Photo by Concord Monitor and Ken Williams

Dr. Matthew Masewic and Danielle Devoll count the receipts after getting the morning mail.

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Matt Masewic opened Boscawen Family Practice two years ago with dreams and a plan. He had ideals about the kind of medicine he would practice. His independent practice would provide a service to the community - no rejecting patients without insurance, no 10-minute, rushed visits.

He also knew that finances would be tough. He brought in his brother to help him renovate the modest office he rented from the town, bought used equipment and furniture, and hired a bare-bones staff. He figured that this combination of frugality and quality medicine would help his practice survive.

But he was wrong. At the end of the month, Masewic will close his practice, leaving behind the rehabbed building and his roster of 1,200 patients, and holding about $500,000 of debt.

"My heart's broken," he said. "I gave it everything I had and it didn't give back."

The last two years have been a crash course in medical economics for Masewic, who knew it would be hard but didn't realize just how hard.

While the Concord area is experiencing a shortage of primary care doctors - a recent Monitor survey of practices found that eight out of nine in the city were closed to new patients - demand for medical services hasn't been enough to keep Masewic and other private practices afloat. Greenbriar Family Health in Northwood, another independent primary care practice, closed earlier this year for financial reasons. And Pittsfield Medical Center is in talks with Concord Hospital to sell the practice, according to Concord Hospital President and CEO Mike Green.

"It's very simple economics," said Dr. Rick Kellerman, president of the American Academy of Family Physicians, who said that family practices around the country are suffering. "The payment for what we do as family physicians, as important as that is, has not kept up with the expenses in our office, whether it's nurses, malpractice insurance or keeping the lights on."

Masewic's financial troubles have been even more acute than those of his peers, because he decided early on that he would not turn any patients away. He takes patients with private health insurance, but also patients with Medicare and Medicaid, which often pay him less than his cost for the visit. An Army Reserve veteran, he even takes military insurance, which pays so poorly that the next nearest provider is in Manchester.

Perhaps worst of all, he takes patients with no insurance at all and doesn't require them to pay him up front.

"I didn't think it would be so difficult to collect," he said. "I thought if I provided a good service, they'd pay for it."

Compared with the primary care practices owned by Concord Hospital, Masewic also doesn't benefit from economies of scale. He pays more for medical supplies, has a tougher time negotiating with insurance companies and has to hire an outside contractor for his billing. But primary care is such a tough business that even Concord Hospital doesn't make money on the practices it owns.

"We are in the same state as Masewic and anybody else," said Green of Concord Hospital, which started acquiring local primary care practices about 10 years ago, when it saw that many would go out of business without the hospital's financial and managerial support. "We still basically subsidize the primary care practices."

Saying no sometimes

Like Masewic, Concord Hospital doesn't turn away patients with low-paying insurance. Green said the profitability of the individual practices it owns varies according to the payer mix: The more commercial insurance a practice collects, the more likely it is to be in the black. (next page »)