The new money medicine and your health: A retired doc explains the changes in the system

Unhappy doctors retiring in droves. Obsession with physician productivity. Doctor appointments are hard to get. And — it’s going to get worse.

A retired primary care internist in a major metropolitan area shared some thoughts with me about the state of medicine today, especially primary care. Our first private talk was so interesting that I asked him to amplify, on the record. He spoke on condition that I not identify him or his former practice.

Here’s our conversation, lightly edited for length and clarity

Jeanne Pinder

How has the profession of medicine changed with the corporatization of medicine?

The doc

There’s much more obsession with productivity.

Which means “how many patients did you see, or how much did you make?”

The doc

At my former medical group, I heard — I haven’t verified this — that they’re cutting almost in half the length of time you spend doing a physical.

The problem with these financial groups and investors is they don’t really think about health care. They’ve never seen a patient. They don’t know what it means to be in a room when somebody comes in for a visit and is there for their Medicare physical, but they also have other chronic problems, and sometimes an acute complaint.

It takes like 10 minutes just to get the vitals done and get them up on the table. They will come in with a walker, their daughter, maybe two daughters. Before you even get going, 15 minutes have passed, and you have another 15 minutes to do a Medicare physical. It’s ridiculous.

I think there’s a feeling that the older physicians who are retiring now trained at a time when there was more inclination to take a longer history, as opposed to sending somebody for tests. For example, if there is a murmur, let’s do an echocardiogram. Rather than using my time allotment to try to figure out this potential infection, I’ll just refer to an infectious disease specialist. There’s a whole lot more of that going on.

Another thing is, in my group, we didn’t have to work weekends — it was optional. Now they’re adding some mandatory Saturday hours periodically, if your total number of hours for the week is not a certain number. The number of hours you needed to be considered a full-time person, which affects bonuses and so forth, was less. Now they are increasing the number of hours you need to work to the mid-30s per week. That might not sound like much, but if you’re spending three hours a day doing paperwork, returning phone calls, and answering emails, it’s a lot of hours.

Vacations have to be ‘cleared’

So that’s mid 30s, like 35 hours of time in clinic plus X number of hours?

The doc

I don’t know the exact number of hours you’re seeing patients in person, but if you’re adding the number you have to see per week, and you’re having people do some Saturday hours. I mean, these are people with young children.

Also, I took a day off every week. I usually did paperwork that day. Now it’s hard to do that sort of thing. We used to be able to just say, “I’m taking a vacation in July, the last two weeks.” Now it has to be cleared.

One of my buddies is a well-regarded specialist, in his 60’s. He was recently recoiling when there was a meeting discussing the number of hours. He sees his specialist patients and his primary care patients, and he’s very good. Patients love him. He’s someone you’d want to trust with your life if you were seriously ill. He was bitching and moaning about how to give proper care.

Now, the question is, the statistics show, lots of people retiring — lots of older doctors. I was lucky that I reached retirement age, just when all the shit started. My group was bought twice in two years, and each time there was a transaction, Yeah, the doctors got some money for that — you could consider a payback for all the years,

I started my career when it was considered draconian, compared to the previous generation that was in private practice and ran their own show.

Younger doctors

Like Marcus Welby MD?

The doc

Yeah, that kind of thing. It’s all relative. I sometimes wonder whether younger doctors, who only know this system, think it’s normal. If you did some research, you’d read about this emphasis on productivity and the bottom line, and the fact that the people running things don’t know anything about treating patients.

This was not something that you could have foreseen in a sale?

The doc

I don’t think it’s mattered, because they needed the capital to keep running the business. They couldn’t have afforded to keep going.

As you pointed out, you get a chunk of money when you sell. Did they sell for that reason?

The doc

I don’t think anybody was pushing to sell my group. We’re not talking about zillions. I think it all came as a surprise.

I bet you if you polled all the doctors, except for the really greedy assholes, they would love to go back to the old days, when we had shareholder meetings and a cohesive group. We all had phone numbers of go-to people we could call if we had an issue, whether it was an [electronic medical records] issue, or something else. Once the first group came, we didn’t even know who to call. And then when the second came in, it got even worse.

‘They needed the money’

I would have expected under a sale, that you would lose a certain amount of control. You just you didn’t realize how much you were losing?

The doc

I don’t think it mattered. They needed the money.

I long for the days where we had shareholder meetings and shareholder bonuses. Every year, we’d get like about 100 grand, you know, just on top of salary.

And then also cohesion, you used to get together every three months with these dinner meetings to go over financial stuff and clinical staff. That was run by two physicians. Pretty smart guys. But they saw patients. So they really knew what it meant to be a doctor. You’d go to these meetings and see your buddy from radiology, see a buddy from ear, nose or throat, and kind of felt like you’re part of something.

