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The most compelling stories often challenge some of the convenient lies that we’ve allowed ourselves to believe. Dr. X’s story is no different. Not only does Dr. X’s account of his time under the hospital system fail to fit neatly into a larger narrative about how and why hospitals provide care, but it also defies nearly every myth that’s ever been perpetuated in service of positively branding what X reveals to be a broken system. While it’s tempting to dismiss his experiences as solely indicative of the state of a single institution, stories from primary care physicians across the country seem to corroborate, rather than call into question, the existence of a national problem. Confronting the failures of the healthcare system may be hard, but ignoring them is even harder. Dr. X knows that better than anyone.
It took four years of medical school and a brief stint in an emergency medicine residency program for Dr. X to realize that the ER just wasn’t for him. “I thought that working in emergency medicine would make for a better lifestyle, but I ended up not caring for it at all. Most of the problems people came in for could have easily been solved by good primary care.” That realization catalyzed Dr. X’s interest in family medicine, and during his subsequent residency in primary care, his passion steadily grew. “I became really captivated by the transformative potential of quality primary care—not just for individual people, but for the entire nation. For my third year grand rounds discussion, I gave an hour-long talk about the value of primary care. I wanted my colleagues to see what I saw. I wanted the entire community to start appreciating the importance of a continuity of care.”
After he completed his family medicine residency, Dr. X joined a well-established family medicine practice that had been started years earlier by two physicians who were as passionate about primary care as X himself. Despite this, the transition was rocky. “In residency, doctors aren’t under the same pressure to code a certain way, and if they are, at least they don’t have a non-clinical administrator pressuring the to make sure they see a certain number of people. When I started working in corporate medicine, I tried my best to still spend a reasonable amount of time with each patient—at least more than the standard ten minutes. It’s unrealistic to expect that we can help patients with chronic conditions like diabetes, hypertension, depression or high cholesterol in such a short amount of time, so I tried accommodate longer visits.” Under the hospital system, however, physicians like Dr. X are not rewarded for their good intentions. “It was made clear to us by the administration that if didn’t reach a certain quota of patients, it would affect our compensation.”
Dr. X thinks most doctors transitioning out of residency want to continued delivering high quality care, but quickly recognize the difficulty in achieving that goal. New hires come in with high spirits, unaware of the extent of external pressure and not yet burnt out from years of overwork. As Dr. X notes, the change in these physicians is readily apparent to everyone—especially patients. “It’s not uncommon to hear patients say, ‘Well, whenever I first started seeing my primary care doctor after he got out of residency, he took so much time with me. He seemed like he cared about me, and he really listened when I discussed my problems. But as time went on and he got further into his career, the length of our visits got shorter and shorter.’” Obviously, it’s not that doctors become uninterested or stop caring about their patients over time. As Dr. X explains, most physicians do their best to resist outside pressures in order to provide quality care, but in the long term, it’s simply not feasible.
On a typical day, Dr. X would arrive at the clinic with a full schedule consisting of 20 to 25 patients. “If you do the math, that limited my time with each patient to seven to ten minutes. In that extremely short amount of time, I had to address the acute problem that brought them into the office, or, if it was a chronic problem, I had to address each of their diagnoses. Most of those minutes were spent interacting with the computer screen.” The introduction of Meaningful Use requirements forced doctors to worry more about filling out forms on the electronic medical record than actually taking care of patients. “All the protocols aimed to further the financial interest in the hospitals. For patients who were living in a medical home, there was a particular way we had to check certain boxes to ensure the right designation and largest reimbursement for the hospital. Extra coding requirements made us even busier, leading more primary care docs to refer to specialists because we didn’t have enough time to address the problems ourselves. I eventually started to realize that the monetary value of primary care physicians in the hospital system came through referrals. The more patients we saw, the more we would refer to specialists and order tests, both of which could get higher rates of reimbursement through insurance.”
