Dr. Aaron Bornstein paused, his energetic steps halting at the threshold of the room as his eyes skimmed the medical chart he had plucked from a basket on the wall. Then he opened the door.
The 5-year-old girl had come to Middleboro Pediatrics in Lakeville for an annual visit, and Bornstein began with a barrage of questions to her mom. His fingers typed furiously as he asked about a range of topics, from swimming safety, sunscreen, and bedtime, to reading, sharing, and school. He turned to the girl, asked about rhyming, counting, concepts of time — milestones in childhood development. He moved from behind the computer and checked her ears as he asked if she could tie her shoes.
After the half-hour visit, he made his way to the next, another well visit with a pre-teen, standing in the room with his mom. Now at a different computer, Bornstein went through a different list, tailored to the patient’s age — family history, vitamins, sleep, puberty.
Bornstein flit from room to room that morning, seeing his usual 15 to 18 young patients during his 12-hour day, murmuring questions and answering inquiries from his staff in the corridors between visits. The hallway walls were printed with overlapping letters of the alphabet, a jumble that seemed to mirror the myriad thoughts and tasks cycling through Bornstein’s head.
Bornstein’s father had started Middleboro Pediatrics 46 years ago, and it was now a fixture in the community. The practice’s four physicians and three nurse practitioners serve approximately 4,600 children and are medical consultants to seven districts’ school systems, as well as for child care and summer camp programs at multiple local YMCA branches. It has been repeatedly recognized by the nonprofit Massachusetts Health Quality Partners for excellence in pediatric preventative care.
The practice was busy this day; it is always busy. And yet it is struggling, straining under the weight of unprecedented financial challenges, including rising Medicaid enrollment and steep labor and supply costs. Simultaneously, it’s had to cut down on the number of patients it sees each day due to staffing shortages and longer visits by patients with increasingly complex conditions, including, ever more commonly, mental health concerns among pre-teens and adolescents.
This is the story of many independent pediatric practices in Massachusetts today. Serving the health of children has never been more vital — as patients require increasingly complex care. And many practices, particularly those caring for high numbers of patients on Medicaid, say they cannot sustain the work. In the Southeastern part of Massachusetts, the number of pediatric primary care practices has dropped nearly 10 percent in the last decade, according to data from Massachusetts Health Quality Partners a nonprofit focused on improving patient experiences. In addition, many hospitals have shut units that serve children, requiring Bornstein to spend additional time seeing patients turned away at hospitals and sometimes consulting with hospital physicians on urgent cases.
So much is at stake, starting with access to care for some of the state’s most vulnerable children. But also at risk is a way of life, a small practice seeing children over multiple generations, providing comfort to families while meeting a child’s medical, developmental, and social needs rather than meeting a quota of visits per hour.
Bornstein knows his practice is better off than many in his region. Though independently owned, it is part of a network of practices and is affiliated with Mass General Brigham, the largest health system in the state. That has helped Middleboro Pediatrics negotiate some of the most favorable reimbursement rates from insurers. If he is struggling, he often thinks, what does that mean for others?
Bornstein looked over the medical chart for a 16-year-old girl, who sat on his exam table as her mom stood nearby. The teen had lost 55 pounds in the previous 18 months because of vomiting and stomach pain.
Bornstein’s graying hair was pushed back from his face, his eyes scanning the computer notes through dark-rimmed glasses. He was concerned not just about her health but also about her ability to access care in the coming months.
The teen was enrolled in MassHealth, the state’s Medicaid program, which due to the expiration of pandemic policies was in the process of reviewing all of its members’ eligibility. Her mom, he knew, should have been receiving notices to update her information with the insurer. He asked the girl’s mom, Rebecca Andrade if she had received anything from the insurer, but she hadn’t, not for a long time.
That was concerning to the doctor. Approximately 43 percent of Bornstein’s patients are enrolled in MassHealth — a share that has increased progressively from 12 to 14 percent in 2006. The state expanded MassHealth eligibility in 2006. Since then, the numbers have ticked up in lock step with the crisis of the moment — the 2008 recession; the COVID pandemic, when many parents lost jobs and businesses; and the opioid epidemic, which placed many children into the custody of their grandparents, many of whom live on fixed incomes.
“MassHealth is important, not simply because they help serve patients who have low socioeconomics. It is the main payer for a lot of our medically complex kids,” Bornstein said. “The kids who need the most care and expertise are typically on MassHealth.”
