Health care industry's diagnosis: Sick — from a lack of doctors

Dr. Paul Aguillon saw 10,000 patients in 2017.

This year, he projects that number will jump to 12,000. 

"Even as busy as I am, it’s going to be a struggle to keep this (practice) open," Aguillon said during his lunchtime breather. "If I didn’t love it, I would have to think about doing something else."

The one-man show — Aguillon executes every medical procedure and test at his private family practice in Seaford, Delaware — sees 35 to 50 patients a day. That's double to triple the average rate of about 16 visits, per the American Academy of Family Physicians.

Aguillon's practice operates somewhat like a walk-in clinic, as only about 10 patients a day are by appointment. He works six days a week and barely vacations, taking one week in December.

Private, independent physicians like Aguillon are a dwindling breed, as large hospitals and medical groups increasingly buy up practices and pull physicians into their systems with competitive pay and loan repayment assistance. 

Aguillon says he could not have afforded his own practice if his father hadn't sold the family business to him a few years ago. Equipment, utilities, mortgage and business loans give doctors little incentive to start their own practice.

"It’s very hard to get a business loan when you’re already half a million dollars in debt," Aguillon quipped.

Doctors across the country are struggling to keep up with heavy regulations and the high costs of becoming a medical professional. Several said they spent more time filling out electronic medical records than they did seeing patients.  

"That’s not what doctors are meant to do," said Dr. Thomas DeMarco, vice president of Peninsula Regional Medical Group based in Salisbury, Maryland. "They’re not data entry specialists. That’s a huge problem for most doctors right now."

Adds DeMarco: "We’ve regulated medicine to the point that in certain respects it compromises quality care."

It's also part of the reason why much of the United States, including the rural Delmarva Peninsula, where Salisbury and Seaford are located, is seeing a physician shortage in several fields, particularly in primary care.

The Association of American Medical Colleges projected a national primary care shortage between 14,800 and 49,300 physicians by 2030. Delaware, Maryland and Virginia are all designated health professional shortage areas by the U.S. Department of Health & Human Services. 

Atlantic General Hospital, with offices in southeast Sussex County in Delaware and Worcester County in Maryland, reported a deficit of 12 primary care physicians in its service area.

This will be an extended shortage, AGH chief executive officer Michael Franklin says, because the proportion of people over age 55, who typically require more medical care than younger populations.

While medical experts say there are more doctors now, those numbers aren't keeping up with a growing population, which will greatly impact patient access. If people can't see their doctor for preventative, maintenance and early care, more could end up in the emergency room. Older people especially are overburdening the health care industry, DeMarco said, and according to AARP, 10,000 baby boomers turn 65 every day. 

"Our demographics have dictated one of the biggest reasons why we’ve got this (shortage)," DeMarco said. 

In addition, medical students graduating with hundreds of thousands of dollars in debt might gravitate more toward specialties that "reimburse them the most," DeMarco said, sidestepping other more needed fields they could have chosen if finances weren't a factor.

Aguillon's office is 31 years old, with the wood-paneled walls and looming expenses of new air conditioning and plumbing systems. While Aguillon loves the autonomy of being a private physician, he has to pinch pennies. He and his wife still rent. They budget their expenses so he can invest more in the family practice. 

"I’m looking at the bottom dollar, and it’s going to be a struggle," Aguillon said.

Patients feeling the doctor shortage

If Donna Lichtenberg was sick in 1994 when she moved to Sussex County, she could call her primary care doctor and get in the same day. 

That's not true anymore, the Frankford resident said.

"And if you’re really sick, your advice is to go to the walk-in," she said.

Lichtenberg's experiences in the health care industry have changed as rapidly as the population in Sussex, which grew by almost 100,000 since she moved there 24 years ago.

Seeing her doctor went from a five-minute drive to calling months in advance for an appointment and carving out half her day for travel and wait time.

Now, Lichtenberg, who is 81, often drives 45 minutes to Lewes where her medical specialists are.

Lichtenberg says she will go to urgent care or retail clinics, like those held at national pharmacy chains, when sick. Such facilities are popping up throughout Delaware and fill the gap from the First State's lacking primary care services, a phenomenon health department Secretary Kara Odom Walker calls "concerning."

"Delaware is the third most expensive state for per person health spending," Walker said. "We don’t have enough of a foundation of primary care and prevention."