Dr. X makes it clear that no one really benefited from this increased flow of funding into the hospital. “Because our schedules were already full starting most days, people who called in with problems that they felt could be addressed over the phone couldn’t get their questions answered. The calls started coming in from the minute the receptionists turned on the phones, but no doctors had little time to call them back. Most of the time they schedule was filled up, so those patients who wanted to be seen for a cold or a urinary tract infection or an ankle sprain would have to urgent care and be seen by a doctor who doesn’t know them.” Dr. X sees this as a lose-lose situation. “The patients who come in for a scheduled visit get the short end of the stick, the people who call in get the short end of the stick, the people who come with urgent problems get the short end of the stick, and, after trying and failing to meet all these demands, doctors feel like they’re not providing meaningful care. It’s pretty demoralizing for everyone involved.”
Despite the fact that doctors were struggling to provide quality care because of administrative pressure to see more patients, the hospital still went forward with new policies supposed to ensure patients satisfaction. The irony of this move is not lost on Dr. X. “We all started getting evaluated with Press Ganey reports. These patient satisfaction reports started to be sent out with our monthly financials, with the implication being that these scores would eventually affect our compensation. If patients weren’t happy with their care, it would directly impact our pay. Throughout it all, the administration continued to encourage doctors to see as many patients as possible. I remember a few years ago when the physicians at our clinic had some concerns about our operational costs. Since we were paying rent to the hospital system, we had no control over them; every time we expressed concerns over our finances, the response was always the same: ‘If you saw more patients, you wouldn’t have to worry about expenses.’”
According to Dr. X, administrators frequently gave subtle—and not so subtle—recommendations to doctors about increasing their patient load. “I remember a meeting specifically where an administrator came to the meeting with a graph to prove that we were not pulling our weight in terms of patient care. While we were reiterating the importance of giving good care to our patients, he was glorifying a doctor who saw forty patients a day.”
Non-clinical administrators who knew little about providing patient care repeatedly attempted to regulate physicians’ time and manage their priorities. “If we said we didn’t have time to add more patients, they suggested we stop taking our weekly administrative half-day. What they didn’t understand is that most docs use those ‘half days off’ to call back patients, complete unfinished charts, and address more complex patient issues.” The latter task was made more time consuming when the hospital system started putting small minute clinics in local pharmacies retail stores “These clinics refused to share information with primary care physicians whose patients used their services. It only took a click of a button, but they still declined to integrate the care. That made me realize that they didn’t care about clinical quality—they just wanted to see more patients.”
In the middle of all this, the healthcare system began to transition to a new electronic medical record. While doctors had been given prior notice that change was forthcoming, one aspect wasn’t widely discussed: none of the meaningful clinical information would be transferred from the old system to the new system. “We were told that it was the physician’s responsibility to do the vast majority of data entry into the new system. We were also told that we would need to cut the number of patients that we would see by about 50% once the new system was implemented . Even though we didn’t like having huge patient loads, the reimbursement system required us to keep our numbers high to get paid reasonably. We asked if we were going to get financial assistance during the transition to the new EMR but the hospital said no. It really eroded any previous confidence that anyone in the administration had any sympathy for primary care physicians.”
During Dr. X’s final year under the hospital system, administrators began instructing doctors to treat patients differently according to their insurance plans. “We would get emails that would say: ‘From here on out, anyone who has X, Y or Z health plan should be seen within twenty-four hours of their initial call.’” The administration continued enforcing new protocols, escalating frustrations among doctors until things reached a breaking point. “It was the straw that broke the camel’s back,” Dr. X says of a meeting earlier in 2015. “I won’t bore you with how Medicare Advantage programs work, but the long and short of it is this: one of their representatives instructed us to call certain elderly patients into the clinic for a medically unnecessary visit for the purpose of coding their charts to extract as many diagnoses as possible. They wanted high-paying diagnoses from Medicare to benefit the insurance company and health system. We were told that we would be paid $100 for each visit.” These unapologetically unethical new standards compelled Dr. X and his colleagues to engage critically with the administrators, even though their jobs were on the line. “A few of us raised our hand in objection at this particular meeting and asked for further clarification. The original statements were repeated; we hadn’t heard them incorrectly. At this point, all six of us stood up and walked out of the meeting. I had considered the possibility before that we were all just working for the insurance company, but after that meeting, it was undeniable.” Following the initial meeting, Dr. X sent a number of emails to the administration, condemning the new policy. “The emails I got back acknowledged that it was potentially unethical, but ultimately underscored the fact that millions were at stake and we needed to get on board.’ That’s when I knew I had to get out.”
