Doctors are forced to choose between really small or super big

I am a little fish in a big sea. And so are most of us. Or used to be. For better and for worse, the era of private-practice, outpatient medicine as we know it is coming to an end.

And faster than we thought. The choice now: down size or super size. No longer can a doctor operate a private practice as a solo practitioner or in a small group practice. We are getting swallowed up very quickly now by the bigger fish in the sea.

I tried this route after my residency, and so did you, probably. But the declining insurance reimbursements coupled with the increased administrative load has made the business of medicine into something I can no longer engage in. I, like you, try and try to make it work with faster software and electronic billing and automatic this and automatic that.

But at the end of the day, running the practice took over the energy of the clinical practice. Instead of being able to spend time with my patients, I found I had to spend time with my patient’s insurance company.

“Hey Doc, I have one more question,” my patient tells me.

Not one more question, I think, I still have 36 people I have to see and now I am running behind.

In order to keep up we have to give up or give in. Not everything, of course, but the stuff that matters.

So the choice becomes this: will you down size and choose to limit how many patients you can take care of, reducing your staff and all of the administrative burden. Maybe even choosing to not file insurance any more?

Or will you super size and join a big group or corporation or hospital practice where there are lots and lots of staff and lots and lots of doctors to treat lots and lots of patients?

You really can’t choose both and it is becoming clear that you have to make a decision.

Really small or super big. There is no right answer, of course, the only bad decision will likely be not deciding.

I chose to down size and drop insurance and drop my staff and drop my office. Now I see patients in the back of a converted ambulance (my new mobile office) at home or work or even a Dunkin Donuts parking lot. It was most important to me to be able to get to know my patients and spend time with them and convenience them.

But plenty of you, in fact, most of you, will choose to super size and join the bigger and bigger groups.

Either way, please choose. Our patients require lots more attention now than ever before. And the worst thing we can do is to pretend that we can keep up this private practice gig, like we have been for the past 50 years.

We all have different ideas about how best to take care of our patients, but we do need to agree that now we must choose: down size or super size. The regular size is no longer working.

Craig Koniver, author of Connected: The New Rules of Medicine, consults with physicians around the country at The New Rules of Medicine.

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  • Anonymous

    Where I live most doctors are in a group practice. One problem I have repeadily dealt with is that the billing code is incorrectly choosen. So than an endoscpy is coded as a breast exam. Of course when I bring it up to the doctor they have no clue, and refer me to billing. when I get the chance to call billing they usualy tell me that they have not recieved anything and to waite. So a few months go buy and eventualy I get a call from collections after the bill has been sumbitted to a collection agency. Because of the number of months that it has gone “unpaid”. Is there anyway to handel this problem, because it’s destroying the dr patient relationship. I’m not sure if a doctor has the power to do anything with the people in billing. It’s bad enough when things get misdiagnosed, that’s fine I can deal with that. But now the bills are going to get screwed up?

        

    • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

      This is what happens when there are too many people in the system and their is not specific goals. Of course the doctors have a say in how the claims are filed. Sounds like it may be time to drive a little and find a new doctor. There is no reason to stay with a doctor just because of location. For now, there are plenty of doctors all over. Try talking with a few different ones and see what feels right to you.

      • Anonymous

        That’s what I thought the answer would be. In respect to you and other people who are posting under their real name. Can we talk via email, or some other method that would allow me to be more specific with out discredditing anyone? Because what I would realy look for is a doctor who owns the practice. That way in the event that I don’t have health insurance, i’m a contract software developer, I can have an agreed to amount for services. Which brings me to my next question, is im told to alk to billing reguarding finding out the cost, and they tell me that it could range, and couldn’t give me a price list for different services offered.
                      I guess ultimate question is how do you know before seeing a doctor if they own the practice or not. To may knowledge there are no doctors within a 4 hour radious of where I live who are retainer doctors. Yes as a child my primary care, who has since retired, I could go and see him with or without insurance and know what the bill would be based of what we did in the room. Obviously it only included what could be done in the 4 squar walls of his facility. So never includes things like CT scans or anything sent out or done outside. Or are my expections too high?

      • Anonymous

        That’s what I thought the answer would be. In respect to you and other people who are posting under their real name. Can we talk via email, or some other method that would allow me to be more specific with out discredditing anyone? Because what I would realy loke is a doctor who owns the practice. That way in the event that I don’t have health insurance, i’m a contract software developer, I can have an agreed to amount for services. Which brings me to my next question, is im told to alk to billing reguarding finding out the cost, and they tell me that it could range, and couldn’t give me a price list for different services offered.
                      I guess ultimate question is how do you know before seeing a doctor if they own the practice or not. To may knowledge there are no doctors within a 4 hour radios of where I live who are retainer doctors. Yes as a child my primary care, who has since retired, I could go and see him with or without insurance and know what the bill would be based of what we did in the room. Obviously it only included what could be done in the 4 squar walls of his facility. So never includes things like CT scans or anything sent out or done outside. Or are my expections too high?