After the deals went through, we’re all just kind of on our own. Yeah, we have local executive directors.

The executive directors are chosen from inside the group?

The doc

Nobody was as good as the first two people we had. They were the founding guys. So in terms of how it’s changed: more patients, more hours, less cohesion, less group identity, less input.

Financial speak is ‘indecipherable’

Like a cog in the machine?

The doc

Kind of like that. Yeah. If I was 50, I don’t know what I would have done, because I personally have a hard time with authority.

These meetings with these financial guys — I still attend these Zoom meetings. They’re talking this financial speak that is indecipherable. I never hear them talk about patients. The words “patient care” never touch their lips.

Revenue cycle management. Value-based care.

The doc

I’m not saying that there weren’t areas that could have been more efficient on, but I think the whole experience from the physician standpoint …. For somebody who cut their teeth in medicine 30 years ago, it would not be a particularly pleasant experience.

I always liked to say my patients, “I love doing this” — meaning being in the room with them. As soon as I close the door and go back to my desk, not so much.

Retirement is way up

So does that mean people are leaving?

The doc

I think the statistics show that retirement among older doctors is way up.

Are they leaving to go play golf? Or are they leaving to found a startup?

The doc

That I don’t know. Some of these people are still pretty vigorous. There are restrictive covenants, non-competes. The [Federal Trade Commission] ruled recently.

But they are not enforceable, right?

The doc

I think they typically only last for two years. It does have implications for your insurance — part of the contract, if you start working, doing any kind of clinical work within two years in that area, you lose your tail coverage [coverage for incidents that happened during the time you had your policy, but a claim was not filed until after your policy expired] and malpractice insurance. Unless you’re willing to pay tens of thousands of dollars to maintain it.

Also I can’t tell you how much the electronic medical record has created work for doctors.

The electronic record’s problems

It was supposed to make things easier, right?

The doc

We’re now the de facto coders. Like we see a patient, I write my note, then I have to figure out if it’s a level three visit or a level four. And then you have all these clicks. The system that we picked up is called Athena. Everyone hated it, except for the orthopedist type guys, who think it’s great because they just have that one thing, that one problem.

Here’s an example: Used to be, when I get back labs, I would click a button on our system, and the most important labs, the ones that really matter, would immediately type out on this grid. It would leave out all the unnecessary details. It just had the normal ranges and was very clear. Then you could write to the patient, “Your labs are above… Please note…” and include further details.

Under this new system, you have to send patients the raw lab reports with all the unnecessary details. A raw lab report includes all this meaningless, abnormal stuff, like something for the kidney called BUN, where normal is up to 20. Anybody who practices medicine knows that levels are often in the 20s and even low 30s. It could be due to being on a water pill or just lab variability, and it’s totally inconsequential. But of course, you’re gonna get a letter back saying, “I just saw my lab report, and the BUN is 21. Normal is 20.”

So I ended up making a macro that I sent to every patient. It would say, “You may see some other labs on the report that are out of range. Please note that this is common, and unless I say otherwise in this letter, there’s nothing to worry about.” That stopped some of the callbacks, but the callbacks increased regardless.

There’s a new law in New York State that went into effect a couple of years ago. Patients have to get their lab results as soon as they’re ready. So they would get the report before you had a chance to call them with the results, or write about the results and explain what they mean. That caused more callbacks and certainly a lot of anxiety.

I have a friend from childhood who is undergoing a rather anxious workup for a lung nodule. He had a biopsy recently, and the pathology report was sent to him before his doctor even called him with the results. The result looked OK, but imagine if it had said, “Conclusion: adenocarcinoma, stage four,” or something similar. That’s the kind of stuff that people are getting routinely now.

The law that says the second they’re in, they’re ready to go out. What doctor do you know is on board with that?

Well, your beef here is with the state legislature though, not with private equity, right?

The doc

It’s just another example of how it’s made a primary care physician’s job to some extent, harder. Because, I mean, you get labs taken this morning, you’re probably gonna get results by 3 p.m. I’m not gonna be back to you because I’m seeing patients, right? And then I have to write notes. If it’s inconsequential, I might not get back to you till the weekend. Or whatever, because I’m prioritizing the people with true abnormalities.

How the sale took place

Not to identify you too much, but you were an early member of the group. When the decision to sell was made, you were in a position of being a deciding person, right? You had like partnership votes, right? What was that conversation like — were there people wanted to do it and people who didn’t want to?

