As health care systems grow, independent primary care physicians are a dying breed | Healthcare/Hospitals

A little white schnauzer named Oakley, half a dozen peacefully floating seahorses, and Arleen, a nurse who has worked there for 23 years, greet patients at Dr. Alan Yager’s Metairie private practice.

While most of his 800 patients come to see him in the cozy office tucked away in the more closed grounds of East Jefferson General Hospital, he still makes house calls. Patients have her phone number, and they can call or text her whenever they need as part of her concierge service.

“Twenty years ago everything was like me,” Yager, 63, said from behind an antique desk surrounded by family photos and gifts from patients. “I’m kind of a dinosaur.”

Yager is one of a dwindling group of primary care physicians who have maintained an independent practice instead of joining a larger health care system.

As hospital systems consolidate in Louisiana and across the United States, they bring with them coordinated care with specialists, a streamlined approach to scheduling, the ease of electronic health records, and bargaining power over companies. insurance. At the same time, independent primary care practitioners are on the verge of extinction, and at a cost, some say.

“There are great systems that are in place with these healthcare entities, great ways to track that,” Yager said. “But I think the patient-doctor relationship is disappearing.”

According to the results of a 2020 American Medical Association survey, more than half of physicians are working outside of private practice for the first time since the group began tracking physician employment in 2012.

The coronavirus pandemic has accelerated the trend. In 2019 and 2020, 48,400 physicians left independent practices for larger systems. Hospitals and businesses bought nearly 21,000 practices during this period, and at the end of 2020, 7 in 10 doctors were employees of hospitals or companies, such as private equity firms or insurers , according to a report by the Physicians Advocacy Institute and Avalere. Health.

Rising overhead, increasing administrative requirements, increasing use of urgent care points, and the pull of rapidly expanding hospital systems have combined to reduce the number of these practices. Some of those remaining, including Yager, have turned to membership or “concierge care” where patients pay an annual fee.

In an open letter to Congress last year, the Physicians Advocacy Institute, a nonprofit that advocates for fair payment policies and contracts from payers, said more doctors selling their practices won’t were “no surprise,” given the “high administrative costs that reduce time with patients, onerous regulatory compliance burden and expense, and anti-competitive contracting and payment practices by mainstream insurers and hospitals .


A photo of Dr. Alan Yager’s father, Dr. Isadore Yager, who served as East Jefferson Hospital’s first chief of staff in 1971. The photo is next to Alan’s desk in his office on Houma Blvd. at Metairie on Friday, October 28, 2022. (Photo by Chris Granger | The Times-Picayune | The New Orleans Advocate)

There are benefits to growth. Larger hospital systems treat a higher percentage of Medicaid patients, who cannot afford the additional annual fees of an enrollment practice. Salaries are often higher initially, some doctors said, and health systems typically deal with taxes, malpractice insurance and other administrative issues.

At the same time, some doctors resent the number of patients they are asked to treat in large systems and the speed with which they are treated. And those who have chosen to remain independent say the trade-offs erode patient trust.


Dr. Alan Yager sits at his desk with his dog, Oakley, in his office on Houma Blvd. at Metairie on Friday, October 28, 2022. (Photo by Chris Granger | The Times-Picayune | The New Orleans Advocate)

Dr. Ed Lafleur, who opened a private practice in Lafayette in 2004, opted to join a large system in 2011. Part of the talk, he said, was that the hospital system would manage employee and patient issues. other duties so that he can concentrate on medicine. .

But six months into a three-year contract, he wanted out. To make money according to the model of the system, he had to spend 7 to 10 minutes with the patients. There wasn’t enough time to focus on nutritional advice or listen to patient issues.

“I could fix just about anything — runaway diabetes, blood pressure, acid reflux, autoimmune disease, obesity — but to do that takes time,” Lafleur said.

He is back in private practice and uses a concierge doctor model, where he charges patients an annual fee. He spends two hours with patients on their first appointment.

“If I have to go back to seven minutes, I’ll start a lawn service,” Lafleur said.


Ka-Yan Tong knows the challenges of owning a private practice.

“On weekends, I go to Sam’s to get toilet paper, I go to get cleaning supplies,” said Tong, a doctor who has been practicing in Metairie for 12 years. “You do everything in private practice.”

And the compensation model generally doesn’t match what she might earn at a large hospital. In the early years, she earned less than during her residency.

It has become more difficult financially for many young doctors to start their own business. In the 1960s, a medical degree today cost the equivalent of about $45,000. In 2022, medical school costs an average of about $230,000, according to research group EducationData. This means that new doctors have thousands of loans when they would need to borrow more to open a new practice. At LSU School of Medicine, a public university, in-state tuition is nearly $33,000 per year. Doctors like Yager paid around $1,800.

Independent doctors also have less help in complying with federal reports. Physicians who treat people covered by Medicare — typically a large percentage of patients — must report health care outcomes or face reduced reimbursement rates.

They also lack the bargaining power of larger systems and face more resistance from insurance companies, said Dr. Devan Szczepanski, who has clinics in Covington and Florida.

“I have at least five extra employees because I got pre-approvals or even fought to get paid for a regular visit,” Szczepanski said.

Tong said she stayed independent for one reason: “freedom.”

She wants to keep her own schedule and manage her time with patients.

“When you work for yourself, you can decide, I want to spend more time with my patients,” Tong said. “So I see fewer patients.”

The concierge model

Dr David Myers, a solo independent practitioner in Metairie, believes that independent doctors have more incentive to keep patients out of hospital than those who work within a larger network.

He sees a lot of patients who come from large systems.

“They feel like a pawn in a giant game instead of having their individual interest front and center,” Myers said.

Some physicians have managed to thrive independently under the concierge or membership model. Yager switched to this model 10 years ago and charges patients $400 a year. Myers and Lafleur are part of a network of independent doctors, called MDVIP, which costs patients between $1,800 and $2,000 a year and includes access to a legal and IT service. The company also helps doctors negotiate rates with insurance companies.

Others work on an adherence model and tailor their practice to what interests patients. In Covington, Szczepanski has a practice that takes traditional insurance. His two membership practices in Florida offer traditional primary care alongside integrative medicine — things like hormonal and nutritional genetic testing.

For Yager, building a personal connection and trust with patients is vital. His father was also a doctor and was one of the founders of East Jefferson General Hospital, which was purchased by LCMC Health in 2020. A portrait of the elder Yager looks at a stack of files in his office son. Yager said his dad used to do house calls in a boat in the bayou — which is the kind of thing that no longer exists.

Yager points to the initial hesitation and then outright rejection of the COVID-19 vaccine as an example of the importance of a personal connection with a family physician.

“People don’t trust health care,” Yager said. “They trust the people who take care of them.”

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