MARCH 2, 2014
TAYLORSVILLE, Ky. — Dr. Sven Jonsson, a primary care physician in this rural community, is seeing a steady tide of new patients under President Obama’s health care law, the Affordable Care Act. And so far, it is working out for him. His employer, a big hospital system, provides expensive equipment, takes care of bureaucratic chores and has buffered him from the turmoil of his rapidly changing business.
“This is just a much saner place for me right now,” said Dr. Jonsson, 52, who left private practice to work for the system, Baptist Health, in 2012. “I’m probably going to live another five years.”
About 25 miles away in the more affluent suburb of Crestwood, Dr. Tracy Ragland, 46, an independent primary care physician, is more anxious about the future of her small practice. The law is bringing new regulations and payment rates that she says squeeze self-employed doctors. She cherishes the autonomy of private practice and speaks darkly of the rush of independent physicians into hospital networks, which she sees as growing monopolies.
“The possibility of not being able to survive in a private practice, especially primary care, is very real,” she said.
Dr. Jonsson and Dr. Ragland represent two poles of that primary care system. Both live and work on the outskirts of Louisville, with the patience required of family practitioners who spend long days troubleshooting routine problems like back pain and acid reflux. But the similarities in their practices end there.
About 265,000 residents of Kentucky have signed up for insurance through the Affordable Care Act, and most have been found eligible for Medicaid, which the state expanded under the law. Primary care offices are supposed to be their point of entry into the health care system, providing the preventive care and upkeep that are crucial to improving the nation’s health.
As an independent physician, Dr. Ragland must carefully devise strategies to keep her three-person practice afloat amid rising overhead, flat or dropping reimbursement rates, and new federal rules, many of them related to the health care law.
She said that she embraced the goal of extending health coverage to far more Americans, but that Medicaid paid too poorly for her to treat any of the new enrollees. And while she is accepting some of the private plans sold through Kentucky’s new online insurance exchange, she has rejected others — again, because she considers the payment too low.
Only about 40 percent of family doctors and pediatricians remain independent, according to the American Medical Association — and many, including Dr. Ragland, feel that harsh economic winds that were already pushing against them have been accelerated by the Affordable Care Act.
“We’re in an unknown time,” she said.
Dr. Jonsson is less mired in the daily worries of running a medical business. His hospital system, with far more bargaining power than a private practice, negotiates with insurers on his behalf, pays his overhead and malpractice insurance, and handles much of the ever-expanding paperwork. It provides him with an X-ray machine and a costly system for keeping digital patient records, a move encouraged by the new law. He has been able to take his first long vacations in years, including a recent month in his native South Africa.
“It’s that stability factor,” Dr. Jonsson said. “People know they can get a certain amount of salary, and the hospital’s not going anywhere, you know?”
Since the passage of the act in 2010, hospital systems have been acquiring physician practices to shore up their market positions and form networks to take advantage of incentives under the new law. For now, Baptist is taking a financial hit by putting so many doctors on staff: Moody’s Investors Service downgraded its credit rating in September, citing “increased losses from an aggressive and rapid physician employment strategy.”
Baptist enlisted about a dozen of its primary care providers in the Louisville region to take on new Medicaid patients, officials there said, both to get more paying customers in the door and, as a nonprofit system with a stated charitable mission, to help more of Kentucky’s poor get medical care under the law.
“We all have to sort of dig in and work hard and see what happens,” Dr. Jonsson said.
Dr. Ragland is both a general internist and a pediatrician, treating infants to patients in their 90s. Her office is on a winding road lined with horse pastures and upscale subdivisions, with a big sun-splashed waiting room and a Pilates studio next door. She grew up on a farm and does not bother wearing a white coat.
One Monday this month, she saw 15 patients at an unhurried pace, partly because she had some no-shows because of bitterly cold weather.
There was Marcia Robinson, 54, who learned she had shingles in December and was seeking follow-up care before a Caribbean vacation; Dylan Waddle, 10, who had a bad cough; and Margaret Smith, 77, who was dealing with a painful wisdom tooth.
“She’s very attentive,” Mrs. Smith, a retired piano teacher, said of Dr. Ragland. “She doesn’t just cut you off.”