  • http://twitter.com/freelance1m Olivia Emisar

    Instead of choosing one size, why not go for a European system where you make a good living and never have to deal with a middle man? – Lots of time with your patients and you get to do what you were trained to do: take care of people. The minute it becomes a ‘business’ it is no longer about people.  In the United States, it has not been about people in a very long time.

    • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

      I agree that it has been about the middleman for far too long. There are many reasons why our health care system is different than in Europe. Nonetheless, people today are consumers and want choices so why not provide them with lots of choices: the standard, conventional approach that most doctors offer OR a more convenient high-touch approach that I and many other direct pay doctors offer?

    • Anonymous

      This comment is one misconception after the other. 1. The middleman is always the government in socialized systems. Pretending there is no middleman is laughable. 2. Business IS people oriented. Unless granted a monopoly (by the government) a business either pleases its customers or fails. Imagine what medicine would be like if the PATIENT was the customer instead of the insurance company or the government.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      On this board, Pam Wible is about the only doc who doesn’t have to deal with middlemen.

      But more to the point, what makes you think the Europeans do not have to deal with middlemen? What makes you think European medicine is not about “business”?

      In Europe……or Canada or anywhere else for that matter, the middleman is government (Canada or the UK) or private insurance that’s government-regulated for better or worse (France, Germany for example).

      The French have their own insurance hassles. The French word for doctor is “médecin” the word for “paperwork” is “paperasse”, useless paperwork is “paperasse inutile” health insurance is “assurance maladie”.

      If an American doctor’s fee is higher than what insurance pays, we may or may not bill the patient for the balance. It depends on the doc’s preference (or employer’s preference for employed docs), as well as market conditions and what the law allows in that specific situation. We call it “balance billing”. The French term is “dépassement d’honoraire”.

      Their Medicaid equivalent is CMU or “couverture maladie universelle”

      Yes, the doctors there balance-bill to maintain their own business, and it’s as resented there as it is here. Their doctors refuse their Medicaid, same as we do. Their own illegal immigrants have access problems, same as we do, and their own Doctors Without Borders run clinics in France itself, and all over the European continent.

      http://www.rue89.com/2008/09/09/on-a-teste-pour-vous-les-medecins-qui-boycottent-la-cmu
      sante-medecine.commentcamarche.net/forum/affich-61-cmu-refuse-par-un-medecin
      http://www.agoravox.fr/actualites/sante/article/cmu-discrimination-sociale-des-10868
      http://www.mutualite.fr/L-actualite/Assurance-maladie/Acces-aux-soins/CMU-le-medecin-traitant-est-votre-allie-contre-les-refus-de-soins
      http://osi.bouake.free.fr/?France-Trop-de-medecins-refusent

      It reminds me of that book, “French Women Don’t Get Fat”
      http://www.amazon.com/French-Women-Dont-Get-Fat/dp/0375710515/ref=sr_1_1

      French women get fat. To say obesity is nonexistent in France is just silly. Are their numbers better than ours? Yes; unfortunately, they are catching up fast.

      Same with their healthcare. They have the same problems we have. Is it better? I’d say their problems are less than ours, but same as obesity, they’re catching up fast.

      • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

        BTW…….The reason for the French-English dictionary thing with the terms, is you now have the terms to Web search and find the same complaints doctors and patients have here, they have across the pond, in another language.

  • John Key

    I dont understand why more physicians don’t adopt a “cash model”.  Most agree that the third-party payment system, both private and governmental, has loused up the fee-for-service system?  So why not drop out of all of it, see patients for cash at a reasonable price–charge an amount not much different from a private copay and still make money. 

    Others claim to be doing this but I have not seen verifiable reports.

    • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

      Not sure either. I have a direct-pay practice and it works very well. Patients receive better care, I think, because I am able to 100% focus on them and not the insurance stuff–no distractions. There is no transparency as the patients know exactly the costs of the services.

      I think most doctors are fearful of making that leap. But more and more are going to–either forced or by choice. Either way, it is a positive change for medicine.

      • http://www.capko.com Laurie Morgan

        I think it’s a lot easier for physicians who have a large number of existing patients they can move over to the new model; if patients are happy with the care they receive then they’re more likely to roll with the direct pay approach.  Building from scratch in areas where insurance coverage is high is probably more challenging.  But existing patients could see the benefits of paying directly, especially if they know their doctor will have fewer total patients and more time for them.  I recently heard of two primary care docs who converted to a $3,500/year concierge approach.  They cut their patient count down to a few hundred each — which of course is fine at $3,500 each, especially given that the overhead is much lower.  But I don’t know if they couldn’t have done this without a lot of happy current patients or in a less wealthy area.

