The Patriot-News, PENN Live March 17, 2013 | Dr. Scott Setzer knew when he chose to become a family doctor, he wasn’t going to make the money a specialist would, but that was OK.
He didn’t go into medicine to make money –although, of course, that would be nice.
Mainly he just loved the idea of building relationships with people in a way that could really make a difference in their health and quality of life.
But in his traditional practice, he started seeing the business aspects interfering more and more.
“I found myself spending a disproportionate amount of time on billing and coding, arguing with insurance companies over why I prescribed the drug I did rather than a cheaper one, trying to demonstrate ‘meaningful use’ of electronic patient records in order to receive an incentive,” said Setzer, who said he has watched the nature of primary care change since he began practicing here in 1997.
As Setzer experience first-hand, the business side of doctoring is changing. The number of solo practitioners who are members of the American Academy of Family Physicians fell from 44 percent in 1986 to 18 percent in 2008.
“The days of physicians coming out of medical school and hanging out their own shingle to practice medicine are over,” said Dr. C. Richard Schott
Moving forward, doctors are either joining health systems or hospitals or turning, as Setzer did, to what has been called “concierge medicine,’’ where patients pay a fee that ensures them access and gives the physician financial breathing room to schedule longer visits.
“The days of physicians coming out of medical school and hanging out their own shingle to practice medicine are over,’’ said Dr. C. Richard Schott, president of the Pennsylvania Medical Society.
“Doctors coming out of medical school today aren’t considering that and there’s very little training for how to run your own business,” Schott said. “The economics of practice, regardless of which venue you choose – solo practitioner or employed physician – are quite different than 10 to 15 years ago.”
The benefits of being part of a hospital or health system
More than 60 percent of doctors age 40 and younger are employed by a hospital, physician group or other entity, according to a survey done last year by The Physicians Foundation, which sent more than 630,000 email questionnaires to doctors and received 13,575 responses. Merrit-Hawkins, a physician search firm that assisted in the survey, reported that only 1 percent of their search assignments last year were for solo physicians compared to 22 percent in 2004.
But the move away from solo practitioners does have positive aspects Schott said.
“You are seeing movement away from a volume-driven reimbursement system towards something that is more value-based,’’ Schott said. “Traditionally, doctors haven’t paid attention to cost. These changes cause doctors to look at the appropriateness of what they order vs. cost.”
There are definite positives for doctors who are employed by a hospital or health system, said Schott, a suburban Philadelphia cardiologist who used to be in solo practice.
“They enjoy the fact that a hospital gets reimbursed substantially more from Medicare and private insurance than a doctor doing the same thing in his own office would get,’’ Schott said. “Employers can offer salaries and benefits that exceed anything a doctor could make in private practice.”
Richard LaVanture, senior vice president and chief strategic officer at Holy Spirit Hospital in Camp Hill, said working in a hospital or as part of a health system allows doctors to spend more time focused on patient care. As part of a larger organization, doctors don’t have to worry about core services such as billing, coding and documenting, technology support and marketing, he said.
“In this perfect storm of health reform mandates, the economy, high-deductible insurance plans and a diminishing workforce as baby boomers are aging, the trend away from solo physicians, especially in specialty areas like cardiology and oncology, is definitely increasing,” LaVanture said. “And now that perfect storm is making its way into primary care as well.”
It’s a win for patients as well, who enjoy more focused attention of a physician who isn’t worried with running a business and a higher level of care coordination with available services within the larger health system, LaVanture said.
“Doctors do give up full independence, but what they gain is substantial,” he said.
Not all doctors are happy about the changes they are seeing, however.
The Physicians Foundation report found three quarters of physicians are somewhat or very pessimistic about the future of their profession. It noted that those in the field longer had a dimmer view as opposed to a generally more positive outlook among younger physicians. The report also found that more than 50 percent of physicians surveyed said they planned to cut back on patients, work part-time, switch to concierge medicine, retire or take other steps that would reduce patient access to their services.
A different model for solo practice
Dr. Christine Cassel-Mackley, who owns Brownstone Dermatology Associates in Hummelstown, used to work for a medical center but opted to open to her own business to gain back time with her children, now 7 and 9.
The only reason she can afford to fly solo is elective cosmetic work, which clients pay for out of pocket, she said.
“About a third of what I do is cosmetic work,” she said. “I could definitely see it becoming difficult to be on your own if you didn’t have that option.”
While she loves the flexibility of her schedule, she said, “There are business aspects I’ve had to learn and there is a lot of fear going out on your own – you don’t know if you’ll have enough patients and be successful.”
Setzer knows that fear well – he faced it head on when he decided to leave the traditional family practice of which he was part owner and open his own concierge practice in October 2011.
“It was a huge decision for me to leave my patients of 14 years, but the way I rationalized that is that I was losing those relationships anyway because of the way I was forced to practice,” said Setzer, who describes his Lemoyne practice as “relationship-based continuity of care.”
Yes, he’s a solo practitioner, but not in the traditional vein. Patients pay $2,000 annually to have 24/7 access to Setzer and the guarantee that when they call the office, they will be seen that day or the next. In the office, patients get hour-long appointments; two and a half hours is allotted for annual physicals. There are no co-pays and no costs for in-office testing.
“This is really my passion – the synthesis of the science, the people stuff, the good feeling you get when you really help people,” he said.
Setzer was pleasantly surprised by how easy it was to build his patient base – he passed 200 patients at the eight-month mark, about half of whom followed him from his other practice. He is currently expanding his office space and adding an aesthetician and leasing space to massage therapists.
Concierge medicine is sometimes criticized as being healthcare for the wealthy, and Setzer acknowledges it can be expensive. He offers a discounted price of $1,200 for children ages 10 to 25 to help defray cost for a family.
Setzer doesn’t participate with insurance, but upon request, patients can get a summary of services to submit on their own. Often, though, claims are refused because he doesn’t assign a dollar value to services.
He said he would like to see employers offer to subsidize concierge care for their employees and insists they would reap benefit in healthier employees who are enjoying a higher level of care.
Patients have his cell phone number and his email address. If a patient can’t get into the office, Setzer is happy to swing by the house for a home visit.
“In truth, people have such good access to me that they don’t call me much after hours. I’ve only been woken up twice in the middle of the night,” he said. “Part of it is, we have a relationship and they value that. This is how old-fashioned medicine is practiced. When there’s a personal connection, it’s better.”
WRITTEN BY CAROLYN KIMMEL, For PennLive.com
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