Two and a half years ago, Timothy Welebir, MD, left his 15-year-old urology practice in San Bernardino, California, to set up a new one in Boise, Idaho. He chose Boise because it offered a life without the high levels of pollution, crime, and intrusive managed care he endured in southern California.
“I made the decision to move my practice from San Bernardino, leaving my patients who had actually become my second family. My two sons stayed in southern California to finish their college education, and I made the move to Boise with my wife.” He says it has taken some time to develop his practice, but he has never regretted the move.
A lot of other people must have the same idea. Boise’s population has grown nearly 25 percent since 1990, and the physician community has grown correspondingly. It is not hard to understand why they are coming. Boise offers a medical community not dominated by managed care, a safe environment, and lots of unspoiled wilderness for recreation.
Welebir says that he has been well accepted into the community—at least the medical community. “Idahoans don’t particularly like to have outsiders come to their state and they get quite clear about that. But most people here, including physicians, are not originally from Idaho. I have been accepted into the medical, social, and church community very well.”
As Welebir’s experience indicates, Boise’s growth is a result of people moving in from other parts of the country. While that growth facilitated Welebir’s adjustment to Boise, it also threatens the amenities he came to enjoy.
A simpler system: The Boise medical industry
At the moment, certain aspects of the Boise medical industry are reminiscent of simpler days. Although Boise’s hospitals provide dedicated, state-of-the-art care, the physicians enjoy a primarily fee-for-service market with mostly small groups and solo practitioners.
A. C. Jones, MD, a third generation Boise physician, sees a lot of people coming to Boise to escape the rigors of changing medicine elsewhere in the country. “It’s grown a lot of in the last four or five years. There has been a huge influx of physicians trying to get away from managed care [who are] coming into this community.”
Jones illustrates how much the Boise medical community has grown since his grandfather’s day: “When my grandfather would be getting ready to go to the St. Luke’s Ball, he would invite all of the members of the medical community over to his house for a cocktail party before the ball and everybody in the medical community showed up.” Now, he says, there are more than 400 physicians on staff at each of the city’s two primary hospitals, and the Ada County Medical Society has 480 members.
Even Welebir has noticed the surging physician population. “I have never seen so many physicians in such a small area before. I’m sure it’s because it’s a nice place to live. I was accepted here because there was a need for my position at the time. Since I arrived, two more urologists have also arrived,” he says.
“I know that many gynecologists have come into the area recently as well as orthopedists,” says Welebir. “Many physicians are not doing as well as they would like because of the number of other physicians in their same specialty. All specialties appear to be, in my opinion, bursting at the seams.”
Mark Rutherford, MD has also seen competition increase for physicians in the Boise market. He came to Boise eight years ago from Kansas for his family medicine residency. After completing residency, he stayed with the program as a faculty member for three years. Although he says the market in Boise is good and his practice is growing fairly rapidly, he contrasts his experience of establishing a new family medicine group with that of his colleagues who started practices several years before.
“I watched several of my companions come out of residency while I stayed there in the faculty position, and they just caught fire,” he says. “It changed quite a bit even in as short a period as three years. A lot of physicians have moved in in the last few years. It’s tightening up quite a bit.”
Jones says he believes the growth is slowing. “Our requests for staff privileges in the hospitals and our requests for membership in the medical society have slowed down compared to the last three or four years. I don’t know of anybody that is actively looking.”
“I think that most of the doctors here are pretty busy. I think that there are some specialties that are overfull,” says Jones, an otolaryngologist. He says two more otolaryngologists recently moved to Boise. “We just had two people come this summer. Before that, the last folks that came here were about six years ago. So we had two people come and nobody leave. Now I think that they’ll both do well. On the other hand, I don’t know that somebody else in my specialty would want to jump right into a situation where two new people just came to town.”
Nevertheless, some physicians do still come to town and just hang up a shingle. ‘There are an awful lot of people in solo practice and I think that if you come and do good work and you make yourself available, you’ll probably do okay even if you’re just going solo,” says Jones.