Pediatrics is rarely a lucrative field. Even commercial insurers pay less toward care for children than for adults, Bornstein said. MassHealth insurance follows a similar pattern, but is even more stinting. In one model, MassHealth pays around half of what commercial insurers pay, according to Bornstein. Even though MassHealth patients make up over 40 percent of Bornstein’s business, historically they account for approximately a quarter of his revenue.
MassHealth is a huge force in the market, the insurer for almost half of all children in the state. And yet, practices working with higher portions of patients on Medicaid are “actively losing money,” said Dr. Mary Beth Miotto president of the Massachusetts Chapter of the American Academy of Pediatrics. Independent practices, which aren’t owned by larger health systems, cannot subsidize those losses with adult care or hospital care.
“Because of the reimbursement issues, I think practices like ours are slowly being strangled,” said Dr. Howard Kay, president of Brockton Pediatrics.
A potential bright spot is that more patients may soon switch from MassHealth to commercial insurance. The state is attempting to move people off MassHealth insurance, auditing its rolls for the first time in three years, due to the expiration of the pandemic policies on April 1, which had prohibited states from kicking people off MassHealth during the crisis. The governor’s office has predicted that the process will remove 300,000 people, or 12 percent of the current rolls, who now earn too much to qualify, forcing families to move to higher-reimbursing commercial plans.
But Bornstein had a different outlook, worried that some of his patients, like Andrade’s daughter, will slip through the cracks and lose coverage altogether. Such fears have proved real in the past. (A spokeswoman for MassHealth said in an e-mail that the state was committed to making sure residents remain covered.)
If his patients lose insurance, that creates a business problem for him, but a real crisis for children who need his care. Bornstein said he will, and is required to, care for sick children with an urgent issue, regardless of whether they had insurance. But he wouldn’t be paid.
Bornstein’s blue face mask pulsed in and out as he encouraged Andrade to reach out to MassHealth, to make sure she wouldn’t lose coverage in the midst of her daughter’s complicated medical diagnosis.
In the room with the teen, Bornstein spoke to another concern. She had been off her anxiety medication for a bit, after struggling to stay connected with her psychiatrist. He recommended Andrade push harder to get the psychiatrist to update her daughter’s prescription, and if she ran into problems, to call or message him so he could help.
Treating children with mental health diagnoses is increasingly required of pediatricians, but providing that care comes at a cost, given the low insurance reimbursement rates. One commercial insurer pays 30 percent more for a wart removal than for a typical office visit for depression, according to Bornstein.
Indeed, pediatricians find themselves responding to many health needs that, in an adult population, would likely be addressed by specialists.
“I’m not only the pediatrician. I’m the psychiatrist, I’m the developmental specialist,” said Dr. Cheryl Greenfield, president of Gleason & Greenfield Pediatrics in Marion. “Those are technically specialty care visits and should reimburse at a higher rate because they are longer. But in the pediatrician’s office, it is all paid like a regular medical visit.”
With visits often stretching longer, Bornstein’s practice struggled to make up for lost patient volume. March was going to be the month the practice had enough staff to finally resume its pre-pandemic hours on weekends. Then several employees left or went on leave.
Longer visits, meaning fewer visits, have hurt revenue, even with help of some federal grant money. Revenue at Bornstein’s practice was down 20 percent in 2020 and again in 2021, compared to pre-pandemic levels. Last year revenue was still down 10 percent compared to pre-pandemic levels.
At the same time, expenses have ticked up. The practice must compete against other industries to hire staff, and is paying more to recruit and retain them. Salary costs have swelled by 20 percent over pre-COVID levels. Medical supplies have likewise grown more expensive.
“Everything we do costs more, and yet the revenue on the other side of the equation has not budged,” said Dr. Jesse Hackell, chair of the American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, and a president of one of the New York State chapters of AAP. “That’s what has created a problem. Ten years ago, the problem wasn’t nearly as acute.”
Hundreds of practices, including Bornstein’s, are experimenting with a different approach that may help. They have joined a MassHealth program that offers a lump sum per patient per year, instead of paying for each individual patient visit. The state said the program will likely increase revenue to participating practices, though some practitioners are skeptical.
Facing so much uncertainty, many physicians said they have pulled back on the only area within their control — their own salaries. Bornstein has reduced his compensation by a fourth, compared to pre-pandemic levels, though he was working longer hours. His partners also reduced their compensation. Now all were earning below the state’s average pediatrician salary of $197,800, despite their years of experience.
