Hospitals courting primary-care doctors

June 19, 2011

In one of the first concrete steps to remake the way medical care is delivered, hospitals are competing to hire primary-care physicians, trying to lure them from their private practices to work as salaried employees alongside specialists.

The push is forcing doctors to make decisions about how to deliver care to patients, many of whom have relied on long-standing relationships with trusted independent neighborhood physicians and wonder what lies ahead.

It also spotlights benefits and drawbacks for patients and doctors alike in one of the health-care overhaul’s much-touted initiatives, set to begin next year. The law will reward teams of doctors, nurses and others if they coordinate to provide better care at lower costs. As front-line doctors, primary-care physicians are key to this effort.

In some cases, hospitals are seeking to take over existing practices; in others, they are hiring new graduates or relocating doctors from outside the region to prepare for accountable-care
organizations.
Some physicians want to work for hospitals and are seeking to play one option against the other, doctors said. But many others remain wary.

Primary-care physicians wrestling with the implications of becoming hospital employees or trying to go it alone say it’s ultimately about changing the way they have practiced medicine for decades.

“All the rules are changing,” said Jonathan Plotsky, 56, a longtime Rockville internist who has talked to Shady Grove Adventist Hospital about joining the staff.

Plotsky’s father is a psychiatrist who has been practicing medicine the same way for decades. But Plotsky worries about joining a hospital and turning over care of his patients to others.

“All I have is my patients,” he said.

For many doctors, the salaried jobs may come with greater security, but the trade-off is less individual freedom over how many patients they see and how they care for them, they said.

“It’s like the local coffee shop versus Starbucks,” said one family- medicine doctor whose Montgomery County group practice rejected a hospital system’s offer. The doctor, who spoke on the condition of anonymity, did not want to name the group or system because the doctors work closely with one of the system’s hospitals.

But hospitals are moving quickly to add to their primary-care staffs.

In 2008, about half of physician practices were hospital-owned, according to an industry group. A survey last fall by another industry group found that 74 percent of hospital leaders planned to hire more doctors in the next 12 to 36 months. Most want primary-care doctors.

Locally, all the major hospital systems have ramped up efforts. In Northern Virginia, Inova Health plans to hire 200 primary-care doctors over the next five to eight years. In suburban Maryland and Washington, MedStar Health, which operates Montgomery General Hospital, Georgetown University Hospital and Washington Hospital Center, has increased its primary-care doctors system-wide to 180, jumping more than 20 percent in the past 18 months, after being static for more than a decade.

Baltimore-based Johns Hopkins Medicine, which owns Suburban and Sibley hospitals, is also hiring more primary-care doctors.

What this means for patients is unclear.

Even though they may continue to see their doctors in the same building as before, patients will benefit from one-stop medical shopping, proponents say. Internists and specialists working under the same corporate roof will, in theory, be better able to care for them than a disjointed fee-for-service approach where a family doctor may not know what treatment a patient received during a previous emergency-room visit.

Patients will also have greater access because, unlike private practices that can reject insurance, hospitals don’t have that luxury.

But other experts say economic factors could hurt patients.

Hospital-employed primary-care doctors are a way for hospitals to direct referrals to their own specialists. If health-care rules change to pay hospitals one lump sum for taking care of someone the entire year, instead of payment for each service or procedure, a huge incentive exists for hospitals to own as many pieces of health care as possible.

That is likely to put more pressure on salaried doctors to meet a bottom line, experts and doctors say. And that could change the intimacy of long-standing doctor-patient relationships.

Experts are concerned, too, that if one hospital system becomes too large, it will result in less competition and higher prices, a charge that hospital executives deny.

No matter what happens in the larger political health-care battle, hospitals and doctors say they are preparing for a fundamental shift in the way they organize, practice and deliver care.

“Health systems such as ours have all of a sudden realized that we want to get involved with primary-care physicians, which is new,” said Gaurov Dayal, chief medical officer for Adventist HealthCare, which operates Shady Grove Adventist Hospital and Washington Adventist Hospital.

