In 2003 70% of doctors owned their practice and in 2009 it stood at 30%, a dramatic reversal. Most physicians now have gone to work for someone else.
This change has snuck under the radar. It’s really alarming. However it hardly fazes most practitioners and it is passively accepted. Patients are not yet fully aware of this turn of events. In spite of many conversations expressing my concern with fellow docs it seems to fall on deaf ears. The medical profession has limped away from taking any lead in shaping their future, no matter if it means much regret in the coming years. It may even drive many away from the profession.
Even though a health care law has passed it does not address this issue. It will certainly need tweaking over time. Identifying those core issues and getting enough people to come to that common realization that this affects “me too” is my aim. Hopefully it sparks some movement towards a critical mass to resuscitate a dying institution that has had such a precious history. I’m not very liberal on this notion since it has served the public in ways that can not be substituted by 9 to 5 healers (I call them partial care specialists).
My intention and hope is to bring the ground level of the health care industry into view. This is my initial step up to the plate to start a conversation. I hope it is the beginning of “a beautiful relationship.” Dr. Don Green
I have long thought that the commodization (is that a word?) of the medical fields is the biggest mistake we can make. For instance, all these for-profit hospitals. Ug. And there are monetary incentives in many places for sending patients for tests at these larger firms – a kickback, really, for wasting health care dollars (as many unnecessary tests get performed in the name of getting that bonus). Just some really bad ideas.
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p>But as to why doctors are getting out of private practice, I’m not sure where to begin to explain that. Is it the medical malpractice costs? Is it that they have so little control over patient care these days that they might as well work for someone else and let them deal with the hassle of business management, billing, and dealing with the HMOs?
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p>It would be nice if someone did a survey of those who remain in private practice and those who have decided to work for larger outfits to see what happened.
I do not know of any surveys but I know the business side of practice is a crazy quilt. One former BCBS executive stated at rounds that he presided over 16,000 different accounts. The underpinnings to support such nonsense for all concerned is astronomical and very discouraging to doctors entering practice.
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p>Medical schools discourage private ownership and provide no background education on this subject for doctors to be. They are at sea when it comes time to select what they’re going to do with the rest of their lives. They slide into the path of least resistance, saddled with loan debts and family responsibilities(I just want to practice medicine).
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p>Further the present payment system makes doctors a commodity(I like your word) and it is increasing. Unless payment is simplified and uniform for the same services we will see further diluting of doctors allegiance to their patients. They will be wards of their employers. The plank doctors are walking is very long and therefore they can not see the end of it. Hopefully the day is not far off when there will be some realization that they are no longer in charge of their professional life and will wake up to the fact they have traded it for some very short term or non existent benefits.
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p>Stranger yet they are told they are actually improving a patient’s care by being salaried. This is the song sung by owner hospitals and insures. However the public at large has not gotten the chance to vote on that one. Now that’s a survey I’d like to see!
been better-serviced by small practices than large ones, in whatever field of medicine I’ve needed care in. It’s really inevitable that smaller, family-like practices are going to give better care, because that’s ultimately how they get their business (maintaining happy costumers, good word-of-mouth).
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p>I find that no matter the kind of medicine being practiced, I always get better treatment and more personal time by the doctors when the practice is smaller and the doctor-patient relationships more personal. This is true for me whether it’s been the dentist, eye doctors or my primary care physician. In each of those cases, I migrated from larger/corporate practices to smaller/family ones and got much better treatment.
They had a booth at the Tea Party Express rally, displaying Ayn Rand books on the table, and obviously oppose “socialized medicine” and promote capitalism and private doctors. Their mission is to, well, it’s here.
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They also believe medicine should be unregulated and private doctors should be allowed to offer for sale whatever services and technologies they can invent, including genetic engineering and reproductive human enhancement technology, even though such technologies, once invented, would lead to bigger government, more regulation, worse health, higher taxes, etc. It’s just one example of how short-sighted Randoids are, even as they imagine some long-term utopia of selfishness leading to great achievements and triumphs of the human spirit or whatever motivates them.
This sounds like a return to the period before the establishment of medical schools on a scientific basis and a system of licensing of physicians in this country. Around the turn of the century a private report, the Flexner Report, highlighted the dismal condition of the free for all status of training in this country. It helped established curriculum and requirements for medical schools and the requirements for proper training. Doctors training began in hospitals under the tutelage of experienced and scientifically grounded practitioners.
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p>It was understood that there needed to be agreement on what it meant to be a licensed physician.
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p>No one here or in other countries has proposed that doctors not be free to choose once they are properly educated how they practice.
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p>It is the present system of payment that is driving docs to be employees. It is ready access by patients with a secure way of paying for care that ensures individual care. The tea baggers are arguing against what is actually needed to sustain private practice(“Don’t touch my Medicare”).
That’s apparently what Harry Reid’s GOP challenger thinks should happen.
Although it was not strictly compensation there were indeed some patients who showed appreciation by giving me some things of their own creation. I received paintings, hand crafted art works, vegetable and fruit from their gardens, and once some basement made wine(I could only manage one sip–probably an off year).
