Fee-For-Service Private Practices Face Dark Times.

Dr. Tracy Ragland, 46, an independent primary care physician, is anxious about the future of her small practice. The law is bringing new regulations and payment rates that she says squeeze self-employed doctors out of even practicing medicine. She cherishes the autonomy of private practice and speaks darkly of the rush of independent physicians into hospital networks, which she sees as growing monopolies.

“The possibility of not being able to survive in a private practice, especially primary care, is very real,” she said.

Dr. Ragland represents the grim reality of bureaucracy sublimating our primary care system. She lives and works on the outskirts of Louisville, spending long days troubleshooting routine problems like back pain and acid reflux.

So far, 265,000 residents of Kentucky have signed up for insurance through the Affordable Care Act. Most have been found eligible for Medicaid, which the state expanded under the law. Primary care offices are “supposed” to be their point of entry into the health care system, providing the preventive care and upkeep that are crucial to improving the nation’s health.

But, as an independent physician, Dr. Ragland must carefully devise strategies to keep her three-person practice afloat amid rising overhead, flat or dropping reimbursement rates, and new federal rules, many of them related to the health care law.

She said that she embraced the goal of extending health coverage to far more Americans, but that Medicaid paid too poorly for her to treat any of the new enrollees. And while she is accepting some of the private plans sold through Kentucky’s new online insurance exchange, she has rejected others — again, because she considers the payment too low.

Only about 40 percent of family doctors and pediatricians remain independent, according to the American Medical Association — and many, including Dr. Ragland, feel that harsh economic winds that were already pushing against them have been accelerated by the Affordable Care Act.

“We’re in an unknown time,” she said.

Dr. Ragland is both a general internist and a pediatrician. She treats infants to patients in their 90s. On a Monday this month, she saw 15 patients at an unhurried pace, partly because she had some no-shows because of bitterly cold weather. Now had she been practicing direct care, she would have seen fewer than 15 patients in a day, most likely, and been able to engage with her patients who needed help unlimited times.

Halfway through her day, Dr. Ragland walked into an exam room and found Aline Burgin, 61, waiting for her. “I haven’t seen you in a while!” she said, noting that Ms. Burgin’s last visit was two years earlier. Ms. Burgin, who works the overnight shift at a nursing home, said she had temporarily dropped her employer-sponsored insurance because it was too expensive.

“It’s $170 out of my paycheck every two weeks,” she said.

Dr. Ragland, being that she’s still in the fee-for-service universe, had to ask if she visited the healthcare exchange for help.

Ms. Burgin agreed to take the phone number for Kynect, the state exchange. Then she lingered in the exam room, telling Dr. Ragland about her sister’s recent death from emphysema and the guilt she felt about not being with her that day. Dr. Ragland listened for nearly 10 minutes making her appointment about 30 minutes long — 10 minutes longer than the usual appointment time. Dr. Ragland said that this kind of flexibility is what she treasures about private practice.

“Some patients need five minutes; some patients need all kinds of time and follow-up,” she said. “I never want to be in a situation where my employer tells me I need to be more productive or I’m going to have a severe cut in my pay.”

Now imagine if she practiced direct care and was able to spend up to 45 minutes or longer with her patients. And imagine that instead of fearing the dark times of socialized healthcare, she was telling students how to start practicing medicine like she could be. That could shine a light on the dark times facing private practices. But first, it’s realizing that bureaucracy is the dark cloud looming overhead.