The doc

We had a meeting and the guy who was the CFO at the time said kind of, “You’ve probably heard rumors that we’re exploring a deal with [XXX] and the problem is that we really need capital — we can’t go on. They’re going to be coming to meet with us and discuss their plans.”

I don’t remember a lot of preliminary discussion, it kind of just happened. So then they met with these people. They spent a lot of time explaining how much they cared about. A year later, they sold. So it wasn’t like it was this long debate.

You may not know what it looks like in other groups, but is that pretty typical? Like, “Here it is.” Do you have friends who’ve gone through this?

The doc

I don’t know. Most of my friends aren’t in primary care.

But I think in general, doctors are known to be financial idiots. And if somebody you trust says, “so we really should do this” – of course there’s a vote, but you have less time to really think about this.

Docs not financially savvy

I have never thought that doctors are financial idiots. That never occurred to me.

The doc

I would never want to run a business. I have friends who are more financially savvy than me, but I was among the less financially oriented people. I think we all pretty much rubber-stamp stuff.

I feel like I was there for the glory days. I probably bitched and moaned then also.

So you had two sets of owners? Was there a significant difference between them?

The doc

I sent in my resignation letter, as soon as the deal with the second one went through. I’m still in touch with two or three people I hang out with. And every one of them is pretty unhappy.

Are there any happy doctors?

I don’t know anybody who’s happy in the medical profession. Is that possible that there are no happy doctors out there?

The doc

Think about it. You’re under a lot of pressure to increase productivity, work longer hours. You have less control. The job itself has always been very demanding and stressful, although that was part of the bargain.

So I think there have been early retirements, earlier than you might expect, which is really a problem because the population is aging. Just at the time you need seasoned doctors.

I mean, think about an operation on a carotid artery — somebody who’s done 10 of them is better. There actually was a study that showed that the number of surgeries that you did on that made a difference in your outcome.

Frequency is a proxy for quality. There aren’t any good quality metrics anywhere in in healthcare, but yes, frequency is a proxy for quality.

The doc

I never felt financial pressure in that way because I’m sort of a outlier in a sense that I just have no interest in money. I don’t think about investments. My biggest expense is running shoes.

But some of these people I know just feel beleaguered. There’s no input. I don’t think they respect the local medical directors. You know how it works — The Peter Principle. Somebody who was a good clinician might be a shitty director? It’s just different skills. It’s a hard job, don’t get me wrong – but I know some incredible physicians who were felt not up to the task. A good journalist but a lousy editor. A good teacher, a lousy principal.

Scarce appointments

You mentioned retirements, people leaving the profession. From my end, what I see is nobody can get a doctor’s appointment.

The doc

I recently referred two of my neighbors who really needed a good primary care physician to somebody. It’s a new patient visit — this was a month ago [in May], and they couldn’t get in before October.

You can get into all kinds of subtle arguments about whether the physical is overrated. These are people well into their 70’s. And they’re just trying to establish a relationship with a doctor.

I suppose that once they get in, it will be easier for them to make follow-ups, because stuff will come out. What I used to do with my patients: My system was to book them again before they left the office. So I’d say “I’d like to see you in six weeks.” If you don’t have anything that’s six weeks, just double-book them at four o’clock or whatever it was.

I’m always surprised when people can’t get appointments in a timely manner. But maybe I had more time in my schedule because my panel was closed for a long time. So when people passed away or left town or whatever, or maybe I had less demand, I don’t know. But if it was an acute thing, you just fit them in.

I have had this experience myself. My doc is at Montefiore. The physical is six months out, unfailingly.

The point of primary care: Continuity

The doc

What if you had an urgent need to be seen, like within a week say?

Typically it’s the nurse practitioner. If I’m lucky. Sometimes they don’t even have that. She practices with two other doctors, actually now with one other doctor. Sometimes I see her. We’ve written multiple stories about this — about how you can’t get a doctor’s appointment. What that then does is drive people to urgent care — which we know about urgent care, right? Or to the emergency room.

The doc

The whole point of having a [primary care provider] is seeing somebody you know. Continuity. I used to joke that everyone who went to urgent care got a throat culture, regardless of what complaint –

And antibiotics.

The doc

And antibiotics, even if the throat culture was negative.

It’s really bad. I can’t get my own experience because I’m sort of connected. And I kind of get in, but people who are not connected — somebody I know couldn’t get a physical with her new doctor, who took over from her old doctor, for many months. So they referred her to either a [physician assistant] or a [nurse practitioner], who, when I was there was well regarded.

