Where is my Doctor?

I have wonderful memories of my pediatrician in Boston in the 50’s & 60’s- like many of you I grew up in the world of private, solo physician practice. But that model is rapidly vanishing in America.

The intimate setting of the personal doctor is being replaced with large multi-specialty clinics, specialty-specific conglomerates, and physicians working as employees of hospitals or healthcare systems.

Mind you- today’s care may be as excellent as “the good old days”- if not better- but many people are nostalgic about the doctors’ offices they remember. Where have those physicians gone? Is this another result of Obamacare??? Actually not- the answer is far more complicated.

Physicians are People Too
In generations past physicians were more likely to stay working way beyond the normal retirement age- many died in their 80’s with their proverbial boots still on. However, as society has changed so have the expectations of physicians.

The late stage baby-boomer doctors are retiring earlier than their predecessors, and that trend is expected to accelerate. Younger generations of doctors are far more invested in work-life balance and creating a post-practice life. To foster their family and individual interests they are more likely to seek practice settings that give them control over their schedule.

We certainly can’t fault people who want to have more time with their loved ones- and research would show that “balance” leads to healthier physicians delivering better medical care. But you can’t be a doctor in solo practice and have that kind of freedom. Accordingly, young doctors- and mid-life doctors looking for some relief- are choosing practice settings that allow structured, predictable patterns- such as employment by a hospital, huge physician clinic, or large health care system.

The Math Doesn’t Work
The cost of running the little physician office many of us remember is another reason they are disappearing. The number of legal requirements and compliance issues now mandated in a medical practice have increased dramatically over the last 3+ decades- as have the costs of insurance, licensure, equipment, computer technology, and staff.

Worse yet, physician reimbursement- by both government and private payers- has been declining as overhead has risen.

Of course medical practices are not the only businesses that have encountered rising overhead- but they are different than other industries because physician payer contracts and federal law prohibit the shifting of any of the burden of running a practice on to patients. Wal-Mart can pass the cost of business on to all of us as customers, but if physicians pad their charges they are risking criminal penalties.

In contrast, employed physicians have corporate offices to manage all of the business of medicine, including absorption of the cost and responsibility of legal compliance. In addition- because the employers tend to be very large- these doctors can gain efficiencies of scale impossible for an individual practitioner.

The bottom line is that the cost of keeping that fondly remembered private physician office open is a major reason why so many have now been closed and/or acquired by other businesses.

Employed Physicians Can’t Pick and Chose
When physicians leave solo practice they may give up many of the headaches of running a medical office- but they also usually give up the ability to pick and choose their patients. Many Americans have lost their doctor- even though he or she is still on the corner where they used to be seen.

When the employer limits which insurance plans they will participate in -such as refusing to see patients covered on an ACA Exchange policy- or decides to cut out high-risk fields of practice- such as obstetrics- the physician must follow. The patient may feel “dumped” by their doctor- but their doctor is no longer in control.

The Office is Open… for a Fee
The same forces of economics and wanting control over their day-to-day lives is why many of the remaining small doctor offices are turning away patients- even those who have been with the physician for many years- as they become “Concierge” (or “Boutique”) practices.

In this model of practice a physician requires a payment directly from the patient for an extra level of services- while the patient gets more attention from- and better access to- their doctor.These practices can be very rewarding for the doctors- as well as the patients who can (or will) pay that premium- but this revolution in medicine has left many patients behind.

Saying Good Bye
The world of health care is being turned on its head. Change can be hard, and for many Americans the hardest adjustment of all is the loss of their neighborhood physician. The significance of that loss needs to be recognized but also understood- it has been inevitable for decades. No law, political upheaval, or mandate is going to return solo practicing physicians to our delivery system- more and more they will become a nostalgic memory of the past.

What Does This Mean?

Compliance: There are many laws that pertain to medical offices- complying with all of these regulations can constitute a full time job for at least one employee.

Concierge” (or “Boutique”) practices: Many physicians, particularly in primary care, have decided to enter into separate contractual relationships with a limited number of patients in exchange for an additional level of service. This practice model has been met with some controversy.