The Washington Post

Could a contract take your longtime doctor away?

- EMILY SOHN health-science@washpost.com

I received a form letter recently from my health clinic that told me my primary-care doctor was leaving. Her colleagues would welcome me into their care.

I had been seeing her for more than a decade and didn’t want a new doctor. But when I called to ask where she was going, receptioni­sts said they didn’t know — a response that made me wonder whether her contract prevented them from telling me. I also worried: after years of building a relationsh­ip with a doctor I trusted, would I have to start all over with a new provider?

Several weeks later, I talked to my doctor, Sally Engebretso­n, who explained what had happened.

She had decided to change jobs, but her contract included a noncompete clause that prevented her from working for a competitor within 10 miles for a year after she left. A nonsolicit­ation agreement also meant she couldn’t tell patients where she was going. If they asked, she would need to tell them to search online for her.

My husband happened to have her cellphone number. Without that, finding her would not have been easy. A week after she started her new job at a clinic 14 miles away, Internet searches still turned up her profile at the old clinic first. My husband called her old clinic to renew a prescripti­on, and the receptioni­st thought she still worked there.

Neverthele­ss, many of her patients decided to wait until they could track her down. As a result, she spent the first few weeks at her new job dealing with health crises and ordering urgent tests, including CT scans and colonoscop­ies — all for her long-term patients.

“I had people that had heart disease and lung disease,” she says. “And a lot of them said to me, ‘I’m just so complicate­d. I don’t trust anybody else. So, I just held on until I could find you.’ ”

It’s not clear how often doctors sign restrictiv­e covenants, the contract clauses that limit where they can go or what they can say after leaving a job, says David Clark, a partner at Epstein Becker & Green, a law firm in New York. But restrictiv­e covenants are widespread in many industries — including, anecdotall­y, in medicine. Just recently, Clark says, his mother’s eye doctor told her that he was leaving his practice but couldn’t tell her where he was going.

Laws vary by state — both in what’s allowed in physician contracts and what is enforceabl­e. In some states — including Massachuse­tts, Rhode Island, Delaware and Colorado — health-care systems can’t legally enforce contract provisions that prevent health-care employees from working for competitor­s. Other states — including Texas, New Mexico, Connecticu­t and Tennessee — allow them with various limitation­s on how restrictiv­e they can be. Most states don’t have any statutes addressing the issue, Clark says.

Hospitals and clinics may justify restrictiv­e clauses as a way to protect their investment­s in physicians, says David Meltzer, an economist and primary-care physician at the University of Chicago. He imagined a scenario in which a hospital spent a lot of money to hire a prominent surgeon, supplement­ed by expenditur­es in support staff and advertisin­g, only to have the surgeon soon leave the practice for a competitor down the road.

“There is a reason why these exist,” Meltzer says. “It’s not just a ridiculous control mechanism, necessaril­y.”

For a physician, signing a noncompete offers an economic trade-off, at least in theory, says Michael Richards, a health economist at Baylor University in Waco, Tex. In exchange for signing over some freedoms, the doctor gets the benefit of an establishe­d practice that covers overhead costs and comes with a stock of patients.

“It doesn’t strike me as something that doesn’t make sense at all in health care,” he says.

But restrictiv­e clauses are increasing­ly raising new questions for doctors. With trends toward consolidat­ion of health systems, for example, many clinics and hospitals encompass a large geographic range. Restricted by a noncompete clause, physicians in those systems might not realize how far-reaching their contracts will be in limiting job opportunit­ies close to home.

“You might be talking about an entire city and suburban outlying areas that are now actually going to be inaccessib­le for you for some period of time,” Richards says. Telemedici­ne is another example. If doctors consult online with patients in other states, their geographic range of practice expands even more, he says.

“Noncompete agreements are going to become an even thornier and less clear issue going forward,” Richards says.

By interrupti­ng the continuity of care between doctors and patients, restrictiv­e clauses could also harm patients, research suggests.

The first randomized study to assess the value of consistent care was published in 1984 and found that men who were assigned to see the same primary-care doctor for every visit showed lower rates of hospitaliz­ation and fewer admissions to the intensive care unit than men who saw different doctors at every visit. “The ones who saw the same doctor did radically better,” Meltzer says.

In the first attempt since then to establish the health outcomes of seeing the same or different doctors, Meltzer says, he and colleagues found that patients were much happier when they got care from the same primarycar­e doctor across visits. And they were about 15 percent less likely to end up back in the hospital if they consistent­ly saw one physician. They presented their findings at a conference last year.

“If you’ve got a really complicate­d history and that history is one that would be very hard to convey to someone else — or you feel like you’ve had a lot of challengin­g relationsh­ips with doctors and you’ve finally found one who gets you — those are valuable things,” Meltzer says.

Engebretso­n’s experience illustrate­s how important relationsh­ips with their doctors can be for people.

During her first two weeks at a new clinic, she says, she saw nearly 80 patients who followed her there from the old clinic. Many are in their 70s and 80s and don’t want to have to find new doctors and explain complicate­d health issues all over again. Some live next door to the old clinic, 14 miles away.

“The only thing that you really need to practice good medicine is a good relationsh­ip with the patient,” Engebretso­n says. When clinics prioritize business over patients, she adds, patients suffer. “It’s bad for patient care and especially for vulnerable people, it’s terrible. They need to be able to know where you’re going so they can make a conscious decision.”

“There is a reason why these exist. It’s not just a ridiculous control mechanism, necessaril­y.” Economist David Meltzer, referring to noncompete clauses for physicians

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