WOODSTOCK — After nearly 20 years as an internal medicine doctor at a clinic, Lorissa Segal is striking out on her own.
Segal was set to see her last patients at the Dartmouth Health-run Ottauquechee Health Center in Woodstock Friday and will begin seeing patients at a new private practice in the old Sunset Farm building on Maxham Meadow Way on Tuesday.
“I love primary care and I wanted to create something where I would be able to stay in this town and continue to take care of the community here,” Segal, 48, said in a recent interview.
At the Woodstock clinic where Segal, of Barnard, has worked since 2008, she said there has been pressure to complete appointments more quickly and to devote more time on complicated billing paperwork. The clinic has lost its “close-knit family feel” over the years, she said. She has been thinking about making a change “slowly over the last several years.”
“It’s a difficult career. It can be hectic and busy and all-consuming,” Segal said.
At DH’s clinic, Segal sees about 1,100 patients. In private practice, she plans to see 350 patients, which she hopes will give her more time to spend with each encounter, offer flexibility with scheduling, allow her to connect with subspecialists and provide a higher quality health care.
Her private practice can also ensure Segal’s patients always see her, rather than a physician’s assistant or nurse practitioner because she has a full schedule.
“A healthy provider is the best kind of provider,” Segal said. “I think this new practice will allow me to practice in a way that I want to, which is to really spend time with patients and that allows me to take care of them and continue to work in this field.”
DH has been preparing for Segal’s departure since she notified leadership of her decision to leave a few months ago, Mt. Ascutney CEO and President Matthew Foster said in a Wednesday statement.
“We wanted to ensure continuity of care,” Foster said. “Any patient, should they choose, will be able to continue their care with the other providers in the clinic. Additionally, we have been actively recruiting to add an experienced physician to the team. The clinic continues to welcome new patients and same day access remains available at the clinic.”
‘Gradual trend’
Segal said she has watched as the changing nature of the job has forced many of her colleagues into early retirement or other fields, she said. She hopes that switching to a smaller, private practice will help her to avoid her own burnout and stay in Woodstock for many more years.
Segal is the latest in a line of Upper Valley health care providers transitioning from large academic medical systems to non-traditional primary care practices.
Drs. Alex Grossman and Elizabeth Wolfe left the VA Medical Center in White River Junction to launch Upper Valley Direct Primary Care in Lebanon in January, a subscription based micro-clinic. Audrey Lohr, an advanced practice registered nurse, left North Star Health in Springfield, Vt., to launch Flora Primary Care in White River Junction last April. Lohr now provides primary care integrated with functional medicine.
The phenomenon seems to be a “gradual trend” emerging around Vermont as providers become overwhelmed by large patient panels, paperwork and a desire to get back “that personal touch in medicine,” Vermont Medical Society Executive Director Jessa Barnard said Monday.
The shift is understandable, Barnard said, given that providers are spending more and more time on paperwork and are increasingly “overburdened.”
Transitioning to a direct primary care or similar model “means that the patients who are able to access that kind of care probably get very good care and a lot of personal attention.”
But, she said, there are potential pitfalls.
“We certainly can see the attraction, but then the concern is, first of all, there wouldn’t be enough clinicians if all providers did this and not everyone can afford it, so you would start to see access limited,” Barnard said.
Women’s health focus
Though she will continue to see adult patients of all genders, Segal is particularly interested in women’s health.
She is trained to place and remove IUDs, long-term, reversible contraceptives, and is “very interested” in menopausal health, hormone therapy and other health issues particular to women.
“I’ve taken the time to learn about a lot of women’s health topics and want to be able to provide that care to my patients instead of referring them to a subspecialist if they don’t need to go,” Segal said.
She is especially interested in menopause care, which is becoming more widely available for patients. Segal said this is likely because menopausal hormone therapy, or hormone replacement therapy, was thought to be unsafe until recently.
After reviewing an early-2000s Women’s Health Initiative study and expert guidance and public input, the U.S. Food and Drug Administration rolled back warnings from menopause-related hormone therapies in November that the agency said were inaccurate.
Segal said when she was in medical school about 20 years ago, doctors were not taught about hormone therapy because it was considered unsafe.
“There were a lot of women who missed the opportunity to receive that care and now, I think the light is coming to the fact that it’s actually safe for a lot of women to use during this transition,” Segal said. “(…)I think it’s very appropriate care to be providing, and I’m happy that we’re in a place where we can feel comfortable providing that care.”
Operational support
Segal’s new practice is affiliated with MDVIP, a Florida-based company that partners with independent primary care providers to offer membership-based care.
Segal will accept private insurance, Medicare and Medicaid to cover standard preventative and sick visits and services.
Patients will also be charged an additional $2,400 annual fee for testing not typically covered by insurance including tests for lung function, heart activity, fat and lean muscle mass composition, grip strength and extensive blood work.
The annual fee also covers “technology, legal and operational support provided by MDVIP,” a spokesperson for the company said Wednesday.
Working with MDVIP has helped Segal to handle many of the technical elements of running a business such as setting up electronic medical records and billing systems.
“That has always been a huge hurdle for me mentally,” Segal said. “Like, ‘Wow, if I decide to go out on my own how am I even going to juggle all of these things?’ “
Segal said she understands that the subscription fee may be prohibitive for some patients, but hopes that many of her current patients will transition to the new practice.
“In the long run,” Segal hopes the new clinic will “actually provide more primary care access for people” by allowing her to stay in the field and provide better care for patients. She also hopes to continue teaching medical students and said perhaps seeing a different model of primary care will encourage more students to go into the field that has been declining.
By 2030, Vermont will be short about 190 internal medicine providers based on aging demographics and projected demand, according to data from the Vermont Medical Society.
Direct primary care for all
A bill, S. 197, in the state Legislature supported by the Vermont Medical Society aims to create a monthly insurance reimbursement model for primary care in Vermont so doctors can “see patients more flexibly and creatively,” the Medical Society’s Barnard said.
The Vermont Medical Society is advocating for the bill, which notes that Vermont primary care practitioners currently spend half of their time, on average, completing “administrative tasks.”
The bill aims to spread some of the benefits of direct primary care while limiting paperwork for doctors and allowing them to continue to see the same number of patients, Barnard said. It would also allow doctors to support patients in ways that are not typically reimbursed, such as through phone calls, text messages or nurse visits.
“We’re not officially calling it this, but one of the ways to describe it is to get kind of a more direct primary care system for everyone,” Barnard said of the bill.
The bill would also increase the proportion of health care spending dedicated to primary care in Vermont and continue a scholarship program for medical students who practice primary care outside of Chittenden County. It has been recommended by the Senate Committees on Health and Welfare and on Appropriations.
“If we made it a great state to practice primary care, we’d attract more primary care physicians,” Barnard said.