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p>Although none of these would count as dependable income they were all received with much appreciation. Just as the numerous letters and holiday cards that came to me over the years they all had a special meaning beyond dollars and cents. It was a source of real professional pride to have people, my patients or their families, show gratitude for the services I gave.
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p>Medicine at its general level works best as a cottage industry in my estimation. It is already in the works to destroy this in favor or care being delivered in clinics as stated in the diary.
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p>People will have to step forward to stop this trend. Everyone who lives at the top poo poohs this concept of one on one care. I hope it is not too late to preserve it. By the way in other industrial nations they have kept this construct of a personal physician or provider and still spend less with better results.
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p>I recently had a hospital administrator point out a business journal report that we have a better record on cancer care in this country versus those socialist nations for people over 65. I did not know what to say at first but then realized they had made the argument for me–these are people on Medicare and usually have a personal physician paid for with public funds. I would not say he was a tea bagger but certainly was swallowing their convoluted logic.
People who have never been self-employed don’t ‘get’ the kind of merchant-consumer interaction. One thing that has made our economy so vulnerable to big business failures is the difficulties government has raised for very small and self employed businesses.
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p>Your description of your situation parallels the destruction of agriculture – first government subsidies, then government price controls, then the ‘consolidation’ of small farms into agro-conglomerates, then the increasing burden of regulations designed for agro-conglomerates falling on remaining individual farms, and then…commoditization.
The hospitals and clinic groups are the ones buying practices and hiring doctors on salary. This has been a smoldering problem untouched by any government intrusion. We do have several parts of our economy that are wielding more power than they can handle often creating even more problems in their wake.
It’s kind of like how not taking a risk is itself taking a risk. Government acts sometimes by not acting, because there is government everywhere, from Canada to India, Austrailia to Cornwall. And government subsidizes and creates incentives and disincentives even when it doesn’t try to. Subsidizing corn affects the price of airplanes. Investing in highways affects health care. In this case, the government is encouraging hospitals and clinic groups to buy practices and hire doctors on salary. I think the government should seize ownership of all private hospitals and put all doctors and staff on payroll, and it should be good pay, so that people want to be doctors.
…, except it isn’t.
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p>You want to imply a causal relationship from price controls to consolidation, except we haven’t been controlling prices in medicine, so any consolidation you see in the medical field can’t be because of controls.
And the farm program didn’t cause it’s ultimate problems right out of the box. It took years of bad decisions, which we will have the chance to make again with health care.
… then you are implying a causal relationship. Otherwise they are coincidences.
First, the best care has longitude of service – not interchangeable providers.
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p>Second, the self employed solo can stick to their ethics without corporate overlords saying, in my profession, for example “back off – its too political” as happened when I clerked for a Big Firm in Michigan.
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p>And Third, I remember a family doctor who visited and monitored my scarlet fever at home so I would not be exposed to other sick kids with other microbes when I was already very sick.
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p>There are more germs, microbes, fungus, etc. in doctor’s offices and hospitals then in a patient’s home. But then, that was in 1956.
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p>Not EVERYTHING has gotten better.
I ALSO had scarlet fever in 1956! My house was quarantined, and my dad had to sleep elsewhere in order to go to work! The milkman wouldn’t come to the porch, but would only leave the bottles at the foot of the stoop – and wouldn’t take bottles away, so we lost the deposit!
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p>And I couldn’t understand why the DOCTOR could come and go to the house….
…American life expectancy at birth is lower than the rest of the industrialized world, but if we make it to 65 we suddenly live longer than anyone. Again the difference is that 65 is when OUR single-payer kicks in.
Thomas Paine: “Time makes more converts than reason.” Common Sense
I don’t care whether my doctor owns his own practice. I do care whether I get adequate time and attention. I can think of many reasons why doctors may not want to be responsible for running their own business and don’t find it especially distressing that many choose not to do so.
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p>I am concerned that some healthcare providers may make it difficult for their doctors to spend enough time with their patients – that is what we should be worried about — not whether the doctor owns the practice.
I want to be on reasonably solid ground before I comment. If you could say why doctors become employees rather than owning their practice I could better explain my viewpoint. However someone who is an employee is not free to determine policies, how they spend their time, or even how they are compensated for their work.
Another look at the employed physician world. This scenario will only spread over the years.
In return for giving up responsibility for business issues any employee in any business risks the chance that their employee may make poor decisions or make unpleasant rules. Given a good enough job market the answer is to find a new employer if you are not happy with your current job. Indeed, that is exactly what doctors in the Boston area do. If a practice is not paying its primary care physicians enough or not giving them adequate working conditions they invariably find their best doctors leaving for better jobs. And those that really want to go it on their own and start their own practice can do so.
I think your link below summarizes several of the good reasons for doctors not wanting to run their own practices. The important ones are the management issues, not so much salary. Few doctors see themselves as financial or personnel managers – that’s not why people go into medicine and those aren’t skill sets that are selected for in the training process. As a result, it’s attractive when a hospital offers to take responsibility for dealing with insurance companies, do the patient billing, and make sure you get a front office person for the day when your regular front office person calls in sick.
