(Note, November 2021): The current COVID-19 pandemic has put a huge strain on America's health care system in innumerable ways. Among its many other consequences has led to fatigue and burnout among health workers, leading many health care professionals to leave the field. (According to an October 2021 report, one in five health care workers has quit their job since the pandemic began.) But the huge burdens that accompanied COVID only exacerbated an already existing crisis in health care staffing. One aspect of that crisis— an increasing lack of primary-care physicians — is examined in this article from the June 2010 issue of Connecticut Magazine.
The front line of medical care—primary-care doctors—is crumbling as med-school grads opt for better pay and a more predictable life.
When I get sick or it’s time for my annual poke-and-peek, I head for a small, 60-year-old, two-story white clapboard building that is the antithesis of one of those gleaming high-tech shrines to modern medicine. I park myself in one of the half dozen wooden chairs that grace the small waiting room, and after what is usually a short wait, I step into the bright windowed office of my primary-care physician, Henry Maresh, something I’ve been doing for more than a decade now. It’s a relationship that has lasted longer—and is certainly more intimate in certain ways—than my previous two marriages.
He has treated me for the usual ailments—coughs, colds, aches and pains—and he’s referred me to any number of specialists along the way. I was lucky to find him—he was on a list my wife’s employer provided—after we moved to Connecticut back then. A year or so later and I probably wouldn’t have been his patient. Like about a quarter of the primary-care physicians in the state, he has not been taking new patients for some time. In so doing, he’s part of a trend that does not bode well for the thousands of newly insured patients expected to seek primary-care docs in the wake of the federal health-care reform act.
He still practices what might be called the Marcus Welby medical model. He listens, asks questions—usually cracks a joke or two—and draws on decades of experience to decide a course of treatment. His advice has always been sound, despite my efforts to thwart him from time to time.
There aren’t a lot of high-tech gizmos around. He just recently added a laptop to his medical bag and is working on his typing skills. Even so, he says that by the time he gets the computer to look up a prescription, he could have written 10 by hand. Like many older practitioners, he is not so sure about the current push for electronic medical records. The up-front investment probably won’t pay off by the time he’s ready to retire.
“It’s a low-volume practice,” he says. “I don’t have any physician assistants. My patients are aging, so that Medicare now constitutes about 60 percent of the practice”—which comprises about 1,500 patients.
It is also a comfortable practice, built on a model that, according to a recent Connecticut State Medical Society (CSMS) survey of primary-care physicians, most doctors find satisfying. Even so, an alarming one in five say they are thinking about shutting down their practices because they are unhappy with the practice environment in Connecticut that includes burdensome administrative requirements and malpractice issues.
Connecticut cannot afford to let this dissatisfaction continue to build and see its army of primary-care physicians disappear. In many ways, they are the gateway to the health-care system, or at least its hub, coordinating care through referrals to specialists and following up on patient care. However, they complain that an increasing percentage of what they do on the job, especially the time spent on paperwork, is not reimbursed, either through government programs or private insurance. Payment is usually limited to face-to-face patient visits and whatever tests and procedures they can perform.
“There are a lot of challenges,” says Sandi Carbonari, a pediatrician at Children’s Health Center in Waterbury. “The biggest one is time. The kinds of things that need to be done in terms of paperwork and that sort of thing are onerous. It takes an enormous amount of time. And then once you get all that done, you still have to do what you need to do for the patient.”
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).
One result of too few or too busy primary-care physicians is that patient visits to emergency rooms, even by insured patients, will increase, only adding to the overall expense of health care for all.
The CSMS report does offer the silver lining that in 2010 medical schools nationally saw an increase in the number of graduates choosing primary care. The new medical school at Quinnipiac University might make a little difference. Still, it will take at least five years before any new graduates complete residencies and join the workforce, assuming they stick with their initial choice, and further assuming that enough of them will want to practice in Connecticut.
“The question becomes, ‘How do we get them to Connecticut?’” says Geragosian. “There are 49 other states out there competing against us. What is Connecticut willing to do to make this state attractive to these young physicians?”
The malpractice issue is an area the state legislature has considered from time to time, and might again. According to the American Medical Association, Connecticut remains one of the “crisis states” when it comes to medical malpractice insurance rates.
“In 2000, for an internist, the average medical malpractice cost was $7,736,” says Geragosian. “In 2007, that was $34,700. That’s a 349 percent increase that put us third in the country. While the increases have slowed, they haven’t decreased significantly” since 2007.
In the meantime, the problem of disappearing docs continues to build.
As McLean puts it, “You’ve got [primary-care physicians] who are 50 or 60 saying, ‘You know what? I’ve just had enough. I don’t want to transfer over to electronic medical records. That’s a complete redo of my life. I’m not going to put in the expense when the payback on that is too long. I’d rather just retire early.’ And the pipeline is dry.”
“One of the biggest things is trying to get more people wanting to go into primary practice,” Maresh says. “There are a lot of older physicians who are retiring [43 percent of them in Connecticut are over 50] and if we don’t have more people to fill the void, as well as the growing need of the population, there’s going to be a severe shortage.”
Various studies show that in areas where there are high ratios of primary-care physicians, patients are the winners. “They have fewer hospitalizations. They have fewer complications,” McLean says. “The data is overwhelming that the more primary-care docs you have taking care of a given population, the better the outcomes and the less expensive the care.”
A lot of students go into medical school thinking about primary care,” he says. “And then it changes. Maybe the people they get exposed to as role models seem too busy, and relatively unhappy at times, and work long hours doing lots of paperwork that they’re not getting reimbursed for. Then [the med students] look over at some of the subspecialists who they see are working fewer hours and doing maybe more sexy things. It looks easier, though it may take more years to get there. So in terms of prestige and income and lifestyle, the primary-care guys look like they’re working too hard for what they’re getting paid.”
Despite the challenges and frustrations, most primary-care physicians remain generally satisfied with their calling, according to the medical-society survey.
“There are benefits to primary care, especially here in Connecticut,” says Geragosian. “In most cases, you’re your own boss. You develop relationships with families that can extend for generations. Your financial rewards are not going to be that of certain other specialties, but there are other kinds of satisfaction. Pediatricians are the most satisfied of those practice groups even though they are across the board the lowest-paid.”
“It’s very satisfying,” agrees pediatrician Carbonari. “You do not go into primary care because you want to play golf at the country club and because you want a nice yacht or to take nice vacations. It’s just really cool when you run into somebody and they say that you really made a difference. You think, ‘Okay, for all the times when you’re not happy about things in the profession, that makes it worth it.’ I know it sounds corny, but there are a lot of kids who go into medicine for that reason. They want to do some good, they really do.
“You develop good relationships with families,” Carbonari continues. “And you’re with them through the hard stuff and the good stuff. That’s very fulfilling. If that’s the kind of thing that gets you, then primary care is where you belong because you can truly make a lasting difference.”
That’s a compelling sentiment, but are enough future doctors listening?
This article appeared in the June 2010 issue of Connecticut Magazine.