And if you read his notes, not bad, you know, maybe a little too overzealous about testing. When her labs came back, there was a very minor abnormality that a lot of people have, it doesn’t mean anything. It’s influenced by age, the guy calls her up and says, “You have stage three kidney failure.” They shouldn’t have said stage three kidney failure — because of her age, there was a slight increase in one of these kidney tests. And she also was on a water pill and another drug called an ACE inhibitor, which are well known among seasoned people to increase the numbers.

It’s an axiom of medicine. You can get classified as you get older as having chronic kidney disease. Stage three, it’s more like a Medicare thing. It doesn’t mean anything, it just means this number that should be 60, sometimes gets into the 50s. This person used the word failure.

And then she said, “What should I do?” And he goes, “come back in a year.” So firstly, he uses this word — to use that word failure, but then say, “you don’t need to come back for a year.” It’s a total contradiction.

Her regular guy, I know him, he wouldn’t have said that, he’s a seasoned guy. But he wasn’t available.

Not enough physicians

We were talking about having a hard time seeing a doctor.

The doc

Now, I’m not against NP’s. There are some NP’s that are better than doctors. I’m not against DO’s. There are some that are better than MDs, they just went to a different school. Maybe the GPA was, you know, 3.6, not a 3.62.

So why are doctors unavailable? You probably don’t have enough physicians. It’s hard to hire physicians these days. A lot of the people coming out of training are women. Now, they want to work part time, because they have kids at home. And I don’t blame them.

I heard that some groups are having trouble just hiring specialists, like they’re down an endocrinologist for a year or more, and the people who are there are getting bombed.

But it’s a disconnect — if the doctors in your old practice are now seeing four people an hour instead of one person an hour, they should be able to see enough patients.

The doc

Well, maybe two and a half.

But it doesn’t quite fit together, right?

The doc

Many people have too many people in their panels. The average concierge doctor might have 300 patients in their panel. Some of these people have 2,000. And that panel is a mathematical thing where if you have 2,000 patients or 2,500 patients, on any given day, asuming that you generally booked with follow-ups on top of what’s already scheduled — unexpected visits. It’s very difficult.

What should a patient do?

So from the patient’s perspective, what is the patient supposed to do? Going to urgent care is a crapshoot, going to the emergency room is completely undesirable. Sitting and waiting until I can get an appointment six months down the road, then that suggests to me that whatever is going on, it’s gonna get worse because it’s not being addressed.

The doc

Absolutely right. And fewer people are going into primary care. Because the rewards are outweighed by the debits.

It’s really a problem. I don’t know if there’s an answer. From the doctor’s standpoint, and for the more affluent patient standpoint. I think what doctors are considering, quote unquote, concierge or retainer practices, is the less inflammatory description.

It doesn’t mean that these concierge doctors are special, great doctors, any more than anyone else. They just want a more reasonable life, they’d rather be on beck and call seven days a week for 300 patients, rather than doing what I’ve described, for up to 2,000 patients.

$3,000 a year to start

As a concierge doc, then do they take insurance?

The doc

So there are people who say, “You’ve got to pay three grand a year, and we take your insurance.” Three grand is the sort of the bonus you pay them for getting you in quickly, and for being available and having the cell number and for not having all these hassles we’re talking about. So obviously that’s skewed toward the affluent.

The thing I didn’t like about that was I kind of liked my working-class patients the best. Just between us. But other people, they just, they’re so beleaguered that they don’t want to take this anymore and go concierge. “I want to have control over my life, and it’s worth it.” And I can’t blame them.

Every six months, we would get these solicitations from MD-VIP, which is one of those groups – “Come down to Florida free of charge for three days in a hotel, we’ll put you and your spouse up, and we’ll show you the ropes.”

I never did it. But if you do some reading about this, you’ll find that there’s some places with different models — for example, take the average 25-year-old who doesn’t have health insurance. Say they charge them a discounted fee for being a concierge person. So once a year they need to pay 600 bucks. And they get their physical and all the lab work and stuff. No need to come back for a year because they’re healthy 25-year-olds.

Direct primary care is a version of that.

The doc

I’m not familiar with the term. But the point is, it’s cheaper for them to just pay a yearly fee that you pay instead of an insurance premium.

We’ve done a bunch of work around DPC. So you have like a monthly subscription membership fee. And it’s rated on age typically. So it could be $39 a month for under 25, and $119 for over 65. And you get unlimited primary care, get discounted labs and tests, you get discounts on prescriptions — they have, like handshake agreements with places, and you can get seen or talked to anytime. Primary care only.

The doc

That works for healthy people, I think, but what happens if your patients have medical problems they pick?

He helps arrange people to find a surgeon or something.

The doc

What’s the incentive for the surgeon to see them and have no insurance?