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Instead, she said, people without primary care doctors or who can't get in with their physician will go to the emergency room for nonemergencies, which costs the state, hospital and patient more money.

Walk-in clinics are also expanding throughout the country: 7,100 urgent care centers and 2,000 retails clinics dot all 50 states. 

Beebe Healthcare has four clinics throughout Sussex County, and last year, the medical center saw 40,000 walk-in visits, compared to 48,000 trips to the emergency room. They serve as a middle ground for people who can't get in with their doctors quickly enough but who don't think are in a situation dire enough for an emergency room visit. 

Retail and urgent care clinics do well for last-minute appointments to address illnesses such as urinary tract infections or injuries like sprains, but "the walk-in doctors don’t know me and I don’t know them," Lichtenberg said.

The number of retiring physicians, coupled with population growth and longer lifespan, has exceeded the number of new physician trainees coming out of med school, said Dr. Jeffrey Hawtof, chief medical adviser at Beebe Healthcare. 

"We have a national shortage of tens of thousands of physicians, and we’ve known that for years," he said. "We have not done anything to increase our ranks and numbers."

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There is no dedicated medical school in Delaware, which ranks 49th for physicians retained in state after a graduate medical education, according to the Association of American Medical Colleges. 

"Looking at the U.S. health care industry, primary care is sick and unwell and needs medical attention," Walker said.

It takes Lichtenberg anywhere from six months to a year to snag an initial appointment with a new doctor, and specialists she hasn't seen in years will treat her like a new patient. 

"You get at the end of the line," she said. "At my age, I hope I make it."

Behind a computer screen, physicians miss their patients

Doctors don't just spend time with patients: In fact, many have said they spend less time with patients than they do checking off the boxes of a heavily regulated, database-dependent health care industry.

Physicians use up several hours — at times bleeding into the weekend — on electronic health record tasks, which are used to track patient health metrics through hundreds of clinical situations. 

"It was created under the auspices of increasing quality care," said DeMarco, the PRMC vice president, "but really it is a mechanism whereby regulatory agencies can create huge databases. It doesn’t necessarily help doctors in real time." 

A recent study in the Annals of Family Medicine found that primary care physicians spend half their work day on the electronic health record.

According to the study, doctors are spending twice as much time interacting with a computer system than caring directly for their patients.

"They throw their hands up in the air and say 'I’m not doing what I went out to do,' " DeMarco said. " 'I don’t have the time to take care of my patients because I spend all of my time in an electronic health record on a computer. ' " 

Christine Degnon is one of those doctors who threw her hands up. Currently a physician in Lewes, Delaware, Degnon said she was tired of spending most of her time "checking off boxes to get paid or have performance evaluations for measures that haven’t been proven to change outcomes at all."

"It's really futile work," she said. 

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How to cure the doctor shortage

Some doctors and companies are forgoing agreements with insurance companies to reduce costs and cut out regulatory middlemen.

More doctors are breathing easier after a radical shift away from insurance companies, hospitals and other regulatory bodies.

"I didn’t really have the courage to do it until it got so bad that I thought, I’m either going to leave medicine or I’m going to try this," said Degnon, who moved to Lewes after finding it lacked primary care physicians. 

She opened her own practice, Coastal Direct Primary Care, earlier this year. 

Direct primary care is essentially a "direct" contract between doctor and patient, with no middle man like insurance payers. Degnon says the goal is to make health care more affordable and accessible by eliminating nonessential overhead costs and insurance middlemen. 

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Patients pay a flat monthly fee, much like a Netflix subscription, and they are given unlimited visits with no copay. Anything she can do in office — like stitches, pap smears, removal of suspicious lesions and weight management — is included in the fee.

The cost? At Degnon's practice, kids up to 18 years old have a $25 monthly fee. Those in the 19-49 age bracket pay $70 and anyone 50 and over pays $100. Families max out at $225.

Degnon tries to cut costs wherever she can: She buys medications wholesale and does not require her patients to come in every time they need something. The monthly fee doesn't pressure her to schedule physical appointments for that steady copay flow, so she often uses text, email and FaceTime to communicate with her patients.

She manages as much of her patients' medical issues as she can, instead of scattering their care across multiple specialists who may not communicate with each other. 