Some primary-care doctors hope that becoming employed by hospitals will allow them to have better work-life balances. Older doctors say the costs of running a business are increasing — such as expensive electronic medical record systems — and that it may help to be part of a bigger organization.

Internist Laura Brown likes being part of the team at Hopkins.

Brown, 46, left a group private practice last fall. She was frustrated by battles with insurance companies that often resulted in dropped coverage for her patients. When patients went elsewhere, her part-time pay took a hit.

She now works part time with seven other primary-care Hopkins doctors in the same North Bethesda office building. About half of her private practice patients followed her. Many of her new patients see her because Hopkins accepts virtually all types of insurance, including Medicare.

She said she earns about the same as before. But she benefits from an electronic medical record system that will tell her, for example, how many of her patients might be affected by new restrictions on a cholesterol-lowering drug. An electronic system also looks over her shoulder to make sure she asks diabetic patients whether they have had eye exams.

“Am I going to resent getting graded to do that?” she said. “I don’t think that’s oppressive.”

In Northern Virginia, Inova Health’s interest in primary-care physicians is prompting some doctors to join forces rather than work for Inova. Several practices are forming a group of 150 doctors that will work as one entity when treating patients but remain in­dependent financially, said Sandy Chung, president of Fairfax Pediatric Associates, one of the groups involved. The combined group would be one of the largest primary-care practices in the region.

“Everyone realizes they have to be big to play in the game. What we’re looking for is different ways to become big without necessarily becoming employed’’ by a hospital, Chung said.

New pressures

It is not the first time that hospitals have acquired physician practices. In the 1990s, the move toward managed care prompted a similar surge, but that effort resulted in huge financial losses for hospitals, and they subsequently divested themselves. This time around, economic and political pressures are such that hospital executives say they have no choice.

Hospitals with primary-care doctors on their team have the resources to “figure out which patients are at risk, which ones need to be monitored more closely depending on their fragility,” said Bob Kocher, lead author of a New England Journal of Medicine report in March about hospital hiring of physicians.

By contrast, individual doctors, who lack those resources, “almost never do this today,” said Kocher, director of the McKinsey Center on U.S. Health Reform.

Locally, Inova Health’s plan to hire 200 primary-care doctors over five to eight years has brought them about 20 such physicians, virtually all of them recent graduates, according to Wayne Diewald, an executive vice president.

Many Northern Virginia doctors aren’t interested because of mistrust dating to the 1990s, when Inova bought practices but then shed them, doctors said.

Hopkins, the newest player, has the longest history with employed physicians. The Baltimore-based powerhouse is making Montgomery County and Northwest Washington “a major focus” for primary-care hires in the next two years, said Steven Kravet, president of Hopkins’s community physician group.

Hopkins has hired 10 primary-care doctors since acquiring Suburban Hospital in 2009 and will open practices at Sibley and downtown Bethesda this summer, he said. Hopkins wants to hire another 10 doctors over the next year and a half, he said.

Doctors from one local practice, Foxhall Internists, declined to become Hopkins employees because they want to keep their independence, said Alexander Chester, Foxhall’s president. The practice, which does not accept insurance, schedules 30 minutes for established patient visits and an hour for physicals; a Hopkins representative told them they would have to see patients every 15 minutes for regular visits, Chester said.

Brown, the Hopkins physician, confirmed that she was allotted 15 minutes for established patient visits and 30 minutes for physicals. But if she is running over, she can ask for help from colleagues and keep working through her lunch or stay later.

Her performance is not based solely on patient volume. “It is about how many and how sick they are,” she said. Hopkins sets a monthly goal for Brown based on “relative value units” that take both factors into account.

Hopkins officials say part of her salary is also linked to quality metrics, such as patients receiving mammograms, colonoscopies and vaccines. She gets a bonus for meeting the goal. “I’m not finding it at all difficult to reach my goal,” she said.

Lena H. Sun is a national reporter for The Washington Post, focusing on health.
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