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Al Key

Primary care practices fall behind specialties

Profile image for By Eric Nishimoto / For the Denton Record-Chronicle
By Eric Nishimoto / For the Denton Record-Chronicle

EDITOR’S NOTE: This six-part series on health care reform is a joint effort of the Denton Record-Chronicle and graduate students from the University of North Texas Mayborn School of Journalism, along with professor George Getschow, formerly with The Wall Street Journal and a Pulitzer finalist.


PLANO — Molly Guthrie and her mom, Amy, went to see their family doctor for a checkup. It was Halloween and Molly came dressed as a doctor.

Her real doctor, Aaron Segal, told Molly all about her plastic instruments that looked just like his real ones — giving a booster shot to her hopes of one day healing the sick, furry or otherwise. Molly, an 8-year-old with blonde hair and big, blue eyes behind blue glasses, looked up at Segal with visible awe.

Devoting his attention and time to patients like Molly is what distinguishes Segal, a family physician for seven years, from today’s rotating teams of medical specialists who may be less focused on the general well-being of patients than they are in providing as many services as possible to treat specific illnesses.

As medicine races ahead with advances in technology and a dizzying number of specialties, the deep sense of trust and intimacy between doctor and patient appears to be losing ground to clinic-based care. A more clinical and centralized health care system threatens to put primary care physicians like Segal out to pasture.

“We feel like we’re the underdogs,” Segal said, speaking for himself, his father, Dr. Irwin Segal, and his wife, Dr. Stephanie Segal. The three serve 5,500 patients inside a Plano medical complex.

Rising malpractice insurance premiums, shrinking Medicare payments and an ever-growing income gap between primary care physicians and medical specialists are making traditional family practices like the Segals’ an endangered species.

For example, a family care physician earns 46 percent of what a dermatologist makes each year, according to the American Medical Group Association, a medical research and survey firm.

Physician-owned practices dropped from 70 percent in 2002 to less than 50 percent in 2008, according to the Medical Group Management Association. The American Academy of Family Physicians has found that over the last decade, the number of medical students choosing primary care has dropped by half.

As the ranks of primary care physicians shrink, sweeping health care reform legislation is expected to pump another 32 million uninsured Americans into the health care system, according to the Congressional Budget Office. Family physicians are worried about absorbing a flood of new patients next year.

“Without [more] primary care physicians to meet this demand, simply providing an insurance card to all will do little to improve patients’ access to high-quality health care or to provide better efficiency,” said Dr. Ted Epperly, president of the American Academy of Family Physicians.

Despite the dark clouds looming on the medical horizon, the Segals said they’re determined to hang on to their practice. They cherish the close, interpersonal relationships they have with their patients. They know their patients by first name, where they work, where their kids go to school, where they go on vacations and what troubles them physically and emotionally.

“We never would think of a patient as ‘that diabetic’ or ‘that hypertensive,’ ” said Irwin Segal. “It’s Jim Smith or Joe Jones.”


Health care guardians

The Segals, in turn, are viewed by their patients as more than doctors who provide state-of-the-art medical services. They are guardians, caring for their patients’ health and well-being from cradle to grave.

Cassie Menard and her 3-year-old daughter, Maggie, are cared for by Aaron Segal. Whenever she gets a “boo-boo,” Maggie turns to her and says, “Mommy, we need to go see Dr. Segal.” Maggie feels right at home, Menard said.

During each visit, the doctors ask about the goings-on in the family’s hectic life. Recently, the subject was bikes. Last Christmas, Maggie’s grandparents bought her a bike with training wheels. Maggie loved her new bike — until her parents raised the training wheels.

“She freaked out and wouldn’t ride it anymore,” said Menard.

She asked Aaron Segal, who coached his children through toddlerhood, for advice.

“Take the training wheels and pedals off and lower the seat and she’ll just learn to scoot around,” he said. “She’ll develop her balance ... and eventually learn how to ride.”

He’s provided the antidote for all sorts of anxieties she’s had over the years raising her children, Menard said. Other patients echo the sentiment on the bulletin board hanging in the Segals’ office, overflowing with greeting cards and photos of smiling children.

“It’s very comforting to know that a family is looking after our family,” Menard said.

While visiting relatives in Austin, Menard seriously burned her hand. Aaron Segal arranged for a dermatologist to treat her burn immediately rather than having her wait for hours in the emergency room of a local hospital. On another out-of-town trip, he arranged for Maggie to see a doctor who long ago stopped seeing new patients.

“The first person I call when I’m in trouble is Dr. Aaron,” Mernard said. “Who else could I expect to do things like that for us?”


Caring for four generations

Irwin Segal, the soft-spoken founder of the practice, graduated from Montreal’s McGill Faculty of Medicine, one of Canada’s top medical schools. He became the school’s first graduate to open a family practice. But he grew weary of Canada’s socialized medicine and moved to Texas, opening his practice in Plano in 1978.

“I’ve been with some of my patients for over 30 years, and their families, some four generations worth,” Irwin Segal said. “By knowing your patients so well, you don’t have to start with a blank slate every time they come in with a problem. We know our patients so we know what’s happening to them — physically and psychologically.”