Already, pediatricians earn toward the bottom end of the range for physicians in the state, according to data from the Center for Health Information and Analysis. The average family medicine physician — who treats patients of all ages — earned $259,460 in 2021. Physicians in other specialties earned on average as high as $351,310.
One night, the parents of a newborn called Bornstein’s practice, worried when they found it hard to wake their infant to feed. The physician on call told the parents to bring the baby to the ER. They went to the closest one, but it did not have pediatricians on staff.
The ER doctor on duty that night examined the child, but sent the baby home. The next morning, the parents came to Bornstein’s office, and the baby had signs of sepsis, an extreme response to an infection that, left untreated, can lead to organ failure and death. Bornstein had to call an ambulance and negotiate with the EMS crews to bypass the nearest hospital, bringing the child instead to a hospital with pediatric expertise.
“The [physician in the ER who cared for] the baby is an experienced doctor. But once these hospitals lose pediatric people, they don’t have someone to bounce an idea off of. You lose expertise,” Bornstein said. “If we weren’t here ... that kid might have died. It probably would have died.”
Hospitals across the state have increasingly shuttered pediatric programs, and the number of inpatient beds available to accommodate children has declined — from 1,181 in 2016 to 979 in 2022, according to Department of Public Health data. Those drops have made the presence of pediatric practices in the community all the more critical, Bornstein said.
And yet, there are fewer of them. In the last 10 years, the number of pediatric primary care practices in the state has declined 5 percent, dipping from 677 in 2013 to 645 in 2023, according to Massachusetts Health Quality Partners data. Of the practices that remain, 40 percent have only one or two clinicians.
The declines could be a function of closures or of consolidation — or both. Before announcing last month that his Brockton practice would close this summer, Dr. Mark Hausman had attempted to get his business acquired by the parent company of Brockton Hospital. But Brockton Hospital has been closed since a fire at the hospital on Feb. 7, and the deal “literally went up in smoke,” Hausman said.
The practice, Alan Bulotsky, MD & Associates, had struggled to remain afloat on its own. Approximately 70 percent of its patients were on MassHealth. It had merged with another practice, but one of its physicians retired earlier than anticipated, another took a different job. The practice struggled to recruit to replace them.
The three physicians at his practice have since announced plans to join different offices, only one of which is in Brockton, likely leaving a geographic gap in access to pediatric care. Hausman hopes some of his patients will make the drive to his new Foxborough office to see him, but it is a long trip, especially for those without cars.
He saw the closure of his Brockton practice as the harbinger of a looming crisis, and testimony to how undervalued pediatric care is by insurers.
“There will always be people who want to do primary care pediatrics because of the non-economic value it has to us. But that doesn’t pay your bills,” Hausman said. “It rewards you at night, saying ‘I did well by this family today, made this kid’s life better.’ That has value for those of us who do it. But I can’t tell the person to whom I pay my car payment, I discovered a kid’s leukemia today; is that worth anything?”
Creating larger pediatric physician practices may help by introducing economies of scale. But there is a risk on this path: the potential waning of the personal touch so vital to the specialty. Hackell, of the American Academy of Pediatrics, said that at larger physician practices, particularly those owned by private equity or insurer groups, doctors are pressured to see more patients per hour, giving them less time to form a bond. Patients unable to access care may turn to urgent care centers, which don’t offer comprehensive care.
“If people are willing to have their health care be episodic care, and no continuity and no relationships, they will get that,” he said. “But I don’t know if they will be satisfied by that for long.”
Despite the rigors of his day, and as harried as he felt, Bornstein took his time with patients, even if visits stretched beyond the mostly 15-minute slots. It allowed him to cover topics beyond their most recent complaint.
He looked inside Tatyana Robinson’s ears, as the 4-year-old sat on her mother’s lab.
“Let’s see if there are any Easter bunnies in this ear,” he said. The girl had a minor ear infection, and he prescribed antibiotics.
The child would be back in two weeks for her annual visit, but that didn’t stop Bornstein from talking with her mom, Keisha Robinson, about other aspects of the girl’s health. He pointed out that their town didn’t have fluoride in its water, and suggested Keisha ask for a fluoride treatment at Tatyana’s next dentist appointment. He followed up on Tatyana’s eczema, and other recent illnesses. He then helped Keisha reset her password to access the patient portal online, so she could message him or her daughter’s specialist with any questions.
“Tatyana, you did a great job. You ready for a sticker?,” Bornstein asked the little girl. Then he opened the door, and was on to the next.