Is the death of the solo practitioner a bad thing?

Is the death of the solo practitioner a bad thing?

In recent years, there has been a shift away from solo practice to group practice among physicians. The trend, which some say began in the early 2000s, appears to have accelerated with new incentives proscribed in legislation such as the Affordable Care Act. The push for accountable care organizations seems to be fostering the rapid reorganization of medicine from one based on solo practitioners and small groups to one based on large, multi-specialty groups.

New research quantifies this dynamic shift in the delivery of medical care. Larger groups have certain advantages: access to capital (e.g. health information technology), standardization of practice, and improved market power with insurers. This study — unique in that it looked at the entire universe of physicians caring for Medicare patients — investigated the practice size among several types of doctors: primary care, medical specialties, surgical specialties, psychiatry, obstetrics/gynecology, and hospital-based specialties (radiology, anesthesiology, emergency medicine, pathology, and hospitalists). Medical practices were identified based on tax identification numbers with practice size determined by the number of physicians working under the same tax identification number.

The authors studied changes in physician practice size from 2009 to 2011. In 2009, 30.9% of all Medicare physicians were in large practices (>50 physicians) compared to 35.6% in 2011. The total number of these large practices increased by about 16% over that time frame.

On the contrary, solo practice continued to decline representing 20.8% of the Medicare physician population in 2009. That number fell to just 18.6% of the physician population in 2011. Similarly, the proportion of physicians in small groups (2-10 physicians) declined noticeably from 2009-2011. In 2011, almost twice as many physicians practiced in large groups compared to solo practice. Even medium-sized groups (11-49 physicians) experienced modest declines in the total number of physicians despite the number of medium-sized groups increasing.

Commentary

Recent data demonstrate that physicians across the United States are migrating towards a practice model involving larger and larger groups. Federal incentives — in the form of accountable care organizations, medical homes, and bundled payments — are actively promoting this naturally occurring phenomenon. Many young physicians and female physicians alike are fleeing solo practice in favor of group practice. While some groups remain focused on a single specialty, a serious push toward multi-specialty groups is underway.

It appears that the death of the solo practitioner is not too far around the corner. But is the death of the solo practitioner such a bad thing? For patients, if a greater availability of health IT leads to improved quality of care then perhaps large groups a preferable. Big groups might offer availability for urgent office visits instead of patients being force to retail clinics and emergency rooms.

On the other hand, if large groups lead patients to have less personal relationships with a specific clinician, care might suffer. As physician practice patterns change, the profession must maintain true to the core value of the physician-patient relationship.

Cedric Dark is founder and executive editor, Policy Prescriptions.

Image credit: Shutterstock.com

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  • Kristy Sokoloski

    One of the other bad things about these kind of group practices is that if the patient has a problem with one of the physicians that physician could potentially make it harder for the patient to find another doctor. How could they make that happen? By blocking the patient from access to other physicians within the group that could be a good fit for them. I know someone that had this happen to her.

    • Deceased MD

      I have seen that in specialty groups mostly.I fully agree with you. It is bad practice for the pt.

  • Deceased MD

    “For patients, if a greater availability of health IT leads to improved quality of care then perhaps large groups a preferable. ”

    ??? You’re kidding. Right?

  • ninguem

    The Medical Group Management Association finds that primary care practices have four ( – 4 – ) employees per doc.

    Any solo or small group primary care docs here? Who has four employees per doc? I wouldn’t know what to do with four employees.

    What MGMA does, is survey the big box places, with 100 docs, 400 employees, 50 docs, 200 employees.

    They do not survey the small practices, they simply extrapolate.

    With that, they make an assumption that is not valid. There is INCREASED efficiency with small practices, not less.

    The very advantages Cedric Dark refers to, all of them, relate solely to the ability of an 800-pound gorilla to bend the rules to their advantage.

    Access to capital does not make you a better doctor.

    Ability to negotiate tougher deals with insurance companies does not make you a better doctor. And by definition, it INCREASES the cost of health care. You get the insurance companies to pay you more.

    And not mentioned by Cedric Dark, but mentioned here time and again, is the fact that the big box places charge…..literally DOUBLE…..the fee charged by small practices, because of facilitiy fees.