The problematic protocols and policies implemented over the course of his time under the hospital system challenged Dr. X’s belief in the progress narrative often invoked to prove the possibility of systematic change. “When I delivered my presentation on the value of primary care all those years ago, I could have never predicted that I would be told how to do my job by a person who knew nothing about providing care. If I wanted to make a positive impact in many patients’ lives, I knew I would have to get out from under the hospital system”
A few months ago, Dr. X and his two colleagues decided to leave and start their own private practice using the direct primary care model. “We knew it wouldn’t be easy. Other doctors at the hospital who had tried to leave in the past were told that by administrators that independent physicians couldn’t survive here” Dr. X experiences echoes that of his colleagues. “I was told at least fives times by different people in the administration in the months leading up to our departure that ‘independents just can’t make it in this town.’ Of course, those administrators had some insight into why private practices fail so often in this town. The hospital owns an insurance company, and so, in the past, they’ve just declined to work with certain independent physicians, making it more difficult for them to convert existing patients to the practice.” Non-clinical administrators tried a number of tactics to lower the physicians’ confidence and keep them under the umbrella of the hospital system. “They told us we weren’t equipped to run a business because we were just doctors. This argument didn’t really faze us, especially with the significant business experience on of my partners had before she went to medical school. Besides, I don’t view non-clinical administrators in the not-for-profit hospital system as really legitimate business people either.
When demoralization wasn’t effective, administrators challenged the financial viability of the private practice model. “Apparently, since we couldn’t afford a medical record, we wouldn’t be able to provide care. That argument doesn’t really hold water anymore, what with the advent of new products like Practice Fusion, which is free, and other affordable products like the Atlas MD EMR. So, after that, they tried to enforce a non-compete clause. It was practically a hostage situation at that point; a non-compete would bar us from practicing medicine within ten miles of our current location, forcing us to remain in an unbearable work environment.”
Despite the looming threat of the enforcement of a non-compete clause, Dr. X and his two partners ultimately decided to go forward with their new practice. “We walked into the vice president’s office and handed in our resignations. We were very honest with him; we told him we were planning on opening a direct primary care clinic in town. He was pretty shocked—I think he just thought we were coming in to gripe more about expenses. Even though he seemed certain our practice would fail, he told us the hospital would still enforce the non-compete, meaning that we would be taken to court if we actually opened the clinic. He didn’t challenge the validity of any of our complaints about the unethical new policies. He knew we had cause to leave, but he also knew that we wouldn’t be able to afford a costly lawsuit. He told us that outright. Instead of challenging the validity of our concerns, he simply said that challenging the non-compete would be ‘too expensive’ for us to fight legally, which in hindsight was just another effort at intimidation.”
Yet again, the Vice President’s scare tactics failed. “We were confident the hospital would lose in court, and we told him so. We told them him that we were offering something the hospital cannot offer: affordable healthcare. We told him about the recent cuts to Medicaid, about the void we would fill in our community since our state has not expanded the Medicaid program. We told him about the recent passage of state legislation which gives legal support to the direct primary care model. And finally, we told him that their potential enforcement of the non-compete lawsuit had no foundation. They were trying to enforce a non-compete because they’re scared of a little competition, and that’s not a valid legal reason to do so.
Ten days after that meeting, the hospital indicated that they would not go forward with the non-compete as long as Dr. X and his partners used the direct primary care model to run their practice. “I think they rightly predicted that it would cause a public relations nightmare to go after three primary care physicians starting an affordable healthcare clinic. They still refused to send out a letter to our patients saying that we will continue working in town. That irritated me, of course, since we have a huge number of patients between the three of us, but, ultimately, it just energizes me more. I want to succeed; I want to prove them wrong. In some ways we already have. Direct primary care won.”