Nov. 14--Editor's note: This story is a follow-up to a Special Report published in the Oct. 23 edition of The Daily Times looking at health care trends.
FARMINGTON -- Tough health care regulations, hospitals hiring more doctors and a poor economy make running a private medical practice harder and harder, and many experts see the private practice model facing a serious threat.
The question on everyone's minds is how this will affect patient care. Many experts agree that the old model, and perhaps the intimacy of the long-standing doctor-patient relationship, may be going the way of the house call.
And Farmington is no exception.
During the last four years, San Juan Regional Medical Center has hired more doctors, to the point where nearly half of the doctors who use the facility are hospital employees. That's good for the hospital, supporters say, but local private practioners argue it's a threat.
The arguments
Proponents of the market shifting away from small private practices to larger health care organizations believe patient care will improve and be more affordable.
They say the change will improve communication between primary care physicians and specialists, and will reduce duplication.
Opponents argue that the tendency toward monopoly will drive up the cost of care for patients, and that the push to get patients in and out of the hospital ultimately will result in less effective care.
There
also is the question of the personal connection between doctor and patient. Critics claim that it's less likely patients will see the same doctor every visit at larger institutions, making it difficult to develop the type of intimate doctor-patient relationship typified by private practice.
Another issue for opponents is the question of private insurance. There are signs that the trend toward large health care organizations is contributing to the rising cost of private health insurance.
The problem is that private insurers often have little negotiating power when it comes to dealing with larger organizations.
An issue in Farmington, according to some local physicians, is that the hospital's hiring spree has independent practitioners worried that the hospital seeks to monopolize the finite patient pool of Farmington, possibly driving their practices out of business.
"It's gotten very cold and competitive and that isn't good for patient care," said Amy Robison, who runs San Juan Surgical Associates with her husband. "The best patient care comes when doctors are working together, when they are comfortable."
San Juan Regional Medical Center CEO Rick Wallace is firm when he says the hospital is not hiring doctors to compete with independent practitioners.
"Anytime I recruit somebody, whether they are employed or independent, it's money out of the hospital's pocket." Wallace said. "We do not recruit primary care physicians until the recruiting committee tells us the community needs them."
Reimbursement worries
Another worry for experts involves the way hospitals are reimbursed for Medicare and Medicaid patients. Hospitals receive payments for both programs in lump sums, and those lump sums are getting smaller.
According to Wallace, the hospital saw its Medicare reimbursement cut by $6 million in fiscal year 2010. As the lump sum payments are getting smaller, the hospital is seeing more and more patients.
"The idea is that if you can get patients out of a hospital quicker, it improves the bottom line," said attorney Jim Parker, who specializes in health care. "This is particularly true with something like Medicare, where hospitals get a lump sum payment."
Wallace doesn't deny that getting patients in and out more quickly would be better for the hospital's bottom line. But he does say that in the end it would backfire and cost the hospital money.
"In 2013 and 2014 our reimbursement will be completely changed to paid for performance,'" Wallace said. "If we do everything extremely well we would see a 10 percent bonus; if we do things extremely badly we would lose 10 percent."
One of the ways that performance will be measured is by patient surveys, another is how quickly a patient returns. These performance-based reimbursement models are meant to forestall the impulse to get patients in and out as quickly as possible.
"It also has a provision called core measures, which basically says we have to give everyone that walks through the door with chest pain an aspirin," Wallace said. "There will be 72 requirements like that we have to meet."
The issue of decreasing reimbursements paid by both the government and private insurers to medical providers is having a direct impact on health care in Farmington and is another force driving patients away from private practice and into the hospital, according to trends.
Hospital experience
Bob Larson, a 63-year-old Farmington resident, had a terrible time trying to find a private practice general practitioner in the community because none of the community doctors were accepting new patients.
"I started looking in Durango, but they weren't taking new patients up there," Larson said. "So I got to looking around Farmington and they weren't taking new patients either."
In the end, he had to turn to the hospital, because it was accepting patients.
"I had a doctor at the hospital that I liked, but he left and, lo and behold, they replaced him with a couple of doctors from India," Larson said. "I'm not racist, but I had two meetings with my new doctor from India and he was rude and there were things about him I didn't like."
Larson thought about leaving the hospital and looking for a private practitioner, but he decided to stick it out and see if things would change.
"In the end I decided to stay with the hospital," Larson said. "Since then I have started getting along with him better. If you need a doctor here you kind of got to take what comes along or do without one."
Overall, Larson is happy with his experience at the hospital.
"When I heard that the hospital actually geared up and hired a couple doctors, I thought that was great," Larson said. "I definitely get to see my same doctor. The big deal that I like about the hospital situation right now is that those guys actually seem like they need business."
Larson can get in to see his doctor in a day, compared to wait times of more than a month that he experienced at private practices.
"In that amount of time you would either die or heal up," Larson said.
By no means a scientific sampling, Larson's experience does raise the question: Why should people care if private practice dies out?
Why care?
That is a hard question to answer because the nation's health care system is still in the early throes of sweeping new changes.
But there already are documented problems.
There are examples nationwide of hospitals converting the greater market share that comes with hiring doctors into higher prices for patients.
That is something experts say directly affects patient care because it ultimately works to restrict access.
One of the clearest cases is in Massachusetts, where Attorney General Martha Coakley determined that high prices largely were correlated with market share.
Coakley found that high-price markets in Massachusetts were characterized by controlling local providers who, because of their size, had power over prices.
Massachusetts is a useful comparison because the state's health care laws resemble what the national health care model could soon look like.
"To me, it's a question of whether I want my physician to be independent and accountable to no one other than me and the delivery of my health care, versus my physician who is an employee of a large institution," Parker said. "This change is fascinating to me, it's a whole new ball game."
For Wallace, the way the game is organized may be changing, but the game itself is still all about providing the best patient care possible.
"Everyone is welcome to their own opinion and perceptions," Wallace said. "Our physicians that we bring in, are here for one reason: their patients. The model is not going to make a difference. You are always going to have good doctors and bad doctors. I don't think that it's fair, or even accurate, to say that just because you are employed or independent you are a better or worse doctor."
The question that remains, and may well be answered in the next couple years, isn't about good or bad doctors. The question is: How will the changes affect a doctor's ability to provide the best patient care possible?
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