Retired physician reflects on changes in health care

Editor's Note: This is the second installment of a two-part series chronicling the retirement of Dr. Warren Lovinger. In this article, Dr. Lovinger reflects on changes in health care over the years.

With his recent retirement from medicine and the closing of his doors at the Nevada Internal Medicine office on Dec. 31, Dr. Lovinger sat down with the Daily Mail to reflect on the many changes in health care over his years as a physician. During his career, Dr. Lovinger was the President of the Missouri State Medical Association. He also served as the Governor of the American College Physicians.

“I just wanted to mention some changes that have occurred in my observation since 1980 to 2020,” started Dr. Lovinger. “One is in the delivery of health care. It is dramatic the changes that have occurred in hospital care since I got here. When I arrived in Nevada, it was nothing for a census of 30 or 40 patients there. And the duration of hospitalization was very liberal as to how long you would be there – very much on the European model. That all changed dramatically when the federal government and Medicare implemented a thing called DRGs (Diagnostic Related Groups) in 1982. It started to decrease the duration, or the length of stay in the hospital and also the number of people who were hospitalized.

“At that time, it was routine that people came in hospital to have surgeries or to have diagnostic procedures and all kinds of things. Now, that hardly ever happens. Most things are laproscopic procedures that are outpatient. Things that I've done like stress tests and echocardiograms are all outpatient, basically. The census has dropped from around 40 daily to, on average, maybe about five. It is incredibly dramatic and has had a gigantic impact on rural hospitals in America. Not just here – everywhere. It is fair to say that all of them are in financial straits. If you look up and down I-49, Carthage – which was McCune Brooks (their community hospital) – was taken over by Mercy. What is now called Cox in Lamar, Mo., was the Barton County Memorial Hospital – it went broke and was taken over by Cox of Springfield, Mo. To the north of us, one survivor that is like Nevada has been Bates County. It’s a very well-run organization. It is a county hospital as we (Nevada) are a city hospital. You keep going north, Harrisonville had problems and they are now owned by the HCA which is a corporate organization. You have the Belton Hospital which is owned by HCA.

“The community hospital is a very, very threatened entity. Look west of us 19 miles. The plug was pulled and now they’re down to two physicians left, last time I knew. When we moved here in 1980, I think there were close to 30 physicians in Fort Scott. One of the things that we have in Nevada that is becoming quite uncommon in rural America is young doctors.

“Most rural hospitals are now owned by some big organization. When that happens, the orientation towards community needs tends to deteriorate somewhat. The only two left in our area are Nevada and Butler. We are fortunate in that regard. Long-term care, which I have been involved with my whole career, has gone from the nursing homes where people who were just late in life and needed a place to stay in a mild degree of care to now, where there is great intensivity. A lot of the people, many of them would have been in the hospital previously.” Dr. Lovinger served as the medical director for Moore-Few for 34 years. “My goodness,” stated Dr. Lovinger. “The intensivity of care for some of the people there now would certainly be at least as high as what previously people were hospitalized for. Long-term care is extremely important and it’s not one that’s embraced by many young physicians.”

According to Dr. Lovinger, the distribution of physicians has gotten worse, not better. “You go to Kansas City and there are 50 of everything,” noted Dr. Lovinger. “You come down here and there’s very little, as far as availability of physicians. While this was a problem from the age of specialization, which started when I was a young doctor, now the idea of a physician going out in their own practice is virtually non-existent. Especially in rural America. If you are almost anywhere, you are probably an employee. Now, Nevada still has several independent doctors. I’ve been one of those. I’ve spent my entire career in that regard. The paradigm virtually everywhere is for everybody to be employeed almost always by their hospital. That was the problem that occurred in Fort Scott. When they pulled the plug on the hospital – bam – the doctors who were employed all were immediately unemployed. They’ve got two left that are still over there, and we’ve gotten a couple who have come this direction. It’s amazing how that has evolved.”

