Rising costs force some doctors to restructure
Date posted: February 12, 2014
By Tracee Davis and Hannah Wiest
SHERIDAN — Independent physicians are becoming a rarity across the nation, and Sheridan is no exception. While many doctors are willingly giving up their independence to join larger groups to share the burden of on-call time and back office functions, others persist against growing industry oversight that renders private practice more financially burdensome each year.
A majority of physicians who practice in Sheridan, either actively or in a consulting or traveling role, have admitting privileges at Sheridan Memorial Hospital. This means even if they work in private practice, they are able to admit and treat patients as needed at the hospital, SMH Executive and Medical Staff Coordinator Amy Ligocki said.
Having authorization to admit patients also gives doctors access to a plethora of medical equipment that would otherwise be cost prohibitive to own for a small business. For example, many local chiropractors send their patients to SMH for X-rays before they begin work in their own offices. General medical practitioners can take advantage of the hospital’s lab services to offer numerous specialized tests for diagnostics and case management.
Currently there are 79 doctors who have inpatient privileges at the hospital out of 97 total doctors who practice in Sheridan. A majority of physicians who are not affiliated with the hospital have an established private practice or work at the Veterans Affairs Medical Center or the Sheridan Health Center (formerly the Free Clinic).
Physicians who are not affiliated with the hospital can still order outpatient services such as blood labs, Ligocki said.
Becoming affiliated with the hospital requires a doctor to go through a credentialing process.
“It’s a system of checks and balances,” Ligocki said.
The initial fee to be credentialed as an active staff member is $200, which covers the time and resources to process paperwork, Ligocki said.
Doctors are re-credentialed every two years.
In addition to obtaining admitting privileges at the hospital, Sheridan physicians can take part in the hospitalist program.
The SMH Hospitalist Program was started in April 2011 as a way to provide improved continuity of care for in-patients and greater scheduling stability for physicians who practice in their own clinics apart from the hospital, Ligocki said.
The program consists of seven doctors and several physician assistants and nurse practitioners who are available on a 24/7 rotating basis to provide care to patients admitted to the hospital.
SMH Hospitalists are on-call 24 hours per day for a three to seven-day rotation. They follow a patient’s care while he or she is in the hospital and communicate with the patient’s primary care physician on a regular basis.
Physicians who currently serve as hospitalists include Dr. Michael Strahan, Dr. Ian Hunter, Dr. Jason Ackerman, Dr. Juli Ackerman, Dr. Hanna Hall, Dr. Derek Gilbert and Dr. David Walker.
Most members of the hospitalist team have their own clinics, as well. When they are fulfilling a scheduled shift as a hospitalist, they focus their efforts on hospital patients and usually don’t see clinic patients.
While the hospitalist program primarily serves doctors who have admitting privileges, it can be used by doctors who are not affiliated with the hospital if a patient is in need of hospital care.
Prior to the hospitalist program, physicians who had admitting privileges would have to bounce back and forth between caring for patients in the hospital and patients in their clinic, Ligocki said.
“Before, it was just a matter of those physicians having to admit their own patients, so they all had to have privileges to do that. For instance, Dr. Batty had a clinic and had privileges, and he had to go back and forth and juggle clinic patients and hospital patients,” Ligocki said. “The program helps physicians to separate that and see patients just at their clinic or just at the hospital on scheduled days.”
Hospitalist programs have become common around the nation, Ligocki said, adding that SMH instituted a hospitalist program primarily to benefit patients.
“There are key benefits to the program for the patient such as quicker turnaround times for results and better availability of a physician when needed,” Ligocki said.
A dying breed
With the SMH Hospitalist program in place to cultivate an atmosphere where physicians are allotted more personal time, there is a spectrum of affiliation doctors assume in utilizing the county’s largest medical resource facility.
Dr. Michele Bennett is an example of a physician who operates a private practice in Sheridan and reserves admitting privileges to the hospital. She said that while she enjoys the autonomy that comes with a solo practice, being able to use the hospital’s resources when necessary gives her more care options than she could provide a patient on her own.
However, Bennett tends to shy away from using a hospitalist to take care of her patients.
“I don’t have anything against the hospital or the hospitalist program,” Bennett said. “Most of them have (hospitalists) nowadays. It’s becoming the standard.”
Bennett said she enjoys the benefits of using the program a few times a year so she can take a vacation and not be on call. However, the majority of the time, she sees her job as a family medicine practitioner as a lifestyle to which she is bound.
As a private practitioner, Bennett is always on call for medical emergencies. Depending on what’s going on and what time one of her patient needs help, she meets them either at her clinic or the hospital.
“When my patient lands in the ER, I know that patient,” she said. “That’s a big benefit. They also have a lot of comfort in having me know them and know their case. I take care of them from the time they get in and their aftercare afterward.”
