- Tim Newcomb
As a physician in private practice, Dr. Laura Norris decides for herself how many patients to see each day. She often schedules 30- and 60-minute appointments even though a jam-packed schedule would bring in more money, because she believes that having time to ask patients about their kids, jobs and even their summer crop yield makes her a better doctor. She has practiced this way for 26 years, and she has loved every one of them.
"It's been my dream job," she said in her office at the Cambridge Family Practice last month. "There is no clock ticking behind me."
Lately, though, Norris no longer feels like time is on her side. Three nurse practitioners are leaving for higher-paying jobs, and Norris has only found one replacement. More troubling, her three physician colleagues expect to retire in the next few years, and she has little hope of recruiting successors with the salaries she can offer. Before long, she will be the practice's last remaining doctor.
"It's not a very stable future," she said. "I don't know what we're going to do."
Independent doctors are a dying breed in Vermont. Fed up with shrinking margins and grueling hours, dozens of physicians have left private practices in recent years, retiring early or joining hospitals or rural health centers. Those who have stuck it out are getting older, and many expect to retire within a decade.
There's no wave of replacements waiting in the wings. Buried in medical school debt, most young doctors have no interest in running a business and seek salaried jobs where they can count on a steady paycheck and better work-life balance. The idealistic few still drawn to small-town medicine have second thoughts once they learn what they would make at many Vermont practices. Some doctors, particularly those in rural areas, now doubt that anyone will take their place.
"I'm irreplaceable," said Dr. Donald Miller, Norris' business partner, who opened the Cambridge practice 46 years ago. "That's not because I'm some super doctor. We just can't pay enough to bring someone in."
Long-term, this could amount to fewer choices: More patients will be forced to seek care from hospital practices, where wait times are long. More doctors will decide to work for larger institutions, where they will have less control over the patient experience.
This might not concern those born into the age of corporate health care, or those who treat their doctors like WebMD: Just figure out what's wrong and how to fix it. And consolidation isn't always bad. Bigger organizations have more opportunities to coordinate a patient's care, which can result in better outcomes, and many hospital doctors still succeed in building relationships with those they treat.
But many people desire a more intimate bond with their doctor, something private practitioners say they can best provide.
"It's just like how going to the general store to get your cup of coffee isn't the same as going to Starbucks," Norris said. "Being known, being understood, feeling like you're not just a number — all of that, I think, ultimately leads to satisfaction."
The number of private-practice doctors in the U.S. has been dwindling for decades. Last year brought a milestone: According to the American Medical Association, doctors working for hospitals or health systems now outnumber those in private practice for the first time ever.
The breakdown has historically been even more lopsided in Vermont. Roughly half of the state's doctors were independent a decade ago, but the share had fallen to just 31 percent by 2017, according to a state analysis that year.
It's hard to know how many are left in private practice today — no one regularly tracks this number — but anecdotal reports suggest that the decline has continued. The advocacy organization that represents many of the state's independent doctors, Health First, lost 15 members over the last four years and is down to 128.
Rural areas have been hit hardest. Practices there often have lower-income patients, who are typically on government-funded health care plans that reimburse doctors less. It's also harder to convince doctors to start their careers and raise families in places with few amenities. Franklin County had 11 independent pediatricians less than a decade ago. Now there's only one.
"And I beg him not to retire every time I see him," said Liz Parris, who takes her six children to that last man standing, Dr. Joe Nasca. "I wouldn't know what to do without him."
When private practices close, access can suffer, particularly when doctors retire or leave the state. Shuttered outfits aren't easily replaced; it can take years to recoup high startup costs. Hospitals, meantime, have their own recruitment challenges, and many practices haven't expanded in years.
Meanwhile, Vermont's health care system is feeling the strain of an aging population and, more recently, the pandemic. Independent doctors say they can continue to play a vital role in keeping Vermonters healthy for years to come. But first, they need to survive.
- James Buck
- Dr. Joe Nasca
When Dr. Paul Rogers opened his Johnson primary care practice in the mid-1980s, he employed just one person to schedule appointments, stay in touch with patients and bill for his services. When he retired more than 30 years later, he was paying four people for the same work, and they still struggled to keep pace with all the demands placed on a 21st-century doctor's office.
Running a private medical practice isn't cheap, and since independent doctors base their income on the bottom line, many have devised creative ways to keep their overhead low.
