Primary-care physicians
facing business challenges
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Primary-care doctors' offices must process a large amount of paperwork because many insurance companies have different procedures. Navigating through the insurance red-tape often requires additional staff, which raises overhead costs. |
Primary-care doctors are in a financial crunch -- not from the economy, but from their practice.
In a survey released last month, more than half of 150,000 primary-care doctors polled said they would leave primary care if they could, according to the Boston-based Physicians' Foundation, a grant-making and research organization whose member groups include 20 state or regional medical societies across the nation.
In Lexington, local physicians see the stress of running a busy practice as central to the problem.
“I’m not surprised that they’re unhappy with it,” said Dr. Cathryn Harbor, a primary-care doctor in Lexington, speaking of the national trend. “It becomes difficult because their practice is structured in a way that’s like a dinosaur.”
She described the way the typical doctor’s practice has evolved as “'unsustainable,” as physicians seek to balance their overhead costs with reimbursement by insurance companies.
Overhead for a physician’s office includes such costs as rent or mortgage, equipment, and salaries and benefits for the office staff. Primary-care doctors’ staffs normally include one or two nurses and an administrative assistant to handle appointments, billing and other clerical duties.
To cover those costs and the physician’s salary, doctors’ offices deal with myriad insurance companies, each with its own separate red tape and paperwork, and a physician’s office may require additional staff to navigate complex regulations and the procedures of different insurance companies.
Every year, insurance companies reimburse doctors based on how much time they spend with a patient. Harbor said the reimbursement amount has been steadily declining.
Dr. David Ellington, who shares Lexington Family Practice with two other primary-care doctors, said their practice now has an overhead of 60 percent – that’s almost two-thirds of the practice’s income going to overhead costs.
According to one local retired physician, Dr. Malcolm Cothran, specialists earn more than primary-care doctors.
Primary-care doctors earn their income largely from providing services to individual patients: giving exams, making diagnoses, prescribing needed medicine, and referring patients to specialists. They need to know enough about all the specialties to make accurate diagnoses and proper referrals.
Specialists work with a narrower breadth of knowledge in greater depth, providing more specialized services, including a variety of surgical procedures.
“You get paid more for doing than thinking,” observed Cothran, comparing the specialist’s targeted tasks with the primary-care physician’s wider range of duties.
Ellington agreed that payment rates often seem to reflect the procedure involved.
“If I inject someone’s shoulder with Cortisone, which takes me not very long, I get paid more than I do to sit down and listen and try to work through someone’s problems with heart disease, high blood pressure, and diabetes,” said Ellington.
Faced with high overheads and lower reimbursements, doctors have had to take on a greater number of patients to make ends meet.
“What that means is less and less time with each patient, and more and more prescribing of medicines for things that most doctors know they’re not helping,” said Harbor.
.However, primary-care doctors are essential to the population’s health. They are usually the first people patients see to get the proper care. They have the complete history of their patients’ health in one place, so treatments can stay consistent.
“If you don’t have someone coordinating it, it’s like a bunch of musicians sitting around in a room playing each individual instrument without a conductor to coordinate their efforts,” said Cothran.
He also noted the problem of an aging population. As the baby boomer generation ages, more people will need primary care. “For more people, more is spent on the last three to six months of their life than is spent on most of their medical care throughout their life,” he said.
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| Dr. Malcolm Cothran was a primary-care doctor from 1975 until he retired in February. To fix the primay care shortage, Cothan suggests a single-payer system and creating financial incentives to enter primary care. (JESS RAMOS/ Rockbridge Report) |
But according to a survey published in Journal of the American Medical Association in September, fewer medical students plan to enter primary care. The survey reported that only 2 percent of current medical students would become primary-care doctors.
Ellington said medical-school debt currently ranges from $150,000 to $160,000 for most students. During medical school years, students see the significantly lower income of primary-care doctors and their harder lifestyle compared to those of specialists. Thus, most medical school students decide to specialize.
“It’s a budding nightmare,” said Ellington.
Harbor, Ellington, and Cothran stressed the importance of changing the primary-care system.
“Practices have to evolve to adapt to the changing time,” said Harbor.
She said she believes switching records from paper to electronic made her practice more efficient and streamlined. However, Cothran pointed out that the cost to switch from paper to electronic records could be expensive.
“You can’t just say one thing is going to solve the problem,” said Ellington. “There’s going to have to be some system reform.”
Ellington mentioned Patients’ Center Medical Home (PCMH), a system that merges traditional family medicine with modern technology, seeking to provide better care to patients. The PCMH approach, which has been implemented in practices around the country, emphasizes the importance of the doctor-patient relationship but also integrates modern electronic record-keeping and e-prescriptions. The PCMH website advocates payment reform to better reward primary-care doctors for all their services.
Cothran recommended another possible solution, a single-payer system, which would reduce the red tape from private insurance companies by eliminating them. Instead of the insurance companies, the government would use taxpayer money to pay all the health-care bills. Other advanced nations such as Canada and the United Kingdom have implemented versions of the single-payer system.
He also recommended creating more incentives for people to enter the primary-care profession.
For instance, he said, insurance companies should reimburse primary-care doctors at a higher rate so they would not need to have a large number of patients. That way, they could provide comprehensive and better care to a smaller group of patients.
Despite existing problems, primary care is still worthwhile, said Cothran.
“The rewards of knowing your patients and getting to be their friend as well as their physician is something that I found so rewarding,” he said. “I would do it all over again.”
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