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Having to close your doctor's office: Why is it so hard to see a doctor? Why would you close a medical practice? What's it like to close a medical practice?
Lisa Egbert, MD, speaker for the AMA House of Delegates, talks about how the latest Medicare payment cut forced her to make the difficult decision to close her practice and what this means for her patients. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Lisa Egbert, MD, speaker, AMA House of Delegates
Transcript
Dr. Egbert: Does the average patient understand? Does the average person understand? I think they're getting the message as their physicians are leaving, because so many physicians like me, the independent, the small groups are just not having options.
Unger: Hello and welcome to the AMA Update video and podcast. We spend a lot of time on the program talking about the impact of Medicare payment cuts, especially in the face of skyrocketing costs and what that impact is on physician practices, and eventually, on patients. Well, it's not theoretical or hypothetical in its outcomes.
And today, we're going to talk to a physician who had to make a really difficult decision about her practice. Today's guest is Dr. Lisa Egbert. She is the speaker of the House of Delegates of the American Medical Association. And she's calling us today from Dayton, Ohio. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Egbert, Thanks so much for joining us today.
Dr. Egbert: Thanks, Todd. Happy to be here.
Unger: You have been taking care of patients in your community for almost 30 years. So the decision to close your practice has got to be incredibly tough. Can you just take us through what happened for starters?
Dr. Egbert: Well, first tough is putting it mildly. Probably one of the hardest things I've ever done in my life was closing my practice. Walking you through 27 years, it was a little challenging. But I think I can give you the short synopsis. And I'd be happy to answer further if you have more questions.
But the bottom line is, a practice is a business. And a lot of people don't realize that. They just think the doctor is there seeing patients and not really thinking about anything beyond that. And to be honest, most doctors think that way too. We don't really think about the business because all we want to do is take care of our patients.
Unfortunately, in small and solo practices and private practices, we actually have to think about the business. And what comes into the business is pretty simple. It's the fees that we earn by working as physicians. What goes out of the business that comes out of those fees is everything, everything else—what you pay your staff, what you pay in rent, liability insurance, electronic medical records, on and on and on.
And that is what we call overhead. And it grows and grows and grows over time, just like everything else. Thank goodness for good old inflation. But what hasn't gone up over the 27 years that I've been in practice is what we are paid, we—the practice—we, the physicians who are running this ship, who are the earners.
And if over time nothing comes in to balance what has to go out, you basically get to the point where you aren't making enough to make ends meet. And I will tell you, in my practice, I actually didn't even take home a salary for a couple of years. In the end, put some money in from my own savings trying to keep the doors open as I looked for ways to maybe find a way to keep practicing. And there just wasn't an option for me. And so yeah, I had to make that decision. I had to close the practice because I didn't have a way to keep it open.
Unger: That is just so heart-wrenching to think about. And I think your point there is, I'm not sure folks on the outside understand the payments that come in are going to pay your staff and keep the lights on, literally, and the cost of doing those things are just increasing dramatically. When you took the hard look at your books, so to speak, and you realize you are not going to be able to keep digging into your own savings to run your practice, what went through your mind at that moment?
Dr. Egbert: Find an answer. Doctors are problem solvers. That is what we do by nature. If you come in with a problem, we're going to try to figure out how to fix it for you. Well, I had a problem that I couldn't fix. And as a problem solver, I can't think of anything more frustrating than a problem that you can't fix. I ended up cutting some of my staff. Notably, I'd only had two and a half, two full-time and one part-time person at the end, but I had cut it down to that.
I moved my offices, so the rent was cheaper. I cut back on every service that I could, trying to make ends meet. I also looked outside and tried to see if maybe there was an alternative to have the hospital buy my practice—as many physicians do—or private equity group, or another source of income. But I think, in the end, I was just too small for any of those entities to be interested.
And when they look at my books, just like when I looked at my books, it was pretty obvious that the income did not cover the cost. And so it just wasn't worth it for them anymore than it was worth it relatively for me.
Unger: Now, you said earlier in our conversation, you're there to help your patients. And it's just such an important role that you play for them and in your community. That had to be tough news to share with your patients. What was their reaction?
Dr. Egbert: Oh, awful. It was one of the worst things I've had to do. Again, this whole experience has been one of the worst in my life. I sent an email out to them. And it was very difficult to write, difficult to send, and I think, I know, on their end, difficult to read. Over the two months after the email went out, before the office closed, as I was closing down the practice, literally every day, every patient, almost to a one, ended up in tears and hugs.
Every one of them said, "Can't you find a way to stay?" I got cards, I got letters, I got gifts, I got candy, I got a lot of tears. It was hard. It was really hard. It was like losing a loved one because it was losing a practice. And it was losing my identity as a physician. And it was really, really hard.
Unger: I can only imagine. And the relationship that your patients have with you, given your practice, must be very close. And that's really difficult. And the reality for even a town that's big, like Dayton, that has an impact when a practice shuts down. People need to find new doctors. That's not so easy in certain specialties, so to speak. And in the kind of timing that we're talking about, let's say, with a pregnancy or something like that.
