It is the start of another busy day at the Wildwood Family Clinic on Madison's near east side, and Dr. Paul Wertsch is going through his morning stack of prescription orders. "It must be a big weekend," he muses. "Everybody wants erectile drugs."

Suddenly he realizes why: Valentine's Day is coming up. "Good for them!" he chuckles. "They're thinking ahead."

Caring for a caseload of increasingly elderly patients has its amusing moments.

But it can be exhausting, too.

Over the next eight hours Wertsch will treat a bunch of patients between the ages of 65 and 88 for a range of problems from sinus infections to dementia.

They are the lucky ones.

One year ago, Wildwood Family Clinic, 4901 Cottage Grove Road, started turning away new patients covered by Medicare, the national health insurance program for senior citizens and the disabled.

The plucky little clinic, one of just three in town that has remained independent and spurned overtures from HMOs like Dean and Physician's Plus, has won plenty of admirers for the quality of its primary care.

But Wertsch, a big guy with a droopy mustache who founded the clinic in 1977 with his wife and another graduate of the University of Wisconsin-Madison's family practice program, says he and the other 10 doctors who now manage and own the practice can no longer afford to provide that care to additional people on Medicare, who already make up a quarter of the clinic's caseload and up to 70 percent of the rosters of its older doctors, like him.

Medicare pays only a quarter to a third of every dollar the clinic charges, Wertsch says, often half of what private insurance carriers pay. When you figure that overhead for the clinic — which includes stuff like electricity, staff salaries, and a whopping $700,000 or so for the clinic's electronic records system — adds up to around 80 cents on the dollar, accepting Medicare is a losing proposition, he says. "I love taking care of Medicare patients," says Wertsch, 68. "But every time we treat them we have to dig into our wallets. What kind of business model is that?"

Wildwood is the first clinic in Madison and maybe even the entire state to bail out of accepting new Medicare patients. Dr. Tim Bartholow, a senior vice president with the Wisconsin Medical Society, fears it might not be the last. "This is the canary in the mine," he says.

A massive report released just last week by the federal commission in charge of Medicare suggests he could be right. While more than 90 percent of doctors still participate in the program, a close read of the 400-page report reveals a worrisome trend: 14 percent of participating primary care doctors surveyed refused to accept new Medicare patients, compared to 4 percent of physicians in other specialties. At the same time, the percentage of beneficiaries who report a "big problem" finding a doctor doubled.

"Our nation can't continue on the course we are on," Bartholow warns. "Frankly, this is a dangerous time. We don't want to panic people, but my concern is, are our mothers and fathers and grandmothers and grandfathers going to be able to find a doctor to care for them?"

Medicare has expanded dramatically since 1965, when President Lyndon Johnson signed the program into law with fewer than 10 million people on its rolls. In 2010, 47.5 million people were covered, and that number will continue to rise thanks to the populous baby boomer generation, which started retiring last year.

In Wisconsin, elderly people will make up 22 percent of its population by 2035, up from 13.1 percent in 2000, according to projections made by the state Department of Health Services. In some counties, particularly up north, more than 40 percent of the people walking around could be 65 or older. Even Dane County could be close to a fifth elderly.

At the same time, Medicare has been hit by the same hike in health care costs dragging down the rest of the country's economy. Currently Medicare's $523 billion in annual expenditures exceeds the money it has coming in from payroll taxes. At this rate, it is expected that the fund will run dry by 2024.

U.S. Rep. Paul Ryan's high-profile proposal to fix the program by privatizing it and shifting more costs onto seniors created a political firestorm last fall that is now a major issue in this year's elections. President Obama and Democrats are counting instead on a series of initiatives, including the new health care law, to slow the program's growth.

But it is a short-term "fix," ironically, that was the final straw for Wildwood doctors. In 2010 Congress threatened to cut Medicare fees to doctors by more than 20 percent. It didn't stick — Congress came up with a stop-gap measure as it has done for years now — sometimes as many as five times in a year — to keep the system afloat and physicians from turning patients away. But Wildwood's doctors had had enough.

