By Markian Hawryluk / The Bulletin / May 17, 2009

Earlier this month, Dr. Jeff Boggess, a family practice doctor at Bend Memorial Clinic’s Westside Clinic, spent an hour with a patient from Prineville. The 90-year-old woman had recently moved from California to enter a care facility near her daughter. The two had to travel across Central Oregon to find a doctor who would take a new Medicare patient.

“I’m sorry you have to drive by so many good physicians because you went right on by their offices to get to the Westside to see me,” he recalls telling her.

The clinic is one of the few places in Central Oregon where primary care physicians are still willing to take on all new patients with Medicare. Despite the fact that the government program is the nation’s single largest health plan, capturing virtually every elderly patient, Medicare has become a burden rather than a boon for most primary care doctors. Reimbursement rates have fallen so low that front-line doctors often lose money every time they see a Medicare patient.

The financial pressures are pushing primary care doctors to the brink. They are working longer hours for less money, spending more time doing paperwork and less time face-to-face with patients.

And unless they can find other ways to offset the shortfall, doctors increasingly are taking the reluctant move of cutting back on the number of Medicare and Medicaid patients they see.

The difficulties have had a cascading effect through physician practices and health clinics, and have turned one of the nation’s admired professions into one to be avoided. It has resulted in a vicious cycle in which shortages of physicians lead to tougher working conditions, chasing more doctors from the field and attracting fewer medical students.

Unless the fundamental problems facing primary care are addressed, many believe the situation for patients could get a lot worse.

More patients

Medicare was once the lifeblood of the primary care doctor. It provided quick, reliable funding for physicians to treat the elderly. But as Medicare enrollment and utilization grew, the physician payment formula locked in deep cuts in payment rates to doctors.

Doctors soon found they needed to see more patients in a day to maintain their practice revenues and to cover their overhead costs.

“We’re having to work harder and see longer hours and more patients in order to sustain any of the same income,” Boggess said. “In fact, it’s actually decreasing, even as compared to 10 years ago. I would guess I’m working a third harder to make a third less.”

Boggess said doctors at the clinic typically use their lunch hour to catch up on paperwork, and stay long after their appointments end to finish typing patient notes to ensure medical records are up to date. Insurance claims often require extensive documentation to show the treatment or service was medically necessary, in essence rewarding good paperwork over good care.

“You let things slide so you can stay in the room with the patient,” he said. “It’s a state of chronically feeling not caught up or behind.”

More patients in a day means shorter appointment times, and if any patient presents with a more complicated case than expected, it can throw off the entire schedule. Patients can spend more time in the waiting room, only to see their doctor for what seems like a fleeting moment.

“Because you have an ever-increasing cost of business with flat or minimally increasing reimbursement, doctors have to be more efficient,” said Dr. Sean Rogers, an internist at BMC. “Instead of seeing patients every 30 minutes, now it’s every 20 minutes or every 15 minutes.”

At the same time, physicians need more time per patient to manage chronic conditions and the growing amount of recommended preventive care.

Research shows patients receive only half of the preventive services and health care treatments recommended by current guidelines. Only a quarter of patients are up to date on immunizations, and fewer than 10 percent are counseled about healthy lifestyle habits.

Yet, increased paperwork and documentation requirements mean the average primary care physician spends only 55 percent of his or her workday on face-to-face patient care. The average physician practice must deal with nearly a dozen or more health plans, and follow each payer’s requirements for contracting, credentialing, coding and billing.

Paying for volume

The problem, experts say, is that the current payment system rewards quantity rather than quality, encouraging the drive-by appointments that undermine primary care.

“We’re reimbursed by what we do, so it’s really sort of quantity care,” Rogers said. “The more things I do to a patient, the more I get paid. You’d like to think that doctors are for the most part ethical people, and they won’t do unnecessary procedures to make a buck. But the fact is, the pressure is there.”

Yet, the services that primary care physicians typically provide — the evaluation of patients and the management of their illnesses — pay less than the procedures typically performed by specialists.

Medicare will pay $30,000 for a limb amputation for a diabetic patient, but next to nothing for primary care physicians to help their diabetic patients avoid the medical complications that lead to amputation.

Medicare, on average, will pay a doctor $196.69 to perform a 30-minute colonoscopy, but pays a doctor $90.20 for a 30-minute office visit. And that $90, doctors say, isn’t enough to cover the doctor’s overhead, including rent, staff, supplies and insurance costs.

“You get paid more for doing stuff than for thinking about them,” Rogers said. “If I take out your gall- bladder, that gets paid very well, as opposed to if you come in and see me for all your medical problems.”

The result is doctors who do procedures, usually the specialists, make a lot more money than the family medicine or internal medicine doctors who see patients in their offices. Physician groups worked with the federal government to raise payments for evaluation and management services several years ago, but the increases had only a negligible effect on physician incomes.

