A day in the life of Dr. Marc Shiffman can go something like this: Leave home at 7:45 a.m. Drive 40 miles through rural Colorado to Summit Internal Medicine, the clinic he founded in 2007. Start seeing patients at 8:30 a.m. Stop seeing patients at 5:30 p.m. Do paperwork—forms that need to be sent to insurers, bills that need to be looked over—until 9:15 p.m. Make the 40-mile drive back home. Arrive around 10 p.m. Repeat.
“In a word, I’d say running a solo, primary care practice in rural America is impossible,” Shiffman said. “Rural America is not well-served, and the prospects for the future are gloomier.”
A century ago, half of Americans lived in rural areas, as did 41 percent of their physicians. Since then, Americans have migrated out of rural areas and their doctors have done so at an even quicker pace. Nationally, the United States has 191 physicians for every 100,000 people. In rural areas, that ratio can be as low as 52.3 doctors for 100,000 patients. An American living in a non-Metropolitan area is four times more likely to live in an area with a primary care shortage.
Shiffman has operated a rural clinic, on his own, for five years now. His experience, and decision to shut down business, helps give some insight into the challenges that rural health care faces.
Shiffman opened Summit Internal Medicine in 2007, after he’d spent decades working in hospitals and multi-physician practices in Baltimore and Colorado. He liked the idea of becoming his own boss and running his own office. He also saw a demand: In Summit County, with a population of 28,081, there was not a single internist.
Shiffman ran a few ads in local papers when the clinic first opened, mostly just to get a lot of work. “There was a lot of pent up demand, although I don’t know that people realized it,” he said. He quickly amassed a base of 2,650 registered patients and hasn’t run any advertisements since his first three months in solo practice.
Shiffman enjoys the work he does, mostly because of the relationships that he has built with the patients he sees. But last fall, right around Thanksgiving, Shiffman started thinking that running the practice was becoming untenable for a number of reasons.
There was the overwhelming amount of paperwork: Even though Shiffman had a fulltime billing officer and part-time office manager, he still ended up spending about 10 hours each week filling out paperwork. “If I’m seeing my patients until 5:30 p.m., then I may be at my office until about 9:15 p.m. just trying to get all the forms done on what I’ve been doing,” he said.
The paperwork has become more overwhelming especially in the past year; he’s found himself having to file more paperwork to get a certain prescription, for example, authorized by a Medicare Part D drug coverage plan. “There’s just been this tidal wave of extra paperwork when you’re trying to get patients medication,” he said, noting that 40 percent of his patients are Medicare enrollees.
Shiffman can balance his books and said in the future he may well have been able to do so, but doing so proved exhausting. He spent one weekend a month at a nearby hospital, pulling a 48-hour shift to make the numbers add up.
“If I didn’t do that, I would have to turn my practice into an assembly line and see as many patients as possible,” he said. “That’s not what I wanted. Instead, I give up my weekend every month. My wife gets a little tired.”
Reimbursement from Medicare, for primary care services, tends to be lower than rates paid to specialists. And many of the things that Shiffman does - the phone calls he makes to a patient, or an insurance company to make sure a prescription gets covered - don’t get reimbursed.
When Shiffman looked forward, he didn’t see things getting easier. Many of the hospitals around him, especially in Denver, were forming Accountable Care Organizations, large partnerships of doctors and hospitals that are meant to coordinate a patient’s entire course of care.
Shiffman is one doctor; he cannot manage a patient population in that way. He said that the bigger, nearby hospitals were not keen in having a rural doctor, relatively far away and with few patients, participate. “They have made it very clear that they’re not interested,” he said.
So last November, Shiffman began calling some of his former colleagues at Johns Hopkins University in Baltimore. He was immediately offered a teaching position. He accepted. He wrote a column last month in the local newspaper announcing his decision and the reasons behind it. He immediately heard from patients asking: Where do I go now?
“I tell them we’re trying to recruit a new internist to take over the practice,” Shiffman said. “But unfortunately, as it stands now, there’s not an internist within 40 miles. You can drive 40 miles in any direction, and not find anyone.”
Shiffman calls himself a “dinosaur.” He accepts that “you won’t find me in rural areas,” perhaps as soon as within the next few years. He thinks his patients have lost a level of health care access with his departure, but doesn’t necessarily know a way around it.
“As a solo practitioner,” he said, “It’s just not sustainable.”