Dr. Ragland has seen a handful of newly insured patients since Jan. 1, but most of her adult patients have insurance through their jobs or Medicare. Some have switched to the new private exchange plans that her office takes — all except those offered by Humana, a large insurer based in Louisville, which she said would have reimbursed 20 percent less than what her office gets for Humana plans outside the exchange. Still, she does not hesitate to recommend the exchange to her patients if she thinks it could help them.
Halfway through her day, Dr. Ragland walked into an exam room and found Aline Burgin, 61, waiting for her. “I haven’t seen you in a while!” she said, noting that Ms. Burgin’s last visit was two years earlier. Ms. Burgin, who works the overnight shift at a nursing home, said she had temporarily dropped her employer-sponsored insurance because it was too expensive.
“It’s $170 out of my paycheck every two weeks,” she said.
“Did you go to the exchange to see if you could qualify for some help?” Dr. Ragland asked.
Ms. Burgin agreed to take the phone number for Kynect, the state exchange. Then she lingered in the exam room, telling Dr. Ragland about her sister’s recent death from emphysema and the guilt she felt about not being with her that day. Dr. Ragland listened for nearly 10 minutes, nodding her head and saying, “Mm-hmm.”
By the time they were finished, 30 minutes had passed — 10 minutes longer than the usual appointment time. It is that kind of flexibility that Dr. Ragland said she treasured about private practice.
“Some patients need five minutes; some patients need all kinds of time and follow-up,” she said. “I never want to be in a situation where my employer tells me I need to be more productive or I’m going to have a severe cut in my pay.”
The next morning, Dr. Ragland and her partners had their monthly meeting with a private consultant they hired recently to take over their billing and help them maximize reimbursements. They talked about their effort to recruit a fourth partner, which has stalled partly because so many young doctors now prefer to work for hospitals. And they examined spreadsheets showing their productivity over the previous month, including how many patients each doctor had seen and how much they had billed for each visit. Productivity was down because of harsh weather.
“I want to rent a truck and pick up patients and say, ‘Go to the doctor!’ ” said the consultant, January Taylor-Mills.
One investment Dr. Ragland has delayed making is in a sophisticated electronic records system; for now the doctors are using what Ms. Taylor-Mills called a “very basic” model that is essentially free but not as comprehensive as those used by hospital systems.
As a survival tactic, the practice has joined an “accountable care organization” — a network of physicians, in this case independent, who coordinate care for a group of patients. These networks, encouraged by the new law, reap financial rewards if they improve patients’ health and spend less doing it. Dr. Ragland said her accountable care organization is eager to prove that it can succeed “at probably lower cost than a lot of the hospital systems.”
Ms. Taylor-Mills asked the partners if they were aware that under the Affordable Care Act, primary care doctors could temporarily get reimbursed for seeing Medicaid patients at much higher Medicare rates. The doctors were unmoved; the law raised the rates only for 2013 and 2014.
“It’ll go back down,” said one, Dr. Tony Karem. “It’s all a big game, I think.”
An Influx of Patients
In his Baptist Medical Associates office across from a drab shopping center in Taylorsville, Dr. Jonsson chugged through 30 patient visits one Wednesday in January. He hustled between exam rooms carrying a laptop equipped with voice recognition software, provided by Baptist, that allows him to dictate notes into patients’ digital records.
“There’s no question I have more time,” he said, comparing his life now to when he owned a private practice. But, he added, “I work hard when I’m here.”
For now, hospitals generally provide doctors like him with a baseline salary and potential bonuses tied to productivity — a system likely to change as the Affordable Care Act calls for basing payment on results instead of volume.
His office is utilitarian: a single long hallway lined with exam rooms that Dr. Jonsson, a nurse practitioner and a physician assistant shuttle between. In the waiting room, fliers for other Baptist services — weight-loss surgery, addiction treatment, home health aides — share rack space with magazines like Field and Stream.
Dr. Jonsson, a competitive kayaker who advocates a plant-based diet to anyone who will listen, quickly dispensed with a back pain case and a follow-up visit for chest pain that seemed to be acid reflux. There were also patients with leg cramps, obsessive compulsive disorder, pneumonia and rheumatoid arthritis, most of whom had followed Dr. Jonsson when he went to work for Baptist — or as Steven Pippin, the chest pain patient, put it, “when Obamacare came along.”
