System wears on Drs.' patience

By Cliff Peale
http://news.cincinnati.com

BRIDGETOWN – It’s 9:07 a.m. as Dr. Tim McCarren emerges from his second appointment on a busy Monday.

Another patient is waiting and he has four phone messages to answer. He gets one caller admitted to the emergency room at Mercy Hospital Western Hills and finds an open appointment at 11:30 for another caller with stomach pains.

McCarren then spends 11 minutes on his laptop, filling in information about the patient he just saw, including ordering an MRI exam that his office will have to pre-certify with the insurance company.

“I hate to order that test because it’s going to be abnormal and I’m going to have to act on it,” he says as he walks into his next appointment. “I probably see 100 people a month with back pain.”

If all goes as planned – and it rarely does – he will see about two dozen more patients today, mostly in 10-minute blocks. He’ll end in late afternoon by catching up on the paperwork he couldn’t finish during the day.

Welcome to the life of a family doctor, the first line of medical care for most patients.

Doctors like McCarren and his colleagues at Family Medical Group hear about problems from arthritis to alcoholism. They’re expected to be up-to-date on the latest research and they take turns visiting the practice’s patients in hospitals.

But the job isn’t as satisfying – or lucrative – as it was one or two generations ago.

Then, family doctors made house calls and treated many patients from childhood to retirement. Now, medical-school graduates increasingly are choosing specialties where they can make more money and see fewer patients.

Experts predict this will lead to family-doctor shortages within a generation, particularly in rural areas.

While the shortages haven’t hit as hard in Greater Cincinnati and Northern Kentucky yet, the 5,875 family doctors in Ohio and Kentucky in 2006 will have to grow by 1,600 doctors to meet projected needs in 2020, the American Academy of Family Physicians projects.

Currently, 1,315 primary-care doctors work in the region, including family doctors and pediatricians but not OB/GYN doctors. Nationally, family doctors are only 12 percent of all physicians.

As presidential candidates John McCain and Barack Obama debate ways to restructure the health-care system, the stresses and shortages of family doctors present an ominous trend for patients.

With a population that’s getting older and will need even more medical care, patients face the prospect of longer waits, shorter appointments and less familiarity with their doctors.

“For family doctors, it’s tough,” says Dr. David Mouch of the White Oak Family Practice. “I think it’s more of a demanding business because there just aren’t a lot of us out here. It’s more of a service business.”

Doctors are worried, too.

The average family doctor makes $173,812 a year, but probably still is paying off debt from medical school, according to the Medical Group Management Association. More than half of medical-school graduates owe $150,000 or more.

Only 29 percent of family doctors expect to make more money than last year, but nearly three-quarters said they provide better health care than 10 years ago, according to a survey in May by the American Academy of Family Physicians.

The average doctor also sees more patients – an average of 6,250 encounters a year, or about two dozen each day. That’s up 13 percent from three years ago.

McCarren, 57, who has practiced for more than two decades, says malpractice insurance has become less expensive since family doctors stopped delivering babies.

The paperwork blitz

Most of all, family doctors face a constant need to document every appointment and certify tests with the insurance company, all to squeeze maximum costs out of the health-care system.

Mouch says the record-keeping usually lasts well beyond the work day.

“Family doctors used to be able to write on a 3-by-5 card, put it into the cabinet and be done with it,” he says. “Now, I take my tablet home, sit there watching the Reds and do some charting from the day. Which is stupid, but it’s what I have to do.”

To many patients, getting to see the doctor has become a chore. After time in a crowded waiting room, they might get 10 minutes with their doctor before being shuffled out the door with a prescription in hand.

Behind the doctor’s office door is a series of compromises to financial and time pressures that only minimize the face time between doctors and patients.

Katia Adams, a family doctor at Patient First in Florence, says she takes the cost of a drug into account before prescribing it because the patient’s insurance might not cover it. Demands on her time sometimes make staying on schedule impossible.

“There are only so many patients you can see in eight hours,” she says. “The beauty of family medicine is that you can’t predict what you’re going to see that day. But if someone comes in with a cold and ends up having to go to the hospital, then 15 minutes becomes 45 minutes. So someone is going to wait more than they had planned.”

Working longer, harder

More than a dozen patients are in the waiting room at Family Medical Group in Bridgetown after the door opens at 7 a.m. The office sees at least 250 patients a day, with a dozen doctors rotating shifts at two offices. Each doctor spends one week every three months treating the practice’s patients at Good Samaritan or Mercy Western Hills hospitals.

Patient visits are scheduled in 10-minute blocks, or longer for a physical. Doctors usually get one open block every hour, but some can see as many as nine patients in a row, and by 9 a.m. on most days, there are only afternoon appointments left.

On this Monday morning, McCarren never sits down and is unsure when he’ll have time to eat lunch. He takes his time with most patients, asking about their smoking or their diet before starting to examine them. He says he feels fortunate because he knows many patients by name.

Because of the way they are paid by health insurers and Medicare, the business has morphed into a model where the more patients doctors see, the more money they make.

“In this kind of environment, the only way you can maintain your income is to work longer, work harder and see more patients,” says Joe Hazen, another doctor at Family Medical Group. “All of us work longer hours.”

Few patients, particularly those who have waited past their appointment times, will feel sorry for doctors who make more than $170,000 a year.

They want a doctor who is patient and will talk to them about their problems. Tom Kelley, a 25-year patient of McCarren’s and one of his appointments on this Monday morning, says he always has done just that.

“I’ve been in doctors’ offices where they’re practically running around to see patients. He’s never been like that,” Kelley says. “As long as I’ve been going to him, I have never, ever, been rushed. He is a family doctor. He goes back to the old school.”

Insurance companies, often blamed for problems in the health-care system, say they collaborate with doctors to improve medical care.

Dr. Barry Malinowski, medical director at Anthem Blue Cross and Blue Shield in Ohio, says the insurer’s pay-for-performance plan started in 2004 has resulted in higher payments to doctors who meet quality measures.

Those range from developing plans for asthma patients to not prescribing antibiotics when they’re not needed. The program has slowed emergency room admissions, one of the highest-cost ways of delivering care, by close to 20 percent.

Of about 3,000 doctors in Anthem’s Ohio network, about 80 percent have earned at least a 2 percent increase in fees and nearly one-third get the maximum 12 percent increase, Malinowski says.

Malinowski acknowledges that insurers are asking doctors to get pre-approval for more of their tests. One program started several years ago has kept the level of MRI and CAT scans steady. They had been growing about 20 percent a year, he says.

Malinowski, a pediatrician, acknowledges the pressures family doctors face. “They probably feel like more is being asked of them and they’re not getting reimbursed for some of those increased demands,” he says.

Adams, the doctor at Patient First in Florence, says she doesn’t have to deal with business details much since she’s part of a group owned by St. Elizabeth Medical Center.

But Family Medical Group is one of the largest independent groups remaining in the region. It hired two more doctors last year to staff a Harrison Avenue office.

McCarren says the demands from all directions are among the biggest changes in medical care in his career and can be daunting for medical-school residents who come in for a look.

“Those poor students come in here and say, ‘I can’t do this,’ ” McCarren says. “We tell them, ‘At first, we didn’t think we could do this.’ ”

see original

About