It’s no secret that over the past several years, America has been experiencing a seismic shift in the way health care is delivered. From government insurance mandates and changes to health insurance design to new reporting requirements, escalating costs and the rise of urgent care clinics, the health care picture has shifted dramatically. And it seems the independent family medicine practitioner is getting squeezed as a result.
Dr. Linda Girgis, a primary care physician in private practice in South River, New Jersey, says “it’s getting harder and harder [to stay in private practice] all the time. I think we’re in an area where there’s a shortage of primary care doctors, so I think that’s helping keep the patients coming. But we find we’re working more hours and bringing more work home. It’s definitely becoming a big burden to keep the doors open.”
[See: 10 Questions Doctors Wish Their Patients Would Ask.]
These burdens include those of any small business, such as scheduling and administrative tasks as well as marketing and billing. Unique for physicians are certain requirements surrounding electronic health records and new reporting requirements regarding patient visits as part of the Affordable Care Act. That act, which passed in 2010, mandated not only that all U.S. residents have health insurance or pay a penalty, but also overhauled how doctors reported and billed Medicare for visits.
“It creates a lot of burden on recording patient visits,” Girgis says, so that Medicare can “see that we’re meeting their requirements. It’s not just something that we’re doing at the end of the day. It’s something added on to every patient encounter,” she says, and it’s this increased administrative paperwork that sometimes gets taken home at the end of the day. “With a large organization or hospital, they have a whole IT department and they have people assigned just to that task to make sure they’re staying in compliance. But with a small practice, we have nobody. We have to do it ourselves.”
Despite this increased burden, Girgis says insurance reimbursements remitted to independent doctors like her have not kept pace. “Despite the fact that [we’ve had] cost-of-living increases and overhead increases, the payments we get from the insurance companies have remained unchanged for years and years. As a small doctor, I don’t have negotiating powers to do anything about that. A larger hospital has much more negotiating power. As an independent doctor, the insurance companies don’t want to negotiate with me.”
In many ways, physicians are feeling the same pressures that mom-and-pop stores on Main Street have already been through, with the influx of mega-corporate stores that took place over the past 40 years and changed the way Americans shop. These pressures are leading to burnout for some physicians, says Dr. Ripley Hollister, a family medicine doctor in private practice in Colorado Springs, Colorado, and a board member for the nonprofit physician advocacy group the Physicians Foundation. A 2016 survey conducted by the Physicians Foundation showed “about 50 percent of doctors are having symptoms of burnout on a daily basis,” Hollister says.
This increased burnout has resulted in part because of what Hollister calls the “intrusion of third parties into the patient-doctor relationship. We’ve seen in independent practice over the last few decades that there has been a definite shift in how physicians are able to relate to patients because of the growing intrusion of third parties,” such as insurance companies or employers that can alter the way a doctor is able to practice. “I’m not necessarily defining intrusion as bad,” Hollister adds, “but there’s been this introduction of additional parties into the mix of the doctor-patient relationship that is exacerbated when physicians become employed [by a corporation or other third-party employer] and to some degree lessened when physicians remain independent.”
Nevertheless, a growing number of doctors are opting out of owning their own practices, especially in light of the fact that many will be able to make more money and have better support if they join a larger practice or hospital. This has led to health care experiencing a massive shift toward a “big-box” approach — independent doctors joining larger group-, corporate- or hospital-owned practices.
[See: HIPAA: Protecting Your Health Information.]
A study released by the American Medical Association confirms what Girgis and Hollister have seen from their perspective on the front lines of primary care practice: The independent doctor is disappearing. The AMA’s Physician Practice Benchmark Survey found that in 2016, fewer than half (47.1 percent) of all physicians who provide at least 20 hours of patient care per week owned their own practices. That’s down about 6 percentage points from data collected in 2012. “Similarly, practice size also continued to increase although the shifts in size distribution were small. Sixty-one percent of physicians worked in practices with 10 or fewer physicians in 2012, but only 57.8 percent were in practices of that size in 2016,” the AMA reports.
These data have been corroborated by a 2016 report from consulting firm Accenture, which found that “the number of U.S. physicians in independent practice [which is defined as a doctor who owns a majority of his or her practice and has key decision-making rights] has dropped significantly in the last several years,” falling from 57 percent in 2000 to a projected 33 percent in 2016.
The Physicians Foundation has also found similar trends in its biannual survey. More than 17,000 physicians across the United States participated in the survey, which found that in 2016, 33 percent of physicians identified themselves as “independent practice owners or partners,” down from 48.5 percent in 2012. In addition, physicians reported spending 21 percent of their time on “non-clinical paperwork,” which totaled the equivalent time of 168,000 full-time doctors. And just 17 percent of physicians are in solo practice, down from 25 percent in 2012, the survey found. Perhaps even more concerning, the survey found that “80 percent of physicians are overextended or at capacity, with no time to see additional patients.” This situation only adds to the ongoing doctor shortage that’s been widely reported.
Impact on the Patient
Girgis worries that the trend away from independent practice could have negative consequences for patients. “As a family doctor, I develop a very close relationship with my patients. I have time to talk to them and they trust me. When you have big organizations, they’re pressuring the doctors to see more and more patients. It becomes more like an assembly line to get the patient in and out, and that wears down the trust between the patient and the doctor and things get missed when people are working like that,” she says.
Girgis is pessimistic that this trend can be altered, but she is determined to remain an independent practitioner “for as long as possible,” even if fellow primary care doctors head for larger group- or hospital-based practices. “As it stands, I think it’s going to get worse. More and more doctors are going to leave independent practice because it’s just becoming too difficult.”
[See: 14 Things You Didn’t Know About Nurses.]
Hollister says he thinks direct primary care might be a viable solution that can help restore the patient-doctor relationship as a more one-on-one collaboration. Under this model, patients pay a monthly subscription fee for their primary care doctor, eliminating fee-for-service payment structures and third-party billing. It also gives the physician more control over how to practice, leading to higher physician satisfaction, he says. This “highly individualized” approach gives patients access to their doctors when and how they want to work with them. Hollister says the direct primary care model could remove some of the current complexity and confusion within health care, particularly with regard to how doctors bill certain visits and how health insurers charge patients for various services. These sorts of care models can also provide a more dependable revenue stream for doctors while reducing their time spent negotiating with insurers and billing for reimbursement.
Opponents of direct primary care cite the current fragmented network of hospital participation and note that individuals may still need to carry other health insurance to cover catastrophic events or care that’s not offered by the primary care physician. DPC payments wouldn’t count toward any other insurance deductibles, so in the end, patients may end up paying more for health care than they currently do.
Perhaps the DPC approach will factor into a multi-faceted solution alongside additional changes to the current system. In the meantime, one thing is certain: America’s health care delivery model is in flux and the future of how patients will access primary care is likely to continue evolving.
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Is the Independent Doctor Disappearing? originally appeared on usnews.com