    He works at Baylor, assuming he is still engaged in clinical medical practice.

    If I were practicing independently in Houston, and my fee were, say, $100……if Baylor came by and took over my practice, so now the same office sign reads “Baylor Medical Center Dr. Ninguem”…….my fee would go up to $200.

    I’ve seen this, personally, with my own personal medical care, and I’ve seen it reported in newspapers from Boston to Seattle, and the Wall Street Journal, and NPR for that matter. It happens all over the country.

    He may be right, independent practice may well be dying (though the statics have been called into question). Strange, though, the places considered out “betters”, Canada, UK/NHS, France, Germany, independent practice seems to survive just fine.

    But if it dies in the USA, it’s not because the large entities practice better medicine, it’s because they used their size to rig the rules to their advantage, really to exempt themselves from the rules the small practices live under, and kill the independent practice of medicine.

    When that happens, because of facility fees, expect the cost of outpatient care will double.

    • buzzkillerjsmith

      You’re exactly right. It has nothing to do with more efficient medicine or more cost-effective medicine. Smaller groups are more cost-effective, at least in primary care. I’ll let other fields speak for themselves.

      What we have here is a federal government that has been entirely captured by large corporations, which use their power to kill off their smaller competition. Anti-competitive behavior, pure and simple. More administrative burdens are easier for them to handle with their ability to control prices while those burdens kill off small groups.

      What is sad and almost funny is that a lot of regular people think that things like electronic medical records are designed by doctors to improve care. They are not. They are designed by corporations to make money and they help enslave doctors. Other stupidities like the PCMH are designed by poorly-led, deluded and intimidated groups like the AAFP.

      Our “betters” know independent practice works if it is not under active attack by CorpMed and its government lickspittles.

      In time this country might come to realize that putting medicine into the hands of CorpMed is a horrible mistake. I say might, not will.

      • whoknows

        I am afraid to ask but i must. What is a Patient centered medical home and whose hair brained idea was it? So you can save on office rent or so we can get rid of hospital rooms? Just use a spare bedroom? What’s the scheme here?

        • buzzkillerjsmith

          Wikipedia (Medical Home) can get you started.

          The idea is that care can be improved and costs can be decreased by changing the way doctors do their jobs. We are only to see people who are really, really sick. Other people will see the rest–nurse practitioners, physician assistants, nurses, medical assistants, the folks who answer the phones, moms in the waiting room, maybe some guy waiting for a bus. We will also be charged with managing electronic medical records, providing 24 hours access via phone and email, etc.. etc. We probably won’t get paid any more to do these things.

          The main problem here is that the people who are supposed to do this job in the future, today’s med students, don’t want to do because they know it will be absolutely hellish. So they won’t do it. They’ll continue to sub-specialize, as they do already.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            ok… this actually made me laugh out loud for real…

          • whoknows

            oh I actually started crying. Seriously, so how will anyone be diagnosed if they don’t see doctors? Sounds like a factory.
            The patients will just perpetually go round and round.
            Who started this idea? Sort of feels too much like it is happening already in places or parts of the country.

          • Adolfo E. Teran

            that is called tread mill medicine, I had a doctor in the community that express his concern about my finances. He said maybe I am starving, because I take time with my patients. He said that nobody pays you for that.

          • whoknows

            I like that./ Tread mill medicine. That fits perfectly. What a great phrase. You sound like a great doctor but don’t go broke over this. ..thats for sure,

          • Adolfo E. Teran

            I agree with your comments. Medical homes with all their coordinators and supervisors and assistant supervisors wont make anything cheaper.

    • Adolfo E. Teran

      I agree with Dr Ninguen, I am a solo family doctor, we ( my wife a pediatric NP and I) have a small family med/peds office. We have one medical assistant/receptionist/multitasker, that’s it. I take my patients vitals and bring them in the room, I take the time to take the history and exam my patients. I believe that time will tell if having an ACO with many CEO’s will be cheaper, unless they work for free/goodness of their heart. Unless medicare and private insurances pay for the over inflated overhead.
      I believe that the solo way is not an easy one, but I will continue doing it as long as I can .

