A small white schnauzer named Oakley, a half-dozen peacefully floating seahorses and Arleen, a nurse who has worked there for the last 23 years, greet patients at the Metairie private practice of Dr. Alan Yager.

While most of his 800 patients come to see him in the cozy office nestled in the more buttoned-up confines of East Jefferson General Hospital, he still makes house calls. Patients have his phone number, and they can call or text him whenever they need to as part of his concierge service. 

“Twenty years ago, it was all like me,” said Yager, 63, from behind an antique desk surrounded by family photos and gifts from patients. “I’m sort of a dinosaur.”

Yager is one of a dwindling group of primary care doctors who has maintained an independent practice instead of joining a larger health care system.

As hospital systems consolidate in Louisiana and across the United States, they bring with them coordinated care with specialists, a streamlined approach to scheduling, the ease of electronic health records and negotiating power against insurance companies. At the same time, independent primary care practitioners are inching towards extinction, and that comes at a price, some say. 

“There are great systems that are set up with these health care entities, great ways of tracking,” said Yager. “But I think the one-to-one patient-physician relationship is disappearing.” 

According to survey results from the American Medical Association in 2020, more than half of physicians work outside of private practice for the first time since the group began tracking physician employment in 2012. 

The coronavirus pandemic accelerated the trend. In 2019 and 2020, 48,400 physicians left independent practices for bigger systems. Hospitals and corporations bought up nearly 21,000 practices in that time, and by the end of 2020, 7 out of 10 doctors were employees of hospitals or corporate entities, such as private equity firms or insurers, according to a report from Physicians Advocacy Institute and Avalere Health.

Growing overhead costs, increasing administrative requirements, the rising use of urgent care outlets and the pull of quickly-expanding hospital systems have combined to shrink the number of these practices. Some of the ones that remain, including Yager, have turned to membership or “concierge care” where patients pay an annual fee.

In an open letter to congress last year, the Physicians Advocacy Institute, a nonprofit that advocates for fair payment polices and contracts from payers, said more physicians selling their practices was “no surprise,” considering the “high administrative costs that detract from time with patients, onerous regulatory compliance burden and expense, and anticompetitive contracting and payment practices by dominant insurers and hospitals.”

There are upsides to the growth. Large hospital systems treat a higher percentage of Medicaid patients, who can’t afford the added annual fee of a membership practice. Salaries are often initially higher, some doctors said, and health systems typically handle taxes, malpractice insurance and other administrative issues.

At the same time, some doctors chafe at how many patients they’re asked to treat at large systems, and how quickly. And the ones who have chosen to remain independent say that the tradeoffs chip away at patient trust.

Dr. Ed Lafleur, who opened a private practice in Lafayette in 2004, elected to join a large system in 2011. Part of the pitch, he said, was that the hospital system would handle employee issues and other tasks so he could focus on medicine.

But six months into a three-year contract, he wanted out. To make money under the system’s model, he needed to spend 7 to 10 minutes with patients. That wasn’t enough time to focus on nutrition counseling or listen to patients’ problems. 

“I could fix darn near anything — out-of-control diabetes, blood pressure, acid reflux, autoimmune disease, obesity — but to do that, you have to spend time,” said Lafleur.

He’s back in private practice, and is using a concierge doctor model, where he charges an annual fee for patients. He spends two hours with patients at their initial appointment.

“If I have to go back to seven minutes, I’ll start a lawn service,” said Lafleur.

Challenges

Ka-Yan Tong knows about the difficulties of owning a private practice.

“On the weekends, I’m going to Sam’s to get toilet paper, I’m getting cleaning supplies,” said Tong, a doctor who has been practicing in Metairie for 12 years. “You do everything in a private practice.”

And the pay model doesn’t typically match what she could earn at a big hospital. In the early years, she was making less than she did during residency. 

It’s gotten harder financially for many young doctors to start out on their own. In the 1960s, a medical degree cost the equivalent of about $45,000 today. In 2022, medical school averages about $230,000, according to research group EducationData. That means new doctors have thousands in loans when they’d need to borrow more to set up a new practice. At LSU School of Medicine, a public university, in-state tuition is almost $33,000 per year. Doctors like Yager paid about $1,800.

Independent doctors also have less help complying with federal reporting. Doctors who treat people covered by Medicare — typically a significant percentage of patients — have to report on health care outcomes or face slashed reimbursement rates.

They also lack the negotiating power of large systems and face more pushback from insurance companies, said Dr. Devan Szczepanski, who owns clinics in Covington and the Florida panhandle.

“I have at least five extra employees because of getting prior authorizations or fighting even to just get paid for a regular visit,” Szczepanski said. 

Tong said she has stayed independent for one reason: “Freedom.”

She wants to keep her own schedule and manage her time with patients.

“When you work for yourself, you can decide, I want to spend more time with my patients,” said Tong. “So I see less patients.”

The concierge model 

Dr. David Myers, a solo independent practitioner in Metairie, thinks independent doctors have more incentives to keep patients out of the hospital than those that work within a larger network.

He sees a lot of patients who come over from large systems.

“They feel like they’re a pawn in a giant game as opposed to having their individual interest at the forefront,” said Myers.

Some physicians have been able to thrive independently under the concierge or membership model. Yager switched to that model 10 years ago and charges patients $400 yearly. Myers and Lafleur are part of a network of independent physicians, called MDVIP, which costs patients between $1,800-$2,000 yearly and includes access to a legal and IT department. The company also helps doctors negotiate rates with insurance companies.

Others work on a membership model and tailor their practice to what patients are interested in. In Covington, Szczepanski owns a practice that takes traditional insurance. Her two membership practices in Florida offer traditional primary care alongside integrative medicine — things like hormonal and nutritional genetic testing.

For Yager, creating a personal connection and trust with patients is vital. His father was also a doctor, and was one of the founders of East Jefferson General Hospital, which was purchased by LCMC Health in 2020. A portrait of the elder Yager peers over a stack of files in his son’s office. Yager said his father used to make house calls in a boat down in the bayou — which is the kind of thing that just doesn’t exist anymore.

Yager points to the initial hesitancy and then the outright rejection of the COVID-19 vaccine as an example of why a personal connection to a family doctor is important. 

“People don’t trust health care,” said Yager. “They trust the people that take care of them.”