Independent doctors’ offices in Michigan under threat from coronavirus

Stephen Bell

“If I’m running on one engine, it’s better than if I had no engine,” said Monroe County physician Stephen Bell.

Operating out of a small office in Monroe County, Dr. Stephen Bell could be considered something of a vanishing species.

“It’s just me,” he said, describing his internal medicine practice, which consists of himself, an office manager and a couple medical assistants.

Like many physicians, Bell saw a plunge in patients and revenue in March, as fear of the coronavirus outbreak kept patients from coming in for care and Michigan Gov. Gretchen Whitmer ordered hospitals and state-run outpatient clinics to stop “non-essential” medical services.

Bell said he would normally see 28 patients a day at his Berlin Township office. That’s down to about half that due to the impact of COVID-19 — patients he now sees through telemedicine.

Bell is grateful to be afloat, thanks to a federal loan he got through a piece of the $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) act that will allow him  — temporarily — to meet payroll and pay the bills. That turns into a grant if he keeps all the employees on the payroll for eight weeks.

After that?

“It depends on how long this COVID-19 lasts and how long we get support. If I’m running on one engine, it’s better than if I had no engine. I guess my crash depends on whether that second engine kicks in.”

In less than two years, between 2016 and 2018, U.S. hospitals bought up 8,000 medical practices and 14,000 physicians left private practice and entered into employment contracts with hospitals, according to a 2019 health care consultant report.

Analysts say COVID-19 could further strain independent physician practices throughout Michigan, perhaps speeding their decline. How that affects medical care remains to be seen.

 

Even before COVID-19, independent doctors were becoming a rarity, as hospital systems gobbled up medical practices. Analysts say their disappearance could mean less personalized care as larger health care networks influence how doctors conduct their practices. It could also mean even fewer primary care doctors in parts of rural Michigan.

Three-fourths of U.S. physicians worked independently in 1983. That had fallen to 49 percent by 2012, according to the national Survey of America’s Physicians. By 2018, just 31 percent of U.S. physicians were independent.

 

“The trend line has been pretty clear for a long time,” Marianne Udow-Phillips, executive director of the Center for Health and Research Transformation at the University of Michigan, told Bridge Magazine.

“I think this will give it another push.”

What is lost when doctors close practices 

Independent practitioners already faced increasing pressures that larger medical groups can absorb through administrative backup. The move to electronic health records pries time away from a physician’s contact with patients. Reporting requirements under the Affordable Care Act, including for Medicare payments, add another managerial layer to a physician’s day. Independent physicians also struggle to compete with the purchasing clout and marketing and IT power of larger health groups.

“The thing that makes it really challenging for some small practitioners is they don’t have the infrastructure to get them through a massive disruption like COVID-19,” Udow-Phillips said.

With the trend toward hospital-run or large group practices, she said, “there is a question of what will be lost. Will they lose personal touch with their patients?”

Udow-Phillips said it’s “possible” that may mean fewer medical practices in rural Michigan, where counties in the northern Lower Peninsula and Upper Peninsula already suffer a shortage of primary care physicians, which may or may not be offset by an expansion of hospital-backed physician groups.

Officials at the Michigan State Medical Society say there’s no firm data for the number of independent physicians among the 28,692 active Michigan physicians in 2019. But if the state is on par with national survey results, about 9,000 would be independent.

A MSMS April survey of 900 Michigan primary care physicians underscored the impact of COVID-19 on these practices.

Marianne Udow-Phillips, of the Center for Health and Research Transformation, said independent physicians “don’t have the infrastructure to get them through a massive disruption like COVID-19.” (Courtesy photo)

The survey found that in physician groups of two to five physicians — all but certain to be independent physicians — 80 percent said their patient volume fell more than 40 percent due to the COVID-18 crisis. And 84 percent said their revenue dropped by more than 40 percent.

“The financial strain on practices has been great,” MSMS Executive Director Julie Novak said.

Novak said it’s too early to predict how COVID-19 might shape the future of medical practice in Michigan, or whether it will drive large numbers of independent physicians toward group or hospital practice.