  • Anonymous

    Awesome Craig ~ I would love to film you in action for the documentary we are producing on primary care in America. The story in your post deserves a broader audience. Maybe we can meet in the alley behind Dunkin’ Donuts. . .  Give me a call!   

    Documentary:  http://www.idealmedicalcare.org/docs/The-Documentary.pdf

    ~ Pamela
    IdealMedicalCare.org

    • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

      Will do! Thanks for the offer–indeed an honor. Yes, Primary Care is changing and it is great to be a part of that change….

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      Craig, I’d hold out for Voodoo Donuts.

  • Chris OhMD

    I do not understand why solo practitioners like yourself continue to believe that the “age of solo primary practice is over”. I am a solo practitioner and doing just fine. I see other groups joining big hospitals but I think they are making a big mistake. Medicare does not reimburse more just because you are in a big group. If you do the math, there is much more overhead to staying in a big hospital – if your collection remains the same and overhead is higher then your salary has to eventually go down.

    The challenge for solo practitioners like us is to learn to embrace technology such EMRs, learn some business skills and be innovative. In addition to office visits I do home visits and nursing homes and do tons of procedures – like any other business we have to grow with the environment, not stagnate.

    The current negative mood towards solo PCPs reminds of experts trying to predict the stock market: when the majority of “experts” think the market will go up, it crashes and vice versa.

    I think this is the best time to be a solo practioner if you are creative, innovative and remain nimble to changes.

  • Chris OhMD

    I do not understand why solo practitioners like yourself continue to
    believe that the “age of solo primary practice is over”. I am a solo
    practitioner and doing just fine. I see other groups joining big
    hospitals but I think they are making a big mistake. Medicare does not
    reimburse more just because you are in a big group. If you do the math,
    there is much more overhead to staying in a big hospital – if your
    collection remains the same and overhead is higher then your salary has
    to eventually go down.

    The challenge for solo practitioners like
    us is to learn to embrace technology such EMRs, learn some business
    skills and be innovative. In addition to office visits I do home visits
    and nursing homes and do tons of procedures – like any other business we
    have to grow with the environment, not stagnate.

    The current
    negative mood towards solo PCPs reminds of experts trying to predict the
    stock market: when the majority of “experts” think the market will go
    up, it crashes and vice versa.

    I think this is the best time to be a solo practitioner if you are creative, innovative and remain nimble to changes.I also think such negative thinking is detrimental to society.

    • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

      I actually think I am being positive, not negative. The statistics tell us that primary care solo doctors are leaving their practices to join larger groups. I think it is great how you are making it work for your practice and doing so well.

      I don’t believe, though, that most solo doctors are innovating and changing and that is the problem. I believe that one can definitely thrive being a solo physician, but in order to truly thrive, it will be best to simplify and down size, not try to grow.

      If you are trying to grow, how can you continue to provide the same level of care when you are only spending 10-15 minutes with each patient? If you are spending longer than that, how can you see so many patients in a day?

      The problem is simply that reimbursements are declining forcing primary care doctors to see more and more volume of patients. More volume equals less dissatisfaction by patients and doctors.

      • Chris OhMD

        Craig – I totally agree with you. I think that most PCPs are finding it difficult ot innovate – and who can blame them? We have regulations to worry about in addition to EMR,. meaningful use at the same time. I also agree with you that in order to survive, you have to downsize, no upsize. I follow global business trends and I think the best recommendation for any business for the next decade where DEFLATION will be the main trend will be to “cut costs, preserve cash and DOWNSIZE” – Robert Prechter.

    • http://www.facebook.com/people/Saiyid-Ma/100000480108084 Saiyid Ma

      Hi Chris,

      What kind of innovations are we talking about here? I’m a student and am very interested in hearing how you were able to stay afloat in the minefield many doctors find themselves in. Please contact me (via facebook or PM).

      Thanks!

      • Chris OhMD

        Hi – If you have not decided on a specialty I would recommend FP or internal medicine for all the reasons I’ve discussed. At the end of the day PCPs will do well because demand is high (baby boomers) and supply is low (no one goes into primary care because they have been deluded into thinking that you cannot pay your mortgage). Very simple maths. The other thing to consider is that even with all these healthcare IT startups (most of which will fail), at the end of the day a human (patient) will want to talk to another human (doctor) and not some algorithm as some people are saying. This will not be true for other specialists like radiology (sorry radiologists) where patients do not care who reads their films and much may end up going to places like India (teleradiology).