Many practices still use paper medical records, refusing to switch to more expensive electronic systems. Some doctors enlist their spouses to pitch in on bookkeeping and maintenance tasks. A Richmond pediatrician, Dr. Paul Parker, even shovels his own parking lot.
At Cambridge Family Practice, Norris and her colleagues take penny-pinching to a new level. Homemade curtains cover the exam room windows, obscuring views of cornstalks and a baseball field. A room for minor surgical procedures doubles as a storage closet. "We're even counting paper clips," quipped Dr. Deb Richter, who is one of the four docs. Still, certain expenses can't be cut, and the cost of running the practice goes up each year.
While businesses usually respond to financial pressures by raising prices, that's not an option for independent practices, which rely on reimbursements from insurance companies.
Government insurers — Medicare and Medicaid — have barely increased the rates they pay in recent years, forcing both independent practices and hospitals to rely more on commercial insurers for revenue. These companies in turn face pressure to keep their reimbursements low, since each increase trickles down to ratepayers. With only so much money to go around, hospitals and private practices end up competing for dollars.
It's not much of a fight. Hospitals have more bargaining power and can negotiate higher rates, whereas independent practices say they must practically beg commercial insurers to come to the negotiating table. That's why hospital-employed doctors get paid more for the same services.
Hospital leaders defend the disparity by noting that they provide a broad range of services that don't see many patients but are important to the community, such as neonatal and trauma care.
The de facto referee in this David versus Goliath fight is the Green Mountain Care Board, which determines how much money hospitals can demand from insurance companies each year.
Vermont attempts to limit health care cost increases to 3.5 percent annually, but hospitals often insist that they need much more and threaten to cut services should they be rebuffed. This year, nine of the state's 14 hospitals asked to charge commercial insurers more than the state's growth target. The University of Vermont Medical Center received permission to hike commercial rates by 6 percent.
Meanwhile, independent practices can go years without substantial rate increases. "And at the very same time, those same insurance companies refusing to negotiate with us are increasing their premiums, which we have to buy for ourselves and our staff," said Dr. Toby Sadkin, a primary care physician in St. Albans. "The math is pretty simple: It doesn't work."
Sadkin and her colleagues are now negotiating with Blue Cross Blue Shield of Vermont for what they hope will be their first rate increase in more than five years.
Attempts to close the pay disparity have gained little traction. State regulators contend that raising reimbursement rates for independents would only make health care more expensive. Insurers, of course, agree. "While equal payment is a compelling argument in its simplicity, it's not realistic for our health care system," said Sara Teachout, director of government and media relations at Blue Cross Blue Shield of Vermont. "Health care wouldn't be affordable at all."
But health care is already unaffordable for many, and losing independent doctors will only make matters worse, argues Susan Ridzon, executive director of the independent doctors' advocacy group Health First.
"We need balance. We need options," Ridzon said. "We need this low-cost, high-quality network, because as a Vermont health care consumer, I don't want to have to go to a hospital and pay hospital prices for care that does not need to be done there."
The Green Mountain Care Board surveyed doctors several years ago to learn more about their biggest frustrations. More than a third of the 88 participating independents cited reimbursement rates as one of the biggest threats to their practices. They said they keep their practices alive by working longer hours and always making themselves available — a trajectory many said was unsustainable.
Those who had left private practice for salaried jobs overwhelmingly pointed to the increasing costs of running a practice as a key factor.
Dr. Judy Orton, an independent pediatrician in Bennington, once expected to work well into her late sixties. But now, the 61-year-old doctor says she'll be lucky if she can find the energy to make it another few years. "I'm tired of trying to figure out how to make ends meet," she said.
Rogers, the retired Johnson doctor, started looking for his own exit six years ago. Knowing that he could never sell his practice, he tried instead to give it away. But he found no willing takers after three years, and in 2018, he closed his practice for good. He's since joined Cambridge Family Practice, where he works one day a week.
Solo practices just aren't economically viable anymore, Rogers said, especially for new graduates, who can leave school with up to $300,000 in debt.
"I had $10,000 in loans. My tuition was $3,000 a year. I was able to just set up a practice," he said.
"I doubt there will ever be another doctor in Johnson again."