Changes on the horizon for Boise
Medicine is still evolving in Boise, however. For one thing, Boise is seeing more managed care these days. According to Welebir, managed care is creeping into the Idaho healthcare delivery system, and many physicians in Boise are unhappy to see that. But he hopes that educated patients will prevent many of the negative aspects of managed care from becoming a problem here. “I think patients are aware of healthcare here and they know how good they have it. So they are aware of what can happen with managed care.”
Rutherford says his group does participate in managed-care plans “out of necessity. It’s been a minimal exposure up to this point. Certainly, I don’t think we’ve seen anything like either coast has seen as far as the high degree of management intrusiveness that some of the business side of managed care has put upon physiciansThus far it’s worked out okay. ”
Competition has driven changes in the city’s hospitals, too. In years past, the city’s two primary hospitals engaged in a complementary services plan. Although the organizations are still somewhat complementary, they are each gradually becoming full-service hospitals.
“I think the two hospitals are competitive,” says Jones. “Some 25 to 30 years ago there was a plan to make the hospitals complementary so that one hospital would only have one service and the other hospital would have another service. Now they have kind of each started to evolve toward being a full-service facility.”
St. Alphonsus Regional Medical Center, a Catholic-affiliated hospital, offers a cancer treatment center, emergency and trauma services, a heart center, Idaho Neurological Institute, Orthopaedic Institute, Eye Bank, and Eye Institute as well as the state’s largest dialysis service.
St. Luke’s, founded by an Episcopal bishop in 1902, became the region’s center for cancer, cardiac care, and women’s and children’s services in the mid-1960s. St. Luke’s has Mountain States Tumor Institute, the St. Luke’s Heart Institute, a level III neonatal intensive care unit, and a pediatric intensive care unit. St. Luke’s also is affiliated with Boise’s VA Medical Center and Elks Rehabilitation Hospital.
Most physicians in Boise have privileges at both hospitals and the hospitals will both help new physicians become established. “Both hospitals did make me feel very special and were helpful in making my transition less traumatic,” says Welebir, who primarily admits patients to St. Luke’s.
As the community grows, the hospitals and physicians serving nearby Nampa and Caldwell may have a greater effect on Boise. In July, Med- Partners, Inc. acquired Family Medical Clinic, a 17-physician family practice group with locations in Caldwell and Nampa. The physician practice management company hopes to bring management efficiencies to the group and to enhance the group’s responsiveness to managed-care systems.
Boise: An acquired taste
In spite of the changes affecting medicine, physicians are happy to enjoy the bountiful resources for outdoor recreation that surround them. Despite the initial appearance of the brown, hilly terrain at the base of the northern Rockies, Boise has plenty of natural beauty to offer.
Jones agrees it is hard to see the beauty of the area around Boise at first. “It really is a nice place to be and I think it’s hard to see that on the first blush. It’s dry and it’s brown, and it’s not lush and green like Portland or Seattle or Baltimore or places back east where they get a lot of rain. It’s sagebrushy desert. Boise itself has a lot of trees but the surrounding area looks a little desolate. But it has its own beauty. When you first look at it, you say ‘gees, how could anybody live here,’ but after you’ve been here for a while it’s really delightful.”
The arid climate helps keep the winters from feeling so cold and makes the warm summer days comfortable. Daren Braget, MD, an Air Force physician, came to the Mountain Home Air Force Base just this summer from New Orleans via San Antonio. He says the climate is a significant improvement over that of the sultry southeast. “I spent four years in Louisiana in New Orleans and I spent five years in San Antonio so the humidity here is virtually none,” says Braget. “It’s 15, 20, 25 percent which is a joke compared to what I just left so the weather is beautiful.”
The winters in Boise are fairly mild with relatively little precipitation compared with many mountain locations. It’s not uncommon for Boisians to play golf on a February afternoon and head up the mountains for an evening of snow skiing.
Despite the dry climate, Idaho has more whitewater river miles than any other state among the lower 48, so whitewater rafting is a popular summer activity.
People who don’t enjoy the outdoors don’t seem to fit in, according to Jones. “Boise is not so much of a community that is a spectator community. It is a community of people that go out and do things themselves,” says Jones.