Bennett’s start-to-finish oversight of a patient’s case is quickly becoming a rarity as a new generation of doctors started to take measures that ensure a more predictable schedule and workload. However, Bennett is one of several local doctors that still accepts the erratic lifestyle as part of her calling.
“I guess that’s how I was raised in medical school and residency,” she said.
Bennett chooses not to lean on in-place hospitalist services because while it might be convenient for her as a provider, she said it opens the door for mistakes to creep in.
She said she also sees patients that don’t know the name of their primary care provider because their case has been managed by multiple doctors. In addition, the margin of human error gets wider when patients transfer from one doctor to the next.
“In my opinion, it’s not as good for continuity of care. Mistakes are made when patients are transferred to another doctor, and most patients stay with a hospitalist about three days,” Bennett said.
Dr. John Finley is one of a handful of local practicing physicians that is completely independent of any larger organization and has no admitting privileges. He was quick to explain that is only possible because his practice fills a unique niche within the community.
While Finley has certainly put in his time rotating general call with other doctors, he knew he wanted to get out of that lifestyle as he neared retirement.
“Basically, I wanted to slow down. I was tired after having to make rounds on the weekends,” he said. “If you have a patient in the hospital, you have to go see them, and I was just tired of that.”
That’s why Finley left a practice in Texas to join another doctor at an urgent care clinic in Sheridan.
Finley said the life of his practice has shifted dramatically in the time he’s worked in Sheridan.
“We first opened during the methane boom,” he said. “Our clinic was swamped and we were probably unprepared for the volume we were seeing.”
Finley said when the boom dried up, his business plummeted nearly 70 percent, and is still way down today from where he started.
“Back in those days, we had a lot of patients that had insurance coverage and now, it’s almost rare to see someone with coverage,” he said, adding that an average visit at his urgent care clinic runs between $100 and $130.
Finley explained the concept of urgent care is that a patient can be seen for medical treatment immediately. He said his services are most often utilized when a person’s primary care physician can’t fit them in to be seen that same day. Things that can be treated in one visit, like the flu or a cut needing only a few stitches, can be handled via urgent care without the runaround of an industrial-sized establishment.
“Some practices build up a pool of private patients. I don’t do that. I don’t try to keep patients,” Finley said, indicating he sees his place in the community as one that exists to fill a gap created when primary providers have blocked-out schedules.
“With an urgent care clinic, you can be plenty busy,” Finley said.
“My major drive is to take care of patients,” he continued, indicating he feels the fact he works independently of the hospital is no loss to him or his clients.
Finley said when his independent practice first started up, he often ran into a situation when he needed to divert a patient for higher-level care.
“When we first opened urgent care eight or so years ago, we probably averaged three ambulances a week having to transfer people up to the hospital,” he said. “Now, it’s pretty rare for us to have anything major come through the door, thank God.”
Larger forces in play
With or without hospital admitting privileges, the climate of private practice is changing under the implementation of health care reform. Both Bennett and Finley acknowledge having a small clinic is becoming a lot more complicated and the direction of the medical industry seems to suggest a decisive move toward consolidation of medical providers.
Bennett said she’s seen firsthand evidence of new federal regulations that are making it tougher for a small practice to stay in business.
With the rollout of the requirement for Medicare acceptors to convert files to electronic medical records, the price tag of doctors being their own boss shoots upward.
“A lot of solo practitioners have closed their doors,” Bennett said. “The margin of profit in medicine has really gone down to the wire.”
Bennett said in addition to having to spend thousands of dollars on technical upgrades and attend a two-week training course to get her office’s EMR system up and running, federal regulations also require her to set up an online patient portal and have 5 percent of her patients access that portal on a monthly basis.
“People have no idea doctors are being crushed by electronic records,” she said. “The requirements they have are shocking. It sounds pretty simple, but it’s actually pretty complex and expensive.”
Bennett added that convincing her patients to enroll in an online program and use it regularly feels a bit like a sales gig to her.
Bennett said doctors who participate in complimentary services associated with electronic health records, things like electronic prescriptions, receive incentive pay. However, the phased implementation of the program also includes deadlines to have expensive upgrades completed, or else practitioners will receive a percentage cut in their Medicare reimbursement.
While the new software requirements aren’t painless for larger facilities, a group setting allows for more cost sharing, which is a natural attractant for a practitioner who is looking for the most stable financial outlook available. In addition, Medicare will reimburse large hospitals significantly more than small clinics for identical services.
For the independent business, maintaining technology levels equal with those of a multi-million dollar facility is a lofty endeavor.
“It equates to blackmail in my situation,” Bennett said, indicating she’s seen others in her field retire early or stop accepting Medicare in attempts to dodge the new regulations.
Private practice physicians are also facing increased staffing requirements and a larger office function workload. These factors combined make for a sketchy future for small health clinics.
“I just take it day by day, as long as I can keep paying my bills,” Bennett said. “I’m all fine with that for now, but if something changes where it’s not feasible for me to stay self employed, I might look for an employed situation.”