Astoria doctors Kate Merrill and Angela Nairn say they prefer the independence of private practice despite the challenges doctors employed by hospitals dont directly deal with.
That was part of the motivation for opening Pacific Family Medicine, LLP in 2001.
My father was recently in the hospital, and when I told the neurosurgeon I was in private practice in primary care he looked at me like I was nuts, Nairn said.
Having done both, being employed and being in private practice, Id much rather be in private practice, Merrill said.
Running your own show
The autonomy of private practice is a strong draw, both agree. There are no layers of bureaucracy to go through to accomplish tasks, simple or difficult.
Theres a flexibility in the practice.
They rely heavily on clinic manager Janet Mossman. Shes just two steps away, Nairn said.
If you have a problem, if somethings not running smoothly theres a patient at the counter with an insurance issue shes right there, Nairn said.
Mossman, who keeps the business end of the practice healthy, said insurance reimbursements have dropped.
Over the last year, considerably, she said.
Shes noticed it when shes tried to renegotiate contracts with insurance companies.
Theyre not willing to move as they have been in the past, she said, because theyre changing models as we speak.
In the past theyve discussed how much services would increase. Its only recently theyve discussed decreases to reimbursements, she said.
Its not just private insurance thats been a problem. Medicare and Medicaid reimbursement levels are too low, Mossman said.
For example, Medicare reimbursements for things such as vaccinations have been a problem in recent years.
If we were a big facility we could buy in bigger bulk and keep our cost down, but our usage of such things is so much lower than say, a hundred-doctor practice, and Medicare expects us ... to be purchasing at a higher level, so they want to pay us lower, Mossman said.
The practice continues to see Medicare and Medicaid patients but does not accept new ones.
Merrill and Nairn understand what its like working for a large clinic. They met while employed at the PeaceHealth Clinic in Astoria. Both enjoyed working for the organization.
The clinic closed in October 2001 because it wasnt economically viable, Nairn said.
She and Merrill decided to strike out on their own.
We were lucky we had time in advance to know we were going to be doing this, Merrill said. We could prep everything, and our patients followed us. We started day one with a full schedule.
They did a lot of research before opening the practice. Plus there was space to rent, equipment to lease and supplies to buy.
Some of the equipment came from the PeaceHealth clinic. When the clinic closed, much of it was donated to Columbia Memorial Hospital, which leased it to Pacific Family Medicine on a lease option.
The costs didnt stop there. In 2009 the Health Information Technology for Economic and Clinical Health Act provided incentives to switch to electronic record keeping, with penalties for failing to do so.
Medicare said, Go electronic or each year you will lose this amount of reimbursement, Nairn said.
The feds provided some of the money to buy the equipment, $18,000 per eligible professional the first year, then $2,000 a year the next four years, but it doesnt cover the costs of maintaining it, updating the software and the record keeping, Mossman said.
We eat that, Merrill said.
Thats another reason youre seeing fewer doctors going into private practice, Nairn said.
In addition to Mossman, the company employs two medical assistants, a receptionist and someone to handle billing. The company offers health insurance and retirement benefits, making cuts to reimbursements difficult for the company to swallow.
Business Is Business
I come to work to practice medicine, Nairn said. I am not in this to deal with all the requirements and reimbursements and denials.
Merrill likes to be a little more involved in the business end, but Once we hit the door and were seeing patients, we do patient care. When we have time breaks or lunchtime or if its something quick, Janet will come to us with an issue.
They also set aside a few hours each week outside patient care to discuss the business.
But the time we spend doing that is not more than the employed physician spends in meetings about Where are we going to put the trash can? It cant be in that hall, it has to be in that hall. I dont want it in that hall, its inconvenient, Merrill said.
Despite reimbursement issues, rising costs and constantly changing government reporting requirements, Merrill and Nairn are happy right where they are.
I still think its a great career, Nairn said. Its very satisfying. Its challenging, its rewarding. I wont say sometimes I dont leave and say Why did I do this? but I look back at the past 13 years and its been a happy, rewarding time. With all of the changes itll be more difficult from a business standpoint, but I think if people want to be in medicine, they will always enjoy the clinical aspect.
Merrill added: That makes up for a lot. My main frustration is that it pulls me away from being able to enjoy that part of the whole reason that I do this: the time when I close the door and Im in the room with somebody. I hate everything that pulls me away from that.