    • Peter Cutri

      As a doc in solo practice — Agree! Agree! Agree!  There is such a chorus now about how docs must join bigger groups or become employed to survive.  I think this is one of those cases that if the pundits say it enough it must be true.  Then again, if my goal is to employee physicians why wouldn’t I continue to say how unsustainable it is to be in solo practice.  Do not believe this all you fellow docs who want to be in solo practice.  I think this is the same chorus that appeared some 20 years ago when everyone was afraid of HilliaryCare.  I want to start a new trend – In order to survive ObamaCare you must go into private practice and give up being employed by hospital systems.

      • Anonymous

        Just wondering Pete, have you ever taken any courses in “economies of scale”? 

        • rodney biggs

          Tired of hearing about economies of scale.  Have you ever heard of “diseconomies of scale” in which after a certain size the costs of production actually goes up.  Has anyone come up with the “size” of a practice that actually starts increasing the cost of production instead of spreading out the fixed costs.  I bet this number is smaller than you would think.

          Physicians can only see so many people.  The only way to increase production is to add more physicians, not an extra person to order supplies for the office.  The revenue generated comes from billed services.  Rarely are there any billed services that didn’t originate from the provider.  

          The fixed costs are all proportional to any large practice.  In a small practice, I have a 1500 sq ft office, not a 100,000 sq ft office.  My fixed costs are proportionally small for this type of office.  If we added another physician, our space would need to double and would expect our utilities to also double. 

          As for saying that I could cut costs by having multiple staff members be shared between providers.  Maybe, but it is hard to refute the fact that I have two staff members that work full time to take care of my business.  The ratio of staff to providers doesn’t get much tighter than this regardless of the size of the practice.  My ratio is 2 staff: 1 provider.  We do all of our own billing.  My staff serves multiple roles and either could function in the other’s capacity.  Tell me how many large practices could have anyone in the office do another’s job.  

          Lastly, there’s something to be said about employees being present in every facet of our workplace.  They understand what each and every role is.  They understand that the better they perform, the better they will be treated.  That can’t always be said when your biller’s office is located off-site, filled with temps, and has never even met the providers they represent.  Not a lot of incentive here to do a good job.   

          • Anonymous

            And the billers have never met any of the patients, much less known them and provided them with good service for years, as in our office (we run on two staff members per doc also).

          • Anonymous

            I suggest the following for some interesting late night reading. Do a web search for…

            “Health Reform and the Decline of Physician Private Practice”

            Enjoy!

          • Chris OhMD

            The point we are making is that the majority is wrong. You can google anything about healthcare and it will tell you the same thing” “Solo practice medicine is over” What we are saying as actually practicing solo PCPs is that the majority is wrong – please read again all the points myself and two other astute physicians clearly depicted above.

    • rodney biggs

      I agree wholeheartedly with this.  I am also in solo practice.  Have two staff members besides myself.  Overhead is minimal and I would be willing to put my overhead costs up against any practice.  Of course, this comes with a small price.  I do all of my payroll and bookkeeping myself.  I believe this takes maybe an additional hour per week.  

      When you see the big practices or hospital run practices, the overhead swallows up so much of the revenue that it is sickening.  What is not talked about is how the first few years of a contract with a big group is favorable to the practitioner.  However, after a few years when the practice is hemorrhaging money from high overhead, that same contract will change to recoup some of the overhead costs out of the practitioner’s salary.  These organizations have to be fiscally responsible.  When you can’t reduce the overhead costs, the money has to come from somewhere.  Typically this is from the practitioner’s pockets.  In addition, in large practices bad employee’s have places to hide.  Two people are hired to do a single person’s job.  Then you have to hire a high priced analyst to figure out why the overhead cost is so much.  

  • Jose Hipolito

    .I think what you want is to see patients and bill what you understand and want to the insurance companies and this must pay without objection. This is over my friend.This is over my friend. Today insurers ask all the reports, first to see if they were made​​, and then also to analyze and decide what is better and cheaper for the patient (and is in accordance with the insurance that the customer paid).

  • Anonymous

    The article says, “For better and for worse, the era of private-practice, outpatient medicine as we know it is coming to an end”…
    No truer words have ever been spoken in the world of modern health care. What WalMart did for consumers in the retail sales, what Home Depot did for consumers in the home improvement business, the same will be true for the future of health care delivery. Who’s to blame for the train wreck we call health care? Consumers? Not even close! Consumers have been the abused victims at the bottom of the health care food chain for decades. A radical change to big-box health care can only help consumers. Our broken health care system has milked the cow dry. The goose that has been laying those golden eggs for decades is now on life support. The health care industry has squeezed as much as it can from consumers until we now have 1/4th of Americans either uninsured or underinsured. The game is over. Again I ask, who’s to blame? If you are a currently member of our Mafia like health care industry, a doctor or other health care provider, a hospital, a drug company, a private health care insurance company, maybe you should take a long look in the mirror.