Medicare: Yes or no?

That’s a big question. Maybe they wouldn’t do it. Or maybe he knows people who take cash, because there are people who do take cash.

One guy I know — he has all those different kinds of people. And he has people who are uninsured. He’s opted out of Medicare. But people will pay him that monthly fees so that they can have access to him.

The doc

So he deliberately doesn’t take Medicare. So, again, if you’re 70 years old, and you’re on you got diabetes, hypertension, high cholesterol, and —

If you can’t see your primary care provider, maybe it’s worth it to pay $100 to go see him. Or maybe not.

The doc

Yeah, I’m just trying to see. So do you think that there’s this room there for, quote, unquote, concierge medicine for people without resources, just calling out a different name?

He’ll do things like give you stitches to keep you out of the emergency room, for example.

But he’s got a range of people. And I think he does it because he just hates being in the insurance system. He just doesn’t like being on the hamster wheel. He’d rather have a small panel of patients and be able to do medicine.

The doc

I was temperamentally more cut out for that flow, for sure. But I’m not cut out for running a business.

I haven’t talked to people who are in concierge medicine to see if they’re happy or not. But I know that people have dropped out of my old practice, and a couple of people that are in the process of leaving.

Fed up with the assembly line

But are they doing MD-VIP? Are they doing direct primary care?

The doc

All I heard was to join a concierge practice. The point is they got fed up with the model of assembly line, and they’re looking for alternatives.

One of the things is Montefiore has basically gobbled up all these medical practices in Westchester. I don’t know what their relationship is with White Plains Hospital, Montefiore — sort of overseeing them or something? But to me, I’d rather have a hospital system run my practice than a private equity situation, or a pharmacy company that — they think they know about delivery of care, they really don’t know unless it’s clinics in the back of CVS.

And maybe one of the partial solutions is just all these groups are gonna eventually be taken over by these deep-pocketed hospital systems like Mount Sinai or Montefiore, or Columbia or something. At the very least, theoretically they know more about healthcare than these financial schmos, right?

It doesn’t seem to be going in that direction, because hospitals are employing fewer doctors as near as I can tell — hospitals are like outsourcing their emergency rooms to they call them a “Contract Medical Group,” right? So if you go to the emergency room, you get a bill from the hospital and a then a separate bill from a contract emergency doc. Or a contract anesthesiologist, same thing.

The doc

Yeah, though Montefiore has Montefiore Medical Group clinics all over the place. Maybe they have tons of money.

Ownership by hospital or by private equity

Maybe they don’t want to employ doctors. I mean, they seem to not be a lot of hospitals are getting out of the business of employing doctors. And maybe it’s because the contract medical group is responsible for its benefits and pensions. Rather than the hospitals, I don’t know. Private equity wants to buy all of this stuff, take out as much value as possible and then sell it in three to five years.

The doc

I only know more from a doctor’s point of view. If you just look at the math, fewer people are going into primary care and more people are aging – and more people who do go into primary care are wanting to have a life. It’s going to be harder and harder to make an appointment.

And I’ve read recently that more and more of these [nurse practitioners] and middle-level providers are going into specialty care, so where does that leave the typical patient who needs a relationship with a physician?

What’s the answer?

The doc

I mean, I may end up seeing a concierge doctor, not because they’re a great doctor, but because it’s my only way to get into the office. Yeah — give him my three grand. And I can see them in a week if I need to.

What does the future hold?

Do you have any final thoughts? What does the future hold?

The doc

I don’t know, I just can see it getting worse and worse.

This is something that will never happen: They just made tuition free at Einstein Medical College. If I were running things, maybe if you want free tuition, you have to commit to six years of primary care.

With other public health scholarships, you get tuition paid for, and then you have to commit for years to work in a research area or the military scholarships, I had several friends in med school who were in the Navy and the Army. They got living expenses and tuition for four years, basically do their residency and then pay back years working for that military branch.

A woman friend did a residency in Hawaii. I’ll never forget, it was in the middle of the HIV epidemic and the interns were expected to draw blood. Whereas if you go to these more tony places, they have IV teams and all this stuff. We went to Hawaii for a vacation, we visited her and she lived in this house on a hill with a banana tree. That was her payback. Then she ended up going to the DC area and working in a clinic for a few years. That wasn’t much of a payback.

Another guy wound up in Seattle, no military service, in the sense that we know it — a war situation. Another ended up in California working for Kaiser. Nobody I knew had to do hard duty. So this free tuition — if I was a philanthropist, knowing what I know, I would condition it on that. Does that mean they’ll become lifelong primary care doctors? No, but six years is better than nothing.