"It's not that we are greedy doctors," Wertsch says. In fact, their salaries are fairly modest compared to what colleagues get at some of the bigger clinics in town, he says.

"But all the uncertainty is demoralizing. If we fold, what happens to our other patients?"

•    •    •    •

In 1977 Dan Barry and his wife were hitchhiking around the world when he got a call from Wertsch and his wife, Kay Heggestad, the first female graduate of UW-Madison medical school's family residency program. The two couples played poker together, but Wertsch had a different kind of gamble in mind: Did Barry want to join them in opening a new kind of clinic in Madison?

He jumped at the chance. What did they have to lose, except money?

"We had all these weird ideas, like 'Should it be a commune?'" Barry recalls now. That didn't happen — the partners realized quickly they wouldn't be able to attract good doctors if they really paid everyone the same, from nurses' assistants on up to the doctors — but an egalitarian spirit prevailed from day one.

As a result, the doctors' offices even now are relatively small — there is barely enough room in Wertsch's office for his desk and shelves crammed with books and gifts from patients and friends, including a jar of stewed deer meat and a six pack of beer. But on the other hand, many nurses have stuck around for decades, a sign of a place where staff get along and are well-treated.

In the early days, doctors, patients and staff were on a first-name basis, and on holidays they hung out together and put together silly skits and poems. "It was the age of Aquarius," Wertsch remembers fondly. "We wanted a good, happy place where everybody was treated with respect."

The three partners paid $72,000 for 9 acres of land on the fast-developing east side of Madison and hired an experienced Madison financial adviser and attorney to represent them. By the time the clinic opened in May 1978, they'd put nearly $500,000 into it.

That pales compared to the several million the clinic just spent on a second office in Cottage Grove, an expansion that is typical of the kinds of business decisions it has had to make to remain competitive, Wertsch says. They doctors have also added diagnostic lab equipment and a physical therapy room so that they can do some of these more lucrative parts of the business in-house, rather than sending them out. "You play the game," Wertsch says.

But delivering good primary care has always been the focus of the clinic, which prides itself on eschewing the quotas and rules and focus on profits that exist elsewhere. When they started, the partners were excited about using all the best practices about good preventive care, patient education and counseling that they had been taught in their family medicine courses, which was back then considered state-of-the-art medicine.

Unfortunately, that kind of medicine is often not well rewarded by Medicare's antiquated reimbursement system today, which tends to pay doctors more for high volume and "doing procedures and sticking things in you instead of talking to you," says Tom Oliver, a professor of population health sciences at the University of Wisconsin School of Medicine and Public Health.

The lower reimbursement rate for primary care has made it hard to recruit new doctors into the field (no surprise given that the average debt load for a physician coming out of UW is around $140,000) and to attract them to Wildwood. Younger doctors at the clinic now earn 50 percent more than Wertsch does, he says, and even then he worries the $140,000 or so he can offer them is not competitive with what the big guys are paying in town, particularly when you add in the signing bonuses for new hires that have reportedly become part of what is amounting to a bidding war.

Bigger clinics in town can offset the low rates of reimbursement Medicare offers for primary care services with the more generous fees paid to doctors in lucrative specialties. In addition to playing around with this sort of cost shifting, bigger clinics also benefit from a confusing reimbursement system that pays more for visits to clinics affiliated with hospitals than to independent practices like Wildwood.

"Given how long the clinic has been around, they seem to be doing a superb job. It's just that they're bucking up against the current status quo in money-driven medicine that puts greater emphasis on specialists than on primary care," says Nino Amato, president of the Coalition of Wisconsin Aging Groups.

•    •    •    •

Spending a day with Wertsch at Wildwood illustrates the kind of care that the clinic delivers.

Six hours after phoning in the morning prescriptions, he heads into an exam room to see Vivian Michaelis, 84. She is a tiny woman neatly dressed in a velour pantsuit and pearl earrings who has been struggling with a variety of problems recently.

The doctor is running behind schedule, as usual. That's just the way it goes, Wertsch says. Older patients have a snarl of complicated ills, medicines and worries that have to be straightened out, and that takes time. Even waiting for them to climb onto the exam table, he says, takes time. "They are slow as molasses," he says, chuckling.

