Low Reimbursement Drives Primary Care Docs Away

A 32-year veteran, Dr. Earl Van Volkinburg, gives up his independent practice
The Lund Report

This is the fourth article in a series on the shortage of primary care physicians in Oregon. Also see Part 1,
Part 2 and Part 3. 

January 28, 2010 -- Primary care physicians are abandoning their practices in Salem. It all boils down to money. 

Dr. Earl Van Volkinburg, 65, has become the latest casualty. On March 15, he’ll close his Salem office after 32 years and join Kaiser Permanente two weeks later. It wasn’t an easy decision. 
“I’m one of seven internists to reach that conclusion,” he said. “The business enterprise of internal medicine is a failure. My income has been reduced to what I’d been making in the 1980s.” 
Simply put, the amount of money paid to internists by insurance companies hasn’t kept pace with the economic times. Meanwhile, administrative demands have spiraled, requiring more time to deal with prior authorization requests.    
Medicare has particularly hard hit internists such as Van Volkinburg. Insurers pay them between $38-48 for treating those patients (using a formula known as a relative-value unit), compared to $65-70 for people with commercial insurance.     
At the same time, insurers that offer Medicare Advantage plans such as Providence, ODS, Regence and Aetna have seen their bankrolls surge, said Van Volkinburg. The federal government pays them nearly $10,000 a year for every member for their administrative expenses.  
“I end up getting 4 percent of the pie for taking care of patients, and insurers, just for collecting and shuffling money around, get 15 percent, it’s all backwards,” said Van Volkinburg. “Insurers need to pay us more and back off of inefficient administrative demands.”
Joining an integrated health plan such as Kaiser is the only way primary care physicians can survive, he said. “They can pay me enough to keep practicing and keep me happy.” 
Before making that decision, he thought about opting out of Medicare Advantage and, instead, billing patients for his services. But that would have left people out in the cold who couldn’t afford to pay those bills. “And that would have been too mercenary,” he said. “I would have been rationing people out of my practice.” 
Kaiser has agreed to let Van Volkinburg see his former patients, assuming they join the health plan. “Now it’s their choice. At least I don’t have to make the decision to kick them out.” He’ll also respond to their questions once he leaves his practice and is keeping his malpractice insurance intact.
As primary care practices collapse, most residency programs are being filled with foreign students. Although those doctors are well trained and diligent, they lack social context, said Van Volkinburg, particularly when it comes to communicating with patients about their health history and giving them appropriate instructions.
“That’s what my patients have been telling me when it comes to talking about things so close to their health,” he said. “That’s been the fun of practicing internal medicine. The relationships I have with my patients.”
Van Volkinburg’s long been a progressive voice in the Salem community. When insurers including Regence BlueCross BlueShield left the Oregon Health Plan during the 1990s, he encouraged Jan Buffa, who runs the Mid-Valley IPA, to start a health plan for Medicaid patients.
“When the big boys left because they couldn’t make money on the Oregon Health Plan, Jan Buffa took the lead,” he said. “Now they have the expertise to run an insurance company.”
Buffa called Van Volkinburg a “much beloved and respected independent practitioner,” and said Mid-Valley IPA and the Marion-Polk County Medical Society will help his patients find another doctor.
“It’s a sign of the times -- the practice of medicine -- particularly that of a solo or small practice consisting of one or two practitioners is very challenging and becoming more so all of the time,” she said.


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