Holly L. Stanley, MD

Coordinated Care for Seniors

"I love all the intricate puzzle solving and the advocacy work in geriatrics."

Growing up, Holly Stanley, MD, was as comfortable in a hospital as she was in her own home. In fact, the community hospitals where her mother worked were like second homes.

"I was raised in small community hospitals," says the 51-year-old Stanley, a native of southwestern Florida who decided at age 4 that she wanted to become a doctor. "My mom, a surgical nurse, was a single parent, so I'd often go to work with her. I'd sleep in ICU waiting rooms on weekends, I'd hang out with the ICU nurses and all kinds of doctors -- I was their little protégé."

Drawn to the intellectual stimulation, the challenge of solving clinical puzzles, and the satisfaction of helping, comforting, and connecting with patients that medicine affords, Stanley enrolled at the University Of Florida College Of Medicine after graduating from the University of South Florida. Deciding to become a doctor had been easy. But deciding what kind of doctor to be, wasn't nearly as straightforward, says Stanley, a geriatrician who has, in the course of her career, established and directed a geriatrics fellowship program, a hospital-based senior health center, and a private practice that's thriving even though she has opted out of the Medicare program.

Well into her internal medicine residency at the Virginia Commonwealth University (VCU) School of Medicine in Richmond, however, Stanley still wasn't sure what she'd do next. Each of the internal medicine subspecialty fellowship options she considered had drawbacks. Most had too narrow a focus for Stanley, who wanted to work in a field with a more holistic approach, and one that was concerned with "the whole body," not just, say, the nervous system. Toward the end of her final year of residency, Stanley was approached by another physician who'd been a resident at VCU and had just established the geriatrics division at the university affiliated Veterans Administration medical center. He asked her to join him. She hadn't given geriatrics a thought before. A native of Charlotte County -- the county with the nation's highest concentration of adults 65 and older - Stanley knew she'd enjoy the company of older adults. So she accepted the post.

Within months of starting, she was hooked.

"I loved all the intricate puzzle solving and the advocacy work in geriatrics," explains Stanley, who discovered that providing care to older adults -- who tend to have complicated and overlapping health problems and needs -- was highly challenging, exciting, and rewarding.

Stanley went on to direct VCU medical school's first geriatrics fellowship program from 1987 to 1992. Building the program was extremely gratifying. Stanley had started her career in geriatrics at a time when medical schools were just beginning to create geriatrics fellowships, and hadn't done a formal fellowship herself. At VCU, she particularly enjoyed designing the kind of fellowship program she wished she'd had. "It was fun," she says. "And I loved teaching."

Because the program provided care to Veteran's Administration patients, however, fellows got less experience caring for older women than Stanley thought appropriate. She tried to convince school administrators to start a community-based program that would serve more women -- not only to increase fellows' exposure to a more representative group of older adults, but also to increase older adults' access to comprehensive geriatric assessment and treatment. When the college cited financial constraints and decided against opening the community-based program, Stanley took another tack. In 1991, she started a senior health center at a nonprofit hospital in Richmond, and served as its director and as the sole physician on its interdisciplinary healthcare team.

"I loved the process of creating the center - using my creative juices to put something together, problem solving, and dealing with the challenges of bringing people on board," says Stanley. Once the center was up and running, she relished being able to see a diversity of patients. In 1997, however, the Balanced Budget Amendment changed the way the program, and others like it, were reimbursed. And this began to change the way the center operated. "We differed in our views of what the program's mission should be," says Stanley, describing the conflicting perspectives she and the hospital administration had of the center. "The nature of the practice was going to change, as was the kind of patient we saw, and the amount of time and resources we had." Ultimately, Stanley decided to pursue her vision independently. In 1999, she opened a now flourishing private practice, Coordinated Care for Seniors.

"My vision was to have a resource for those really complicated, time-consuming, increasingly frail and problematic patients who weren't being well managed in the traditional system," she explains. "I wanted to be that resource."

Having her own practice allowed Stanley tremendous flexibility. Not only could she see the most complex and challenging patients, she also had more control over her schedule. The mother of three children -- now aged 20, 17 and 14 - she'd always made balancing work and family life a top priority.

When she opened the practice, Stanley was well aware of how difficult it was for many geriatricians -- and other physicians whose patients were, for the most part, Medicare beneficiaries -- to make a living. Medicare's reimbursement rates were notoriously low. "But I thought, "I'm pretty clever. I should be able to figure out the Medicare reimbursement thing,"" recalls Stanley, whose practice is in Richmond, where she, her husband and three children live. "I thought, "I just need to understand the rules and code correctly and, of course I'll make a living.""

It wasn't as easy as she'd expected. In addition to seeing patients at Coordinated Care for Seniors, Stanley also worked, and continues to work, as an expert witness. Typical assignments include malpractice cases involving nursing homes, and capacity assessment in cases in which an older adult's ability to, say, change his will or sign a contract, is contested. Her work as an expert witness subsidized her clinical work. But it wasn't quite enough.

Increasingly, Stanley considered going the "private contracting" route -opting out of the Medicare system, establishing her own pay schedule, and seeing patients willing and able to cover the tab themselves. And, increasingly, her husband urged her to give it a try. The day, four years ago, that he announced that they could no longer afford to send their three kids to private school, she "opted out." She has no regrets.

Because she's now paid more equitably for her time, she can afford to give low-income patients discounts, or waive her fee entirely. "My Mama didn't raise me to only take care of people with money," says Stanley. She couldn't discount or waive her fees for particularly needy patients before, she notes, because Medicare law requires participating physicians to give the same discount to all patients - regardless of need - if they give a discount to any.

It's because she's committed to ensuring that older adults -- no matter their financial assets -- get quality care, that she's also involved in efforts to reform Medicare, Stanley explains.

In 2000, when the American Geriatrics Society (AGS) asked Stanley to participate in an American Medical Association (AMA) committee that offers the Centers for Medicare and Medicaid Services advice on reimbursement issues, she jumped at the opportunity. Stanley is still actively involved with the AMA committee, officially known as the Resource Based Relative Value System Update Committee, or RUC.

The reimbursement system is exceedingly complex, she says. And there are times when she thinks the best approach would be to start over from scratch, though this doesn't seem likely. At times, she finds it difficult to be optimistic about the prospects for timely reform. But she has no intention of giving up her work with the RUC, and other efforts to improve Medicare.

"Sometimes I think too many in our field assume that someone else will take care of this [problem], and that's a problem," she says, adding emphatically, "I want to be part of the solution."

If she knew, as a resident, what she now knows about geriatrics, its challenges, and its rewards, would she still choose the field?

"I would," Stanley says, without missing a beat.

"There's nothing I'd prefer to do -- I wish there were something I'd prefer to do!" she adds, laughing. "But there isn't. It's intellectually very stimulating; you have to think outside the box. And the patients are so wonderful. You're so appreciated. It's very rewarding."

"Geriatrics isn't exactly an easy place to be," Stanley says, after a brief pause. "But it's kind of a fun, exciting place to be because it's on edge, because it's evolving."