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State Medical Association president laments Medicare reimbursement, rural doctor shortages

It's simply a matter of time, money and people. Dr. Robert Allison said the ability to provide quality care for patients is tied to the time their doctors can devote to them. The problem, Allison said during a recent stop in Mitchell, is that doctors are being forced to see more and more patients a day while the reimbursement they receive from Medicare is dropping and may be reduced even further.

It puts a strain on the doctor and the business he or she operates or works for, he said.

"I can try to provide the kind of care I want to give if I see 15 patients in a day," he said. "But if I have to see 20 patients a day, the quality of care may be compromised."

Allison is the South Dakota State Medical Association's representative on Gov. Dennis Daugaard's Primary Care Task Force.

The committee is chaired by Deb Bowman, a senior adviser to Daugaard, and Dr. Mary Nettleman, the dean of the Sanford School of Medicine.

Allison is the 131st president of the SDSMA, a post he assumed in June. The association presented a report titled "Strengthening Primary Care Access in South Dakota" to the task force in September.

Ensuring access to high-quality medical care for all South Dakotans, especially those who live in rural areas, is a major concern, he said. Fifty-nine of the state's 66 counties are federally designated as health-professional shortage areas, either partially or completely. Further compounding the problem is that significant numbers of current medical providers are nearing retirement age.

"We are already facing a shortage of primary care providers in rural areas," Allison said. "Reimbursement levels and access to care are linked, so as practice costs rise, policymakers must be willing to adjust reimbursement rates for entitlement programs or we will have no one left to care for those who need our services the most."

Allison said the topic needs to be addressed, and soon.

The last governor's task force addressing this issue was in 1996 and focused on improving recruitment and retention of family physicians.

A Norfolk, Neb., native, Allison and his wife, Dr. Marty Allison, live in Pierre where they practice through the Avera Medical Group. They have three children.

"I wanted to practice in a small town where I could do procedures," he said. "I wanted to care for patients from 16 to 106 and provide both in-patient and outpatient medicine. And I just like living in a small town."

In 2011, his home was flooded for five months, and he was helped by fellow doctors while he dealt with that. It's another reason he's happy with the life, and place, he chose.

Allison said he and other doctors feel a calling and a mission to provide care to people. But he said the new doctors often seek something else in their careers.

"What I went to do in Pierre is not what young doctors come out of medical school to do," he said.

The old country doctors who stayed in the same small town for decades are rare, Allison said.

"You won't see many of those anymore," he said. "That golden era of medicine has come and gone."

The sheer cost of medical school often forces doctors to make choices on their specialties.

"What happens is, the debt drives the profession," Allison said. "And to maintain your ability to practice medicine you have to be reimbursed fairly."

Doctors and medical facilities routinely lose money on Medicaid patients, he said.

"You can't bill patients outside of what is contracted with the government; you take what you can get," Allison said.

In an attempt to practice medicine as they wish to, physicians have flocked back to organized hospital systems that provide financial security, organization and networking, he said.

There is a "huge value" in being part of an organization, Allison said.

Physicians have joined health systems such as Avera, Sanford or Regional Health, which is a major provider in the Black Hills. Fifteen years ago, 70 percent of doctors were independents, he said. That has "completely flipped" in recent years.

It used to be there were a lot of two-member doctor teams in business. Now, most doctors work for a larger health network. There are other changes and concerns, he said.

The average age of a doctor in South Dakota is 55, Allison said, and the age is even higher in the middle of state.

There are other factors that make having enough family doctors for the state difficult. Increasingly, doctors are lured into specialty fields by the compensation. A specialist can make several times what a general practitioner brings home.

He admits it can be a depressing thing to examine.

"It is hard to look at the statistics and not be concerned," Allison said.

"It's not hard to recruit family practice to Sioux Falls; it's not hard to recruit internal medicine to Sioux Falls," he said. "That's one of the questions for the governor's task force: How do you get people to go back to Pierre, South Dakota? Winner and Mobridge? Buffalo, Hoven, Faulkton? How do you grow a medical community?"

He said some tough decisions have to be made on where medical care will be available. He looks at Onida, where he used to travel 30 miles both ways to examine 200 charts and see 15 patients in less than a day.

"It's really challenging," Allison said.

Doctors in private practice, as well as corporate health care systems, have costs. Meanwhile, their reimbursement rates are set and the federal government sets rules that make things even more challenging, he said.

"It's like any small business," Allison said. "If you're providing care at a loss, you can't maintain the business. Insurance firms make huge profits and set reimbursement rates."

Allison met with members of the Mitchell Medical District at Chef Louie's on Oct. 8. It was primarily a discussion on bylaws and the election of officers, he said.