  • Anonymous

    The article says, “For better and for worse, the era of private-practice, outpatient medicine as we know it is coming to an end”…
    No truer words have ever been spoken in the world of modern health care. What WalMart did for consumers in the retail sales, what Home Depot did for consumers in the home improvement business, the same will be true for the future of health care delivery. Who’s to blame for the train wreck we call health care? Consumers? Not even close! Consumers have been the abused victims at the bottom of the health care food chain for decades. A radical change to big-box health care can only help consumers. Our broken health care system has milked the cow dry. The goose that has been laying those golden eggs for decades is now on life support. The health care industry has squeezed as much as it can from consumers until we now have 1/4th of Americans either uninsured or underinsured. The game is over. Again I ask, who’s to blame? If you are a currently member of our Mafia like health care industry, a doctor or other health care provider, a hospital, a drug company, a private health care insurance company, maybe you should take a long look in the mirror.

  • Anonymous

    Sorry for the duplicate… 
    When I tried to post my comment, I got a “System Error” both times.

  • Awunsh

    Craig I would love to get a chance to communicate with you offline. Can you reach out to me please? There may indeed now be an alternative to Super Big or Super Small. And I don’t want to sound like a vendor selling wares so I prefer I show you my suggestions and then you decide if it fits and does what I think it does do. As an industry we are deluged with claims of new efficiency, cash flow saviors and work flow enhancements it sometimes gets lost when something that truly does work comes along.

    Let me just say this, as we read all the articles about docs going broke, hospitals closing down, more mandates that will cost to comply with, consolidation and doom and gloom from every possible threat.

    I would like to just compartmentalize and give one small example of something docs can do, they can control and it can make the difference between seeing less patients and actually making more money or seeing more patients and going broke doing it.

    Look at the patient out of pocket portion on the current payer system. It is now 31% or more of our expected cash flow and 49% of it goes uncollected each year. Now uncollected for all you naysayers is not only written off, it is what have been on your books for months with no action, what you write down to get something, and what you spend to collect it, all comes off the top.

    So as an industry we generate 2.6 trillion dollars in revenue annually. Now if even 30% of this is patient responsibility this is 780 billion dollars of which nearly 50% will never come through the door. This is a whopping 390 billion dollars a year that will never be collected, can not be used or ends up in a providers bank account. Why because we keep doing what we have always done.
    This above all revenue streams is the one we have the most direct control over, it can be secured at POC and i can be collected substantially better, and yet we still see providers not even asking for co-pay, let alone remaining deductible and co-insurance before the patient leaves the office from the first encounter. And believe me once they walk out your ability to collect will diminish by 80% within the first 30 days, and by the way you won’t have the claim adjudicated before that timeline so the system plays right into the failure.

    You can identify all these balances at care or before and you can secure the funds in manners that insure payment whether all at once or over shorter time lines with no or little collection costs.

    So if you would allow me to talk with you and show you some options and then you form your own opinion it would perhaps serve all your readers in a positive way.
    You can contact me at anthony.wunsh@medicalpaysolutions:disqus.com (WE ARE NOT A BILLING COMPANY)
    Thank you for considering connecting with me

    Awunsh

  • Anonymous

    The really small practices can’t compete with super big operations in the following way and so they must charge their patients more as a result…
    1) Buying office supplies in bulk
    2) Migrating to EHR
    3) Negotiating for best cost with all vendors
    4) Running a computer system
    5) Running a phone system
    6) Paying full time and/or part time staff
    7) Baying to keep the lights on the and HVAC running and maintained
    8) Accounting
    9) Coordinating care

    The super big operations that “employ” many primary care staff and “employ” many diverse specialties can do all of the above while their medical professionals focus virtually 100 percent of their time doing health care. The small office doctor is the sole proprietor of a very diverse business with much more to do besides health care. My PCP runs a one-doc practice. He always says, “I have so much to do just to keep this place running. I wish I had more time for my patients. 

    • rodney biggs

      I disagree with most of your points.  I don’t charge my patients more just because I’m a solo doc.  I charge the same, albeit I get to keep more of that charge due to my lower overhead.

