SANFORD, NC — Before the coronavirus pandemic, Dr. Andrew Bush treated about 1,000 patients a month at his orthopedic practice. Now he is contemplating bankruptcy.
The surgeon is among the dwindling number of independent physicians in the U.S., where doctors are selling their practices to behemoth hospital systems or leaving the profession altogether.
“I don’t want to give up, because I’m a fighter,” said Bush, whose practice, Central Carolina Orthopedic Associates, serves a blue-collar town of about 30,000 people. “But our summer numbers were very poor. I don’t know what’s going to happen.”
Personal safety risks and pandemic fatigue have played a role in some doctors’ decisions to retire or sell their offices to giant hospital systems, an outcome Bush is trying to stave off.
But some doctors and experts say the trend also shows how billions of dollars in federal aid favored large hospital systems early in the crisis, even as lawmakers vowed to fight consolidation.
“The rich got richer, and the poor got poorer,” said Gee Bai, a professor of accounting and health and policy management at Johns Hopkins University who reviewed how much relief money went to North Carolina’s large hospital system.
The infusion of public money allowed big chains such as Atrium Health, a regional system headquartered in Charlotte, and Durham-based Duke Health, to post bigger profits or pursue mergers.
“If you have the strength and courage to hold on as an independent physician, your life is going to be tough,” Bai said.
Bush’s practice has had financial problems even though he received $300,000 in federal Covid relief aid to help both hospitals and smaller operators afloat. He stopped most in-person visits and canceled surgeries at the start of the pandemic, worried that patients might catch the virus.
As an independent physician in a city where the poverty rate is nearly double the national average, Bush said his prospects are dire even after society returns to normal. According to the US Census Bureau, about 15% of Sanford residents under the age of 65 lack health insurance.
Bush said patient visits have recovered to only half of pre-pandemic levels as residents struggle with high inflation and can’t afford to see a doctor.
According to a nationwide survey conducted by the Physicians Foundation in 2020, approximately 8% of physicians closed their practices in the first months of the pandemic, and an additional 4% planned to do so.
Grants, loans and other support intended to help hospitals and doctors stay solvent went unnecessarily to wealthy hospitals that didn’t need the money, such as independent practices and struggling rural hospitals, according to two state research reports and interviews with academics and doctors. .
The US Department of Health and Human Services, after multiple requests, did not make an official available for an interview to discuss how the Covid funds were distributed.
Despite the federal government’s reluctance to answer questions about the economic impact of distributing Covid relief, some analysts say the results are visible in places like North Carolina.
A state treasurer’s report found that North Carolina’s seven largest hospital systems received $1.5 billion in Covid relief money while collectively increasing their cash and investments by $7.1 billion from 2019 to 2021.
For example, Atrium Health received the most money in the state, including $589 million in Covid relief aid and $438 million in a type of emergency Medicare payment that boosts the hospital’s cash flow by paying in advance for future services. The report found that Atrium will have a net gain of $1.7 billion in 2021 following a merger with another hospital system.
Atrium responded to multiple emails requesting comment.
Bush said the Covid relief aid helped him cover the salaries of 13 of his employees. He said this assistance does not cover the loss of canceled surgeries and office visits.
Bush would not provide numbers but said his practice has not been profitable since at least 2018.
At one point during the pandemic, Bush said, his practice turned to telemedicine and saw fewer than five patients a day.
Bush, 59, said he can’t retire because his practice is in debt. Bush may be willing to sell it but said he has received only one preliminary offer for $200,000 from a statewide hospital system. That proposal was eventually withdrawn.
Asked whether he would advise young doctors to open an independent practice, Bush said, “Absolutely not.” He said the burden of fighting insurance companies for payment and the low reimbursement rates the government offers to treat low-income patients are too much for most doctors to overcome.
About a third of residents in Lee County, where Sanford is located, rely on Medicaid, a taxpayer-supported program that helps low-income people pay for health care, according to data from the state’s Medicaid Tracker and the Census Bureau.
“If I could go back 30 years, I wouldn’t be a doctor,” Bush said. “Looking back on life, it was the wrong choice.”
President Joe Biden has pushed the Federal Trade Commission to fight consolidation in the health care industry. In an executive order issued last year, he said, “hospital consolidation has left many areas, particularly rural communities, with inadequate or more expensive health care options.”
North Carolina has the most integrated health care system in the nation, according to a 2021 KHN analysis of 2018 data from the federal Agency for Healthcare Research and Quality. About three-quarters of the state’s hospitals belong to a large system, the analysis found.
Federal and state antitrust laws are supposed to ensure competitive markets benefit consumers. Researchers have repeatedly warned that consolidation in the healthcare industry is driving up medical costs while showing no clear evidence of improved care. A 2012 report by the Robert Wood Johnson Foundation found that when hospitals consolidate in highly consolidated markets, prices often increase by more than 20%.
The Medicare Payment Advisory Commission, which conducts research for Congress, said in a 2020 report that most markets nationwide are dominated by a single hospital system and that this leads to higher prices.
The North Carolina Healthcare Association, a group that lobbies on behalf of the hospital, declined an interview request. In a written response to questions from KHN, spokeswoman Cynthia Charles said the public benefits when hospital systems purchase independent practices. This ensures access to primary care in the community at a time when small practices are struggling to survive, Charles said. He said he could not provide data on the impact the merger has had on prices.
“We trust our members to make the right decisions for their communities,” he said. Charles added that consumers should be more concerned about large commercial health insurers using market power to obstruct care and delay payments to medical providers.
An analysis of results from an American Medical Association 2020 survey found that for the first time since the group began tracking it in 2012, most doctors do not work for physician-owned practices. The analysis cited the financial impact of the pandemic as a factor.
The loss of independent physician practice threatens to fundamentally reshape the historic relationship between doctors and patients as more doctors become beholden to their employers rather than the people they treat, said Duke University law professor Barack Richman, who studies antitrust law and health care policy. .
Research shows that when doctors work for a hospital system, they refer patients for more tests and more intensive treatment, which means higher profits for the hospital, Richman said. “Studies show that physicians practice differently,” he said. “You no longer have competition to keep patients based on the quality of physicians.”
Bush said he always dreamed of being an independent doctor who would answer patients’ questions and spend time getting to know them. He has worked at Sanford long enough that he deals with multiple generations of some families.
But Bush said he knows remaining independent will be difficult.
He began a new focus on bone care for patients but found that the government would not cover the full cost of the test and that many patients could not pay $60 out of pocket.
“It’s a poor, salt-of-the-earth community, and nobody cares about them,” Bush said. “If we close, they may have to drive 50 miles for care. They are not able to provide gas.”
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