For 47 years Dr. Wilbur Foard has tended to Manchester's aches and pains.
He runs his solo practice out of a 100-year-old, peach-colored Victorian house on Main Street in the north Carroll County town. At 73, he still makes occasional house calls.
Like the Norman Rockwell paintings on his wall, Dr. Foard is the picture of the neighborhood doctor who was once the cornerstone of health care in America.
But with the current emphasis on managed care through health maintenance organizations and preferred provider networks, many health experts say the days of the solo family practitioner are numbered.
"Managed care is going to be the future, and I venture to say that there won't be any [solo practitioners] left except the older ones hanging on until retirement," said Dr. Foard. "In a town this size you get to know families, and we took care of everybody from cradle to grave, but I really think the golden days are over."
According to 1993 statistics for the Maryland Academy of Family Physicians, 43 percent of its 1,145 members are solo practitioners.
Although the solo family practice still represents the most common among member doctors, their numbers have declined considerably. Ten years ago, about 80 percent of the academy's members were solo practitioners, said Esther Barr, executive director of the academy.
"The solo family physician is a dying breed," Ms. Barr said. "The kids coming out of medical school are going into managed care, multi-specialty groups and family practice groups."
Family practice residency graduates who join health maintenance organizations as salaried employees can command average starting pay of $98,000.
"People coming out of medical school are strapped with such large burdens," said Dr. John Middleton, 41, who has a solo family practice in Westminster. "When you're servicing that debt and trying to buy a house, it's very scary to go through the lean years of trying to build a practice."
As employers increasingly choose managed care health insurance plans for their employees, Ms. Barr said many solo practitioners are losing patients because they're not part of a managed care network.
Contracts with HMOs
Dr. Leopoldo Gruss, 66, who has had a solo practice in Essex for 34 years, says 70 percent of his patients are in managed care health plans. He contracts with several HMOs and managed care facilities to receive their patients so he can maintain his practice.
But solo practitioners in more rural areas, such as Carroll County, say the shift toward managed care hasn't really hurt their practices.
Carroll isn't yet dominated by the HMOs and large practice groups that have proliferated in urban and suburban centers.
But that's changing. Last September, the Carroll school system dropped its Blue Cross/Blue Shield insurance plan and switched to an Aetna preferred provider plan. And Dr. Foard said Black and Decker, which has a distribution plant in Hampstead, also replaced its traditional insurance plan with a managed care plan.
As a result, some solo family doctors are having to rethink the way they practice medicine to survive.
Dr. William Linthicum, 48, who has had a solo practice in Taneytown for 18 years, is considering applying to a preferred provider plan to join its network of physicians.
He does it with some reluctance after his experience contracting with an HMO nine years ago.
Accustomed to the independence of a solo practice, Dr. Linthicum had to follow the HMO's regulations on many aspects of patient care.
"All of a sudden, I was put in the position of telling a patient 'You can't go to a certain doctor,' even if they had been going there a long time," Dr. Linthicum said.
Many solo practitioners say they chose to go it alone because the arrangement allows them to treat a variety of medical problems and practice medicine more independently.
More risk involved
With this independence come risk, responsibility and long hours. In addition to providing medical care, the solo practitioner must support a staff and deal with the financial side of the practice.
Solo practitioners say that increased regulation of equipment also makes it difficult for one-doctor offices to stay afloat.
Dr. Donald Hislop, 56, who has a solo practice in Severna Park, said he had to shut down the testing lab in his office because new federal regulations proved too costly and burdensome for him to maintain it.
To keep the lab open, Dr. Hislop said he would have had to hire a lab director. Also, Dr. Hislop would have had to comply with testing procedures to ensure the lab's accuracy that would have cost $300 to $500 every six months.
Dr. Hislop cites closing his lab as an example of the inefficiency in the current health care system. Tests that he performed for 20 or 30 cents, like a throat culture, cost $80 in an outside lab, he said.
In Westminster, Dr. Middleton contracts with several managed care plans to be included in their network of approved doctors. He said he entered into the arrangements not to get more business, but to provide continuity of care for his longtime patients whose employers change health plans frequently.
"Employers shift from one insurance company to another. Whatever's cheaper the next day or the next month they're buying," Dr. Middleton said.
The logistics of participating with several insurance plans can be overwhelming for Dr. Middleton's office staff. He said his employees spend much of their time on the phone with various HMOs and sorting out the "deluge of paperwork" from the different insurance plans.
Since he's nearing retirement, Dr. Foard said he has no plans to receive patients from HMOs.
But he says that some of his former patients who were forced to join managed care plans still come to see him despite the out-of-pocket cost.
One of those patients is Rachel Wentz, 52, who has been going to Dr. Foard since she was a child.
Monthly injections
For the past 20 years, Dr. Foard has given Ms. Wentz monthly gold salt injections to treat her chronic rheumatoid arthritis. Ms. Wentz is a teacher at Westminster High School, and when the county system switched from a traditional insurance plan to a preferred provider plan, her visits to Dr. Foard were no longer covered.
Yet Ms. Wentz continues to go to Dr. Foard for her monthly injections and pays for the visits herself.
"I'm very attached to him," Ms. Wentz said. "Why would you want to switch to somebody else when you're completely satisfied?"
Although the one-doctor office is becoming a rarity, Dr. Middleton hopes to retain his independence for at least another 10 years by maintaining his solo practice while continuing to participate in managed care physician networks.
Dr. Linthicum knows that change is looming, but he wants to keep his options open. He said he may enter into contracts with some HMOs, or become part of a group practice.
"As a person gets older, you get a little more circumspect in your decisions," Dr. Linthicum said.
"It makes you think that maybe some of the managed care programs aren't so bad. After all, there's a certain security there."