Independent Primary Care – Going, Going…

I been walking the road
I been living on the edge
Now I've just got to go
Before I get to the ledge
So I am going
I am just going
I am gone.

Bob Dylan, Lyrics of Going, Going, Gone

Last year, February 12, 2009, to be precise, Stephen L. Isaacs, J.D., Paul S. Jellinek, Ph.D., an Isaacs/Jellinick, a San Francisco firm that advises health foundations, and , and Walker L. Ray, M.D., vice president of the Physician Foundation, a non-profit organization representing physicians in state medical societies, wrote a prophetic article in the New England Journal of Medicine entitled “The Independent Physician – Going, Going…”

Perhaps you missed it. If you did, here is an abstract of the NEJM piece.

“Despite the current focus on expanding health insurance coverage, relatively little attention has been paid to the future of the physicians who provide care for the insured and uninsured alike — specifically, to their ongoing migration from independent solo or small-group practices to larger-group practices, where they are often employees. This trend and its consequences for the care of patients and the practice of medicine have scarcely been explored.”

“The percentage of U.S. physicians who own their own practice has been declining at an annual rate of approximately 2% for at least the past 25 years.”

The trend continues unabated. Only 2% of medical students are now selecting primary care practices.

In the near future, in 2011 when 78 million baby boomers start qualifying for Medicare at the rate of 1300 patients a day over the next 18 years and in 2014 when the health reform law foists 32 million more of the uninsured onto the Medicaid rolls, these new government-subsidized patients will be asking: Where have all the doctors gone? For good reason. Primary care is the common point of entry into the system.

So where have all the independent primary care doctors gone?

• They have gone into surgical specialties, specialties like radiology, anesthesiology, and dermatology, and into internal medicine subspecialties, where the pay is higher, the hours are shorter, and the prestige is greater. Why would they do otherwise?

• They have gone into large group practices, where they are salaried employees with the benefits of paid vacations, pensions, malpractice coverage, and other fringes. Why would they do otherwise?

• They have gone into hospital employment positions, where the pay is equivalent, economy security more guaranteed, benefits are greater, and malpractice coverage is guaranteed. Why would they do otherwise?

• They have gone into locum tenens work, where there is a chance to travel, to pick your location, and where your malpractice expenses are covered. Why would they do otherwise?

• They have gone into administrative or nonclinical careers, where their knowledge is appreciated and where they can climb hierarchical ladders with fringe benefits and stock options. Why would they do otherwise?

• They have gone into cash-only and concierge practices, where they can select the patients they want to see, spend more time with them, and spurn Medicare, Medicaid, and health plan patients and escape the rigors of federal rules, regulations, and harassment. Why would they do otherwise?

• They are retiring because they afford to or because they can’t take it anymore. Why would they do otherwise?

But other physicians, of course, are doing otherwise, either because they approve philosophically of reform under Obamacare, or because it is too late for them to change, or because they are loyal to their current staff and to their Medicare, Medicare, and managed health plan patients.

Whatever the explanation for some staying put in their current practices, overall the number of primary care doctors serving these patients is shrinking rapidly.

“As Alice of Alice in Wonderland said to the Caterpillar, “ I quite agree with you. And the moral of is: Be what you would seem to be, or if you'd like it put more simply: Never imagine yourself not to be otherwise than what it might appear to others that what you were or might have been was not otherwise than what you had been would have appeared to them to be otherwise.”

Otherwise still means doctors can choose their specialty and can practice where and when and how and under what circumstances they please.

How long this state of affairs will last depends on the extent and intent of federal intervention, and how hell-bent and how much money will be spent by government to salvage primary care.

Otherwise independent primary care practice is going, going…