He's not complaining, just stating a fact. Though sometimes worrying about whether he got a treatment decision right gives him a headache.

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"I love Medicare patients. I love their complexity. I love working hard," he says. "It's just that they're so needy. I'm a little obsessive. It's like juggling eight balls at a time, and I'm afraid I'll end up dropping one."

His wife says that he sometimes stays up until midnight filling out his patients' charts at home on the computer.

Heggestad and Barry are both retired, and Wertsch isn't far from retirement himself. The clinic is looking for someone to replace him "when I drop dead," as he puts it. Actually, what he's really planning on doing is working in his garden. For now, neighbors and friends tend it instead, his wife says.

One of those people is a patient, whom Wertsch was horrified to discover was staying away from his practice because one day Wertsch confided to him his frustrations over the whole Medicare situation. His friend didn't want to be a burden.

This reaction worries Wertsch, who admits that as soon as the practice decided to turn down new Medicare patients, he dreaded the day a reporter would ask him about it. He doesn't want to seem cold-hearted and he doesn't want his patients to think he doesn't care about them.

At the clinic, Wertsch asks Vivian and Don Michaelis, Vivian's husband of 62 years, how things have been going. She's eating pretty well, Don says.

"Too well," Vivian says. The joke is one of the few times she speaks during the visit, though she is smiling for much of the time. "You taught him to be a pretty good cook, huh?" Wertsch says.

He takes her vital signs and goes over her medications with her husband. At one time, there were 15 medications, but Wertsch is whittling that number down to eight or so. Sometimes, given how they can interact with each other and her various illnesses, this can be a complicated decision, so he goes online to double-check a few things and review her records. He decides against one medicine, for example, because it can further slow her mental function. "And we don't need that!" he says. He suggests another medicine, to control blood pressure: "It's a good one," he says. "It's what I take."

Then Vivian gets up on the table so he can give her a brief exam; she totters and nearly falls. Wertsch checks her organs, looks in her throat, listens to her lungs, and then checks the ends of her toes and hands to be sure she still has sensation. Finally, he helps her down. "I think you're doing all right," he tells her, holding her hand.

All this takes nearly 30 minutes, more than twice as long as Wertsch took to play with a baby earlier in the day and check her ears. ("You're the cutest little patient I've seen all day!" he exclaimed.)

But the doctor never acts like he's in a rush or impatient.

The longer visits may not pay well under Medicare, but increasingly it is this kind of care that all sides in the health care debate agree can one day cut costs, by giving the elderly the kind of preventive care that has been proven over and over again to control chronic conditions and to reduce emergency hospitalizations. And of course it also provides old people with much needed support and comfort.

"He's always willing to sit down and discuss the problems we have," says Don Michaelis, 87. "He don't ever push you out the door. Matter of fact, he's always running behind."

Michaelis, a World War II veteran and former supervisor at Oscar Mayer, is an enthusiastic fan of not just Wertsch but of the Medicare system that has allowed him to care for his wife in their Monona home.

"It is wonderful," he says. "I hope they never do anything to make it different than it is right now. Just imagine what our life would be like if they decreased it."

A nurse paid for with Medicare funds visits regularly to check on his wife's catheter and to deliver medicine. He was astounded, he said, by the emergency room bill for his wife when she fell and cut her head — $4,800. Medicare paid for all but $236.

But when it comes to the bills for doctors, Medicare often doesn't pay nearly as big a share. When he was having neck problems, Michaelis got a $233 bill for an X-ray. Medicare paid his doctor $26.46, he says. Wildwood records show that the bill for his wife's half-hour with Wertsch will be $318; the clinic will get $98.86.

And so it goes. Medicare pays $54.38 of a $217 bill for an elderly patient with a sinus infection whose appointment ran late that day; a private insurance company pays $108.04 of the exact same fee for the exact same problem that day, even though the patient is younger and takes half the time to see.

It's hard for people like him to make sense of all this billing, Michaelis says. But its easy to come to one conclusion: "These practitioners, they got to do just about everything," he says. "But it sure seems like they're getting the short end of the stick."