Atlantic City Weekly

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Though "Elizabeth Crowley, M.D." appears on her letterhead, many patients and friends know her as "Boots." A family practitioner in Cape May Court House, Crowley has taken an aggressive stance in current debates over our troubled healthcare delivery system. She resides in Marmora with her husband and two children.

Why led you to become a family doctor in a quasi-rural area?

My husband and I knew we'd eventually like to retire to the beach, so we figured why wait until retirement? I love practicing here. Without being too distanced from the high-tech world, we still have a very small-town feel. Suburbia -- like Mount Laurel, where I grew up -- tends to be very anonymous. I did my training in Voorhees -- same thing. Here, you get to know people. Also, there's social, economic, and educational diversity in this community, a mix of people and ideas and perceptions that makes for a very interesting practice.

Whence the term "Boots"?

Simple enough: My feet hurt if I don't wear my Doc Martens. I got my first pair during residency. A friend's husband apparently started referring to me as "Boots," and one day he slipped and called me that to my face. I thought it was wonderful. After the National Public Radio piece on my practice ["Doctor Boots"], use of the name increased.

Healthcare is becoming a four-letter word.

It's a train wreck, a cyclic mess, for doctors, patients and employers alike. Somehow, insurance companies realized they could make lots of money on healthcare. Granted, there was waste when Medicare first started. Doctors worked hard, but, unfortunately, some abused the system. Insurance companies ended up generating the HMO idea, and by the '80's were claiming that they could save lots of money by paying doctors "capitation rates," requiring authorizations for medical tests, limiting medications. It was a vast overreaction -- insurance companies stopped dealing in reality; doctors ended up spending inordinate time grappling with those companies over fee schedules, claims denials, filling out administrative requests; and patients ended up with access issues. There are so many tragic stories about waiting too long to get tests done, or not getting tests approved at all. Look, medicine can't be done by a computer, or computers would do it.

What's your perfect vision of practice?

It matches where I am. In my view, the perfect practice -- and this stems from Dr. Gordon Moore and the Ideal Medical Practices Project -- is where patients get the care they want and need, when they want and need it. People are healthier when those two concerns are met -- they tend to have better diabetes control, better blood pressure control, they're more likely to get their tests. It's not rocket science, it's Marcus Welby.

How has your own practice met the challenges?

When I bought the practice in January 2004, we participated in all the plans. It quickly became apparent that we were losing money on overhead costs with every patient, and seeing more patients doesn't help that -- in fact, it only hurts. So in '05, I dropped two plans, and the month that I terminated my contract with the largest payor was the month I stopped having to borrow money from my brother to pay my staff. My income went up, even though I lost fifteen percent of my patients. Eventually, I dropped all plans, lowered my overhead significantly, and worked directly with the patients rather than insurance companies. Medicare and HMOs don't reimburse, but other insured patients file their own claims for out-of-network coverage. For me, the alternative isn't acceptable -- to cut the time I spend with each patient. The personal connection means everything.

How can things improve?

I'm on the Board of the New Jersey Academy of Family Physicians, which supports legislation that supports family doctors, and I reach out through Web sites and letter-writing. Obviously, people have different opinions on whether to work with what we have, or wipe the current system and go to a universal plan with less of this administrative nonsense. I believe we need a system-wide fix. We should dismantle the old system, get rid of all these little insurance companies and go to one organization, a single payor system, that will set fair rules for healthcare. It could be outsourced, but it would be federally regulated.

How do your colleagues regard your activism?

All good doctors are grappling with these issues, and many are discovering what I did: If you can lower your overhead, you can go back to doing the job that you love. In the Ideal Medical Practices group, many doctors have more traditional models than mine, but everybody's concerned with making patient care their primary concern. If you're spending three to four hours of a 10-hour day fighting with insurance companies, and filling out forms, it's hard to take the time to help patients know what they want and need.