“I don’t know that we would see a massive consolidation of independent physicians. There is always some element of [physicians who want to remain independent]. There are physicians who feel they can establish their own practice and make their own decisions well.”

But with U.S. medical school debt averaging nearly $200,000 in 2018, it appears more graduates are opting for the security of a hospital system over the financial risk and administrative headaches of joining an independent practice. Working for a large medical group offers the prospect of a predictable paycheck and regular hours.

Advocates for hospital or large network physician groups say they can be more efficient than independent practices, while leaving doctors free to concentrate on patients rather than administrative tasks.

But there’s a tradeoff: Working for a system can diminish a physician’s control over clinical policies. It can, for instance, mean pressure from administrators to churn through more patients a day or refer patients to specialists at the same hospital system rather than to a doctor who may be a better match.

For some physicians, it’s simply about maintaining a sense of control over how patient care should be administered. 

Twenty-two years ago, internal medicine physician Martha Gray and a partner started an independent practice, Partners in Internal Medicine.

“We spent $60 for our logo,” Gray recalled.

The practice now has offices in Ann Arbor and Canton, and has grown to five physician business partners and two contracted physicians.

“I wanted to be small,” Gray said. “I like to be in control and run my own thing.”

"You can’t do solo practice anymore. There’s just so much bureaucracy,” said internist Martha Gray.

The practice is getting by for now, thanks to a $660,000 loan through the CARES loan bank known as the Paycheck Protection Program. Because the practice serves Medicare patients — federally insured patients 65 and older — it’s also tapped into a CARES provision that gives the business a three-month advance on those payments.

One way or another, Gray is optimistic her practice will come out of the COVID-19 crisis intact.

But she’s less confident other independent practices will survive.

“I think it’s going to kill them off. First of all, they were dying to start with before this. You can’t do solo practice anymore. There’s just so much bureaucracy.”

‘I hate being rushed’ 

In 2004, pediatrician Scott Moore launched a solo independent practice in Chelsea, west of Ann Arbor. He added an Ann Arbor office four years ago.

Moore said he gravitated toward opening his own practice as he finished his residency at the Ohio State University College of Medicine in 1996 and watched as the OSU medical school bought out independent practices.

“There was this idea that you were going to see this many patients an hour. There was less control over how the patients were managed.

“I did not want to hop into a system where you were seeing a patient every 10 minutes. I hate being rushed. I didn’t want to do this job under those circumstances.”

Moore said he joined a solo pediatric practice in Jackson, practicing there for six years before striking out on his own.

Moore’s practice – Green Tree Pediatrics – now has four pediatricians between the two offices as well as registered nurses, nurse practitioners and clinical support and administrative staff. He is the sole owner.

Moore also tapped into the Paycheck Protection Program (PPP), run through the Small Business Administration. That’s allowed him to retain his staff as the practice began to rely more heavily on telemedicine in the middle of March. 

“That’s been a lifesaver,” he said of his PPP funding.

As patients shied away from coming in for office visits, Moore now sees about 70 percent of his patients via laptop, iPad or cellphone.

But he could only do so because insurers like Blue Cross Blue Shield of Michigan, Priority Health and others guaranteed telehealth reimbursement for providers during the COVID-19 outbreak. The state, meanwhile, relaxed Medicaid restrictions to temporarily allow doctors to be reimbursed for telemedicine for low-income patients.

“We’ve made some really good changes, changes for the better,” Moore said of the abrupt move by commercial and nonprofit insurers as well as federal insurance programs to cover telemedicine.

But it’s unclear how long insurers will continue to fully cover telemedicine visits.

And Moore’s SBA loan expires June 5. Whether there will be another round of funding medical practices can tap into is anybody’s guess. 

Without more funding, said Moore’s wife, Misha Strauss Moore, who keeps track of the practice’s finances, “we would run out of capital at the end of August.” 

Scott Moore said the business would have to find a way to generate more revenue or make cuts.

“The federal government,” he said, “isn’t going to be too worried about Green Tree Pediatrics. It is going to be listening to the big systems at the table.

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Comments

Anonymous
Wed, 05/13/2020 - 10:56am

Poorly written headline. The virus isn't causing these doctors to go out of business, but rather it is the Governor's Executive Orders. Let's put the blame for the destruction of Michigan's medical community where it lies- on Whitmer.