In reference to his long career in medicine, Dr. Lovinger went on to note the various positions he’s held. “I’ve done everything – you name it, I’ve done it,” he stated. “I ran our ER (emergency room) on Friday nights for 10 years. I’d work in the office and then go running to that and it was very challenging. I did inpatient for 35 plus years. I’ve done office for 40 years, long-term care for 40 years... just kind of everything there is to do. That is not the current paradigm. If you are a young doctor, and my children have all experienced this, when you are coming out of residency – let’s say it’s in internal medicine or family practice – you basically have the choice of do you want to be an inpatient doctor (hospitalist) or do you want to be an outpatient doctor (which would be office space)?” Practicing medicine runs in Dr. Lovinger’s family. His son, Dan, is a doctor for the VA system in Columbia, recently finishing as the chief resident there; daughter Laura is in the business arena in Kansas City; and Tom and Sarah, their two older children, are physicians who work for the St. Luke’s system in Kansas City. “Our two kids who work for St. Luke’s are both outpatient doctors and they are busy,” he noted. “I think Tom has 5,000 patients. There is a desperate, humongous need for primary care doctors everywhere – rural, urban, suburban, and so on. It is critical in rural America where it’s competing with the St. Luke’s of the world. The orientation of physicians has changed a lot and one of the reasons that the hospitalist concept in doing ER medicine is popular is because of the hourly concept. For me, when I went out medicine was a lifestyle. You were that 24-hours a day, seven days a week, and I’ve had the pleasure of experiencing that my whole career. Now, it’s more of a job as opposed to a lifestyle. I’m not being critical of that, that is just how it has evolved.”

Another issue that has risen in health care, according to Dr. Lovinger, is the third-party payers. “From the standpoint of finance of healthcare, the third-party payers have come to control everything basically,” he stated. “Whether you want to have a CAT scan, you want a particular medicine, or you want a particular physician, your third-party payer determines that. There’s just constantly this barrage of prior authorizations. There was absolutely no such thing when I first went in to practice. The thought of some third-party group with non-medical people making decisions and controlling basically what happens is very scary. They follow a checklist and if it meets all of those things, ok you can do it 30 minutes later after you’ve wasted that much time getting the authorization. If it doesn’t, you can’t. The third-party payers, not for the better, have come to control what happens in medicine... whether it’s in Nevada, Kansas City, or any other place you go. That has been an unfortunate transition. As a result, it makes having insurance very, very important. If you don’t, you are really in peril. You could have a $100,000 event and it literally ruins people financially. It is not a good thing in that regard.”

Dr. Lovinger also wanted to note that there has also been a lot of progress and good things evolving in health care. “The ability of physicians to help people has increased enormously,” he noted. “Of course, I’m an internal medicine doctor and so I deal with medicines all the time. It’s a different realm than it was in 1980. Some of the things that have gone from having either very primitive medicines, or no medicines at all, to very advanced treatment that really makes a difference in the lives of people includes things like blood pressure, heart disease, cholesterol, diabetes, rheumatoid arthritis, multiple sclerosis, and even Alzheimers disease. All of these things have changed dramatically and things that we can do to help the general health of the population have gone up big time.”

The catch is that along with that, not justfiably in most cases, the cost of those medications has gone up. “It wasn’t maybe 10 or 15 years ago, a little Albuterol inhaler if you had asthma cost $4,” he stated as an example. “Now, the most basic simple thing is $80. Does it cost them more to make it? No. What have they done? It’s profit-taking. We’re the only country in the whole world that lets that happen. Everywhere else – Europe, South America, Canada, every place – they negotiate and say, ‘Here’s what we’re going to pay. If you don’t like this, well you’re not welcome to sell medicines here.’ They are tied in with the third-party payers and we have sadly allowed that again to really take command of what we’re doing. When I went into practice we had good insulins that were super cheap. Now, it’s $200-$400 a month. Sadly, we as a society, have allowed this to get away from people and folks literally are not able to have medicines. That is probably the biggest travesty that we have in our society right now – the cost of medications and the negative impact that has on our ability to care for people. I deal with generics basically all the time, but even some of those are crazy expensive for no justification whatsoever. Totally indefensible as to why they’d be so expensive. That’s an area that we as a society need to work to empower people to have good health and allow their physicians to do what they need to with that. We have all kinds of resources. In rural America, we’re seeing a lot of those go away. Nevada is a great example of a place that took the bull by the horns and said, ‘No, we’re not going to lose that infrastructure. We’re going to pass a sales tax that will keep it going.’”

Looking ahead, Dr. Lovinger recently finished an MBA program that is called CPE (Certified Physician Executive) and it’s through the American Association of Physician Leadership. It is intended for physicians who have been clinical doctors for at least 10 years. “I was certainly the oldest one in our class,” stated Dr. Lovinger. “There were 62 of us. It was a very impressive group of people – one of my classmates was the under secretary of health for the VA system. It was quite a group of people. I was also kind of unique because my interest was in rural health care and maintenance of it. Somehow, I’m going to be doing some things with regards to that.”

In closing, Dr. Lovinger wanted to state his appreciation for the community of Nevada and those he has served for the past 40 years. “We’ve been very blessed and have enjoyed every minute of it."