Independent physicians are a vanishing breed

Dr. Noemi Prieto gets up every morning, prepared to fight her recurring battle. She puts on her makeup, fixes her hair and readies herself to face a world that has become tougher for her and others like her over time. Prieto is a member of an endangered professional species. She is an independent physician. Prieto works at Southeastern Pediatric & Adolescent Medicine, which operates four clinics in the Milwaukee area. She and other independent physicians are struggling to maintain their independence in a market that is heavily skewed to cater to the interests of large hospital conglomerates and super systems.

“It is becoming tougher and tougher to remain independent and to be competitive, both on the administration side as well as the reimbursement side,” said Michael Repka, executive director and chief executive officer of Independent Physicians Network in Milwaukee.

The costs of health care continue to rise. Meanwhile, the levels of reimbursement that independent physicians are paid by insurance companies have declined significantly.

“Reimbursements are the biggest problem,” said Dr. Ajit Parekh, one of four physicians at Pulmonary & Critical Care Associates S.C. in Cudahy. “Reimbursements keep going down while the cost of practicing medicine only keeps increasing, I can’t cut the pay to my staff. I can’t cut the cost of electricity or gasoline, but they keep on squeezing the dollars that we receive for the services we provide.” 

Dr. Victoria Mondloch, an independent gynecologist in Brookfield, said insurance companies only provide independent doctors with a fraction of their actual costs. Mondloch said large hospital systems are able to leverage their size to demand fair compensation from the insurance companies. Independent physicians do not have such leverage, she said.

“It’s take it or leave it, or join a big (health care provider) system,” Mondloch said.

However, a representative of one health insurance company contends that all physicians are treated fairly.

“All parties involved in the health care delivery system have a responsibility to find solutions to the rising cost of health care,” said Kristine Seymour, president of Louisville, Ky.-based Humana Inc.’s Wisconsin market. “Humana works to treat all physicians equally, and we welcome any providers with concerns to discuss them with us one-on-one. Ultimately, Humana’s role is to deliver cost-effective, high-quality health care solutions to employer groups and consumers.”

Still, independent physicians say they are struggling to survive.

“The rising cost of business is a real challenge for us,” said Dr. Ashish Verma of Verma Medical Services in Waukesha. “Especially since primary care is our only venue, large hospital systems have other specialties to generate revenue. For us, this is it, so there are times when we really feel the pinch.”

“Sometimes I feel like Pac Man,” Prieto said. “Day in and day out, I’m just pushing along, trying to avoid getting gobbled up by the insurance companies and hospital systems. We, as independent physicians, don’t have the deep pockets the larger systems have. They can reach into their pockets to stay afloat. For us, it is getting increasingly difficult to stay alive.”

Many independent physicians end up working longer hours and seeing more patients to compensate for the lack of adequate insurance reimbursements, Parekh said.

“To some degree, the patients are even at a loss, because when a physician is forced to run from patient to patient, they may not always get the quality of care they deserve,” he said.

Parekh also expressed concern for lost costs in the number of uninsured or under-insured individuals.

The Independent Physicians Network (IPN) and similar organizations are, according to Prieto, helping to keep independent physicians together and open some doors by sheer numbers.

“The problem that we have as independents is that we are smaller. It’s very hard to compete with the bigger entities, IPN is our vehicle to keep all of us together under one entity to help us keep that overhead from growing to the point where we can’t control it,” Prieto said.

In addition to lower insurance reimbursements, independent physicians face other challenges today, Repka said.

“There are also more compliance issues that independent clinics have to deal with, administrative costs of running a business, the cost of labor, hiring a nurse, a medical assistant, even clerical staff continues to go up,” he said.

“One of the hardest things for me is recruiting and retaining staffing personnel,” Verma said. “We don’t have a recruiting department or the budget to keep back up people, so I have to wear multiple hats.”

Many physicians, including Verma, are not trained professionally in business. And yet, as independent physicians with a limited budget, many have no choice but to handle much of the administrative load, as well, including recruiting, hiring, payroll, billing and even collecting.

“First and foremost, I’m a physician, but then the operations side of things has to be run, as well,” Verma said. “Fortunately, right now I have a staff that can help me out with a lot of that stuff, I could do it, but then I wouldn’t be able to be a very good physician.”

According to Repka, independent physicians receive significant pressure from larger systems trying to purchase physician offices to increase market share.

“I haven’t done specific numbers, but I’m sure it is around 80 percent of the primary care doctors in the Milwaukee area are employed by one of the large systems,” Repka said.

Common Wealth Medical Group, a group of 30 primary care physicians in the Milwaukee area, is forming affiliations for its physicians with both Wheaton Franciscan Healthcare and Aurora Health Care, according to Repka.

“It isn’t final, but I know not all of the physicians are going to one system. I have heard different numbers, and I think it will be fairly close to 50-50,” he said.

Representatives from Wheaton Franciscan and Aurora declined to comment for this report. A representative from Common Wealth Medical Group could not be reached. 

The larger health care provider systems first recruited primary care physicians and now are targeting specialty physicians for their networks, Repka said.

“I think the primary care physicians have been approached much more frequently then specialists like me,” said Parekh, who specializes in pulmonary diseases and critical care. “Primary care physicians are where the patients go. They don’t come to see a specialist directly. So, primary care physicians are the ones who control the flow of those patients.” 

Despite their challenges and setbacks, many independent physicians are determined to maintain their independence. Many of them say their independence allows them to provide higher quality and more personal care for their patients.

Mondloch said the large health care systems are too focused on profit, which affects decisions on patient care, instead of focusing only on what is in the patient’s best interest.

“I choose to remain independent because I can’t work in that other system,” she said.

Many other independent physicians don’t want to give up the autonomy of their practice.

“I have no obligations other than those I have to my patients,” Prieto said. “For me, they are No. 1, No. 2 and No. 3 in my book.”

“A lot of the corporate physicians only work eight-hour blocks. As an independent, many of us work 14-hour days and are on call all the time,” Parekh said, “We have the freedom to cater to our patients as individuals. They get to see the same doctor every time, and I can call my patients personally if something is important. It is just more of a personal relationship.”

“I want to be able to make my own decisions on what I think is best for my patient,” said Dr. Jeff Minikel, orthopedist at the Milwaukee Clinic of Orthopedic Surgery. “I want to be able to send my patients to get a procedure done at a place I am familiar with, one I know will do a good job, instead of being dictated by hospital relationships and insurance companies.”

“I enjoy my autonomy as a physician, and I’m one of those people that is fixed on a certain way of doing things. It would be hard for me to work in a corporation setting. I have a lot of ideas and may not conform to the corporate structure,” Verma said.

According to Repka, the desire to remain independent stems from a number of different desires.

“Many of them are more entrepreneurial and like to have their own say in their business. Others like to be able to decide their own hours or like the locations they are in. They feel they can better serve their patients by being in their own neighborhoods,” Repka said.

However, people don’t realize the toll that independent physicians are taking in order to provide the best care they can, Prieto said.

“If we are made to go away, it will be the patients who will have to pay. They will have less options and higher costs both in premiums and out-of-pocket payments.”

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