Dr. Christopher T. Bajzer, schooled in avant-garde interventional cardiology, arrived in Spokane from Ohio in the summer of 1999. Practicing at Spokane Cardiology PSC, he made an immediate impact, helping the practice land two clinical-research studies that a respected colleague said put Spokane on a new level of research notoriety.


By the end of 2000, however, Bajzer was gone.


He had returned to Ohio to work at the Cleveland Clinic, where he had performed a five-year fellowship prior to coming to Spokane.


They actively recruited me to come back here, says Bajzer, reached at his office in Cleveland. When they approached me, I couldnt say no.


Bajzer is one of about 140 physicians who have left Spokane to practice elsewhere in the past three years, the Spokane County Medical Society says. That number doesnt include retirements and is more than three times the attrition rate that the Spokane medical community typically experiences in that amount of time, says Dr. Rodney Trytko, a Spokane anesthesiologist and a past president of the medical society here. Up till now, Spokane typically has lost between five and 20 doctors a year who have moved elsewhere. Fortunately, administrators say, many of those physicians still are being replaced, but it takes more effort to do that than in the past.


Health-care providers here blame what one calls the physician exodus mostly on reimbursement rates in Washington stateboth for government programs such as Medicare and Medicaid and for private insurancethat are below the national average. In other words, doctors can make more money elsewhere.


Thomas White, president and CEO of Empire Health Services, which operates Deaconess Medical Center and Valley Hospital & Medical Center here, says the reimbursement-rate situation has made it more difficult and more expensive to attract top-shelf medical professionals to Spokane, especially in specialty areas such as cardiology, pediatric surgery.


For example, he says, a radiologist would have commanded a starting salary of $200,000 a year here two years ago, but now might demand $300,000 or more a year to relocate to Spokane. Even that elevated pay level might fall short of what such a practitioner could earn elsewhere, he says.


Adds Trytko, We have a hard time recruiting. All of the physician groups I know of who are looking (to recruit other physicians) are having a lot of problems.


Ryland P. Skip Davis, president and CEO of Sacred Heart Medical Center, says that so far, Spokane is holding its ownattracting as many doctors as it losesbut only has been able to achieve that by working much harder than it once did to recruit. A larger pool of job candidates has to be interviewed these days to land one new physician, he says.


Are we to the crisis point? No, Davis says, but there are significant storm clouds on the horizon.


White and Davis both say they fear that eventually, Spokane will no longer be able to draw top-tier physicians, which has helped it build a regional and national reputation for patient care. They say the presence of quality physicians here, by itself, helps in the recruitment of other quality physicians, and that trend could reverse itself, leaving just average physicians here who attract others of comparable expertise.


Says White, If you take the people you can get instead of the people you want, you dumb down the system.


Bajzer says that on the whole, the caliber of physicians in the Spokane area is superior to that hes seen in cities of comparable size, and even better than that in many larger cities.


He left, he says, because the position at the Cleveland Clinic emphasizes academia more than private practice, giving him an opportunity to spend more time on clinical trials and to teach, he says. (Efforts are under way to add more such academic opportunities in Spokane, White says.) Also, both he and his wife are from the Midwest, and they wanted their young children to be closer to family.


Bajzer says income wasnt a factor in his decision; he says he made more in Spokane than he does now.


That makes him an exception to the rule, though, industry observers here say. Most of the time, they say, physicians move on for more pay, and low reimbursement rates here are the reason.


It starts with Medicare and Medicaid. Though reimbursement rates for those government programs have shrunk across the nation in recent years, they generally are lower in the Western U.S. than they are in the East, Davis says. Thats because reimbursement rates are based on average lengths of hospital stays, and, generally speaking, lengths of stay in the West are shorter than in the East, he says.


Meanwhile, health-care insurers typically take into account what Medicare pays when they set their own rates, so their reimbursements also have shrunk here and are lower than what is paid elsewhere in the country, he says.


Consequently, Spokane physiciansas well as most of those elsewhere in Washington statetypically make 15 percent to 35 percent less than they would in other regions, Davis says.


In fact, says Trytko, physicians here lose money when they treat Medicare and Medicaid patients, because it costs them more to operate their practices and handle the burdensome paperwork of such programs than they get back in reimbursements for the care they provide.


Also, even as reimbursements have failed to keep up, other costs have increased here, White says. For example, in the last few years the number of companies that offer professional-liability insurance in Spokane has dwindled to one from four.


Not surprisingly, White says, premium rates offered by that one company have increased substantially. For instance, a Spokane perinatologist, who handles high-risk pregnancies and childbirths and who has no history of malpractice lawsuits, saw her annual premiums for liability insurance soar recently to $80,000, from $23,000 the previous year, White says. Though perinatology carries more risk than many other types of practices and thus may be an extreme example, physicians in other specialties also are dealing with dramatic increases in malpractice insurance premiums.


Quality of life, an attribute touted in Spokane, might keep one-fifth of the physicians here, White says, but for others, money is the primary factor in their choice of where to practice.


White and Davis concede that people in other careers, many of whom may have suffered job losses or pay cuts in the current struggling economy, might have a hard time feeling sorry for physicians who dont make as much money as they once did.


White says, however, that a physicians practice is a small business, and in some cases, doctors arent making enough money to keep their businesses alive.


If thats you, youre going to go somewhere you can keep your business alive, he says.


For hospital administrators, the physician exodus isnt the only concern. Medical facilities here and elsewhere are in a well-publicized struggle to fill positions for nurses, pharmacists, and technical specialists, such as X-ray technicians and sonographers, among others. Consequently, some hospitals have been forced to pay higher salaries to attract and retain such workers, and to bring in temporary help to fill gaps, which can be even more expensive.


Due primarily to such higher costs and the lower reimbursements, both Sacred Heart and Deaconess had lower-than-usual operating margins last year, Davis and White say. Davis says Sacred Hearts margin has fallen to just 1 percent, while Empire Healths was less than 1.5 percent, White says. Both say their respective margins typically have run between 3 percent and 5 percent.


Observers say there isnt a quick solution to the physician exodus, and long-term solutions involve leveling the national health-care playing field so that physicians in the West are reimbursed at rates comparable to those elsewhere. Some already have stepped up lobbying efforts to push for such changes.


Hospital administrators say medical professional associations are looking at ways to lobby more aggressively for reform. Davis suggests that doctors associations and hospital associations might want to combine their efforts.


For the first time, we can sit with the physicians medical society and say, We have a common problem.