Subee
Wed, 05/13/2020 - 12:00pm

Anonymous: Executive order has nothing to do with the face that people just don't want to go into a doctor's office right now...or the emergency room. Doctors never go broke. They may have to made an accomodation to Covid but I'm one person that's glad it's finally given telemedicine a platform and I hope we never go back. Puhleez, tell me the last time you saw a physician crying into their beer in a bar because they went broke...ridiculous. These small practices are kinda brave people because running an office is so incredibly expensive. But it does make for a happier practitioner. No one wants to be a corporate widget.

Anonymous
Wed, 05/13/2020 - 2:08pm

You are probably right. Those evil capitalist doctors are probably all just lying about their financial situation. I agree with you, comrade- we'll hang these capitalists by their own rope and achieve utopia after all!

Subee
Wed, 05/13/2020 - 12:01pm

Anonymous: Executive order has nothing to do with the face that people just don't want to go into a doctor's office right now...or the emergency room. Doctors never go broke. They may have to made an accomodation to Covid but I'm one person that's glad it's finally given telemedicine a platform and I hope we never go back. Puhleez, tell me the last time you saw a physician crying into their beer in a bar because they went broke...ridiculous. These small practices are kinda brave people because running an office is so incredibly expensive. But it does make for a happier practitioner. No one wants to be a corporate widget.

Moses
Wed, 05/13/2020 - 12:09pm

And yet the OVERWHELMING number of medical experts in the state, nationwide and world wide all support Whitmers orders. They all say stay home to not just stay safe, but help the medical system not get overwhelmed. Nearly 80% of Americans in every poll also agree. So its just you and the right wing nuts tossing fits and blaming Whitmer. Most of us understand there is a pandemic every 100 years or so, we were overdue and now have to suffer awhile. Most of us are being sane adults and listening to and siding with the medical experts. The medical experts who disagree with you so vehemently that they are all over TV calling you idiots and literally creating lines to block traffic and thus block your infantile protests.

Rick Raisen
Wed, 05/13/2020 - 2:14pm

Okay, you count up all your experts on one side, and I'll count up all the experts on my side... wait, are we counting based on numbers? Maybe we should count based on height? Or are we counting studies? Peer-reviewed studies? I'm just joking with you- you and I both know that there is not OVERWHLEMING evidence of anything, and for every expert or model you produce I can produce two showing you are wrong. 94.3% of people agree with this, and if they don't, they are a chicken nut or beer nut or something. You might think I'm a non-human- that I'm an insane non-person whose rights, property, and life doesn't matter- but you are wrong. Just be prepared- if you try to take my rights, property, and life, I will defend it from tyrants and communists like you.

Revere
Wed, 05/13/2020 - 5:38pm

Rick,
Excellent post.
We are locked and loaded, ready for anything. Hopefully nothing happens. If it does, we're ready. Puts a smile on my face to see employees with AR-15's and deer rifles in their cars "just in case" :)

Moses
Wed, 05/13/2020 - 12:22pm

This would be why so many of you react like children. You cant stand and want to deny the reality that experts and the majority of the country disagree with you. They do on this pandemic, on climate science, on social spending on almost everything else these days. Trump and Republicans behavior in general is just one last big infantile titty baby fit, a primal scream as you lose power and have to accept you really are an extreme minority in this country and in the world. You have to fight 75% of the country and experts in every field, because you have since the 80s increasingly accepted and worshiped insulated group think over actual facts.

I dislike the Democrats. But Republicans and conservatives inability to accept facts and willingly disregard reality is on an epic level at this point.

Anonymous
Thu, 05/14/2020 - 11:25am

Cite an expert, and (if I remember to come back here), I'll cite one who says something different. For every expert you cite, I can probably find an example of when that expert was wrong about something. If you cite a fact, I'll cite a different one- you're just cherry picking the data you want anyway. You scream and yell and gnash your teeth and foam at the mouth over your science, and then pretend you're reasonable. You attempt to stop all questioning and all criticism of science, but science is questioning and criticism.

