Primary care, physician shortage - Skinning the Small Primary Cat

Prelude: The WSJ ran this piece on December 15. It explains why solo or small practices have such a hard time surviving. It is right as far as it goes, but it assumes that these small practices are in a managed care setting, which carries with it a high overhead. What it does not say is that there are different ways to skin a primary care cat. One can go into concierge practice, close your practice to HMOs and accept only cash, operate out of a small office with no staff and use the Internet as your support system. Or one can offer one's services to corporations at a per diem rate for each patient.

December 15, 2008

Is the Problem Primary Care or Small Medical Practices?

Posted by Sarah Rubenstein

Misery might love company in primary care. Or at least bringing primary care doctors together into larger medical practices might alleviate some of the problems afflicting physicians on medicine’s front lines.

The Los Angeles Times is out with a piece this morning that explores how hard is is for primary care doctors in small practices to make ends meet. Of course, there’s more than one factor that’s made primary care financially unattractive for many doctors, including the fact primary care docs don’t get the kind of fees from insurers that specialists do.

But doctors who go solo or have just one or two partners have scant bargaining power with insurers, LAT notes, and their overhead also makes it tough to be profitable.

“It’s very difficult, even in rich neighborhoods like Beverly Hills, to set up a solo practice,” said Richard Scheffler, an economist at the University of California, Berkeley, told the LAT. “The doctor has to pay rent, a nurse, have a bookkeeper, billing systems, computers. All of those fixed costs are very, very hard for a solo practitioner to have and survive.”

One Beverly Hills primary-care doc, Tanyech Walford, just closed her tiny practice, where she hadn’t drawn a paycheck for herself since February. The practice cost her $40,000 of her own savings, and she had $15,000 in credit card debt along with her medical-school loans. She plans to move to Maryland for a new job at a 200-physician practice affiliated with Johns Hopkins. Her salary will be $115,000, plus bonuses, health insurance and a pension plan.

“I’ve been spent emotionally, financially, physically, and now I need to have someone else worry about the finances,” Walford told the Times.

Ben Brewer, family doc and WSJ.com columnist, wrote recently about his idea for boosting primary care: a federal tax rebate of $1 a day per person to be paid to a primary care doctor of the patient’s choice. The person would get a predefined basket of medical services, and the costs would be locked in like a subscription fee for cellphone service or movie rentals.