      1.  Supplies aren’t that expensive even when you aren’t buying a crate full of 4×4 gauze.2. Have an EMR, server, 4 workstations, and 2 tablets.  Pays for itself in the automation of charges and retention of records.
      3. Negotiating for best cost.  A lot of time is spent spinning your wheels here.  Once again, as a small practice I don’t see a significant amount of money that I am losing here or negotiations that I am getting a bad deal on.  We are fortunate that we are in an area that practices haven’t competed with other practices causing insurance reimbursement rates to be bottomed out.
      4.  Pretty easy to run a computer system.  Most problems can be fixed with a small amount of troubleshooting.  Most EMRs have a tech line.  Rarely have to call in IT people.
      5.  Phone system is a one time install and doesn’t require any maintenance or education.
      6. Small practices pay less full time and part time staff.  Everyone is directly accountable to the boss.
      7. Small practices can share office space with other small practices to share the costs of usual utilities.  My utilities are proportional to any big company.
      8.  I pay my accountant just 4 times a year for typically under $1500 per year for all their duties.  Most big organizations can’t even come close to this.  Small practices have an easier time doing payroll and bookkeeping on their own.
      9.  Coordinating care?  I get consults and send referrals/consults the same way as big practices do.  Should be no different.  I click the fax button and my EMR sends a copy over to the referring doctor.  No cost to me.

      • Anonymous

        Okay, now take an office with 200 or so health care professionals. All salaried employees. For instance, the kind that will soon open up in many towns and cities all across America. The Hospital Group ACO model. Here we have many PCPs, a variety of specialists, many nurses and technicians, much of the diagnostic equipment on-site, a lab on-site, a department that does nothing but manage the entire office and order supplies, all under one roof. You are saying that the economies of scale don’t put pressure on the solo docs that practice in the same geographical market? 

        • Anonymous

          What you keep refusing to acknowledge is that large ACO-type groups negociate much higher payments from insurers (approx. 250% higher in my area, based on EOBs my patients show me, and then a facility fee is tacked on!) and are much more expensive for the system overall.

          Also, the vast majority of ACOs will not be all under one roof operations. Their operations will be spread out across a community in a multitude of locations, including small offices.

          • Anonymous

            Obviously, you do not have a clue about how rates will be set for ACO groups, do you? That’s a shame. More sympathy I cannot muster. I suggest that you do a web search on the words below, read the article and come back when you are more informed…

            “A Guide to Accountable Care Organizations … – Health Reform Watch”

          • Anonymous

            As always, your rudeness undercuts your argument.

            The article you reference deals only with Medicare payments to ACOs. ACOs will try the Medicare experiment for a few years, but drop it ASAP if the finances don’t work out. Where they see the big bucks is in negociating with non-Medicare payors after they gain a significant market penetration.

          • Anonymous

            You are misinterpreting my sincere sympathy for rudeness? I don’t use a crystal ball to predict the future. I read what the experts publish about fact based evidence. CMS is conducting the current experimental ACO models. So far they have not negotiated with anyone regarding the setting of payment rates. Will they migrate to something different in the future? Only a fortune teller with a crystal ball could possibly predict the future. Do you need any glass cleaner?

        • rodney biggs

          What you don’t account for with economies of scale is the loss of efficiency through bureaucracy. I see both sides of the story as I am a solo doc versus my wife is practicing in a group practice ran by the hospital. I have also seen these large practices housing 200 physicians, buckets of other people, diagnostic equipment in-house and the guy at the top having his salary exceed that of 10 physicians.  

          As for ACO, I’m not holding my breath.  We will see if I’m right.

          As for the comment below about negotiating contracts with insurers, this is where physicians have hurt our field.  We have undercut the other guy just to gain his business.  Then that other guy undercuts us to recapture his old business and gain ours.  All in all, we think that our revenues will be restored as volume increases but are now happy to accept 25% of our billed charges.  Unfortunately, we work harder for less pay.  Fortunately I don’t have to deal with this type of practice.  I’m very fortunate to have my practice and live in my community.  

          • Anonymous

            I suggest the following for some interesting late night reading. Do a web search for…

            “Health Reform and the Decline of Physician Private Practice”

            Enjoy!

          • Chris OhMD

            Dr Biggs, our thinking is the same;. I wish other solo PCPs would see the light as we do. Yes there are challenges and one needs to be nimble (as we are) but I assure you that after all the “complaining & crying” dies down, people will find out that the future as a solo PCP looks fantastic.

    • Chris OhMD

      I agree with Dr Biggs below – in this market there is no “economies of scale” associated with most of what you talk about. EMR, labs, supplies I can get for cheaper than the big hospital next door in fact the docs that work there don’t even know how much they cost (I’ve asked them several times). The textbook “economies of scale” does not apply.

      In fact the opposite does – when one person (me) know everything about the how the business runs in my organization, we save money- e.g. I do my own acct and billing. Did you know that most billing errors occur because the doc that see pts does not enter the codes correctly? Because most docs have no understanding of billing and rely on fulltime staff the errors that they are responsible for do not get corrected for a long time – i.e. costs everyone money.

      I know what pays how much, how much all my supplies and labs cost all the time. so I can stay nimble. Big organization do not therefore waste tons of money.

