The journey from family practice to urgent care

As you may know, I left Maine to come to Virginia to work in an urgent care center.  It was not how I pictured myself when I trained to be a family doctor 18 years ago but the world has changed.

I like my present job fine and there isn’t a bunch of suits looking over my shoulder all day.  That being said, I want to share my thoughts about the recruitment process as it relates to family medicine.   The supply side is extremely low.  The demand is extremely high.   This should make those hiring us increase their offers but it doesn’t!  That is the insanity of it all.   They would rather have no physician at all or pick crappy ones then raise their offers.  It goes against every rule there is in business.

Wherever I went people would offer me a job but the contracts, incentives, workloads, etc. were all convoluted and complicated with such nuggets as severe noncompete clauses.  Basically, if you took a job and then they changed the contract to screw you it wouldn’t matter as you couldn’t work in the area for two years.

The other irrational issue that is pervasive is the new quality indicators.  All those who are hiring doctors want to get in on this so that they may make more money off our backs.  Forget the fact that this crap is unproven, the suits want every penny they can get.  That makes these contracts even more complicated.   People, it is a mess out there.

Unfortunately, there are not many answers.  One is to jump ship into something else (like I did).  The other is to go concierge or cash pay.   Another, interestingly enough, comes from a weird way.  I just spoke with a friend who is also trying to recruit primary care docs.  He is having a hell of a time.  His system is a Federally Qualified Health Center.   These centers serve very poor patients on Medicaid or the patients pay a very reduced sliding scale fee depending on their incomes.  This is a tough population.   The amazing thing is that the federal government has a set fee for every Medicaid patient seen (i.e. approx $100).  Basically, this is old school fee-for-service.  It is authentic medicine, treating all socioeconomic classes, and making money for each person you treat.  It is almost Marcus Welby like and it makes you want to see that ear infection who calls at 4pm.  That is if you were getting part of that fee.  And that is the answer.

Right now the FQHC doesn’t offer a contract like that but I pitched him anyway.  My point is that recruiting would be much easier if they said they would pay you, as a doctor, $50 per patient visit.  In other words, split the government reimbursement.    How simple is that?  You can do the math in your head and see that it also would be very lucrative.  The more you make, the more they make.  Forget the ten page contract with a ton of qualifiers and confounding variables.  Just $50 a patient.  He was intrigued but not convinced.

So now I am asking you.  If you are a family doctor, would you take a job like this?

Doug Farrago is a family physician who blogs at Authentic Medicine.

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  • John Key

    This post identifies, correctly I believe, many of the problems we all face today and you propose some good solutions. I hope the solutions work. I fear, however, the horse is already out of the barn; indeed, the whole damn herd is out and stampeding wildly away. I don’t know if they can be stopped and corralled and put to meaningful use (no pun intended). Too many “suits”, too much government, too many laws, rules and regs. Good luck.

    • Maureen Rudden

      I certainly agree with you and the ones this is compromising is the physicians over 50 and the chronically ill patients.

  • familydoc

    No. FQHCs are heavily subsidized by the Feds and will be dependent on meeting their whims with every new initiative. They also will be subject to heavy cutbacks when we (or our bond holders) finally face up to fiscal reality.
    I’d rather take my chances working directly for patients by growing the cash and direct practice part of my business. That, not FQHCs nor urgent care, will get away from most of the nonsense you complain about.

  • Margalit Gur-Arie

    Just curious: how come opening your own practice or becoming a partner in an existing small practice is not mentioned as an option?

    • familydoc

      Because traditional third party paid practices suffer the same limitation as his urgent care. The price is set. Increased demand does not produce an increase in pay. Many in traditional practices are either hoping to hang on until retirement or working on other models such as the many variations of cash practice.

  • Miriam Delosantos

    As a newly graduated provider, I am facing this dilemma head first. I want to find a job in a specialty practice for two reason. First of all, I prefer the idea of knowing a lot about a narrow subject versus knowing a little about a broad subject. My background as an integrative practitioner would be better suited for the former. But a large consideration is also due to the cattle-mill model of working in primary care. When I got into medicine, this is not the kind of medicine I was envisioning to practice. During my clinical training, I heard many of my attendings complaining about “the suits” and the constant pressure about RVUs. If the Western medical model keeps on focusing more on numbers than on the patient, it is going to lose not only patients, who have been feeling disenfranchised from the Western model for decades, but practitioners as well.

    • Maureen Rudden

      Not only is it frustrating for you, the Doctor but extremely frustrating for the patient.

  • Robert Bowman

    This also illustrates how half enough primary care for the United States is getting worse because of aberrant policy design and how these shape changes in practice. Decreased primary care capacity or lack of enough volume of primary care that can be addressed is made worse when primary care MD, DO, NP, and PA grads are driven away from primary care. Volume is worsened by collaborative and concierge care and nurse managed care that are moves to lower volume. High quality focus such as pay for performance assures lower volume, sends more millions to less access or no access, and clearly disadvantages practices that care for disadvantaged populations as the reimbursement design cannot address social determinant related lower quality measures as Hong demonstrated in JAMA.

    The point of fee for service is strong. Enough fee for service to cover the rapidly increasing costs. Fee for service to drive volume higher and result in more primary care per primary care provider – in shortage now and for the next 30 years. Once we have sufficient primary care about 30 years after a specific training design to resolve health access woes, then it might be possible to look at innovations and “improvements that lower volume. For optimal recovery of primary care and primary care where needed, the recovery design must be predominantly permanent family practice

    • rswmd

      There is nothing about fee for service that is inherently bad: it’s what makes the world go round.

      The problem we have is that FFS in this country has been totally perverted by the corrupt RUC and CMS.

      If we want fewer procedures/tests, pay less for them. If we want more primary care docs, pay them more for the work they do. End of problem.

  • Robert Bowman

    Comments also illustrate accountability to come, which may be worse for non-primary care. Understand that MD, DO, NP, and PA are all expanding in annual graduates, are all more likely to result in non-primary care, and even those training in primary care melt away from primary care in the years after graduation. Add on accountability for ever higher health care costs driven by too much non-primary care. And all because of a design shaped for 100 years to ever more reimbursement for the most highly specialized care, the care most academic, the care most hospital focused, the care delivered in the fewest zip codes. Cost cutting policies for the past 30 years have been discriminating mostly against new physicians, primary care physicians, and physicians in most needed locations as well as half of the American population left behind by design.

    Only designers so focused on so few with little or no awareness of the needs of most Americans would craft such a design. This aberrant perspective is also why they think that American health care is the best, which it is for the few that they see, but not for most Americans.

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