospital district, she has some time to let it build.She is now on call only 10 days a month, but she still work up to 14 hours some days. Being new to the island, she said she is working on making ends meet and making payroll and overhead.And the biking and hiking and gardening she came to do?Heisterkamp smiled.“Not yet,” she said. “Not yet.”"

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