  • ninguem

    Actually…..access to capital. I found that interesting.

    I went to a local bank for capital to start a solo primary care practice. I had a real hard time. I was a dinosaur, so they’d say.

    But I’d see dentists set up straight out of training, with student loans (I’d paid off mine). They didn’t have a bit of trouble accessing capital.

    The capital outlay for a dental practice, the chairs, the drills, X-ray, far exceeds the capital outlay for a primary care practice.

    I’d ask them, they’d gone to the same bank, they got a check cut without blinking.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      That’s because dentists don’t “control” the profit of large corporations. They don’t “order” things that increase revenue for CorpMed, and hence they have no value, so they are left alone to practice their craft.
      The open season on solo and small practice doctors is entirely money driven. You guys are cash cows, and he with the most cows gets to set the price of milk.

      • ninguem

        One interesting thing just came up.

        I’m in this Medicare Advantage plan. I had a small handful of patients. They pay reasonably, for Medicare.

        After a couple years with a small handful of patients, my phone started ringing off the hook. All these Medicare Advantage patients.

        It seems a Big Box Clinic took over a nearby hospital. Service area 50,000 – 80,000 people.

        I take my son to a local pediatrician. When Big Box bought up all the nearby practices, except mine, and a few other people, the fees doubled. I took my son to the pediatrician last year, the fee was “X”. I took him again this year, same pediatrician in the same office, but now instead of “Main Street Pediatrics”, it’s now “Big Box Main Street Pediatrics”.

        The fee is now 2X, for the exact same medical service.

        As I said, the fee doubled.

        Well, it seems the Medicare Advantage plan could not work out a deal with Big Box. They want their facility fees. Medicare Advantage plan is not interested in paying facility fees, paying “2X” for a service for which they paid “X” last year.

        Beginning of October, the Medicare Advantage enrolees got a notiffication, they will lose their Big Box doctors.

        I have found out, I’m the only primary care doc left in that service area, who is not part of Big Box, and signed up with the Medicare Advantage plan.

        The first new patient to tell me that, a couple weeks ago, I figured he had to be mistaken. Half a dozen new patients later, all saying the same thing, I checked myself and it’s quite true.

        The pay isn’t great, but I can make it work. Big Box can only make it work by doubling the fee.

        But somebody’s got to pay that Big Box CEO salary. The CEO, she’s a nurse, worked her way up the ladder, and we gotta pay her $900,000 salary.

        Nice work if you can get it.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          There are all sorts of news that United HealthCare is dumping bunches of physicians from Medicare Advantage plans lately. I wonder if they are “BigBox” owned too…. If so, we may see a renaissance of small practice…

          • Deceased MD

            Huh. I’m beginning to detect a trend here.

        • Deceased MD

          I lost the part of where there is an “Advantage” in that Medicare plan. Kids in foster care have more stability.
          These pts are exploited plain and simple. Do any of these pts have any clout to complain? Is this getting any headlines in your area?

          • ninguem

            It was the only Medicare Advantage plan I worked with, and I only had a small handful of patients.

            So I’m going to punt, and say my number was insufficient to make an opinion. You may well be right.

            I’m serious about the phone ringing, though, so I may find out soon. My numbers are growing rapidly.

            And no, now that you mention it, no headlines.

          • Deceased MD

            Well keep us informed ninguem. It must seem common place in todays HC market, where pt’s plans and providers change faster than musical chairs.

          • Michael Rack

            I’ve read that government funding of Medicare Advantage plans is decreasing in 2014, with the rollout of Obamacare. Be ready for an unpleasant surprise in January, ninguem.

          • ninguem

            You may well be right, I’ll find out, one way or another. The numbers, though growing rapidly, are still small, so I’ll find out soon enough, but not enough to swamp the practice.

          • jpsoule@hotmail.com

            Medicare ‘Advantage’ plans are a misnomer. They offer seniors extra ‘services’ for the same or lower monthly premiums. Gym memberships, free eye exams and dental cleanings, etc. They make up the difference and a handsome profit by severely restricting formulary medications, pre-auths on tests, all scans, rehab, nursing home choices and harassing the doctors to discharge these patients prematurely from the hospital. I no longer accept these patients as new patients and now is when my current patients may enroll in the traditional MC plan.