The Medical Group Management Association reported that primary care physicians had a median income of $182,322 in 2007, while specialists had median compensation of $332,450. Increasing practice costs, the group said, quickly ate up the increase in payments to primary care physicians.

Since 2003, inflation-adjusted primary care physicians’ incomes have risen barely more than 3 percent, while practice costs have increased more than 10 percent.

Combine the long hours and administrative hassles with lower salaries, and it’s not surprising that many primary care doctors are giving up on their traditional practices.

Pipeline problems

Throughout the nation and in Central Oregon, health care experts bemoan the lack of primary care physicians. But there is little hope of increasing the supply. Medical school students are scared off by the long hours and low pay of primary care.

A recent survey found that medical students see primary care medicine as requiring more paperwork, demanding a greater breadth of knowledge and providing a lower income potential than specialty care.

Many will emerge from medical school with massive school loans to repay. The lower salaries in primary care offer little hope of paying off that debt quickly. More than a quarter of medical students surveyed said debt load kept them from pursuing a career in primary care medicine.

Not surprisingly, students with debt loads above $150,000 were the least likely to choose primary care.

According to a letter published in the New England Journal of Medicine, family and internal medicine have become so unpopular that students who opt for residencies in those fields are often viewed as being too weak to obtain any other type of residency.

U.S. medical schools graduated 2,000 fewer primary care doctors in 2006 than in 1998, while the number of patients grew 12 percent.

“These folks are looking at practices that are seeing 30 to 40 patients a day, just running on that hamster wheel, and coming out of it with a third or less income than other specialties,” said Dr. Gary Plank, a family physician with Madras Medical Group. “It’s kind of hard to make the argument that this is a good lifestyle choice.”

Overcoming obstacles

Plank’s case may provide a glimpse of what it might take if lawmakers ever make good on their promises to invest more money in primary care. He completed medical school on a family practice scholarship funded by the Pisacano Leadership Foundation, the philanthropic arm of the American Board of Family Medicine.

“I told the Pisacano Foundation that was one of the reasons why I could go practice where I wanted to,” he said. “One of the things that allowed me to come here was that I had a relatively small debt load.”

Madras Medical also qualifies as a rural health clinic, and receives a wraparound payment that brings reimbursement for Medicare patients up to 101 percent of costs — just above their costs to ensure the clinic isn’t losing money.

“If it’s a difference between losing money and breaking even, that’s a huge difference for a practice,” he said.

Combined, Medicare (for seniors) and Medicaid (for low-income and disabled) account for 50 percent of the group’s practice. They still take patients from public health programs, but they’ve limited their caseload to residents of Jeffer- son County. “We get calls from patients in Bend and Redmond who can’t find a doctor and want to come up and see us,” Plank said.

Plank does some procedures at the hospital, including delivering babies. Despite the urging of their business manager, the six-provider group has resisted packing the schedule with patients.

“We’re averaging between 15 to 25 patients a day. We’ve chosen not to try to see more than that because we feel the care suffers,” he said. “Some of our colleagues are trying to see 30 to 40 patients a day. Those are the practices where you feel like you can only see the doctor for a minute or two.”

Plank knows he could make more money as a specialist or even a primary care physician in a larger city. But he says while his income may rank in the lower third among doctors nationally, it still probably ranks in the top 1 percent in Jefferson County.

“If I’m making $100,000, it’s hard to argue that I need to be making more than that as a primary care doc in Madras,” he said. “But that’s different in L.A. or Portland, or even Bend.”

Balancing costs

Without those additional payments for Medicare patients, however, Madras Medical might have to make some tough choices about how many Medicare and Medicaid patients to see. Mosaic Medical, with clinics in Bend, Madras and Prineville, is a federally qualified health center. About 35 percent of its funding comes from government grants designed to improve access for underserved patients.

But the clinics operate under certain limitations.

“We receive an established set rate for both Medicare and Medicaid,” Mosaic Executive Director Charla DeHate said. “Unlike private practices, where if they see somebody for 15 minutes, they get a certain amount, and if they see somebody for an hour, they get a larger amount, we get paid the same rate.”

The clinic breaks even on 15- minute visits and loses money when appointments run long. Many patients struggle to afford the cost of travel to the clinic, so asking them to come back for another visit is simply not an option.

“We have to run a tight business and be very efficient with our patient flows and staffing,” DeHate said.

And they must find a delicate balance in the patient mix between Medicare, Medicaid, private health insurance and the uninsured. Although 35 percent of funding comes from the grants, the costs of treating the uninsured account for 34 percent of spending in Prineville, 40 percent of spending in Bend and 58 percent in Madras. It’s only because Mosaic can share costs among clinics that the Madras clinic survives.

“If we had to fund Madras on its own,” DeHate said, “we would have issues.”

The clinics are still taking new Medicare and Medicaid patients but can accommodate only six new patients per day. They currently have a waiting list of 300 patients, meaning at least a two-month wait for an appointment.