  • Anonymous

    As a health care consumer and critic, since most of my posts get censored, maybe you should call this blog…

    “Social media’s leading physician “only” voice”

    Maybe you should warn health care consumers that their opinions are not welcome, huh?

    • http://www.kevinmd.com kevinmd

      I don’t censor posts. Any comment that receives a certain number of flags by the readers gets automatically deleted by the system.

      Kevin

      • Anonymous

        Thanks for clearing that up. I’ve never used the flag. I guess because I believe in the give and take of an honest and open discussion. Health care in America deserves the harsh criticism it gets. Often, such criticism hits too close to home for some participants. Thanks again.

  • Anonymous

    Whether super big or really small health care delivery, universal health care that has very strong rules regarding medical effectiveness seems to be the only reasonable way forward for the long haul. The Affordable Care Act (ACA) is as close as we will ever get to universal health care when you consider the insane partisan politics that currently exists in Congress. The key component to the ACA’s success is the individual mandate, originally a strongly supported GOP idea. Republicans are acting like children in that because they didn’t get credit for the individual mandate and because a Democratic President got it passed and enacted, now Republicans don’t like the individual mandate. Talk about flip-flop? GOP leaders in the Congress aren’t being praised for the idea, like Mitt Romney was in Massachusetts, so now they want to take their ball and go home. Ridiculous! Republicans could not care less about the benefits of the ACA for consumers. They only care about political battles within the beltway. Fact is, the ACA will be doomed without the individual mandate. The SCOTUS will hear arguments and make a ruling about the individual mandate before the summer of 2012. The insurance companies all favor the individual mandate for obvious reasons. With the individual mandate, the private insurers will write more policies. A no-brainer! However, doctors, hospital groups and drug companies are split about their support of the individual mandate. In my opinion, those who make a living in the health care industry had better be praying that the individual mandate is upheld by SCOTUS. Health care professionals had better get in touch with their members of Congress and push real hard to support the individual mandate. SCOTUS had better hear your voices loud and clear about the need for an individual mandate. The individual mandate our best chance to begin to reverse the cost curve and rescue our broken health care system and we will only have one shot at doing it. If SCOTUS rules against the individual mandate in 2012, we all had better hunker down and be prepared for the nuclear winter of our broken health care system.

    • Robert Arone

      Sorry Dave, but you are wrong. ACA is a disaster. It is designed to usher in a single payer system, and would eventually reduce all choice for the individual. You know it and that’s why you hate the republicans. And the republicans are only doing what MANY agree with. But if people such as yourself can spin it, like it’s just the politicians, maybe people will go along.

      The only way out of the healthcare problem is competition and get the middleman (insurance companies) out of medical care. If insurance went back to it’s original intent – to cover catastrophic only - people could afford to deal directly with their doctor and the doctor wouldn’t have to process so much paper work.

      But instead we have a few insurance companies and politicians looking to profit from ACA.

      • Anonymous

        We agree on one thing. Eliminate insurance companies. They serve no useful purpose. ACA is a disaster? Now that’s GOP rhetoric, if I’ve ever heard it. The ACA has not completely rolled out yet and already it’s a disaster? Dude, you need to drink another brand of kool-aid because the GOP brew you are drinking now is rancid. The ACA is a disaster, huh? Tell that to the Medicare Part D participants that aren’t falling into the donut hole as deep as they use to. Tell that to the millions of college students that can now remain on their parents health plan. Tell that to the many folks, especially Medicare people, that get complimentary preventive care as a result of the ACA. Tell that to the ACOs that are currently in a mad scramble to organize hospital groups and doctor groups under one roof. What Home Depot did and what WalMart did for their respective markets, the ACO will do for health care consumers. Health care consumers have never had a voice in the past. Under the new rules that sanction ACOs, fee-for-service will not be allowed. Patients will rate these ACO groups. Wellness and good outcomes will control whether an ACO remains sanctioned. The ACA is a disaster, huh? Tell that to PCPs like mine who are already in negotiations to transfer his entire patient base to our local ACO group and he will eventually join them as a salaried employee to treat the exact same patient base. I have all the sympathy in the world for those in denial but the handwriting is clearly on the wall. The train is leaving the station. Get on board, or get out of the way!

        • Robert Arone

          Your solution is remove the insurance middle man and insert the government middle man………I have no idea what you do for a living, but people like you have no concept of capitalism. So arguing with you is futile. Maybe you should read some of the doctors posts here.

          There are some really great cities in Europe you should look into, then you would be happy until you discover that utopia doesn’t exist. Because there are a bunch of us who are not going to allow your ilk do any more damage to this great country.

          • Anonymous

            “allow your ilk”

            ilk?

