On November 24, 2021

Vermont primary care practices feel the squeeze

Dear Editor,

I have been a solo, independent pediatrician for 32 years at Green Mountain Pediatrics, located in Bennington. I have always strived to use best practices with some healthy common sense in the care of my kids.

I love being a part of these children’s growth and maturity, helping their families navigate parenthood. I am into a second generation, taking care of my “kids’” kids. There is a certain satisfaction and pride when they attend school, college, take a job, celebrating the next generation when they call and say they are pregnant and ask if I would be the pediatrician for the new baby.

Currently, I care for around 700 children, ranging in age from the newly born to around 23 years of age, with a payer mix of 50-55% Medicaid, 30-35% BlueCross BlueShield, 10% Cigna and the remainder a mix of other commercial insurances.

My team and I care for a high percentage of children with learning and developmental issues, congenital or birth issues, those living in single-parent homes, in blended families, in foster care, in families with parents struggling with employment, food insecurity, substance abuse and a myriad of other stressors compounded by Covid this past year.

My entire career, I have participated in practice-based health improvement initiatives, office-based research, and education of medical and physician assistant students in the practice. I have been a participant in the Blueprint for 10 years, since it became available to pediatricians in Bennington. I have maintained the medical home status through the National Committee for Quality Assurance at the highest levels for 10 years.

I continue in independent practice because I passionately believe I provide individual attention that is not currently available at a larger hospital-employed practice. I am also, because of the independence, able to make practice improvement changes quickly because it is just myself and three staff members. We were providing telemedicine two weeks after the shutdown last March, with the local hospital-employed pediatric practice not able to do that until well into June.

I continuously strive to respond to meet the needs of my patients. During this past year, it has been the provision of more direct mental health counseling rather than acute illnesses. Time spent providing mental and behavioral health is typically woefully underpaid, but incredibly needed.

Over the past three to four years, it has been increasingly harder for our practice to pay the bills. Payments have not kept pace with inflation and have effectively decreased.

A perfect example is decreased payments for immunization administration. It is disheartening when my practice is consistently a gold winner for childhood and teen vaccination rates. We increase influenza vaccine rates annually, this year at 88%, and have provided flu vaccines for parents/adult family members for over 20 years. This takes a lot of hard work from my entire team.

The cost of needles and syringes have quadrupled in the past year during Covid-19. I had difficulty getting safety needles and, because of the OSHA regulations, I was the only one who could administer vaccines for over six months, as I could not put my staff at risk.

At this point, supplies have normalized, but the costs have not.

Personal protective equipment costs also quadrupled by June 2020, but promised payments to allow for the cost of PPE and the extra time involved in checking in patients to determine Covid risks never materialized and are routinely denied by Medicaid and nearly 90% of the time by other insurers.

I am frugal with what we spend money on in my practice. It needs to improve patient care or efficiency or be a safety issue that needs to be addressed. Between my husband and me, we are housekeeping, maintenance, groundskeepers and snow removal. It is the only way to stay in business.

I was forced to cut down to work part-time only due to cancer treatment in 2017 but a couple of dear friends filled in at deeply discounted pay. I had barely broken even financially when Medicaid payments decreased again and then Covid struck this past year.

The Paycheck Protection Plan helped keep us afloat in 2020. It’s uncertain times in 2021. Payroll and bills get paid first, then I get paid — maybe.

I have wanted to recruit another physician for years. But with insurance payments being what they are and the higher percentage of my practice having Medicaid, it has not been feasible. I have never put a cap on the number of patients with Medicaid.

I was planning on working into my late 60s but will likely call it quits in five years, as will the practice I have built…

I sincerely hope that the state will make a financial commitment to sustain primary care, so that Vermont patients and their families will have independent practices available to help them live their healthiest lives.

Judy K. Orton, M.D., Bennington

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