Running a private medical practice in Connecticut has likely never been easy, but now there are signs that pandemic pressures may have hastened some practices to shutter.
Mark Thompson, the executive director of Fairfield and Hartford County Medical Associations, said that since the pandemic began, his association has fielded a higher number of calls from physicians asking for names of consultants to evaluate and negotiate the sales of their practices.According to Thompson, most cited the pandemic as the last straw. The doctors were unable to sustain themselves financially, and, in some cases, weren’t even able to obtain the necessary medical supplies and PPE for their practices.
“What they were saying to us was, ‘The COVID virus situation just pushed us over the edge,’” said Thompson.
It’s a trend that to an extent confirms a report last month in the New York Times that doctors across the nation are retiring or closing private practices.But in Connecticut, the virus may simply be exacerbating a trend that began long before the pandemic hit.
Dr. You Sung Sang, president of the New London County Medical Association, said that there aren’t a lot of private practices left in New London County. Many, he said, were bought up by hospitals this year, not because of COVID, but because the cost of malpractice insurance and Connecticut taxes make it difficult for private practices to sustain themselves.
“It’s much harder now for small practices to survive,” said Sang.
A 2018 report by the United Health Care Foundation listed Connecticut as having the fourth highest number of primary care physicians per 100,000 residents in the nation. However, Thompson suggested that this has more to do with the state’s location than with its conditions for practicing medicine.
According to Thompson, bureaucratic procedures like insurance policies and dealing with electronic records systems are some of the things that push doctors out of private practice.
“They love the clinical aspect of things,” said Thompson. “It’s the administrative items that are just wearing them down.”
Administrative tasks and large networks
Sushil Gupta, a pulmonologist and member of the Sleep Disorders Center of Connecticut, a private practice with four locations, has been a private practitioner in New Haven since 1997. He said he hasn’t seen anyone in the area choose to go into private practice in about 15 years.
According to Gupta, part of the reason is that insurance companies have periodically tried to drop coverage for private physicians.
In 2013, the U.S. Second Circuit Court of Appeals issued a temporary injunction preventing United HealthCare from dropping coverage of over 2,000 Connecticut physicians. In October 2019, Anthem announced that it was dropping a number of physicians from one of its networks, although it refused to say how many.
Kristin Mahan, a family nurse practitioner who runs a private practice in Uncasville, said that the pandemic exacerbated the challenges with the insurers, who at one point, she said, refused to reimburse copays. Mahan said she ended up having to get the state involved.
“I pay a staff person a salary … $34,000 a year, to fight with insurance companies. And I think that’s criminal,” she said.
There’s also the routine costs of running a small business, things like hiring staff, paying rent, and being responsible for meeting OSHA regulations.
Maryann Bentz, a dermatologist in New London who has been in private practice for 24 years, said she thinks that operating a private practice anywhere is a challenge. But in New London County, she said, the dominance of the large healthcare networks and their tendency to “swallow up” smaller practices make things even more difficult.
“They’re battling buildings from Hartford HealthCare and Yale,” she said. “These two kind of corporate, massive, big-brother institutions.”
Then came the pandemic
At the start of the pandemic, said Sang, many physicians in private practice — Sang included — shut their doors for 6 to 8 weeks. Even groups that remained open saw significantly fewer patients.
Bentz said she was seeing about a third of her normal patient volume in the spring. She also said that she was seeing patients come in with more urgent needs, like lacerations and cuts that needed stitches – problems they would normally take to the emergency room. They came to her with these issues out of fear of being exposed to COVID.
The drop in patient visits resulted in significant financial losses for small operations, according to doctors contacted by CT Examiner, and most said they applied for and received PPP loans, which were essential for keeping their practices afloat. They also learned to adapt, most turning at least partially to telemedicine — although distance medicine was not equally adaptable to every speciality.
Mahan said that they administered flu shots and tetanus shots to people in their cars and her practice offered COVID testing, which brought in new patients. In the summer, they rushed to bring people in for in-person physicals before the expected second wave hit in the fall.
An additional challenge for doctors was the competition with the larger health care companies for supplies — a challenge which in some cases remains. Bentz said that at the beginning of the pandemic, she was making her own hand sanitizer. Gupta and Mahan both said they couldn’t obtain gloves — Mahan said that she ended up receiving 10 boxes from the Montville Fire Department. Mahan also said she wasn’t able to obtain COVID rapid tests, meaning that her patients had to wait two days before she could clear them to come into the office.
“My biggest frustration is that because we are a little private practice, we were invisible to the state,” said Mahan. All the resources, she added, were allocated to Yale and Hartford HealthCare, the two major health care corporations in the area. She said she’s concerned that when the vaccine becomes available, the state will not distribute doses to small practices like hers.
Gupta said that he hopes PPE will become easier to access — he’s still having trouble getting a hold of medical-grade gloves.
He also said it will be important for the legislature to require insurance companies to retain the current reimbursement rates for telehealth visits beyond the length of the pandemic.
“Telemedicine, in my opinion, is here to stay,” he said.
A personal touch
At its core, private practice is a philosophy — one that provides a more personal model for care. The doctors who run private practices say that it has huge benefits both for themselves and their patients. They point out that patients who call can talk to a person rather than an answering service, someone who understands their individual needs.
“We still treat our patients the way they would want their mothers and their sisters to be treated,” said Bentz.
Gupta said he thinks it’s important for patients to have a choice of which doctors they want to see, rather than being bound to the one health care provider in the area.
“To me, taking care of the patient is a personal touch,” said Gupta. “I don’t want to be providing care just by the number, I want patients to be able to talk to me directly.”
Gupta said that he is spending more time after hours on the phone with patients, answering questions about what it means to be exposed to the virus, and counseling patients who are having lingering symptoms. He also said that more and more people are turning to medications for help dealing with their anxiety.
“I have never written that many prescriptions in my life,” he said. “Patients, family members, doctors — all are going through significant pain.”
The doctors also spoke about how important it was to be in charge of their own schedules – deciding when and for how long they will spend with their patients. Larger corporations, she said, set quotas for how many patients a doctor should see per day, which limits the length of patient visits.
“There’s really high burnout with that expectation,” said Mahan, “and I think patients are at risk.”
Mahan said that private practice allows the physicians to have a better work-life balance, and they leave the patient feeling happy.
“[We] go home at the end of the day knowing that we did a job well done, not just that we did a job,” she said.