ACP: What’s a small group practice to do?

ACP: What’s a small group practice to do? A guest column by the American College of Physicians, exclusive to

In 1998 I started a period of national service to the American College of Physicians leading to my term as President for 2010-2011. During that time I kept an almost full time private practice in Fayetteville, Tennessee. Moving between the worlds of health policy and “the trenches,” I understand better than many the tremendous challenges we face in changing health care delivery.

Our practice includes internists, family physicians, pediatricians, and a nurse practitioner. We adopted an electronic health record (EHR) in 2004 and are in the process of moving from a Level I Patient-Centered Medical Home toward a Level 3.

We have seen consultants over the years with slick presentations touting one or more innovations that promise to change everything. These new ideas have come and gone and our practice expenses go up while revenue is flat. Fortunately, six of us are native to the area with strong roots, but our 102 year old practice is facing the greatest challenges in a history that includes two world wars, a flu pandemic, and at least one depression depending on your perspective.

In 1983 our expenses were under 40% of revenue and we had the option of raising our historically low charges to meet new needs. Currently, the opposite is true. Expenses are over 60% without good options to increase revenue. In our particular market, hospital ownership would be complicated and not our best option. In any case, a true “system” of health care should allow a financing mechanism where a core of primary care doctors can maintain a viable practice.

Like many physicians, my partners and I worry about the future. We worry about leaving the community with limited care if we moved away to take any of the many salaried jobs available these days. We may ultimately join larger regional groups if that is the right thing to do but currently we want to survive in the transition.

When we looked for our EHR, we visited a number of practices to see the records in action. In each visit we learned something about practice operations that helped us in ours. Hopefully, we were able to pass along similar tips that were helpful to others.

ACP understands that we have members in many different practice situations and is working to find ways to help all our members adapt to the changing world of health care.

A significant tool has been developed by ACP to help practices starting or contemplating transformation to a Patient-Centered Medical Home. Medical Home Builder 2.0 is an online program that helps an office team improve patient care and support ongoing practice improvement.

ACP has also joined with others to offer AmericanEHR Partners, an online community dedicated to supporting adoption, use, and optimization of EHRs.  AmericanEHR Partners is free and access to the satisfaction data is available to all registered users.

Do any of the readers of this column have ideas about how smaller groups can begin to help each other survive in these difficult times? Are there examples to cite of purchasing power, shared employees, or other ways to help with overhead?

Fred Ralston practices internal medicine in Fayetteville, Tennessee, and is the Immediate Past President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • Anonymous

    “Do any of the readers of this column have ideas about how smaller groups can begin to help each other survive in these difficult times? Are there examples to cite of purchasing power, shared employees, or other ways to help with overhead?”

    The first thought I have is why in the world do you want your practice to become a PCMH? 

    Most of the “studies” so far are just propaganda pieces, but the results are dismal: big increases in overhead, no improvment in patient satisfaction or health, and doctor and staff burnout. If and when the insurers start paying for the added administrative work, it’s going to be a rapid race to the bottom. The largest insurer in my area is now offering $2 PMPM for full level III services, which would be a financial disaster for any practice foolish enough to sign up.

    By avoiding the PCMH and other poorly thought-out schemes, we’re managing to keep our overhead around 51%.

    • ninguem

      What southerndoc said.

    • Margalit Gur-Arie

      The idea behind a patient-centered medical home is a good one. The implementation, however, has devolved into a tangled web of bureaucracy aimed at removing physicians from direct care and placing them in a population management supervisory role.
      This is part of a much larger, “expert” driven consensus that you don’t need fully qualified physicians to deliver medical care anymore, since computer assisted clerks and occasionally mid-level providers, working according to established protocols, can easily manage most patient needs, particularly the poor ones.

      • Anonymous

        Very well said.

        Of course, there are many excellent features in the patient home model. And many doctors already incorporate them in their practice every day. But, if they’re not done within the Rube Goldbergesque official PCMH framework that provides a steady stream of revenue to the NCQA and TransFormed, they don’t count.

        Reading the original post, I don’t know whether to laugh or cry. The past president of the ACP, an organization that is forcing this high-expense, low-return model of practice management on ONLY its lowest earning members, the general internists, laments that the overhead in his practice is out of control.

        Karma bites.

      • Anonymous

        Okay. Its basic folks: Patient-centered means you put PATIENTS at the center not high-priced consultants, experts, politicians, ore even physicians. I think this is where some of us got duped – again!  Here’s the key: Ask patients what they want. Deliver it. And cut out all the “meddling” men. 

        Try it. It works.

    • Anonymous

      Amen southerndoc1! Tell it like it is Brother!

  • PamelaWibleMD

    Fred ~ the best way that I have found for small practices to thrive is to actually put the patients & community in charge of designing their “ideal clinic.” This creates immense community goodwill and financial support. It also creates a culture of volunteerism. Citizens will offer to help out in your office  for free doing gardening, cleaning, making flannel gowns – you name it! In this way we are no longer holding patients (and ourselves) hostage to a model designed by high-priced consultants & experts (which patients are not inspired to financially support). Physicians need to get out of the exam room and collaborate with their community. The answer you are looking for Fred is literally right next door. 
    Pamela Wible

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