Down the hall, Melissa Thomas, the physician assistant, was examining Craig Dooley, a newly insured patient who had limped into Dr. Jonsson’s office with a catalog of ailments, including pain in his knees and shoulders. A physical exam, his first in more than six years, turned up other concerns: possible heart and prostate problems that called for referrals to specialists. He had traveled about 20 miles from Louisville, he said, because he could not find a doctor who would take his newly acquired Medicaid closer to home.
“I wouldn’t normally come all this way,” said Mr. Dooley, 56, who left with referrals to an orthopedist, a urologist and a cardiologist, and an appointment for an overdue colonoscopy. “But I can’t complain. This is good insurance, and I’m overjoyed by having it.”
Dr. Jonsson is accepting new Medicaid patients under the Affordable Care Act because his rural practice has room to grow, said Donna Ghobadi, an assistant vice president at Baptist. In particular, Ms. Thomas and Darline Caldwell, the nurse practitioner, are still building their patient base; Baptist considers these types of providers, who have less training but work with doctors as a team, crucial to taking on new patients in the Affordable Care Act era.
“It’s a way to expand capacity without maybe so much the cost of a physician,” Ms. Ghobadi said.
Dr. Jonsson owned his practice in Louisville for a decade — and did not accept Medicaid, for the same reasons that Dr. Ragland generally does not — but sold it in 2010, months after the Affordable Care Act passed. He did so, he said, expressly out of concern that the law and related requirements were about to ratchet up the pressures and expense of private practice. In particular, he dreaded having to buy and learn how to use an electronic records system, not only because such systems are expensive but because doctors’ productivity slows down while they are learning the computerized systems, threatening tight margins.
“I’m not sure how I could have done it,” Dr. Jonsson said.
When he is done seeing patients, he tends to the grapevines he recently planted on his property with plans to make wine.
“I don’t have to go look at anything related to the finances of the office,” he said. “I can actually go dig a hole on my farm.”
Support for Doctors
On a recent blue-sky morning, Dr. Ragland drove to the State Capitol in Frankfort with a mission: proposing that Kentucky provide scholarships to medical and nursing students who agree to practice primary care in underserved areas for at least three years. She is on the board of the Greater Louisville Medical Society — part of an attempt to become “more outward-looking,” she said — and wants to offer ideas for easing a worsening shortage of primary care doctors.
She sat down with State Representative Larry Clark, the Kentucky House speaker pro tem, and State Representative Jimmie Lee, who oversees the House human services budget. Mr. Lee peered at her, arms crossed, as she made her pitch. Money was tight, he told her, and a new bill that would give experienced nurse practitioners more leeway to practice independently — being voted on by a committee that day — would likely do more to address access issues because there would never be enough primary care doctors.
“I’ve got seven doctors in my family, and there’s not one of them who’s a family practice doctor,” Mr. Lee said. “I’ll tell you why: because they don’t make any money.”
Dr. Ragland smiled, resolute. “Listen, I’m pro-nurse practitioner — very much,” she said. “There’s no question we have to have them, but until we supplement their training they can’t substitute for us, representative.”
The lawmakers suggested a second meeting with members of Gov. Steven L. Beshear’s administration and ushered Dr. Ragland out. She made her way to the building’s cafeteria, where a group of nurse practitioners were celebrating the unanimous committee vote in favor of the bill expanding their authority.
“I don’t get the emphasis on primary care is so important, but primary care physicians aren’t,’ ” she said, sitting across the room from the group.
Over the following weeks, the nurse practitioner bill won passage in the Legislature, and Governor Beshear signed it into law. Dr. Ragland had another meeting with the lawmakers, who agreed to keep discussing her proposal and perhaps bring some version of it to the Legislature next year.
In Taylorsville, the new patients are still coming. Dr. Jonsson’s practice has seen dozens of them — even though he left on Jan. 17 for five weeks in South Africa, where he helped at a remote clinic. While he was gone, Ms. Caldwell, the nurse practitioner, and Ms. Thomas, the physician assistant, handled the patient flow.
He had never been able to take more than a week off in private practice, he said — “if you did, you really didn’t earn anything that month because it all went to overhead” — and Baptist’s willingness to let him do so was another source of new happiness. The typical fears about hospital employment — pressure to refer only to other Baptist doctors, for example, or to bring in as much revenue as possible — have not burdened him, he said, at least not yet.
“I don’t know where I’ll be in 10 years,” he said, acknowledging that the uncertainty pervading his profession may lead him down yet another path. “Hopefully I’ll be here and hopefully I’ll be happy, right?”