      • Kristy Sokoloski

        Dentists in my area have gone more corporate. I haven’t seen as many solo practices within this area in recent years. And the ones who are the cash cows whether being part of a corporation or not are the cash cows. If that wasn’t the case it would be much easier for people to have access to dental care which is not the case at this time. Most people in this country can’t get access to dental care.

      • Noni

        Are you familiar with the Crimson Continuum of Care? Our hospital is educating our department about this. Looks like they want to educate us on big box philosophy. Google the term if you are unfamiliar. I’d love to hear thoughts from the Kevin regulars.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          I am familiar with the Advisory Board which is the consulting company that sells the Crimson analytics products. The big data thing….
          I think you may be referring to the piece that analyzes the “continuum” (or sum total) of each physician’s performance indicators, including costs, and then drags in the ones needing remediation for a series of educational conversations, or something like that.
          The company is pretty open about its goal to maximize clients’ reimbursable quality, while managing costs down, so ultimately profitability is improved.
          I think this is the philosophy, and obviously it is much more complex than making any one patient feel better, hence the need to reeducate the troops from a “continuum” perspective.

          • Noni

            “ultimately profitability is improved.”

            There it is…in a nutshell. Thanks, Margalit.

    • Deceased MD

      That makes no sense. What reason do they give you for the denial? Sue them for discrimination. Yeah like that’s ever going to happen.

      I know since the mortgage debacle it is nearly impossible trying to get any kind of loan. With the stringent criteria they give now it’s ridiculous.

    • Adolfo E. Teran

      when I was going to open my practice. I applied for a business loan to bank that send me medical offices financial papers on the mail. The banker told me that he also send my application to the SBA loan. They both rejected my application, I was too risky because I was upside down in m y home mortgage. I told him : are you serious, look around and you will find out that I am not the only one. I had a credit card debt of 7,000 because i had to pay a tail malpractice insurance that the previous employer refused to pay. I had to pointed out that he told me that my credit score was almost 800′s .
      anyway I had to look for another bank that gave me the loan.

  • Deceased MD

    Just realized we are all being “enlightened” by Dr. Dark. Sounds like he has gone over to the Dark Side of the force.

  • Kristy Sokoloski

    Not necessarily. Not sure what the answer is, but so far with my Primary Care office that is connected to the hospital I haven’t had any problems. Every person’s situation is different. Three of my doctors (and they are specialists) still have solo practices. I wish there was an easy way to deal with this.

  • Rob Burnside

    “If large groups lead patients…care might suffer.” For me, “Doc” (played by Milburne Stone) from TVs “Gunsmoke” will always be the archytype. If he were practicing in my hometown I’d be first in line, though it would likely be a very short line indeed. The Wild West is gone, replaced by the Land of Big Box Oz. Rugged individualism all but eliminated, anonymous group-grope all but sanctified. Our “new normal” our grandchildrens’ reality. We’ll have to learn to live with that, or live around it.

  • Claire

    Just as the post from the doctor who left clinical practice entirely mad me sad, so too does this one. I think it is terrible that a person who went to school to treat patients and actually, [GASP!] PRACTICE MEDICINE will be put out of business by big box doctor’s offices. I know the analogy is woefully inadequate, but it’s like the small business owner who had a small family run hardware store and provided excellent customer service for decades going out of business because a Wal-Mart when in down the street. We are lucky that we still have the ability for everyone in our family to go to a 2 doc PCP practice and 2 doc pediatric practice. Their experience and information is invaluable. They know every medical quirk of our entire family and when I take the kids in for problem X, the pediatrician automatically remembers when he was 2 and had problem X and how we treated it and what the outcome was. He is able to take that information and use it and come up with a plan. He has a brain and he’s not afraid to use it to think for himself. It’s a novel concept these days. I would hate it if they had to shut down and I had to go to a McDoctor.

    • ninguem

      Claire, the Wal-Mart comparison is more accurate if Wal-Mart was allowed to charge twice as much for that screwdriver, as the Mom-and-Pop store.

