Gone are the days of doctors carrying black bags making house calls, but in Vermont, it’s getting harder and harder to find those family doctors’ replacements.
Primary care practice is a disappearing profession, says Dr. Paul Rogers, M.D., who owned a private practice in Johnson for 37 years before retiring last August.
“The model of somebody coming to a small town and opening a practice — which is what we all did, every doctor in this county was a private, small practice —30 years ago, that’s gone,” Rogers said.
That’s hard for him to watch, because he says patient care goes down when people can’t see their doctors, or can’t find a doctor to manage their care.
The numbers back up what Rogers is seeing.
A memo from Jessa Barnard, executive director of the Vermont Medical Society — it represents about 2,000 physicians, assistants and medical students statewide — said that in 2016, compared to 2006, there were four fewer physicians and 35 fewer full-time employees in practices.
There was a net decrease of 12 physicians in primary care internal medicine, and five in family medicine, according to Barnard’s memo, which she presented in April to the Senate Health and Welfare Committee.
And the future supply of primary care physicians in Vermont looks bleak.
Barnard said 47 percent of Vermont’s primary care physicians are over age 60, and likely to retire soon.
“We’re seeing more and more physicians retiring, so how can we support people staying in practice longer? A lot of that has to do with the administrative burdens of practice. A lot of physicians are thinking of retiring earlier than they might have,” Barnard said.
Can’t give it away
“Most doctors don’t want the burden of running a practice. They want to be employed. We’re a nation of employees now, and physicians are no different,” Rogers said.
“My dream was to have somebody come in and I’d cut back to a couple of days a week and I could have done that for quite a while longer,” but nobody was there to pick up where he was planning to leave off, Rogers said.
He loved running his practice, and says the administrative work wasn’t a burden to him, but the medical students he got to know couldn’t afford to run a private practice in Johnson with the medical school debt they were carrying.
“I’d been trying to give my practice away for three years, and I’ve had medical students that have come through my office and felt that the kind of practice I did — which was a solo, private, community-based practice where I owned my own practice — was exactly what they wanted to do, only they couldn’t afford to do it.
“Even giving my practice away was not a viable option when medical students come out with $300,000 worth of debt and could get a much higher salary than I could offer” working in bigger practices, Rogers said.
And, government health insurance programs reimburse larger practices at a higher rate than smaller practices, Rogers said, so doctors flock there.
No real connection
But Rogers says patient care suffers when doctors consolidate their efforts into larger practices, since they’re located outside rural areas.
“In these larger corporate practices, the chances of (patients) even seeing their own doctor are small,” Rogers said. “When you call over, you’re going to get a menu that you have to push nine times and then finally get somebody to call you back who has no idea who you are. In smaller practices, you know your own patients and that translates into better care.”
He says fewer patients are hospitalized within 30 days of discharge in smaller practices compared to bigger ones.
And overall, communities are healthier when they have a private practice, Rogers said.
“There’s no investment in the community. When I set up my practice in Johnson, I owned the practice. My name was on it. I had my building. Now, if a doctor works for a large nonprofit organization, it’s a job. They’re employees, and they can take their 401(k) and move to a better opportunity. There’s no real commitment to the community, to your practice,” Rogers said.
What about the spouses?
Christopher Towne, director of federally qualified health center operations at Northern Counties Health Care and a member of the Morristown Select Board, said he handles recruitment and retention of providers, and he struggles to find them.
“The demand just far exceeds the supply. It’s a changing environment. There’s simply not as many choosing that residency,” he said.
“The other barrier that we face is often providers or physicians are married to other professionals, so our particular area, especially Lamoille County, is not dissimilar to the Northeast Kingdom. There are just not a lot of professional-level jobs. When someone moves here, we are often looking for jobs for two people,” Towne said.
“We always like to have spouses or significant others visit, because you need to have them comfortable. It’s equally if not more important. We connect people with real estate agents; we inquire what their family situation is. We try to ensure that they’re going to have a good fit there, and sometimes that does mean looking into opportunities for their spouses. It’s challenging,” Towne said.
Patients who can’t see their primary care physicians end up using urgent care centers or emergency rooms instead.
“One big challenge is often the emergency rooms — the volume goes up, which, as we know, is the most expensive place to deliver care,” Towne said. “Health outcomes can suffer. Primary care providers do a lot of chronic disease management, which require ongoing appointments. It can have a detrimental impact on the overall health of the community” when primary care doctors retire and aren’t replaced, Towne said.
State task force formed
“It’s a terrible model,” Rogers said of reliance on emergency rooms. “It’s not good care and it’s going to be, without exaggeration, probably five to 10 times as much as a visit to their family doctor.”
State Rep. Lucy Rogers, D-Waterville — and Paul Rogers’ daughter — is on the House Committee on Health Care. She sponsored a bill that was signed into law this year, establishing a task force to discuss retention of physicians in Vermont.
“When we talk about access to health care, access always used to be equivalent to affordable health care, so we talk a lot about affordable health insurance,” Lucy Rogers said. “I think that’s extremely important, but the flip side is, if you don’t have physical access to health care, it doesn’t matter if it’s affordable or not if you can’t get to it.
“More than people describing a lack of access to health care, it’s more a matter of looking at these trends that are happening that are happening in Vermont, too, and trying to be proactive about having a vision for where we’re headed and making sure we don’t get to a place where people don’t have access to health care,” Lucy Rogers said.
“I loved my practice. I loved my patients. I just never wanted to be an employee, and it’s a shame that that’s not becoming a viable option for the next generation of physicians,” said Paul Rogers.