Lynn and Dave Thompson’s three daughters, ages 19 to 27, have seen only the Segals. The couple began seeing Irwin Segal 33 years ago when they were newlyweds in their 20s. The family practice has served as the Thompsons’ only doctors ever since.

“At every stage in my life,” Lynn Thompson said, “Dr. Irwin has been able to figure out a plan to deal with it.”

They camped out at the Segals’ office on many days during their daughters’ teenage years.

“I kept thinking that it was all much harder than it should be,” she said. “We must have done something wrong.”

Irwin Segal assured them that was the way it was supposed to be, that high-schoolers should be awful so that you want them to leave home, she recalled.

“When you hear it from your doctor, you think, ‘OK, I can relax,’” Lynn Thompson said.

When she tore her anterior cruciate ligament in her knee, she was “scared to death,” she said, just thinking about the surgery, unable to sleep or focus on anything else. She scheduled an appointment to see Aaron and Irwin Segal. Through the course of an hour and a box of tissues, she unleashed her fears about the surgical procedure.

“I won’t be awake to watch him [the orthopedic surgeon] and notice if anything bad happens,” she told them.

Aaron Segal tried to humor her, saying she wasn’t the type who can hear saws going in an operating room. Irwin Segal also tried to ease her fears, saying that if she didn’t wake up, she wouldn’t ever know she didn’t.

The two doctors “talked me off the ledge,” Lynn Thompson said.

Now, she is struggling with caring for her elderly parents. Her mother suffers from dementia. Irwin Segal is providing care and counsel to Lynn Thompson and her parents, but also recommended that she and her mother seek help from a gerontologist.

“Through it all,” she said, he provides “a calm, logical, get-you-to-the-right-place and help-you-move-forward way.”

As Lynn Thompson discovered, her doctors — like many family physicians — play an indispensable role in accessing and coordinating patient care.

“Family physicians and their primary care peers are the front door to our health care system,” Epperly said. “They are the first contact patients have, and they are the physicians to whom patients turn for help navigating our extremely complex health care system.”

Bad business but good medicine

The Segals maintain a smaller patient load than many of their peers so they can spend more time with each patient. The time they spend in the examination rooms isn’t always billable. But the extra time spent with their patients often provides benefits that contribute to their patients’ health and well-being.

“It’s bad business, but it’s good medicine,” Aaron Segal said.

Irwin Segal shakes his head over what has happened to his practice since the 1970s and 1980s, which he calls the “golden years” of family doctoring.

“Back in the ’80s, we didn’t need a lot of overhead ... [just] one RN [registered nurse] and one receptionist,” he said. “Now, from a business standpoint, we basically work for the insurance companies. … [The] problem is because fees are set by insurance companies, fees are going down and overhead is going up.”

Stephanie Segal sits in an examination room with a mother and her teenage daughter, preparing to conduct a checkup on the daughter. The mother came to the appointment armed with a pile of insurance documents and many questions about medical procedures and insurance issues. The doctor spends 20 minutes explaining medical procedures she considers necessary but which might not be covered by insurance.

The mother looks skeptical, explaining that her insurance company had warned her to “not let your doctor order anything that we don’t cover!”

Dealing with insurance companies accounts for one of the biggest increases in the doctors’ overhead costs. The Segals pay two staff members to handle their patients’ insurance issues, spending 30 to 45 minutes on the phone verifying each patient’s coverage and benefits. Haggling with clerks and filling out paperwork can become a nightmare when a customer service representative is new and doesn’t understand the job.

The Patient Protection and Affordable Care Act is purported to relieve insurance headaches and help primary care providers with a new health care delivery system known as the accountable care organization. Proponents say such groups offer cost-efficient care by having primary care doctors and specialists coordinate under one roof and share overhead. The legislation also authorizes an increase in Medicare payments for primary care services, including payments for “cognitive care” that isn’t currently covered.

In other words, a primary care physician “would get more for talking to and examining a patient and less for doing a lab test,” said Dr. N. Thomas Connally, a retired primary care physician and advocate.

Still, many primary care physicians are skeptical that reform will be the elixir that has been promised. They’re convinced the legislation will usher in one-stop, multi-specialty, high-volume health care focused on treating symptoms rather than a patient’s overall health needs.

“When you incentivize someone to go somewhere else other than their primary care physician, you’re really fracturing their care,” Aaron Segal said. “And, in the end, it leads to higher-cost care or it prevents us from doing preventive measures that reduce cost later.”

Duane Guthrie simply can’t imagine going to another doctor’s office. When he discovered a spot on his neck, Guthrie called, knowing he would get in for an examination quickly.

Aaron Segal removed the tissue. When the biopsy came back showing some risk for cancer, he decided to play it safe and sent Guthrie to a specialist for further examination and treatment.

“I need [Aaron Segal] … to make sure that I’m getting good care,” Guthrie said. “I feel confident that he’s on top of it.”

The Segals covet their kinship with patients like Guthrie for the same reason.

“It’s that one-on-one relationship with each patient ... I love it,” Irwin Segal said. “I have a barber that I’ve been going to for 25 years even though there are less expensive barbers closer to home. But we have a relationship. I just don’t want to be a number.”