Look, you don't worship God, so you've now made Science your religion and you worship at it's alter with the same faith and unquestioning obedience to what you think are its beliefs that one would expect out of any religious endeavor, and you follow it's priests with the same certainty as any religious person would. Questioning you or arguing with you turns into a religious discussion. But your religion does not have the right to take away my liberty, property, or life.

Not Anonymous
Wed, 05/13/2020 - 1:57pm

That's the typical myopic tone by the wee faction % of people here in Michigan. The virus is causing this, not the government. Geez dude.

Gerald Sheds
Fri, 05/15/2020 - 12:43am

The old 'repeat the lie often enough until it becomes a truth' tactic, eh? I get it- it's the best you got. The virus issued the executive orders, and the virus in Michigan and a handful of other states continues to issue executive orders and hold on to power. The virus made the Governor refuse to share power or work with the Legislature. The virus is exactly the sort of bogeyman to blame all your problems on, or Trump (although Trump keeps slipping out of all the darn hoaxes you throw at him). The virus made me post this comment mocking you, and the virus is going to cause me to raise rents and prices on you so that I can continue to pay my bills, causing you to lose your home. Bummer for you- blame the virus.

Tam
Thu, 05/14/2020 - 12:39pm

This has nothing to do with Covid-19: "U.S. hospitals bought up 8,000 medical practices and 14,000 physicians left private practice and entered into employment contracts with hospitals, according to a 2019 health care consultant report." This has everything to do with "for-profit medicine." The hospitals "buying up" smaller hospitals, medical practices, etc are run by investment companies whose ONLY concern is how to make more money - they couldn't care less about health of the people of this country! Just like the factory farms which are running the small farmers off their land, these investment companies have the power (money) to destroy and are clearly doing it across Michigan.

George Hagenauer
Wed, 05/13/2020 - 11:46am

If you think the governor's orders you are naive - a lot of people I know including those with serious ongoing medical conditions are avoiding medical offices these days to avoid the virus- since contracting that would be even worse. Personally I would like to contrast our decentralized chaotic health care system with those in places like New Zealand and Canada. Based on conversations with friends who are doctors in Canada that system seems to be a lot easier for physicians to manage their businesses under. A lot less bureaucracy with a single payer system. Likewise on a trip to New Zealand the small physician offices seemed to exist and be fine. Maybe we need to quite looking at our problems and start looking at where things are working which often is not America these days- especially in the area of health care.

steve
Wed, 05/13/2020 - 2:01pm

Spot on George! Peel the onion and you find that the health care system has failed us yet again. But this time it's an epic failure.
I surely feel bad for the small rural clinics and doctors out there. Health care reform would help them immensely.

Tree Cutter
Wed, 05/13/2020 - 8:20pm

By health care reform, do you mean single payer health care run by government monopoly? What efficient Federal agency should it model itself after? Try not to include agencies which are or will shortly be bankrupt. Fiat money isn’t the best, but things have to be paid for unless you expect everyone to work for free.

Ann Farnell
Wed, 05/13/2020 - 5:31pm

Martha Gray was my physician when I lived in Ann Arbor and she was just terrific! I have had three serious misdiagnoses and one over-medication since I moved Up North and gave up the wonderful care I got from her!

middle of the mit
Wed, 05/13/2020 - 7:30pm

Pablum. Why? This money quote right here;

[[[In less than two years, between 2016 and 2018, U.S. hospitals bought up 8,000 medical practices and 14,000 physicians left private practice and entered into employment contracts with hospitals, according to a 2019 health care consultant report.]]]]

In my little town which isn't really little compared to other towns and townships up here, there hasn't a "private physician" for at least 4 years. All of the doctors work for a few clinics that are affiliated with larger hospitals.

I won't say that the pandemic isn't hurting them. But I did a telehealth appointment just this month and my doctor wanted a blood sample. I was told to wait until June after all this blew over. Two days later I called the office to see if I could make appointment because I don't want to do it June after the "cabin owners" flood the town. Guess what? I walked in, they asked me a few questions, took my temp and then I walked through the door. No one was there, but no one was allowed in without a mask. I had my blood taken and then I left.