Part of the Family
- James Buck
- Samantha Brown and her kids Jayson, 5, and Callie, 18 months
After learning she was pregnant six years ago, one of Samantha Brown's top priorities was finding a pediatrician. Not just any pediatrician, though. One who would take the time to get to know her and whom she could get to know in return — a bond that, she hoped, would make her more comfortable voicing her concerns.
"I'm one of those people that tend to be put on the back burner. I don't like to speak up," explained Brown, a 27-year-old single mother.
Brown knew some of her friends took their kids to pediatricians at the UVM Medical Center, while others saw Dr. Joe Nasca, that sole remaining independent pediatrician in the town of Georgia. All were satisfied. But those who went to practices owned by the Burlington hospital didn't always see the same doctor, and that worried Brown. Wanting consistency, she chose Nasca.
The two first met at the hospital on the day that Brown gave birth. She was immediately struck by Nasca's "aura," she said, describing him as warm and welcoming. She felt the same way during her initial visit to his office, where staff greeted her by name before escorting her to a nautical-themed waiting room with a surfboard and a life preserver on the wall and painted fish swimming across a sea-blue tile floor. Driving home, she knew she had made the right decision.
Independent doctors say they provide demonstrable benefits to Vermont's health care system, from shorter wait times to cheaper care. But the benefits that patients cite are more intangible: comfort, trust, the belief that their doctor is invested in their health.
It was the desire to provide this level of care that first drew Nasca from Buffalo, N.Y., to a group practice in Franklin County three decades ago — and later pushed him to branch out on his own.
In 1991, Nasca became the fourth doctor at the St. Albans independent practice Mousetrap Pediatrics. As the practice doubled in size over the next 15 years, Nasca felt it was losing its personalized touch. The phone tree grew more complicated. His weekly night on call felt like it lasted an eternity, the phone ringing nonstop from anxious parents, most of whom he had never met. He started to have chest pain.
"Eventually, I just said, 'Look, I have to go,'" he recalled in his office one day last month. "'The confusion, the uncertainty. I can't live with this all the time.'"
He opened his own practice right off Exit 18 in the town of Georgia, where he's been for the last 15 years. Meanwhile, his independent peers in Franklin County have disappeared. The two doctors who ran Franklin County Pediatrics shuttered their offices. His old colleagues at Mousetrap sold out to nearby Northwestern Medical Center.
Leanne Blanchard was pregnant with her first child when Nasca went solo. A physical therapist, Blanchard preferred the warm atmosphere at private practices over the "clinical and sterile" hospitals. But she was unsure whether Nasca would really be on call around-the-clock as he promised. Her mind was eased the first time she called late one night and he immediately called her back.
"When he comes into that room with your child, it's like your child is the only child in the world in that moment," Blanchard said. "You never feel rushed. You never feel like you're asking a stupid question. He's just so calm, collected."
Brown, the single mother, has moved several times since choosing Nasca over the hospital and now lives in South Burlington, about 30 minutes away. She could likely find a pediatrician closer to home, but she refuses to make a switch, citing the trust she's developed with Nasca over time.
That bond only deepened last month, after the doctor helped her overcome one of her worst days as a parent.
Nasca was showing a visiting reporter around his practice when his office manager interrupted to tell him Brown was on the phone. Her 1-year-old daughter, Callie, was feverish and vomiting. Brown wanted to know whether to take her to the emergency room.
When Nasca got on the line, Brown listed the symptoms. "She just took a three-hour nap, and her eyes are, like, rolled back into her head," Brown explained. "I can't get her attention for the last 15, 20 minutes. She's not acknowledging me. Her body is tensing up. Her body is extremely shaky."
Brown then began to say something else but stopped, her voice melting in sobs. She said her daughter's name several times. "What is she doing?" she asked anxiously.
"She's having a seizure, Samantha," Nasca responded. "We need to call 911." He asked his office manager to send an ambulance to Brown's house. He instructed Brown to flip the young girl over onto her belly to prevent her from choking on vomit. He asked whether the girl was breathing; she was. "Just keep holding her," he said in a steady voice. "She's going to be OK."
Nasca stayed on the line for another 15 minutes, occasionally asking questions while assuring Brown that help was on the way. Eventually, sirens could be heard, then the voices of emergency responders. Nasca told Brown that he'd call her back once she was settled in the emergency room. Before hanging up, he told her, "You did good, Samantha."
