Recruiting For Primary 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 shitty 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, please answer the survey below and tell me if you would take a job like this:
[poll id=’6′]

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  13 comments for “Recruiting For Primary Care

  1. Susan Hirsch, M.D.
    August 27, 2012 at 9:37 am

    Why didn’t my comment go through?

  2. Susan Hirsch, M.D.
    August 27, 2012 at 9:36 am

    $50 per pt sounds pretty low, considering many will be poor, sick, depressed, unemployed, non-english speaking, smoking, diabetic /obese/htn/PVD/hyperlipidemia/CAD and c/o various things that may or may not be life-threatening….this takes more than a few minutes. I work in a clinic with residents and each case is more complex and horrific than the next. At least on our private side, more pts are basically healthy or at least everything under control and can be seen (usually, not always!) in a timely manner.

  3. Bridget Reidy
    August 25, 2012 at 11:35 am

    The problem with FP in America is the culture even more than the pay and administrative issues. I am working in one of those clinics now, and can’t finish my day despite no shows because of my dogged insistance that I know what the meds I’m prescribing are for, and sometimes even agree that the they are appropriate. The patients act like they don’t have to answer any questions and I suspect with the doctor excess in the area other providers have contributed to that problem. Oh yes we’re in a shortage area because there’s very few doctors who want to do good comprehensive care. But there’s plenty of docs who want to see you freqently for small things, or at least they behave that way with a pill for every complaint and no comprehensive problem list on their chart. We have to pay less for these visits and start paying per minute to change that. I would never sign an RVU contract in a system that calls it complex to have am MA do the PMH and overextensive ROS but the cumbersome EMR makes every previous notes so meaningless a 15 min service takes an hour.

    In Canada where there’s a true physician shortage you can make a good living getting $33.00 before overhead on most visits providing good care, because the patients and ER docs and hospitalists and specialists expect you to do it and the urgent cares aren’t trying to create repeat clients handing out antibiotics and opiates. The patients are a cross section of society, don’t doctor shop, and are pleased when you ask a few questions before you pull out the prescription pad. As long as specialists do 40% of the primary care, don’t report to us, and patients with choices mistakenly believe that’s better, while primary care gets the patients who have trouble getting to the point or think they shouldn’t have to, and simple visits pay more per minute than complex visits done and documented well, good primary docs will always struggle whoever controls their pay.

    • August 26, 2012 at 8:30 pm

      The powers that be should read your post.

      • Doug Farrago
        August 27, 2012 at 8:18 am

        Don’t put money on it.

  4. Pat
    August 23, 2012 at 9:15 am

    I spent years excited about doing family medicine, genuinely convinced that it would be the best fit for me. Several years in I found that (1) it is very, very tough to make a decent living commensurate with the level of investment and work required; (2) the constant whining over trivial complaints, expectations for magic fixes, and the (learned) need to regard every patient as a potential threat sucked out whatever fun I thought I was going to find. Other than that, it was great.

  5. Kurt
    August 22, 2012 at 4:13 pm

    The days of Family Medicine are numbered as we know it. Current folks like the above are lucky to find the niche market. Oh BTW, one still has to do that MOC crap even if one doesn’t even perform that crap they are being tested on anymore. As it stands, the rise of the NP’s is on the horizon. With the loss of hospital practice and continuity of care, that phase of medical care is coming to a close. Medicine is going towards shift care. ie. “Don’t die on my shift!”
    If that is the case, Family Medicine is a dinosaur and no longer serves a need. We’re expected to “cure” everyone and not get re-admitted in 30 days. Well, at least I had 25 decent years and having to just deal with office stuff might be not as stressful. With Geriatrics it takes more time to do a quality job with a concomitant
    drop in income. “Ain’t no money in old people.” But it’s where the
    world is headed. Old time FP R.I.P.

  6. Charles Lipson, M.D.
    August 22, 2012 at 1:48 pm

    A Net of 50$ per patient is not too bad. Probably comes out to $1000 to $1200 per day. Still a poor return for the investment made, but better thab the average GP net. The biggest problem will be the culture shock of working in a health center. The vast majority of patients are of very low class and or immigrants who just think differently than we do. I speak from experience. I volunteered at no salary in such a center and it is tough.

  7. Jeff Mack, MD
    August 22, 2012 at 12:27 pm

    I work in a cash only weight loss clinic and see up to 45 patients in an 8 hour day. The length of visit can be as short as 3-4 minutes for followups who are doing well and up to 30 minutes for an initial encounter with a complicated patient. I also perform BoTox injections and hormone pellet implants which require a minor surgical procedure. I receive a straight $18 per patient.

    Broken down to an hourly rate, it amounts to between 75 and 100 dollars per hour. To me the pay is adequate albeit not great. The advantages, however, involve no Sunday or holiday hours, no after hours call, no fighting with insurance companies and minimal paperwork. It’s a nice little niche.

    In a true family medicine clinical practice where one sees 15 to 20 patients daily, I think $50 per encounter would be excellent pay. That still leaves $50 to cover the clinic’s overhead, but would not leave much to pay for the administrator’s Lexus. Therefore, I doubt this pay model will be given serious consideration.

  8. J. R. Johnson
    August 22, 2012 at 10:48 am

    I am happy as a clam in solo practice taking the common insurances (including HMOs) in my area. I am board certified as a internist but have a hospitalist do my in-patient work as it helps tremendously with life style issues. I see 20 patients in 8 hours and take home over 100% more than I did when I saw the same number of patients while being employed by a large healthcare organization. I have some business issues to deal with but I find that I enjoy that part of being solo. 50 dollars per patient would be a significant pay cut from my current income. I have no administrators to tell me how to practice and my hand picked office staff is a joy to work with. I keep hearing that solo practitioners are a dying breed, but I find this practice style to be very rewarding and would never think about going back to an employee position.

  9. jim kelly
    August 22, 2012 at 8:55 am

    heres a better idea. feds contract with only primary care docs upon board certification to pay the median salary of all physicians ( aabout 350k). guaranteed for 20 years. in return primary care docs have to see 4000 wrvu/year. if you see fewer, you get taxed at a higher rate on the 350k. if you see more, you get to carry over the surplus to the next year. lifetime wrvu 80000 wrvus then can retire with same benefits as military. patients pay nothing and can vote with their feet. if youre a crappy doc or there are too many of you in beverly hills, you dont make your annual wrvu quota. you want to work in rural america, you get paid the same as the guy in nyc. takes out primary care medicare, medicaid, insurance companies, hospital suits, maldistribution of physicians, encourages residents to enter primary care and lets patients vote with their feet (capitalism at its best).

  10. Don
    August 22, 2012 at 8:53 am

    I have been running an independant practice for 30 years. In the best of times the overhead hasn’t gotten under 60%. Anyone paying me $50 per patient and only getting $100 per patient would be losing money. So……………it isn’t going to happen in the setting you described.

    • Doug Farrago
      August 23, 2012 at 2:59 pm

      If there was NO billing, no coding, no insurance at all the why would the overhead be that high? Let’s say you opened a small office that just charge $75 a visit. Why couldn’t you get your overhead down to $25 on each patient? That would include MA and a front staff person.

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