This is the lessening of America. Or we could call it a lesson in America about America. Conservatives will say it is about Doctors stealing money, much like they did during the car insurance debate. But ask a doctor where most of their money goes. Bureaucracy. Some of it comes from the doctor, but a LOT of that comes with having to have specialists in each branch of Insurance company coding and billing. That is ALL PRIVATE business bureaucracy.

This is what conservatives have been pushing for as long as I can remember. Let me show you that Sonny Purdue said it best for you.

https://www.startribune.com/sonny-perdue-to-farmers-go-big-or-just-go/56...

[[[[Earlier this week, Agriculture Secretary Sonny Perdue visited a dairy expo in Wisconsin, where farmers are hurting badly. When asked about the future of the dairy business, Perdue said, “In America the big get bigger and the small go out. I don’t think in America we, for any small business, we have a guaranteed income or guaranteed profitability.”]]]]

Why do we think that small doctor offices should be helped when we don't help anyone that doesn't have a multi-million or multi billion dollar operation?

Who do doctors think they are servicing? For that matter, who do farmers think they are servicing?

Those aren't the right questions? I KNOW! Who are your legislators servicing?

How is it that during a World Wide Pandemic and World Wide shut downs the stock market hasn't tanked and doesn't seem to be worried about it?

And WHY AREN'T WE PROTESTING THAT!!

Instead the people that want us to be PATRIOTS are being told this:

https://politicalwire.com/2020/05/12/fox-news-extends-its-work-from-home...

“Fox News stars are echoing President Trump’s call to ‘reopen the country’ and urging people to get back to work in the face of the coronavirus threat. But Fox’s offices won’t be opening up anytime soon,” CNN reports.

“A Friday memo from Fox Corp chief operating officer John Nallen extended the company’s work from home directive through June 15. On that date, at the earliest, Fox Corp properties like Fox News will begin a gradual reopening of offices. The date could very well be delayed further.”////

Why? Maybe because of this?

https://politicalwire.com/2020/05/12/thousands-getting-sick-on-the-job/

https://politicalwire.com/2020/05/13/lower-income-households-hit-hard-by...

Remember that you don't want the Governor to have complete control?

https://politicalwire.com/2020/03/22/trump-wants-control-of-economic-res...

[[[The Trump administration and Senate Republicans have called for giving the Treasury Department the authority to disburse hundreds of billions of dollars in emergency federal loans to firms hurt by the economic impact of the coronavirus.”

“Congressional Democrats have demanded the legislation include guardrails to prevent firms who receive the emergency aid from firing their workers or stripping them of their health care… They also are balking at giving Mnuchin so much authority to determine which firms receive the assistance.”]]]

Notice the portion in the last paragraph that has to do with firing workers?

https://politicalwire.com/2020/03/27/the-next-financial-crisis/

https://politicalwire.com/2020/05/01/trump-alumni-benefit-from-lobbying-...

https://politicalwire.com/2020/03/26/relief-bill-includes-bonanza-for-re...

https://politicalwire.com/2020/04/09/relief-bill-allows-fed-to-not-keep-...

https://politicalwire.com/2020/04/09/fed-unveils-massive-emergency-program/

https://politicalwire.com/2020/05/12/house-democrats-unveil-3-trillion-r...

“Republicans rejected the legislation even before they saw it as a liberal wish list that would go nowhere in the Republican-led Senate, where Majority Leader Mitch McConnell (R-KY) said he was at work on crafting liability protections for businesses instead.”//////

Why is Mitch McConnel crafting up liability protections for business when this is all nothing more than the flu?

We have to come to terms. And there is only one segment of our populace that isn't doing that. They think they world was built for them and their freedumbs and they don't care about you at all. WE need to understand that.

Nobody wants to be locked down. Who would want that? But if this is nothing more than the flu and it is fake news.........why are those who tell us it is fake news at FOX News not allowed to BE THE PATRIOTS THEY ARE?

Do you expect to hear them complain about their own companies policy?

LOL!!!!

I hear meat packing plants are hiring! And I see a shortage in my store and higher prices.

Go get ya some!!!

Be a PATRIOT!!