            Hey Kevin, remember me? I’m the one that never uses the “flag” at the bottom of the post.

            When someone, especially a so-called medical professional, calls you “ilk”, is that when you click on the flag? Huh?

        • http://twitter.com/MichaelCJudge Michael Judge

          Limiting health insurance companies to catastrophic injury only and eliminating insurance companies are two very different things. We all know that insurance operates effectively in many other aspects of life. Health insurance is well known to operate outside the normal parameters of their other-industry counterparts. Health insurance companies serve the same vital role that they do in those other industries.

          There are some who have benefited from ACA, sure. You outlined some of them above (but fail to mention that Part D bled money before and now gushes with the shrinking doughnut hole from ACA), but to say that there are only successes so far is incorrect. The CLASS gimmick to help ACA pass through the CBO has fallen apart. Without those savings, the selling point that it will help decrease the budget is a farce. Those who were told that ACA wouldn’t change insurance for those who liked their plans were lied to. Their rates also increased faster than expected without any health legislation, and much faster when considering the projections that ACA would actually decrease the cost of insurance. What do you expect when insurance companies are forced to cover preexisting conditions? (This happens to be one of the few ideas I am on board with, but I also understand that it is more, not less expensive to accomplish.)

          If you think that monopoly consolidation by ACOs will grant patients a greater voice in the market, you are mistaken. It is the secretive nature of the contract process that prevents patients from having a voice. If a government mandated price is instituted, then the patient also has no voice. Either way that idea is sophomoric. You are also mistaken that fee-for-service isn’t allowed with an ACO. There have been some recent pilot projects for bundled payments, but no results so far that I am aware of. Some ACOs may take on some insurance risk, but that may not be the norm and isn’t required at this point in time.

          It is very easy to talk about “wellness” and “good outcomes” driving payment for patient care, but the devil is in the details. What kind of patient responsibility is required to achieve these goals? They are most responsible when it comes to outcomes related to managing chronic conditions.

          Getting out of the way means that older physicians will retire earlier than anticipated. Physicians like my father who have continued solo practice in rural America don’t have the time to make up the capital cost of an EMR/PM system adoption. When the HITECH stick comes into effect, they will switch to cash only which actually gives the most voice to the patient or leave the market entirely.

          ACA is a compromise of the worst kind. Trying to adopt universal healthcare on the largest scale in human history met the steadfast resolve of Republicans who had some ideas that never really saw the light of day in the media or with the President. What we ended up with was a questionably Constitutional individual mandate and a bunch of stuff mashed together that looks more like socialized medicine than not.

          • Anonymous

            Ah yes! More Republican spin. Suck it up my friend! You and your K Street buddies at the AMA, the AHA, AHIP and PhRMA are in for a real treat. While not perfect, the ACA is the best thing the health care consumer has seen for a very long time. Decades in fact! It’s got momentum and average Americans aren’t going back to the status quo you love so much.

          • http://twitter.com/MichaelCJudge Michael Judge

            To be considered spin, it must first be refuted, which it was not. I mentioned nothing about the status quo, though the healthcare industry could hardly be designed in a worse fashion than it operates today. In fact, that is one thing we can agree upon, though it is a poor inference to assume that this is an either/or argument. I am decidedly against the status quo as well. The ACA may be the law of the land right now, but it is far from the only opportunity for improvement in the industry. Expansion of HSAs, decoupling health insurance from employment, and purchasing the insurance you want regardless of which state offers it are a handful of ideas to address the basic issues that plague our healthcare system.

            It is precisely because the government is so large that K Street exists in the first place. By continuing to increase government size and scope, it gives K Street greater opportunity to lobby. The AMA is on board with ACA anyway, so I don’t know why you think my comments are bought and paid for by them when I speak about the issues with the legislation. Free minds and free markets create prosperity, not Republicans or Democrats.

  • http://pulse.yahoo.com/_UDJTUH45CFUC6LKCBLB6FGRDKU Diane

    Just adding from someone who lives in a decent size metropolitan city and works in health care that while we do have a bunch of doc groups joining the 2 big “private” (as opposed to the university) hospital system groups, it could be to be under their EMR system and whatnot since that’s how it’s all promoted in the advertising and they were already large groups to begin with. But just the same, there are still a whole bunch of small groups of 1-3 docs in practice with no association to any “system” that I can tell in our big 5 county area. These range from internal med/family practice to specialists. We see orders from them all. And actually, since we do orders from all over the state, we get orders from the more rural areas where there are plenty of 1-2 doc practices as well as those in the other bigger cities with bigger groups. And these docs are serving Medicare and Medicaid patients and managing to stay above water just fine as far as I can tell. We’ve only had a couple regulars drop out of touch over the years and I’ve always guessed they’ve just moved on…