      In fact, let me make the comparison that much more accurate. Wal-Mart gets to force the community to pay the difference.

      Mom-and-Pop charges five bucks for that screwdriver.

      Wal-Mart charges four bucks for that screwdriver, but then forces the community as a whole to pay an additional six bucks. The closest comparison I can think of, to compare with the “facility fees” charged by the big box places.

      Mom-and-Pop gets five bucks for that screwdriver, Wal-Mart gets ten bucks, total.

      Then Wal-Mart goes around claiming they sell cheaper screwdrivers, look at the list price, and claim they do it because they are smarter than Mom-and-Pop, better business managers.

  • southerndoc1

    From the article you link to:

    “When return on investment (ROI) for the PCMH model redesigns from 2006-2010 were assessed, results demonstrated an upward trend but had yet to reach a statistically significant break-even point.”
    Even the AAFP is now admitting that “transforming” to the PCMH model costs 100k per doctor just for the set-up, without addressing ongoing costs.

    The insurer may save a little money (which I doubt they return to their enrollees), while the doctor’s overhead goes through the roof. Great.

    • ninguem

      Of course southern

      All that matters is more money to the suits.

      Patient care be damned.

    • Adolfo E. Teran

      It is refreshing to read about your comment. I do not know if the author of the article knows that the suits does not work for free. I will have to hire a football team of people that would never,never work for free. I will have to see patients every 5 minutes to be able to pay for my PCMH home. I can tell you that my patients would wait hours in my lobby and they will have a hard time to see me.
      I guess that is cool and modern .

    • Cedric Dark

      Here’s some additional info from an article we recently reviewed: http://www.policyprescriptions.org/pchms-do-not-reduce-overal-costs/
      Suggests PCHMs won’t save money in the long run even though the authors of the paper really hope they do.

  • buzzkillerjsmith

    Come on down, Cedric. There’s an open office next mine. Show me how it’s done.

    • Adolfo E. Teran

      your point is a great one, it is easy to talk about the medical home when you are employed by a hospital or by a company who sells medical services to the hospital. I used to work in an urgent care owned by the hospital. I was not working directly for the hospital since they used an agency. The suits betrayed me and stabbed my back over and over without checking my Tdap status . I can tell you when you are working for suits, you can feel something sharp in your back any time.

  • Deceased MD

    Huh? Pray tell us more. This is a new one on me.
    How did the hospital group explain that one?

    $300? Wow I should have gone into data entry.

    • dontdoitagain

      Believe me I was as surprized as anybody. I found it when I was going over the itemized charges from my out patient surgery bill. I questioned it and the hospital, instead of answering, removed it from the bill. I don’t know if it was for a fax, an e-mail, an entry etc. but I do know that the crna could have taken the “data” back to his shop with him.

      I also found a charge for a machine (flouroscope) that wasn’t used on me. I know this because I was militant about not getting Versed. (or g/a) I convinced the billing clerk that I was AWAKE without amnesia and that the machine was never used. Then she said, get this, the machine was in the OR with me and COULD have been used if the doc wanted to and thus, the charge for it. I threw a fit over that one too and it was removed from the bill.

      It would take the whole page to list every single item, like the hospital did, that I objected to. There is lots of stuff on the itemized statement (which isn’t that easy to get btw) which appears to be nothing but bill padding.

      Previously I had gotten a $280 charge to enter the words “general anesthetic” on my chart. (at my first ill-fated surgery) I questioned it and it was removed. I hadn’t agreed to g/a anyway for the stupid minor surgery and it royally pissed me off.

      Anybody who wants to keep their bill down, even with insurance, needs to have the treatment center produce an ITEMIZED STATEMENT! There’s a LOT of this kind of thing going on.

      • Deceased MD

        Wow that’s really lame. The gimmick is no longer hundreds of dollars for a bandaid. It’s charging for things that are not even used.

  • Deceased MD

    Have a taste of your own medicine…..
    Try it out yourself as a patient.

