The slow death of private practices

Doctors have been bemoaning changes in the practice of medicine for years and with good reason. It’s harder and harder to make a go of it in private practice. In recent years our area has lost several small practices — Hal Grotke’s Redwood Family Practice closed, Dr. Garcia retired, Teresa Marshall’s solo office shut its doors, Eureka Internal Medicine transitioned to Humboldt Medical Specialists (which then became St. Joseph Hospital Medical Group) and Beverly Copeland relocated to Ashland.

As I was writing this, Dr. Windham announced that he is ceasing the provision of primary care at his small office. Unfortunately, young, freshly trained physicians are not arriving here to take their places. Most recent graduates take positions with large organizations that can offer loan repayment funds, regular hours and a steady salary. It’s no wonder new physicians want to be employees with reasonable pay and limited hours. If you are not working for yourself, there is no reason to be overworked.

The days when a doctor could show up in a small town, rent an office and hang out a shingle, sadly, is pretty much over. The knowledge base necessary to run a small business is not part of medical education, and few new graduates want to tackle such a task. In addition to business basics, running a medical office requires much more. One must follow a myriad of regulations surrounding everything from patient confidentiality to the inclusion of specific features in your electronic health record to successfully navigating the Rubik’s cube of medical billing. Large organizations retain staff that specialize in human resources, bookkeeping, medical billing and so forth. In a small practice, one person has to learn many different duties which can be a daunting prospect. Employment law is complicated and detailed. Our practice got fined once because we waited a few days to pay a terminated employee instead of cutting that last check right away.

The computerization of medicine has added another layer of expense and complexity. After purchasing the electronic health software, we must pay an IT company to maintain it and provide repairs. We pay for design and maintenance of a profession website as well.

Medical billing alone has become complex and difficult. Our office has over 13 different payors who all have different reimbursement rates and rules. We have three full-time billers who work on claims, submissions and collections. Another handles medical records and referrals, and we get so much paperwork send to us that we need one full-time employee just to scan it all into the electronic medical chart. I don’t know how one busy doctor could handle all that.

One could argue that medical care has no business being run as a business anyway. Providing medical care to a sick person is vastly different than selling someone a pizza, or fixing their broken toilet. Maybe it is better that most primary care is now handled by large, not-for-profit clinics, health maintenance organizations — such as Kaiser — or large hospital-affiliated multi-specialty groups. Things have gotten so complicated now that patients don’t need a single physician anymore anyway — they require a team of professionals to monitor their health program. Those of us that have experienced it will miss the intimacy and autonomy provided by the private practice model. Those of us who have not experienced it won’t know the difference. Hopefully, all the patients who have lost their doctors in this transition will be able to find a new health care team in this brave new world of medical care.

Emily Dalton is a physician who blogs at Dr. Emily’s Blog.

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