Cost escalation

Private insurers also have trouble finding primary care doctors to see their patients. According to Pat Gibford, the CEO of Clear Choice Health Plans in Bend, patients often wait 12 weeks for a routine appointment.

“Most of our plans require that our members have a primary care physician,” she said. “When we go to assign somebody, practices are full, and a lot of practices are closed. They’re not taking any new patients until somebody moves away or passes away.”

Bend Memorial Clinic and Mosaic are often the only places the plan can find to take its primary care patients.

Rogers said BMC has made some internal changes that have allowed the primary care doctors to take Medicare patients without fear of losing money.

“Medicare has always been a paradox for a multispecialty group,” he said. “Medicare reimbursements for specialists are still pretty good. Our specialists want to get those patients. And so to get those patients in the door, you need primary care.”

In previous decades when BMC accounted for more than 90 percent of the primary care physicians and a good percentage of the specialists as well, safeguarding referrals from primary care doctors to specialists may have been less important. But as Central Oregon has grown, the clinic now represents less than half of the primary care capacity in the region, and faces increased competition for patients from outside specialists.

The clinic has also invested in imaging technology and other services that allow for better care of patients, but also are the types of procedures that are more lucrative under Medicare.

Nationwide, private and public insurance plans have seen tremendous growth in imaging services and laboratory tests, at least suggesting that physician organizations might be ramping up use of such ancillary services to offset the shortfall in primary care payment rates.

“It’s a concern to insurers, it’s a concern to Medicare. That’s why they’re beginning to change the rules,” Gibford says. “It isn’t universal. If somebody gets imaging or labs, it doesn’t mean that they overutilize, but it certainly does happen. It becomes a revenue stream, and people push, push, push.”

But in many places, without the ancillary revenue or the specialty income, Medicare patients would have even fewer options.

DeHate said that if BMC had not made a commitment to see Medicare patients, the access problem would be significantly worse.

“We all have to be thankful that they’ve been able to think outside the box and figure out a way to make that work,” she said. “If they didn’t, Medicare patients would not be seen. The drawback to that is that the system is spending more, but as an organization, you do what you have to do to be able to take care of the patient.”

Stopgap medicine

In the long run, many Central Oregon physicians and clinics believe the only way to address the access issue is to recruit more primary care doctors to the region. Madras Medical and BMC are both actively pursuing new hires.

But despite Central Oregon’s lifestyle draws, it remains difficult to recruit physicians to the region. In addition to a national shortage of physicians, Oregon practices have the additional hurdles of competing with states that have much higher Medicare reimbursement rates and have passed tort reform, said Dr. Brian O’Hollaren, a Bend urologist.

“There are states on the East Coast where physicians are paid three to six times as much, and so are hospitals. And patients are getting far greater service in those states compared to Oregon,” he said. “I think all our problems we’re seeing in terms of physician supply and patient access stem from the fact that we get paid so little from Medicare. I’m not sure the patients know that they pay the same amount into Medicare, yet they get less in terms of coverage.”

The Medicare payment formula locked in historical differences in physician practice patterns, including lower costs for Oregon physicians. Over time, as payment rates increased, the differences between geographic regions widened. Oregon and Washington have among the lowest payment rates in the country, and rates in Central Oregon are lower than in Portland.

Specialists like O’Hollaren often find they must fill in the gaps by providing primary care services when their patients can’t find a primary care doctor.

“We feel pressured to do that, yet at times, unqualified to do that,” he says. “We spend a lot of time talking to poor primary care physicians about trying to take more patients, and they don’t have room for them. They acquiesce, but it makes their life very difficult.”

Internal conflict

If the health care system invests more money for primary care physicians, it could mean less money for specialists. And that could be a difficult political fight within the medical establishment.

“That creates a huge, huge problem because the power structure in medicine is heavily skewed toward specialty care,” says Lisa Dodson, the director of the Rural Health Programs at Oregon Health & Science University, Oregon’s sole medical school. “That creates this us-versus-them mentality.”

That tension between primary care physicians and specialists has hampered health reform efforts. There is widespread agreement that the nation desperately needs to boost primary care and that demand could soon skyrocket. Proposals to move toward universal health care would increase demand for physicians by 4 percent, increasing the projected physician shortfall by 25 percent, or another 31,000 doctors.

Reform advocates argue that more primary care doctors could help reduce costs, by keeping patients out of more expensive care settings, including specialist offices, urgent care and emergency rooms. Primary care physicians say they can take care of 90 to 95 percent of the medical problems that patients face and refer only those patients who truly need a specialist’s care.

“We’re still responsible for the access inroad,” said Boggess, the BMC family physician. “If we don’t do our job, the patients end up in the ER and urgent care centers, and break the back of St. Charles, because they have no choice. Or they end up in places where they’re overly worked up and tested and great expense spent, when their primary care doctors who know them would be able to help keep that cost down.”

Markian Hawryluk can be reached at 541-617-7814 or at mhawryluk@bendbulletin.com.