By Elizabeth Losada
SDN Staff Writer
The family physician, in the eyes of many medical students, is a solo physician with a comprehensive practice that treats patients over their entire lifespan. While this type of practice is possible, solo physicians, especially those in urban and suburban areas, are facing many challenges as they try to sustain full-scope solo practice in today’s healthcare climate.
Family medicine was born as a specialty in the early 1970’s in response to the increasing specialization of American physicians following World War II. The number of U.S. physicians who designated themselves as “general practitioners” decreased from 79.2% in 1938 to 17.3% in 1970, while self-designated “specialists” increased from 20.8% to 75.7%1. The specialty was designed to train physicians who would provide general medical services for patients of all ages, and would treat patients in an emotionally supportive manner that was consistent with the values of the patients’ community.
Since family medicine’s inception as medicine’s 20th specialty, family physicians have come to care for more patients daily than doctors in any other medical specialty: 199 million of the 822 million patient visits in 2000 were to family physicians1.
While the specialty has thrived as one that offers patients a wide range of services — from delivering babies to routine office visits — the scope of a particular family physician’s practice can be limited by factors specific to the local healthcare market. The presence of managed care organizations, reimbursement rates set by insurance companies, hospitals’ restrictions on physicians’ use of their facilities, and even a family physician’s personal need to limit work hours, all influence the breadth of care that a physician can offer to patients. Doctors in solo practice, who tend to operate with small staffs and limited time to devote to administrative tasks, may find their practice styles most affected by these factors2.
One such physician, who has maintained one of the few solo family practices in his region of the suburban San Francisco Bay Area, is Dr. Randy Clarke. During his last 25 years in private practice as a family physician, Clarke has experienced many changes in the type of services that he is able to provide to his patients. After finishing his residency in family medicine in 1981, Clarke was able to obtain obstetric, surgical, and ICU privileges at his local hospital. “Even though I had been trained to deliver a full scope of care, these privileges were difficult to obtain as a family doctor due to specialty turf hassles,” Clarke said. “But for a time between 1982 and about 1992, I was doing obstetrics, full medical and ICU admits, minor surgical cases, and putting in my own lines. I was having a great time.”
Because the procedures brought in high income, Clarke was also able to start an office practice that was over 90% underserved patients with Medi-Cal. Medi-Cal reimbursements were low, but Clarke was reimbursed at much higher fee-for-service rate for patients with private indemnity-type insurance who soon came to him as well for the full scope of care he provided. “It was a source of pride that I could build up such a practice,” Clarke remembers. “My patients had a choice of any doctor, and they chose me!”
Clarke first faced challenges to his style of practice in the late 1980’s, when HMOs came to the area. He noticed that his HMO patients, even those patients with whom he had developed long-term relationships, could be pulled from his care at the whim of the insurance company and assigned to other doctors. There were problems with reimbursement as well. Most HMOs in the area practiced capitation, a reimbursement plan that gives physicians a set amount of money each month for taking on the HMO’s patient. “This method of reimbursement puts doctors at financial risk if a significant number of their patients need a lot of care,” said Clarke. “While receiving $10-$12/month per patient may sound like a good deal, consider what happens when patients get sick and need to be seen often: there goes the budget. Since office charges, and not collections, average $75/patient/visit, if you see an HMO patient more than twice a year, you lose money.” Additionally, capitation did not allow physicians to bill for procedures and other office services, like EKGs and urinalysis, and also did not reimburse primary care doctors for hospital services. With this new method of reimbursement, Clarke’s income dropped significantly. He was not alone: nationally from 1995 to 2003, primary care physicians saw their net income decline 10.2%3.
Facing financial challenges, Clarke had no choice but to change his style of practice. “The scope of my practice begins shrinking around this time due to not being reimbursed for procedures. Injections, minor surgeries, fractures, and hemorrhoid banding now went to specialists per the HMO protocol. Hospital work became less viable because we were doing admits and making rounds for free. And my hospital privileges became increasingly difficult to exercise because it was necessary to call consultants for everything.” Clarke gradually pulled away from the hospital work he had enjoyed for many years and also saw a decline in his obstetrics practice for similar reasons. By 2003 he had formally resigned from all hospital staffs and was seeing fewer children since he had stopped delivering babies. This experience was not unique to Clarke’s practice. According to data from the AAFP, from 1987 to 1998 the percentage of family doctors who worked in ICUs dropped from 72% to 55%, and the percentage doing obstetrics dropped from 41% to 30%4.
As his practice shrunk in scope, Clarke had to adapt his office to a new style of medical practice that saw an increased volume of patients, often 35 to 50 per day. “When the HMO’s first came to town, the goal for most of us was to sign up as many patients as possible,” Clarke explains. “We were naïve about the implications of the contracts we were signing as we just wanted to keep our patients. Most primary care docs became ‘triage docs’ that did superficial assessments and referrals to specialists.” Faced with the challenge of not being reimbursed for simple office procedures like pelvic exams, Clarke had no choice but to make referrals and to take on more patients, hoping to stay afloat financially. Eventually, he realized that he was losing money by taking on more HMO patients and resigned from plans that offered the worst reimbursements.
After cutting back his office staff significantly, Clarke has been able to maintain a busy practice that is committed to providing the best care possible to all of his patients, many of whom have been with him throughout his practice’s changes. Dealing with the bureaucracy of insurance plans still remains his biggest challenge. “We have been inundated with superfluous paperwork which has not controlled costs or improved quality,” he said. “And as a physician it is frustrating to have to explain procedures to non-medical people in these plans in order to get approvals.” Despite all of the hardships, Clarke is committed to practicing medicine for at least another twenty years. “We are blessed to be in this profession and I don’t ever regret becoming a physician. I just regret that we have created a flawed system for our patients based on profit.” Clarke looks forward to the day when reforms in the current system will lead to a new model that emphasizes the preventative care and full scope of practice that he most enjoys providing.
1. Graham, R, Roberts, RG, Ostergaard, DJ, Kahn, NB, Pugno, PA, and Green, LA. (2002). Family Practice in the United States: A Status Report. JAMA 288: 1097-1101.
2. Sturm, R. (2002). Effect of Managed Care and Financing on Practice Constraints and Career Satisfaction in Primary Care. J Am Board Fam Pract 15: 367-377.
3. Tu, HT and Ginsberg, PB. (2006). Losing Ground: Physician Income, 1995-2003. Track Rep (15): 1-8.
4. White, B. (2000). Are the Edges of Family Practice Being Worn Away? Family Practice Management 7(2): 35.
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