Primary Care Crisis

I decided to write to Maryland's Health Care Reform Coordinating Council today, in order to express my concerns about the primary care shortage.  My letter is included here:


To Whom It May Concern:

Greetings and happy holidays!  My name is Holly Ryerson Dahlman and I just spoke with Joyce Meyers at your office.  She pointed the way to this opportunity to weigh in on the health reform issue.  Whereas, I would love to attend public forums, my time is limited as I am a private practice general internist in solo practice.

First of all, I would like to applaud the Committee for its heart to expand access to affordable healthcare to all Marylanders.  It is not only the right thing to do, but it is the fiscally responsible thing to do.  My comments on health care access can be found in an Op-Ed I wrote in the Baltimore Sun last October.

I am writing the committee now primarily to express grave concerns about the state of affairs in the primary care workforce.  Since starting in practice 11 years ago, I have watched disturbing trends in my profession.  When 3 out of 6 of my former partners in practice announced that they were pursuing concierge medicine, I decided to branch out and start my own practice.  I stand morally and ethically opposed to concierge medicine and dislike the model for practical reasons as well.  Yet, I have been somewhat surprised to watch one colleague after another who was originally opposed to the model succumb to its temptation.  This trend is the direct result of the tremendous financial pressure that primary care physicians have been under for many years.

With a flatline in insurance compensation for our services in the face of rising business expenses, primary care doctors in small practices face the likelihood of being driven out of business altogether.  Some physicians have met the crisis by refusing to sign contracts with insurance companies.  Others are joining hospital-owned practices, which enjoy more negotiating power but also pose conflict of interest and may encourage increased healthcare spending. Others, like myself, are trying to tough it out and do the right thing in our hearts and participate with major carriers.  The problem is, our profit margins are too narrow to sustain crises like the 9 weeks total of Medicare non-payment this year.  Being so close to the edge puts us at risk for burnout or choosing other career alternatives.

It is my understanding that the Committee aims to address the primary care workforce shortage by offering loan repayment.  I applaud this effort, as it is a necessary step in the right direction.  It is necessary, but not sufficient, however.  In order to sustain the existing primary care workforce, the payment structure needs to be revamped.  The current payment system has resulted in a tremendous salary gap between primary care and specialty care and encourages performing expensive procedures rather than thoughtful prevention and approaches to disease management which are cost-saving.  As for salaries, the average internal medicine salary is approximately $150,000; whereas cardiologists and gastroenterologists enjoy $300,000 to $350,000 average salaries.  I am grateful to my colleagues who are specialists and am glad they exist; however, their services are not worth more than twice the value of my services.  Primary care practitioners face the ever increasing complexity of keeping metastable, chronically ill patients out of the hospital.  We are treating many, many diseases in the outpatient setting that would have been grounds for hospital admission ten years ago.

Models like the Patient Centered Medical Home make a whole lot of sense but will only be possible if they are adequately compensated by insurance carriers.  The CareFirst PCMH model is a farcical non-option for practices of fewer than 5 physicians due to the tremendous administrative obstacle posed by their "Panel of 5" requirement.  The 12% increase in compensation only barely catches up to increases to primary care physicians that CMS is finally enacting next year.  It will not be enough to cover the upfront cost of implementing this model, even though the model has proven to save healthcare costs in other states where it has been implemented.  I tried to negotiate an alternative, but they will not engage in negotiation with small practices.

Now, as I stand waiting to hear whether the MHCC will select my practice for their PCMH Pilot Program, I wonder whether or not I will really be able to stay in practice.  I am unable to hire another physician with the confidence that they will feel appreciated and well-compensated.  At the start of my new practice in 2006, I had hired a PA and another internist to work for me part-time.  Though I paid them a competitive internal medicine starting salary, both left the practice within 2 years wanting to be paid more.  While I took this personally at the time, I now realize that they should have been paid more. I should be paid more for what I do.  It is wrong that a PA who is working 40 hours per week at a local ER, with 10 hours per week of administrative time, earns more than I do.  I work my tail off to practice with excellence, to keep my patients healthy, and to address the needs of many sick patients.  I want to care for them all, but sometimes doing so has meant working without vacation and working through an interval of serious personal illness last year.

Our state will need to have a more robust primary care workforce to meet the increased demand for healthcare as people become insured.  Believe me, having a frontline of thoughtful doctors is necessary to stem the vast expenditures that could result from people seeking primary care at the specialists' offices.  Besides, I don't think the specialists want to do my job.

Please do not hesitate to contact me if any questions should arise.

Professional regards,
Holly Ryerson Dahlman, M.D.