Afterward, Nasca tried to suss out what, if anything, the interaction meant for this story. He suspected that Brown's daughter had suffered a febrile seizure, a scary but common occurrence when a child's temperature spikes.
Maybe if Brown had called a doctor at a hospital practice, she would have gotten a directory, then reached someone who knew none of her background, who hadn't spent a dozen hours with her over the last five years. But would that have mattered?
Nasca himself described his response as little more than "virtual hand-holding."
Still, the interaction meant something to him, he said. And he suspected it meant something to Brown, too. "That'll be a big part of the family story," he said. "'The time that Callie had the seizure, and you were on the phone with me for 15 minutes, Doc, and you called the ambulance.'"
"That's worth something, isn't it?"
Later, Nasca called the UVM emergency department and confirmed his suspicion about the seizure. He then called Brown, who told him that Callie was back at home already and feeling better, so much so that she was running around the house and playing with their hamster, Stuart Little.
He set up an appointment to see the mother and daughter the next morning.
- Glenn Russell
- Dr. Laura Norris in front of a painting of Jeffersonville in the waiting room of Cambridge Family Practice
Salaried doctors at large medical systems are more insulated from day-to-day financial pressures, but they are often encouraged by administrators to cram their schedules, leaving them less time with each patient. Doctors in private practice, meanwhile, have autonomy but a far less stable income. Choosing between the models can often be boiled down to a single question: What's more important, security or autonomy?
But what if there were a way to have both a consistent revenue stream and the freedom to spend more time with each patient?
That's the driving question behind what's known as "direct primary care," a relatively new model of medicine that allows physicians to avoid the more frustrating aspects of traditional health care — insurance paperwork and overloaded schedules — and instead focus on patients.
Rather than bill insurers, direct primary care doctors charge a flat fee that can cover anything from office visits and virtual communication to certain basic procedures. Participating doctors say they manage without the additional staff needed to navigate the health insurance system.
Patients pay on average about $75 a month, or $900 a year, studies show. The biggest advantage in return is access: Visits typically last longer at direct primary care practices, and most offer flexible scheduling, including after-hours phone calls, emails and texts.
Patients are still encouraged to carry some type of insurance in case of medical emergencies, surgeries or expensive tests. But for those with cheaper, high-deductible insurance plans — who are more likely to put off seeing a doctor for financial reasons — the model offers a way to seek regular preventative care. An increasing number of employers have started to cover such memberships, hoping it will encourage more employees to address problems early and reduce expensive future claims.
Direct primary care practices have been cropping up across the country over the last decade. There are now more than 1,600 practices in 48 states, according to DPC Frontier, a trade organization. But the trend has only just started to catch on in Vermont: Several practices have opened in the state in the last few years, while a growing number of doctors facing diminishing returns now say they're considering a switch to the model.
Dr. Marian Bouchard runs Fiddlehead Family Health Care in Bristol, a direct primary care office. It's her second stint in private practice after spending the last eight years at a Federally Qualified Health Center, a model of primary care championed by Sen. Bernie Sanders (I-Vt.), and subsidized by the federal government, to care for underserved populations.
Bouchard appreciated the center's mission but said she started to feel as if she never had enough time in the day, "like I was a juggler with my foot out trying to catch the ball before it hit the ground," she said. She left, opening her Bristol practice last year.
Patients pay fees based on their age; children start out at $20 a month, while people over the age of 55, who are more likely to have chronic conditions requiring more frequent contact, pay $90 a month.
The fees cover visits and virtual consultations. If patients require more complex care, Bouchard said, she refers them to specialists just as any primary care doctor would.
The model isn't without skeptics. For starters, many people can't afford to pay hundreds of dollars or more in membership fees on top of insurance premiums, and some critics fear that widespread adoption of the direct primary care approach would only exacerbate inequities.
There are also questions about its large-scale applicability. At their core, direct care practices seek to provide more in-depth care than a traditional practice — and that means seeing far fewer patients. Bouchard's patient load is now under 400, less than a third of what it was at the center. If many more doctors switched to the model, critics say, more Vermonters would have trouble finding a primary care physician.
