The front line of medical care—primary-care doctors—is crumbling as med-school grads opt for better pay and a more predictable life.
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She cites a case in which a child needs to see a specialist. The primary-care doctor makes sure the child gets where she needs to go, and that when the results come back, they are communicated to the child or parent. “If you have a child with complex needs, all those various specialists don’t talk to each other, so you have to be the communicator in coordinating all the various things a child needs,” she says. “We’re sort of the orchestra conductor—and that’s all nonreimbursable time.”
It also means a lot of extra hours. A typical day might start at 8 a.m., with the doctor seeing patients till 5 p.m., with an hour off for eating and catching up. “After 5, it’s taking home two to three hours of paperwork,” says Robert McLean, a primary-care physician in New Haven. “Or leaving around 6 or 7 and maybe returning a phone call or two from home. And then a couple hours more of finishing up notes or doing more paperwork. The amount of time outside of seeing patients is three to four hours a day, usually—unpaid.”
In theory the extra work is bundled into the fees he gets for visits, says McLean, “but it is extra time. It makes a lot of people very frustrated at the hours that they’re working to deliver the care that needs to be done.”
Bucking a national trend toward larger groups, most of Connecticut’s primary-care docs are small-business operators. Ninety percent of them practice in groups of four or fewer physicians, so economies of scale that might relieve administrative burdens don’t really apply. The small practices in Connecticut are “totally against the national trend,” according to Audrey Honig Geragosian, a co-author of the CSMS study. It’s a “mind-set issue,” she says. “Folks here are independent. They like to run their own shops. They like to practice the way they like to practice. It is unique to Connecticut and New England certainly.” But without big offices and staff dedicated to processing paperwork, it means more work for the doctors. Small practices also find it too expensive to install electronic record-keeping—estimated between $25,000 and $30,000—which is expected to become mandatory.
About 10 years ago, according to McLean, hospitals started buying up medical practices, usually consisting of specialists, to ensure a steady flow of patients into their facilities. “That didn’t work well at the primary-care level because the hospitals found they couldn’t run the primary-care practices efficiently,” he says. “Hospitals may not have realized how much primary-care practices depend on the volume of visits to generate revenue. Hospitals’ own financial models are based on the number of procedures they do. I get the sense that when primary-care physicians sold their practices to the hospitals and then became salaried outpatient doctors, there was not adequate productivity in the payment formulas. The primary-care doctors weren’t as motivated to work really hard and see lots of patients. So the general revenue stream of those practices tended to decrease to the point that the hospitals found they weren’t profitable enough.”
Conversely, the primary-care doctors who do well financially have had to become more entrepreneurial because so much of their income is based on performing procedures. The economic model is a simple one under the current set-up: The more tests and procedures you do, the more you get paid. “One can argue it’s good or bad, but they’re doing tests like bone density in their offices that normally I’d refer out because I figure that’s in the realm of radiologists,” Maresh says. “They do it better than what I do. So I haven’t wanted to get into all that stuff. But the people doing well in primary care have become entrepreneurs.”
The situation is reaching critical mass in Connecticut as primary-care practices lose doctors to retirement and are not attracting enough new doctors to meet even current need—a need that is expected to increase dramatically as provisions of the federal health-care legislation providing insurance coverage to more people are felt. As the CSMS survey bluntly points out, “the state may not have enough primary-care physicians to meet the expected demand for services.” The shortage, it says, will be particularly acute in rural areas such as Tolland, Windham and Litchfield counties. The typical Litchfield County primary-care physician could be looking at an additional 283 patients, according to the study, while his or her New Haven County counterpart might have to accommodate 192 new patients (added to an average patient base of around 2,500).