The Changing Field of Medicine: Exploring Alumni Perspectives with Peter Igneri ‘92 and Jill Pattison ‘12
By Charlie Woolsey ‘19
It’s a chilly evening in late October and I’m sitting across from Ward Castelli ‘21 in a Wiggin Street Coffee booth, providing a welcome distraction from his chemistry homework. I’m asking him to tell me what he doesn’t know when it comes to the medical profession, curious to learn the motivations and aspirations of a Kenyon pre-med student. Castelli grew up in a family of doctors and has always dreamed of entering medicine himself. While medical school has always been part of his plan, he’s still not sure as to what type of doctor he wants to be.
“[I] want to get as big of a metaphorical taste of all the possible career paths because once you’re in it (medical school, residency), it’s so expensive and arduous, you better know why you want to do it.”
In medicine’s quickly changing technological and regulatory climate, undergraduate students like Castelli are struggling to understand how the field is different from the career their parents’ generation knew.
According to Jill Pattison ‘12, DO, some of the biggest changes to the field are the financial and regulatory difficulties of operating in private practice and the subsequent decline of the primary care (PC) field. “It doesn’t make sense for a PC doctor to see 30 patients a day to break even,” she says. Pattison recently graduated from Ohio University School of Osteopathic Medicine and is a resident physician at Riverside Methodist Hospital in Columbus, Ohio. Her Dad was once a privately practicing cardiologist who experienced the shift toward consolidation firsthand.
“The main reason you see the transition [away from private practice] is the up-front cost that a small private physician can have, even with partners. You can’t make a profit from that,” Pattison says. Much of these up front costs include more required medical paperwork and negotiation with insurance companies, compounded by rising medical school debt. As a result, doctors are giving up their private practices and working as salaried employees for hospitals, even if it means having less autonomy and being limited by administrative superiors and insurance companies.
The most concerning aspect of the decline of private practice is the threat that it poses to the primary care field. Not only are doctors closing up their in-town independent offices and concentrating their services at regional hospitals, but fewer new doctors are actually going into primary care because it is less profitable than specialized fields. With the average medical school student graduating with around $150,000 in debt, specialized fields, which often pay twice as much as primary care, are considered much more attractive options. This incentive to specialize is rapidly impacting the distribution of talent as primary care physicians currently make up around 37 percent of all doctors. This number is especially concerning when one considers that 56 percent of all office appointments are made with a primary care doctor.
All of this has consequences for patients. A primary care physician often serves as a patient’s first contact with a health professional, and is responsible for the initial diagnosis of a health concern, referring patients to specialists if necessary. If the decline in primary care physicians continues, patients with potentially major health concerns may have to forego preventative treatment, potentially not seeing a doctor until they visit the ER with a much more dangerous health concern. As a result of the decline of primary care, “we have become an emergency medicine driven field. That’s bad for obvious reasons,” Pattison explains, as the ER should be reserved for true emergencies. Pattison believes that the reimbursement of primary care doctors has to change.
Clearly, the decline in the number of primary care doctors is transforming the landscape of medicine. But what makes private practice and primary care no longer profitable for most doctors? To find out, I talked with Peter Igneri ‘92, PA-C, MMSC, Vice President of Kaufman Hall & Associates, a healthcare consulting group. To Igneri, the changes come down to regulatory frameworks and the insurance companies which he says have made it “nearly impossible to make enough money and be in private practice as a primary care provider.”
When Igneri graduated from Kenyon in the 1990s, most providers operated under a capitated care system. Under the capitated care model, a primary care provider was paid for every patient enrolled in their practice regardless if they needed care or not. This discouraged doctors from providing more care than was necessary and kept costs down. Doctors were thus incentivized to treat patients as early as possible to avoid having to use more costly medical procedures. Under capitation, primary care was financially sustainable in private practice.
Starting in the early 2000s, the industry transitioned to the fee-for-service (FFS) model in place today. Fee-for-service means doctors make money not by members but by appointments. Igneri pointed out to me that the fee-for-service system presents a serious dilemma to the primary care profession.
“While it’s safe to say that nearly all doctors are concerned with the wellbeing of their patients, they also need to make a living.” Under the fee-for-service model, these two goals are positioned in tension with one another. This insight may help explain why there is a perceived drop in the quality of preventative care, because for primary care physicians, “it doesn’t matter what your outcome is, you make more money by seeing more patients,” according to Igneri. Less time with each patient can mean a limited ability to catch potential dangerous health condition early on, and a limited opportunity to build the doctor-patient relationships which often result in a patient being more likely to follow a doctor’s care recommendations.
The fee-for-service system has benefitted specialists, who can charge large fees per appointment. However, it has proven disastrous for primary care doctors, who now must fill their schedules with appointments to turn any kind of profit.
As for the future, Igneri sees more radical innovation on the horizon in the form of platform changes and cost transparency, shifting how medical services are distributed and paid for.
“Healthcare is routinely thought of as a content provider. You go to see a doctor because they are the content expert on medicine. You choose doctors based on their expertise.” But moving forward, “people are going to start choosing [healthcare] based on platform, because they are so used to that with things like Amazon. Amazon didn’t create the products that they sell, they created the platform.”
Platforms that connect consumers to the doctors that they need in a cost effective manner might succeed due to increased cost transparency, or the ability of patients to see how much they will pay before visiting a doctor under new health plans. This will allow consumers to compare the price of care at multiple locations and choose the best option available to them. Patients will have more mobility, siphoning money away from traditional hospitals and possibly back towards doctors in private practice.
“There’s plenty of room to improve our healthcare system. I like my job as a consultant [because] I can help solve these problems,” says Igneri, who continues to work as a physician assistant and was previously a hospital administrator.
“I think going into medicine is different today then it was 25 years ago, there’s no doubt about it,” he says. But considering where the field is heading, “I wouldn’t go back to yesterday. These changes have been painful but necessary in many cases.” For students like Ward Castelli and others pursuing medical school, these changes to medicine are both daunting and exciting. The career decisions of aspiring doctors will be much welcomed by a profession that is critically understaffed, especially in the primary care field.