    • Cedric Dark

      Fortunately I haven’t had to be a patient recently. But if I were, I personally would prefer the personal relationship with the same doctor longitudinally. That said, I’d like them to have access to specialists if needed with my data available to all the clinicians via a unified system.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        And if you had to pick two out of three (same doctor relationship, access to specialists, unified informatics system), which one would you leave out? Or if you had finite resources to invest, which one would get the least funding?

        • Cedric Dark

          As a patient: same doctor relationship and access to specialists. But as a systems thinker (i.e your funding question), I’d invest more in the primary care relationship and the unified informatics. I work in an ER. I see the hassle with un-unified information daily as patient’s hospital hop or get referred and are subjected to repeat testing simply because the PCP or outside facility wasn’t thinking to send the data with the patient.

          Quality isn’t just about being a good doctor. It’s also about being a good agent for the patient…and that means not wasting the patient’s time and/or money.

          For instance, a patient was sent to me recently with a fracture needing follow up and I had to repeat imaging for the specialist consult. The patient had to spend hours waiting for the specialist. So we – as a society – waste time and money on duplicitous testing when I already knew the diagnosis based on the photo the patient took on their cell phone of their XR from an outside hospital.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Good answer. Thank you.
            Just a tiny remark though. I think in the systems thinking scenario, there is an implicit assumption that we already have a satisfactory supply of specialist access, which needs to be optimized by informatics to save time and money. This is not an entirely accurate assumption for all people, so if I had to fund a new system, say, for the poor, I would fund proper primary and specialty care before delving into informatics. Some say that proper informatics should come first to reduce expenditures on both primary and specialty care. I have my doubts….

          • Adolfo E. Teran

            when I sent my patients to the ER. I make a call to speak with charge Rn or ER MD/DO, I fax them my notes, labs, xrays and make sure they got it. I also give my patient a copy of my note with labs and a business card staple to the papers.
            I use an EMR so every person who can read will be able to understand why I am sending the patient.

      • Deceased MD

        Exactly. As a pt, you would not want to be in a PCMH.

        • Cedric Dark

          The PCMH is just a gimmick. Primary care physicians should have been doing this (being multi-disiplinary) ANYWAY for the past 50 years. But they’ve dropped the ball in my opinion. The point of my post was simply to report that the solo doctor is on the decline in the US. Bigger groups are becoming the norm. Whether or not it’s a good transition is determined by multiple factors including the doctor-patient relationship, overall quality of care, availability of appointments (so that people don’t have to come to the ED for something a PCP could handle but won’t because they’ve gone home for the day or can’t squeeze in another appt).

          • southerndoc1

            “But they’ve dropped the ball in my opinion”

            See a patient with DM, COPD, CAD, new onset depression, a sprained ankle, and a viral URI, and only get paid for treating the URI – yep, we learned to drop those balls. See a patient with the worst headache of her life, and have to close down your office for two hours trying to get a pre-auth for a scan – yep, learned to kick that ball to the ER real quick.
            Having worked in a very large group and in a small private practice, I know that I’m much more likely to work in the extra patient in the later situation. Pay solo and small groups at the same rate as the big ones, and the difference in quality of care would be staggering.

          • Adolfo E. Teran

            I agree, if I see a medicaid patient I got paid 20′s dollars per visit. The same patient go to a Community Health center and they get paid more, much more. I laugh at the people that dare to compare private doctors with the community health centers. they care comparing apples to cars.

          • Deceased MD

            Thank you for the detailed response Cedric. In what setting do you work?
            Most of the docs on this board are in private practice or believe in solo practice. As southern doc pointed out nicely, it’s an uneven playing field. And most on this board, i will let them speak for themselves, feel that big hospitals are undermining solo practice and that it is destructive to medicine. For one,driving costs up with hefty facility fees that solo docs could do much cheaper. Solo practice certainly has worked well for a long time. How are the hospital systems that are driving up costs, a solution to the problem?

  • Adolfo E. Teran

    Cedric, study? really? , I do not know if you are aware that payment is not the same everywhere in america. You may find places that may reimburse better or pay for those PCMH. Also you may find places that insurances dont want to pay for an UA even if the patient is coming with dysuria and gross hematuria. I do not think studies will help because of the level of payment is so different .

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