Bouchard sees the equation differently. To her, questions about access to care must not only include whether someone has a doctor but also whether that doctor actually has time to talk to them when problems arise. The traditional primary care system also poses financial barriers: Patients without insurance or on high-deductible plans often avoid visiting doctors because of money concerns, she said.
"I've seen people putting off care and putting off care and putting off care and then ending up in the ICU," she said.
She recalled one such patient — a man in his fifties — who had bronchitis that later became pneumonia and ultimately killed him. "The whole point of direct primary care is that you don't wait until you're dead to show up to the doctor, because you've already paid for it."
Bouchard also argues that the model might actually keep some doctors in private practice, because it gives burned-out doctors a chance to find joy in their work again. "People are retiring because they have had it," she said. "If you're a family doctor and you've devoted your life to training to do this, there's a lot of you that's in this ... You don't stop painting if you're a painter, right?"
Primary care doctors aren't the only ones looking for alternatives to the status quo. Six years ago, a group of specialists joined forces to propose Vermont's first outpatient surgery center, offering both patients and doctors another place for surgeries outside local hospitals. The Green Mountain Surgery Center in Colchester offers a limited range of outpatient procedures. It's a for-profit venture run by physician-managers.
Vermont's hospital trade organization vehemently opposed the facility, arguing that it would introduce unnecessary capacity into the system, thereby raising prices while siphoning moneymaking procedures away from already struggling hospitals. After a protracted review, in 2017 the Green Mountain Care Board finally approved the center, which opened its doors two years later.
The surgery service has proved to be a smashing success, its leaders say, saving Blue Cross Blue Shield an estimated $5.5 million to date. It's also helped bolster the ranks of Vermont's independent community.
When Dr. Gregory McCormick, an independent ophthalmologist in South Burlington, performed all his cataract surgeries at the UVM Medical Center, he managed about a dozen in a day. At the surgery center, he performs up to 28 surgeries in a day. By more than doubling his efficiency, he said, he's managed to sustain his practice despite stagnant reimbursement rates.
The center attracted several specialists to Vermont. They include Dr. Susan MacLennan, a plastic surgeon who spent 15 years working at the UVM Medical Center before leaving in 2015 because she felt she was no longer able to provide personal, high-quality care there. She spent the next three years in western Canada, all the while keeping tabs on the proposal back in Vermont. When the surgery center finally opened, she took on a minor ownership stake and moved back across the border.
She was inundated upon her return with patients stuck with long waits at UVM's plastic surgery department, including many seeking breast reconstruction or sex reassignment surgery. Soon, she started looking for a new partner and recently managed to hire a native Vermonter who was practicing out of state. "It's the happiest I've ever been in my career," she said.
- Glenn Russell
- Curtains sewn by Dr. Norris in an exam room
Back in rural Vermont, the future is far more uncertain.
Nasca, the Georgia pediatrician, hasn't set a retirement date. But he's already 63, and the days only seem to be getting longer. Each year, he invites residents at the UVM Medical Center to visit his practice on the off chance that an idealistic young doctor might want to take it over. None has showed any real interest.
In Cambridge, patients ask Miller every day about his retirement plans. He suspects that's partly because he's known some of them for so long; he's seeing the fourth generation of certain families. "And I suppose some of them think I look like I ought to retire, too," the 77-year-old joked.
Miller dialed back his hours six years ago and now works only three days a week: two seeing patients and another on paperwork and other administrative tasks. He still enjoys the work, but he's not sure how much longer he can do it. "I'm burnt out," he said.
Knowing she cannot sustain the practice on her own, his partner Norris is considering her options. One is to switch to direct primary care; she recently had a video call with Bouchard to discuss the benefits and took note of how happy the doctor seemed. But Norris can't shake the feeling that she'd be doing a disservice to her patients by requiring them to start paying her a monthly fee for access she already provides. "I don't know very many of them who could afford it," she said.
The only other solution is to join a hospital or the county's Federally Qualified Health Center. It wouldn't be too difficult: The health center has already inquired about absorbing the practice and keeping Norris on. But appointments at the health center last half as long as the ones she now schedules, meaning she would have far less time with each patient. Gone would be the days of taking 15 minutes to listen to someone's relationship problems or the struggles of life on the farm.
Maybe none of that matters in the long run. Maybe having the time to build trust doesn't make her a better doctor. "But I think it does, or else I wouldn't have done it this way for so long," she said. "And that's what scares me."