Every day, Dr. Leslie Miller of Fairfield thinks about selling her practice to a hospital health system.
“Everyone in this environment thinks about throwing in the towel and going to a hospital every day,” said Miller, a sole primary care practitioner for 20 years. “The business side is the problem,” she said, referring to the costly and time-consuming demands of medical insurance and government regulations.
Dr Khuram Ghumman has chosen the unusual route of working first in a hospital system and then moving into private primary care practice because he opposes the “corporatization” of health care. He said conflicts of interest can arise if an owner and his employed physicians have different goals. “I wanted to be responsible to my patients,” Ghumman said.
Nationally and in Connecticut, hospital systems and private companies are increasingly purchasing private medical practices and resuming commercial operations. American Medical Association statistics show that only 46% of physicians had their own practice in 2018, up from 75% in 1983.
In Connecticut, hospital health systems range from large groups, like Yale New Haven Health Services and Hartford HealthCare, to systems owned by a single hospital, like UConn Health. They are all non-profit except Prospect CT Medical Foundation, a for-profit company that owns hospitals in Waterbury, Manchester and Rockville.
There are also other medical systems, such as Pro-health doctors, owned by Optum, a division of the company that owns insurer United Healthcare. Private equity firms have also invested in medical practices, including orthopedics and emergency medicine groups.
One area of acquisition of active practice is primary care, at a time when the demand for preventive health care is increasing with the aging of the population.
Primary care practitioners in practices in hospital systems with 30 or more physicians increased from 1,100 in 2016 to 1,441 in 2019, a 31% increase, according to state data Office of Health Strategy (OHS). At Yale, they went from 368 to 491 (33%); Hartford HealthCare 73-198 (171%); and Middlesex Health System from 32 to 38, (19 percent). Acquisitions include physicians, medical assistants and nurse practitioners.
Hospital health systems say they provide improved, streamlined and coordinated care because primary care providers and specialists can work together and have easier access to patient medical records.
But studies show that acquisitions drive up the cost of healthcare and doctors lose the freedom to manage their own schedules.
Ghumman, who practices in East Granby, said he spent an hour with patients for physical exams and half an hour for follow-up visits. “I just want to ask the doctors the question: who do you work for? ” He asked.
Miller said she preferred her autonomy, that she was comfortable with the way she ran her practice, that she liked the privacy of it and the ability to give patients the choice of how to do it. refer to a solo practitioner.
Dr Andrew Wormser, a New Haven internist affiliated with Yale’s Northeast Medical Group, said “there is a certain lack of autonomy” but added “that they still give us enough for us to practice. as we want ”.
Wormser is part of the Connecticut Medical Group, formed by a group of doctors in the 1990s to pool resources. He explained that a more complex regulatory climate and the resulting need for investment in electronic medical records prompted the sale of the practice to Yale in 2012. Under the agreement, the 31 physicians are contractors, not employees, but Yale owns the company. “The hassles of running the office are gone, which is a lot,” Wormser said.
C-HIT requested interviews with officials from Yale New Haven Health, Hartford HealthCare, Trinity Health of New England and the Connecticut Hospital Association (CHA); none were granted. The CHA made a statement, saying: “Partnerships between hospitals and health systems and physician practices preserve and expand access to care, support improved care and often enable new modalities of care based on value.
Isaac Kastenbaum, vice-president of the association Primary Care Development Corporation, said primary care practices are particularly ripe for an acquisition or merger.
“What is required of a primary care practice today is very different from what was required 20 years ago,” he said.
Regulatory and insurance requirements require “an amount of staff, technical expertise and capital that independent firms simply cannot muster on their own, or it is very difficult,” said Kastenbaum, whose l The organization provides loans and technical assistance to primary care providers. .
Financial losses and costs associated with practicing medicine during the COVID-19 pandemic have exacerbated pressures on private practitioners, said Dr Gary Price, president of the National Doctors Foundation and a plastic surgeon Clinton. “COVID has made a bad situation worse,” he said.
Independent practices are also threatened because young doctors do not want to run companies. They want to be employees focused on the practice of medicine and a balanced lifestyle, said Victoria Veltri, executive director of OHS.
State effort: improve health care, control costs
The OHS is spearheading a project to increase spending on primary care with the aim of improving health, controlling long-term health costs, improving access and quality of preventive care and address the social determinants of health. A 2019 report of 29 states places Connecticut at the bottom of primary care spending, defined as in-office medical care and outpatient visits. The report of the Patient-Centered Primary Care Collaboration and the Robert Graham Center found that Connecticut spent 3.5% of its healthcare spending on primary care between 2011 and 2016.
The state’s goal is for primary care to account for 10% of overall healthcare spending by 2025. “A better resourced primary care system can create better patient outcomes and reduce overall healthcare spending over time, ”Veltri said.
She said there is a growing interest in “team care” to meet a range of patient needs. This means that primary care practices could include, for example, social workers and pharmacists in addition to physicians.
“This is how primary care evolves,” she said. “We try to keep people healthy. We try to intervene early in health care issues and address things like the social determinants of health, the social drivers of health, ”she said.
This comes at a time when shortages of primary care physicians are projected through 2033, new physicians are turning to more lucrative specialties to help pay off medical school debt, and Connecticut is struggling to attract new physicians. doctors. According to an Association of American Medical Colleges report using 2018 data, Connecticut ranked 41st in the country for retention of physicians who attended medical school or trained as residents in the state. .
Meanwhile, a proposed law would give the state more control over acquisitions of medical practices by allowing state review for acquisitions of any size, instead of the current minimum of eight physicians. It would also remove the current presumption of approval.
“You could be a Yale or Hartford HealthCare or Nuvance and could acquire a practice of seven, another practice of seven, another practice of four, another practice of five” and this is not subject to the review of the State, said Veltri, explaining this lack of scrutiny prevents opportunities to limit increases in health care costs. Costs to patients and the Medicare program are higher in hospital offices, according to the Physicians Advocacy Institute.
Hospitals and doctors opposed the proposal in a recent legislative hearing. Dr Jeffrey Cohen, head of clinical services at Hartford HealthCare, said his system had acquired 30 practices with fewer than eight doctors in the past three years, adding that there were “few doctor’s offices with eight”. He warned that independent doctors could close their doors while they wait for exams to be done.
In a press release, the Connecticut State Medical Society said many small-group medical practices barely survive, but said: “It is not for lawmakers to dictate under what circumstances doctors can decide to sell their practices.” The medical society said the state should instead focus on issues facing independent doctors, such as insurance contracts that don’t allow doctors to negotiate rates, exclusion policies and high rates. professional misconduct.
Manage your own practice
Ghumman said he was spared a lot of paperwork due to the structure of his practice, with seven doctors, five nurse practitioners, a medical assistant and enough office staff to handle business operations. “If you have systems in place that work for you and your patients, you can still do it without having to be part of a large business system,” he said.
He compared the current healthcare landscape to the days when most independent pharmacies were bankrupted by chain competition, eliminating the choice of going to a small pharmacy.
“If you lose the ability to make choices in health care, it’s a sad day for everyone, not just for doctors, but for patients,” he said.
This story was reported in partnership with the Connecticut Health I-Team (c-hit.org), a non-profit news organization dedicated to health reporting.