The primary care quandary

Over the last year and a half, the number of patients seeking treatment for serious injuries or illnesses at Chico Immediate Care has noticeably increased.

“We’ve had heart attacks, dropped lungs, gunshot wounds, seizures, meningitis,” said Dr. Brad Smith, owner of the clinic for nearly 30 years, during a recent interview. And while he acknowledged that his clinic is designed for exactly that—quickly addressing urgent health problems—he said many of those patients would have benefited from preventative medicine, but simply didn’t have access to it.

Also, those in dire need of attention are usually mixed in with others seeking treatment that falls distinctly within the realm of primary care.

“It’s become ridiculous—50 percent of the people who come into our clinic are there for something they should go to a primary care doctor for,” he said. “You have someone with a cut on his arm waiting to get sewn up behind three other people who are there to get their blood pressure medication refilled.

“That’s the result of the primary care shortage.”

A lack of primary care practitioners is a national issue—a study conducted by the Association of American Medical Colleges projected there will be a shortage of 45,000 primary care doctors by 2020, accounting for the millions of people newly insured under the Affordable Care Act—and the trend is very much a problem here in Chico. About 20 years ago, there were about 30 private primary care physicians in Chico, Smith said. Since then, there has been natural attrition due to doctors dying, retiring, moving elsewhere, or transitioning to hospital-based care.

The problem is they haven’t been replaced. By his latest count, there are about half as many primary care providers in town these days.

As a result, Chico Immediate Care has increasingly served as a safety net for those who can’t find a regular doctor. Smith said it’s common for patients at the clinic to say, “I don’t have a doctor. I’ve called every practice within 30 miles, and not one of them can take me.”

And so Smith decided to take things into his own hands. Just last week he opened a new clinic in Chico—Premiere Primary Care.

The shortage of primary care practitioners in the Chico area was a situation many in the local medical community saw coming, said Dr. Roy Bishop, CEO of Argyll Medical Group in Chico, which he founded in 2001.

“We don’t have any large, integrated health care systems that can put in the necessary capital to build clinics, recruit doctors and get decent contracts with insurers,” he said.

Both Bishop and Smith identified low insurance reimbursement rates as the biggest obstacle for attracting new primary care providers.

“We need more primary care doctors in the community,” Bishop said, “but the current business model is not going to bring them here.”

For instance, Bishop’s current contract with a private insurer reimburses him at 90 percent of Medicare’s rate, which is already so low that many physicians won’t accept it as payment. “And that’s after a huge fight,” he said. “If I was a solo practitioner, rather than part of Chico’s biggest primary care group, they would try and pay me 60 or 70 percent [of the Medicare rate]. It’s truly awful.

“Most young doctors want a salary and benefits and they don’t want to take any business risks,” he continued. “The old model, where doctors were self-employed, is dying simply because the reimbursements controlled by the government and insurers are so low it’s no longer a viable business.”

Smith agreed, adding that there’s little incentive for medical school graduates to open their own practices, given that entering a specialty field is often far more lucrative—no small consideration given the massive student loan debts most med students accrue. Further, the logistical aspects of running a primary care office such as meeting federal and state mandates, tracking paperwork and managing an office can be daunting.

Bishop is doing his part. In an effort to address the issue, he and other area physicians have formed the California North State Independent Practice Association (IPA), which aims to bargain collectively with insurers for better rates. Successfully doing so might allow the IPA to attract more primary care physicians to Chico.

In a perfect world, providing primary care wouldn’t be such a hard sell, Bishop said. After all, it can be a rewarding field.

“I enjoy the contact with patients and entire families, looking after them for many years and doing my best for them,” he said. “But sometimes I feel like I spend half my time looking after patients and the other half fighting the system.”

Premiere Primary Care, which shares a building with Enloe Prompt Care off Bruce Road, is staffed by two physicians new to Chico. (Smith said he was able to recruit them through “dumb luck” more than anything.) Based on the number of appointments in the first week, he believes it will be operating at max capacity within two months—despite not having advertised at all.

Further, Smith is already planning on opening two similar clinics, another in Chico and one in the Paradise area. He said he’ll open the second Chico clinic as soon as he’s able to staff it.

Indeed, now that he’s established an infrastructure—including an electronic health record system on a cloud server that allows doctors at any of Smith’s clinics to access patient files—opening new clinics is purely a matter of recruiting primary care physicians. He knows as well as anyone that it won’t be easy.

“But I got very frustrated and tired of seeing nobody do anything about primary care in Chico,” he said. “We can’t just sit here and watch this train run off the end of the track, because that’s where it’s going.”