"I have several patients who have used this analogy," Degnon said. "They say, 'I just want someone to captain my ship.' "

One of those patients came to her on 22 medicines, some of them interacting with one another. She effectively cut the woman's number of medications in half, making her regimen "much more manageable," Degnon said. 

Her patients, ranging from young families to small business owners, usually still have insurance even though she doesn't accept it. 

"You have homeowner’s insurance, but you don’t use your homeowner’s insurance to change your light bulbs or when you have plumbing issues or when you need AC repairs," Degnon explained. "That’s all maintenance, right? You use your homeowner’s insurance when you have a hurricane or a fire.

"Health care should be the same," she said. "The real bottom line is that primary care is cheap. It doesn’t need to be expensive. It’s when you start paying for it through insurance that it becomes expensive."

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Degnon's practice is one of a few direct primary care facilities in Sussex County, and one of several hundred throughout the United States, including the Eastern Shore of Maryland.

Like Degnon, Healora, a company that connects doctors and patients seeking medical procedures, eliminates insurance from the cost. Healora president and CEO Thomas Farmer says his Los Angeles-based company reduces 50 to 70 percent of administrative costs.

"What’s happened over the last 10 years is deductibles have gone up insanely," Farmer said. "The common man and woman can’t afford a $12,000 or $14,000 deductible." 

The average annual deductible for individual plans was $4,578 and family plans ran $8,803, according to eHealthInsurance, an online health insurance marketplace. 

Healora is like a travel fare aggregator website. Patients can book the same procedure through Aetna, Signa or Healora, and each of those companies will have a different price on it.

Side effects of direct primary care

A doctor's patient panel usually drops, and dramatically at that.

The average panel for a regular doctor is about 2,000 patients, but direct primary care physicians usually cap off at 600. 

Jumping from the insurance lily pad to the cash-pay also requires a "huge amount of savings" for the doctor, Farmer said, and Degnon projected she can survive for two years on no paycheck while she grows her panel. 

"I will probably never make what I made as an employed physician," she said. "Most people are not doing this because they think it’s an easier way to get rich. Most of the physicians I know have taken pay cuts, but the quality of life is so much better and the job satisfaction is much better." 

It's a tug of war between direct primary care physicians who report lowered stress levels and increased quality of life, and others in the health care industry who believe taking on less patients is problematic for the entire field.

Hawtof, the chief medical adviser at Beebe Healthcare, calls direct primary care a "model that can't win."

In the midst of a national doctor shortage, "we can't afford for all of it to go that way," he said. 

But Degnon disagrees, arguing that doctors like herself may have left the medical field if direct primary care hadn't been an option.

"Nobody went to medical school to check off boxes and spend a lot of time coding and billing," she said. "Direct primary care brings the model back to old-fashioned family medicine, when doctors just took care of patients."

Direct primary care isn't the only way to get away from loads of electronic tasks, DeMarco argues. His hospital, Peninsula Regional Medical Center, is employing a consultant to shift that responsibility away from doctors and onto clinical support staff.

The consultant, Team Care Medicine, limits a doctor's time spent entering data so they can make clinical decisions and "actually talk to the patient," DeMarco said. 

They've employed Team Care Medicine for about four months now, and while DeMarco said it was expensive, it was "well worth it," increasing both the quality of care and physician satisfaction. 

"They are very happy," DeMarco said of PRMC doctors, adding that they start to feel like a doctor again, spending more quality time with patients and getting home at a reasonable hour.

"This was all I knew"

At Dr. Aguillon's office in Seaford, warm afternoon light streamed into his office. It was still the lunch hour, when the waiting room is at its most quiet. 

"You can make twice as much as I would make, starting out, working for a big hospital as opposed to being an (unaffiliated) family doctor," he said. 

But Aguillon loves the autonomy and carrying on the decades-long traditions of his father, who used to let some patients pay in eggs or yard work or maybe nothing at all — because that's just what he did.

It's what his son does now for people who struggle financially, despite Aguillon's own financial setbacks of keeping an independent practice in rural Delaware open. 

"Growing up in the field, for me this was all I knew," Aguillon said. "I knew my father as the family doctor. I really enjoyed what I saw in him, enjoying his life. I just liked it, the idea of talking to people."

tgoebel@delmarvanow.com