Doctors’ pay rises with new patients

‘Social obligation’ cited for access to Brigham, MGH

Getting in to see a primary-care doctor at Massachusetts General and Brigham and Women’s hospitals has for years been notoriously hard, with many popular practices closed to new patients. But now, reflecting dramatic shifts in health care, the prestigious hospitals are paying doctors more if they agree to accept new patients.

The Harvard-affiliated hospitals are tying about 10 percent of doctors’ salaries this year to the size of their practice and the complexity of their patients’ illnesses.That means the hospitals’ 360 employed primary-care physicians can increase their pay, now roughly $200,000 a year for those who work full time, if they see more patients than the average, or if they have many patients with multiple medical problems. Their pay can fall if they take care of fewer people.

The program is already having an effect when many patients have trouble finding primary-care doctors. Dozens of internists at the Brigham and Mass. General are bringing on one or two new patients a week.

Hospitals have “a social obligation to provide access to care,’’ said Dr. Timothy Ferris of Partners HealthCare, the parent organization of Mass. General and the Brigham. But he said the initiative is also intended to prepare for changes in how hospitals and doctors are being paid. As health insurers and government programs seek to control medical costs, they are increasingly paying providers based on their number of patients and how well they are cared for, instead of on how many services patients get.

Mass. General and the Brigham are hiring more nurse practitioners and physicians’ assistants to help doctors with the increased workload and to create a team approach they believe will improve medical care and help address a longstanding shortage of primary-care physicians. Existing patients may see their doctors less often as nurses and assistants take over routine care such as blood sugar checks for patients with diabetes, high blood pressure monitoring, “well baby’’ visits, and diagnosing skin problems.

The shift is an example of how widespread efforts to control medical costs and improve the coordination and quality of care are trickling down to individual doctors and their patients.

Internists and other primary-care doctors are already so pressed for time that they “feel out of control . . . like hamsters on a wheel,’’ said Dr. Joseph Frolkis, vice chairman for primary care at the Brigham.

They are in “survival mode’’ and not motivated to take on new patients, who are more time- and labor-intensive than existing patients, he said. Yet, many patients need doctors, and many practices need more patients to survive financially.

Partners’ push to open primary-care practices to new patients could also benefit its 60,000 employees, many of whom cannot get appointments with primary-care doctors in their own organization. Partners, the largest private employer in Massachusetts, just launched a new insurance plan that provides financial incentives for employees to get care within its network.

“So many practices were closed,’’ Frolkis said, and the only people who could get in to see popular physicians were those with connections. “We are taking it out of the realm of getting a favor,’’ he said.

Doctors were “pretty mixed’’ about the new salary plan, which started last year with a 2 percent incentive, said Dr. Katherine Sakmar, a Mass. General physician who works in Revere. “People were afraid they were going to lose money. I was afraid of that.’’

But she was pleased that the new system credits doctors like her who treat many patients with complex problems or mental illness. Previously, “everyone wanted to have the 30-year-old healthy lawyer; they came in once a year, had no medical problems, and required no paperwork,’’ Sakmar said. “No one wanted to see the retired 70-year-old with multiple problems and diabetes.’’

Her patient load was calculated to be close to the average of 1,600. But, Sakmar, whose practice had been closed to new patients, realized she could eventually make more money by adding patients.

Dr. Patricia Gibbons, a Mass. General internist who had not accepted new patients for a decade, began adding one new patient a week late last year, even though she has enough patients in her practice already to qualify for the incentive.

“What I have to balance is how much can I accommodate the request from the hospital, versus what would create chaos for my existing patients,’’ she said. Her practice is expecting help from nonphysician caregivers.

Some doctors like Sakmar and Gibbons are worried about being overwhelmed with requests, so they have not told the hospital’s physician referral hot line, which gets 200 requests a week for primary-care doctors, that they are adding new patients. Instead, they are taking requests that come into their offices, mostly by word of mouth.

David Cutler, a health care economics professor at Harvard University, believes the changes are good for patients, as long as the hospitals follow through on their promise to provide qualified nurses and assistants to help doctors and the doctors are willing to delegate work to them.

“What people are afraid of is a return to the managed-care era where the doctor has to see patients every seven minutes and gets frustrated,’’ he said.

Many hospitals and doctors’ groups are eager to grow for the same reasons as Partners. Insurers are increasingly putting providers on a budget to care for groups of patients, giving them the opportunity to make money if they spend less than the agreed upon amount, but also putting them at risk to lose money if they exceed it. Providers that can spread risk among more patients will have a larger cushion if some patients require very costly care. The Brigham and Mass. General have traditionally been high-cost hospitals, but Partners says the new payment models will help lower their costs.

Lahey Clinic in Burlington adopted a policy late last year that guarantees new patients an appointment in 48 hours. “Payment reform is part of the reason,’’ said Dr. Richard Nesto, chief medical officer. “Everyone is trying to get bigger. One way is to have more patients in your system.’’

Ann O’Malley, a researcher at the Center for Studying Health System Change, a nonprofit in Washington, D.C., said it will be important for expanding providers to monitor patient satisfaction, including whether they can get appointments when they need them.

“There is a caution here,’’ she said. “At what point does volume exceed capacity? How do you know when to stop?’’