Featuring Dr. Nancy Niparko, a pediatric neurologist, and host Brenda Gazzar on how common health insurance industry practices drove her to shut down her private practice. Can doctors stay in business when today’s reimbursement rates in some specialties can be lower than they were 30 years ago?
What’s driving U.S. doctors out of private practice?
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Welcome to Code WACK!, your podcast about America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar.
Why are physicians in private practice struggling today? What can be done to help make doctors’ lives easier so they can better help patients? To find out, we spoke to Dr. Nancy Niparko, a pediatric neurologist who once was in private practice and now works for Children’s Hospital Los Angeles doing outpatient clinics.
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Welcome to Code WACK! Dr. Niparko.
Q: You used to be in private practice. Tell us why you made the switch?
Niparko: Well, I transitioned three years ago from a private practice when I was part time at Cedars Sinai Medical Center. In private practice, medical insurance companies are essentially putting private practice out of business. That’s the way I sum it up. The reimbursements for what is called cognitive medicine has gone down over the last 30 years so that they actually pay less for a one-hour doctor visit compared to almost 30 years ago.
Cognitive means we don’t do surgery, so your pediatrician, your internal medicine doctor, your psychiatrists, they sit and they talk to the patient. They examine the patient. They explain diseases. So, psychiatrists kind of got it right early on. They started charging for a time, but the rest of us, even though most of what we do is talking with the patient or physically examining the patient without tricks, those reimbursements have actually gone down so that it’s really impossible to maintain a private practice unless you regularly spend three or five minutes with a patient.
Q: Uh huh. How has this changed over the years?
Niparko: Well, when I started out of training in 1990, what was paid for a routine, new consultation was more than you can get from almost any insurance company now, even the best ones. So, the actual dollar amount went down. That’s not to say that probably 80-90% of the managed care groups, even PPOs but they’re not paying the same amount , the $300 that was the going rate. In 1990, the numbers are somewhere between the high 20s to 40% of every health care dollar is kept by the medical insurance company.
Q: Got it. How do you feel about that?
Niparko: Well, it put me out of business because you could not maintain an office with all the fees that keep going up year by year, or at least decade by decade. You can no longer afford to do that. I can no longer. I held on for a long time, mostly working for free a great deal of the time and working very, very long hours, and it just made no sense. I had a few different offices that I would share with pediatricians to save money — and even pediatricians and internal medicine doctors, they supplement their income by what it costs for giving shots, immunizations and such.
But if you’re a neurologist like me and I really enjoy solving problems, and getting to the bottom of things, and sorting out all the information you have from other doctors before you can’t afford to do that. I just kept working harder and trusting secretaries and they tended to be overwhelmed and not very honest or open and so I got taken advantage by a number of people.
Q: Uh-uh. Do you think you would still be in private practice had that not been the case?
Niparko: I don’t think so. You have to understand that the rules set out by insurance companies kept changing, and you had to have a brilliant secretary, who worked very very hard and a nurse if you needed it. And those kinds of people can get better salaries doing something else if you’re that smart. I consider that part of the ploy of the healthcare system, that these medical insurance companies, they’re making deals with the devil left and right and different devils and to run after them and give them all the, give them the information they need, jump through the hoops they keep forwarding, people give up.
In fact, at one point, I had a very expensive bill collector who told me — she was wonderful. I wish I could have afforded to keep her but I couldn’t — she said that the standard medical insurance company routinely refuses the first application for payment from every doctor because they know a large percent of those doctors will never get it together or their staff won’t get it together to reapply. And a lot of times there’s nothing wrong with the bill that you submitted.
What happened and what the history that I wish people would understand is that it sounded so lovely in the mid 90s when businesses started to say doctors are not good business people, and we need to teach them how to be business people. So what happened is that you had these first managed-care groups come in, and I had colleagues, close colleagues who had been in the business for a while and they kind of liked it because they invested in some of these and there was a significant return on the investment dollar in the mid 90s with the move to HMOs and PPOs and all the managed care groups. But what happened is they made things more efficient, they squeezed more work out of people and the world keeps expecting that same return, and it can’t happen. It’s already been right down to ground level, I mean, the nurses, everybody is working very hard. There’s all sorts of crazy things that get done. Instead of having a registered nurse who is your nurse in the hospital and gets to know you and takes care of all your different needs and that’s too expensive. So instead you have some untrained person doing the bottom stuff maybe LVNs doing something intermediate, but what you do is you write out job descriptions to the exact detail, and then you can hire a less educated, a less trained person to do it and what the higher-up people do is end up spending all their time, taking notes to ensure insurance companies that those things were done, so that people can get paid. So, education and training is getting really wasted.
Q: So was that the straw that broke the camel’s back then?
Niparko: I think it was just time. I went on way too long, and you know, it sounds like I’m a doctor, I should not worry about money but you have no idea how even being a rather frugal person who doesn’t do much extravagant things, it became impossible. So I’m happy not to be worrying about the billing. It really comes down to insurance companies.
Thank you, Dr. Niparko!
Find more Code WACK! episodes on ProgressiveVoices.com and on the PV App. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for health care reform around the country. I’m Brenda Gazzar.
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