“A lot of Idaho is government-owned land—either BLM (Bureau of Land Management) or forest service or state,” Jones explains. “Because of that, you don’t have to ask permission to go out on the land. You can go hiking, and you can go hunting and certainly fishing, and there is whitewater rafting and canoeing and kayaking readily available. It doesn’t take a huge amount of money to be out and doing things recreationally, and doing it on a daily basis, that people go on vacation to do.”
Braget agrees. “If you’re an outdoor person this is the stepping off point,” he says. “There is so much to do.” In the winter there is snow skiing with multiple areas within an hour-and-a-half drive. Sun Valley is 100 miles from Mountain Home. In the summer, Braget says, “River rafting is phenomenal. There are so many rivers available. There are all the national forests and hiking; there are so many reservoirs around here for fishing.”
With the Rocky Mountains in Boise’s backyard, alpine ski slopes are close neighbors. At Bogus Basin Ski Area, just 16 miles north of Boise, skiers ply 58 runs day and night from late November through mid-April. World-famous Sun Valley is just 154 miles away. The parks and forests have trails for cross-country skiing.
Government land is also used to protect the region’s wildlife. The Snake River Birds of Prey Natural Area just outside Boise serves as a refuge for the endangered raptors. In Boise is the World Center for Birds of Prey, housing an exhibit on the biology and ecology surrounding these endangered birds. Falcons, eagles, and other rare birds of prey are reared at the facility to be released into the wild.
City life in Boise
Even if they can’t get out of town to the forests and rivers, the Boise River runs through the center of downtown, so residents can enjoy rafting and fishing even within the city.
“Boise itself is very beautiful,” says Braget. “The river runs right through the city. It’s very pretty; lots of trees. The nickname for Boise is the “City of Trees.”
The city’s more than 2,000 acres of park and recreation land lies mostly along the river and includes the riverfront Greenbelt. Residents walk, bike, and skate along the belt’s 20 miles of paths. Kathryn Albertson Park is a walking park in the heart of the city. The Morrison Knudsen Nature Center on the Edge of Municipal Park allows visitors to observe life in a typical mountain stream.
In addition to the parks, Boise offers other important elements of urban life. Braget has found that Boise, just a 30-minute drive from Mountain Home, lacks no urban features that he will miss. “Virtually everything to do in San Antonio is available in Boise as far as the arts and symphony and all. As far as shopping goes there is a monster mall in Boise with all the shops that you would need.”
One urban feature that Braget will not miss is a high crime rate. “One of the neat things here is having been in New Orleans which is the second most violent city in the U.S. and then having lived in San Antonio is it’s just a relief to be away from crime. Where the news used to be dominated at night in San Antonio with murder, murder, stabbing, stabbing, rape, rape, there is just none of that here. That’s kind of a relief.”
All the doctors appreciate the quality of life in Boise and want to preserve it. “One of the biggest pluses of Boise is that it’s a fairly large city but it still has a real small town feel to it. So it has a lot of the advantages of safety, the sense of community of a small town plus a lot of the amenities of a bigger metropolitan area,” says Rutherford.
The city’s growth is stressing its infrastructure, however. Rutherford says that he has witnessed traffic and crime levels increase in Boise. “Being out here eight years now, I’ve seen what the growth has done as far as levels of crime, levels of traffic. I can tell a big difference as far as what the traffic flows are doing. It’s kind of one of those things where the infrastructure is starting to almost drown a little bit because of the levels of growth.”
Welebir says he has detected the effects of growth even in the short time he has lived in Boise. “This growth, unfortunately, brings congestion on the roads and streets and freeways and the ever-dreaded crime. I have seen a change in this regard within the last two years.”
These levels of congestion are still minimal compared to what Welebir left in California. “To me it’s wonderful. I don’t see any problem, but I have seen what people talk about.”
The city’s leaders don’t want Boise to ever face traffic problems on that scale, and they are already working on a solution. The city council has voted to allocate funds for a six-month test of a commuter-type train to see if such a program could help offset traffic problems.
Rutherford has another solution for that and other growth-related problems: “I’ve always said that I want to build a wall around the perimeter of the state right now. There are a lot of people coming in,” says Rutherford. “I’d hate to lose our little town with too much exposure.”
Bett Coffman is the associate editor of Unique.