Reform is suffocating private practice by design

Cleveland and northeast Ohio are not hospitable to private practice medicine.  I should know.  I’m one of them.  Private practice is fading as health care reform suffocates it by design.  When this occurs, the public will have lost physicians who, in my view, have practiced patient advocacy and service at a higher level than our employed counterparts.

Keep in mind that the first half of my professional career was spent as an employed physician and the latter half as a private practitioner.  So, I know the advantages and drawbacks of each model first hand. Of course, there are employed physicians who are outstanding doctors and private practitioners who are not, but I maintain that a physician who owns his business has a stronger incentive to provide excellent service to patients and to referring physicians.  This just makes sense.  Don’t we find that when we shop or dine out or stay at a Bed and Breakfast that there is a different level of service from those who own these businesses?  If a store closes at 5:00pm and you arrive at the locked door at 5:05, would your chances of gaining entry inside be greater if the boss were there rather than an employee?  Get the point?

I recognize and have expressed in this blog that there are advantages to the employed physician model which eliminates and reduces conflicts of interest that confront those of us who practice in the private arena.  However, doctors on salary and the institutions that employ them face their own unique conflicts and challenges that can interfere with their healing mission. Fee-for-service medicine leads to over-utilization while models that restrain costs may restrict care, access and service to patients.

One service that our small gastroenterology practice offers is rapid access for patients who need or desire an expeditious appointment.  This is tough for sprawling and expansive group practices, as we have in our neighborhood, to duplicate.  Yet they try.  The big dog medical institution in town is now advertising that they guarantee a same day appointment to any patient who desires it.  Sounds good so far.  I wondered how they could pull this off since it’s a vexing task for me even to reach these docs on the phone, let alone try to arrange a timely appointment for one of my patients.  Here’s the sleight of hand.  Sure, the institution will grant the patient an appointment, but it’s not with his doctor and may even be across town in a satellite location.  Is this what most of us have in mind for a same day appointment?  While it’s a tricky marketing ploy, it’s a poor play at customer service.  These patients would do better to present to a local urgent care, which offers a same day visit with a doctor who is likely less than 10 minutes away.

Years from now, when we are all enjoying Cadillac care at Chevrolet prices, where will I be?   Private practice will be long gone, but my skills will still be useful.  I’m hoping I can land a position as a docent in the fee-for-service wing in the Museum of Medical History.   I’ll be paid on salary, of course, like doctors will be everywhere.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • OldeStyleLiberal

    “Cadillac care at Chevrolet prices”

    Uh, no. You will see Yugo care. I sense you know that.

    • ninguem

      More like a Trabant.

  • Rezmed

    In our fight against any reasonable payment reform, we have become corporate employees. We wrongly thought that if we reformed like Canada, Germany, or Switzerland we would become pawns of some socialist government system. But in reality private practice in many countries with either single payer or regulated universal health insurance, is alive and well. Instead we will end up working in the corporate coal mines of the medical world.

    • drg

      So well put. The problem is it’s under the guise of private practice—with the public image of looking as if private practice is really a private enterprise. I don’t think they know yet that the private practice system is collapsing. Sort of like the housing market was before the mortgage debacle.

    • Margalit Gur-Arie

      Not only it’s alive and well, but it is also generating lower overall costs for the system, presumably because nobody is entitled to extract gratuitous profit from medical care.

      It’s not too late though…. There is still time to reverse this trend, but it will require that you guys stop fighting each other for a few dollars in a rigged zero sum game and present a compelling united front.

      Perhaps patient advocacy’s last grand stand…. it just may work.

      • Rezmed

        I think it is too late… for the next 1-2 decades at least. Large corporations hold all the cards, pull all the strings and have the ear of the policy makers. They will have the interfaced EHR’s, and will control cost – like Walmart. Maybe when good EHR’s are common, formularies are standardized or made transparent, and info sharing is easy and cheap, — when you don’t need an army of staff and an MBA to run a practice…. then private practice will grow again.

        But lifestlye choices like shiftwork, steady pay and benefits, and unionization may be the carrots that keep docs from leaving corporations. I still go to Walmart.

      • Arvind Cavale

        How do you propose we do that? I ask because some of us in SE PA are doing something like that…taking a stance and getting help from business leaders who value our services. What we need is a mushrooming of such efforts in various parts of the country.

        • Dr Steven Horvitz

          Agree with Arvind.
          Take a stand with your patients. Prove to them that you are on their side and that the present direction of govt care has sided with corporations.
          Personal vs corporate care??
          Ask your patients which they prefer.

          If you are in primary care, take yourself out of the system and get paid directly by your patients. If you have a good rapport, you will do fine. If not, then go get a salaried job and be miserable with your lack of autonomy.

    • jmarshall

      Agreed. . . Private-practice is, indeed, a cost-effective alternative to hospital employed MDs. In St. Louis, we have collaborated with a local union to find that our private-practice MDs save their self-funded plan more than $5,000 (approx 25%) for every knee replacement. And, yes, we do need to get together and communicate the truth to the pubic and employers alike about the cost and overutilization being exacerbated by hospital employed MDs. Some kind of “private-practice consortium”, if you will. . .

  • Vikas Desai

    the dominance of large health instituions will only further the costs of healthcare. The endless nickel and diming that insurance companies have done to small practices, as well as the extraordinary cost to implement EHR have done an excellent job phasing out the private practice doctors. As more private docs get thrown to the wayside for employed docs and various other “providers” the hospital systems that own them can “name their own price” to the private insurance agencies who then will gladly transfer over the costs to the consumer and spin as consumer driven “flexible spending”, which will in turn increase costs rather than curtailing them.

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