Dr. Egbert: And getting harder and harder. As you and I even know, as a patient, it gets harder and harder to find a physician that's taking on new patients. So yeah, that was really difficult for me to lay on my patients. And you're right, these are patients that I have had for 27 years. I have delivered their entire families. I've delivered their family's families. I have seen daughters, people that I delivered in my practice who came back as patients.
So yeah, that was a hard thing to lay on them, in addition to not being able to be there for them. Dayton is not a huge town, but it's not a small town. It's somewhere in between. But that having been said, there are only a few groups left. And of the groups that are left, I think there were four physicians who retired the same year that I did.
So, the capacity for the groups, the physicians that were still seeing patients to take on all of those patients was very difficult. The group that I covered with actually couldn't even take any of my patients. So I had to pass them on to other groups in town that did have some capacity. I stopped doing OB the year before I stopped altogether because I didn't want any patient to be mid-pregnancy at the time that I was leaving. I couldn't do that to them.
One of the things that I loved most about being a solo OB/GYN was that I saw them from the minute they had a positive pregnancy test all the way through to the delivery and after. And I delivered 98%, 99% of my own patients. So that was one of the things I really loved about my practice, and I hate to see go.
Unger: We talk, again, a lot about access and the impact of Medicare payment cuts, increasing costs on access. It really hits home when you tell the stories that you do, which just means these patients, that they're cut off from their traditional provider and they may not be able to find someone that they trust as much or close to them in the community. Do you think other people out there in the circles are understanding now what the ramifications are?
Dr. Egbert: I can certainly say my patients are understanding, especially my Medicare patients. I had Medicare patients since who saw me for 27 years, literally from the start of my practice, several of them coming from over an hour away because they wanted to come to a female OB/GYN and were willing to drive to do so.
My oldest patient at the time that I retired was 98 years old. Super sweet patient. I saw her at least four times a year to take care of a very specific thing that I won't mention here. But something that actually a lot of OB/GYNs don't do. And so she loved that she found me, that it was something that I was comfortable doing and doing for her.
It was hard to say goodbye to her. Very hard to say goodbye to her. So yeah, one by one, patients understand. Does the average patient understand? Does the average person understand? I think they're getting the message as their physicians are leaving, because so many physicians like me, the independent, the small groups are just not having options other than to be bought up by a hospital or a private equity or somebody else because the money just doesn't add up.
It just doesn't make sense. And that's too bad. That's too bad. Losing that small town doctor, that small one-on-one practice, I don't think we're going to get that back.
Unger: Yeah, my mother lives in a different part of Ohio from you, but same thing. Primary care physician office goes away. Relocating to another doctor is not so easy when a lot of them are not able to take on any more patients.
Dr. Egbert: And Medicare is the worst. I mean, Medicare is the thing that drives all physician fees. Every insurance company bases their payment fees, their fee scale on Medicare. And Medicare, over the entire 27 years that I was in practice, and then some, has not increased their rates to physicians. In fact, if you compare it to inflation, they decreased by over 30%.
How can you do that? How? How can you keep—how can you make ends meet when what comes in is decreasing and what is going out is increasing? I mean, I'm not a business major. Fully admit it. No doctor is. But even I can understand that those bottom lines just don't add up.
Unger: Well, I have to say, listening to your story and others that are like this, it has a lot of impact. And we know how valuable it is for legislators who are looking at things like Medicare payment reform to hear from you when they're making decisions that impact medicine. If you could just communicate one thing to legislators to hear right now, what would it be?
Dr. Egbert: The Medicare physician fee schedule is broken. It does not work for physicians. And more importantly, it does not work for the patients that we serve. You need to fix this now and fix it permanently. There is no alternative.
Unger: Now, coincidentally, of course, with your leadership position in the AMA, you've been a fundamental part of our top priority focus, which has been around reforming Medicare payment. Can you tell us a little bit more about what the AMA is advocating for and how physicians and patients can help?
Dr. Egbert: Sure. We have, first of all, a website called Fix Medicare Now. And I encourage all physicians and patients to go there and learn more about the crazy Medicare fee schedule and how it works and why it's stuck in Congress. And we all know how good Congress is at getting anything done.
The bottom line is, it's something that they need to understand and fix because there is no other way. It has to be congressional action. And so the AMA has been nonstop telling our congressional leaders. In fact, the doc caucus has been really supportive of us trying to fix this problem. We had a bill that was up and had hoped that it would be incorporated into the recent, or last year's, I guess, the end of the year's funding continuation, but it wasn't.
We had hoped that it would be in the most recent one that just went through, I think, a day ago, and it wasn't. At some point, it has to. And the point is now. Point is now before more physicians like me are forced to close their doors when they don't want to, and patients are forced to find a new doctor when they don't want to. And it's before there aren't enough new doctors for patients to find.
Unger: Dr. Egbert, thank you so much for joining us and sharing what you're going through. I know it's a difficult conversation to have. And really appreciate you being here.
In the episode description, you'll find a link to fixmedicarenow.org, where you can learn more about the issue and how you can get involved. And to support the AMA's efforts to reform Medicare payment, please consider becoming an AMA member at ama-assn.org/join.
That wraps up today's episode. And we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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