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p>The down side is that you give up some flexibility in patient care. This is a difficult area to evaluate rationally. There is no doubt that primary care providers want to send their patients to the best available specialists. But clearly, not everyone can have their cancer treated at the Mayo Clinic. The critical question is not “How do I maximize patient care options?” it is “How do I maximize patient care outcomes?”
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p>And this is where being a hospital employee might be a better option than running your own practice. If you spend 10 hours a week checking your metrics instead of seeing patients, your throughput is way down. If you try to bring your throughput back up by shaving 5 minutes off each visit, patient care is sub-optimal. There is a case to be made for doctors outsourcing the non-patient care work to others. Your note of the article in the Times is a good example. Even if EMRs are the silver bullet for primary care doctors’ time management issues, should a physician really be the one spec’ing the system? It seems to me that’s a better task for an IT department.
The Times today gave a peek into the issues facing salaried primary care doctors. It does not seem to be an answer to a better professional life and any changes in the practice to better things will have to be run through headquarters. By the way they do not service people in hospitals and probably leave this to hospitalists. Is this what the public wants?
I don’t think they really care whether the doctor owns the practice or not. I know that I don’t.
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p>I don’t think it is even remotely accurate to suggest that doctors who are employees have to run everything through “headquarters”. Nor is it remotely accurate to suggest that PCPs will not visit patients in hospitals.
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p>Also, I don’t see what is wrong with leaving the primary responsibility for the care of hospitalized patients with hospitalists whose training and experience is focused on medical issues related to hospital care.
It is not whether you or I care. It is what will happen as time moves along.
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p>Doctors are now getting fired if they don’t meet “productivity goals.”
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p>Being fired as a professional is a major blow to one’s morale. This is especially true if it is based mostly on business not professional goals.
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p>As an employee MDs are not making the rules and do have to adhere to policy if they agree with it or not or they will indeed face dismissal.
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p>If a physician leaves for one reason or another it is not just a matter of moving on but patients are left stranded. They have to go where their doctor went or start over with someone new. This is a problem.
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p>How physician and patient relate to each other is indeed being altered. The pace is not yet perceptible to most but when it is, many will be wondering—How in the world did this happen? Nothing like a head’s up so if action is needed it will be a stitch in time.
There is nothing preventing doctors from having private practices if they really want them. Most of your arguments revolve around how unpleasant it is for doctors to work as employees, but that would seem to be a self-correcting problem if true especially since there is a shortage of PCP and GPS. As I said, doctors who are employees can always quit and find a better employer or go into private practice if they think it will make their life better.
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p>The reason that fewer doctors are going into private practice is probably because the bigger practices have been gradually doing a better job of providing a good work environment for them with good pay. I know that my own father, when he was in private practice, hated the business aspects of his job.
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p>I am sure that family issues also plays a role here. Another major change in medicine is that there are many more women in the field especially in primary care and the spouses of married doctors in general are much more likely to also work than used to be the case. It is much easier for a doctor who wants or needs to take time off to raise kids if they are in a large practice with many other doctors to pick up the slack.
Could you tell us something about your costs? For example, what percent was spent on staffing? On rent/utilities/capital equipment? On insurance? On band-aids?
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p>It’s always struck me that doctors offices are empty a good bit of time — particularly the time when other people aren’t at work. Now, I understand that doctors would rather not work on early mornings, late evenings, or weekends, but it’s always struck me that doctors could make more use out of the money spent on offices and medical devices if they worked together to share some more difficult hours, thereby getting more hours of use per day from their facilities (thereby reducing the cost per patient), and have hours which are easier on people who have jobs, kids in school, etc.
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p>If rent, utilities, and capital equipment aren’t particularly expensive relative to other bills for the private practice doctor, then this isn’t worth it financially. If, however, those particular bills are larger, this seems like a way to lower costs and improve patient experience (yes, at the expense of doctors working hours other than 9-5 M-F).
My overall expense was 42% of total income. Of that 83% was for personnel and payroll taxes, some 36% of total revenue. By opening up more time you are adding more personnel expense mostly. Extra service will add to your bottom line. However if all doctors end up working the same number of hours, not more, this will not add to their income. If the off hours produce more visits than otherwise then there will be gain.
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p>You have brought up a reality of medical economics, namely costs are relatively fixed for any particular office, hospital, or other outpatient site. The gain comes from added performed services. However there is a limit. There are only so many services to be provided in a particular area. If each player sets out the same offering, the pie is more thinly divided. What everyone calls competition is really a business plan to increase market share, not provide what is actually needed. The attempts to push this faulty strategy adds expense since each unit of care now carries a higher price tag or it can not be sustained. The cost is then shifted to insurance subscribers via undisclosed negotiations.
I’ve been thinking about why it is private practices are disappearing, and one reason might be that their costs are higher — a lack of economies of scale. The thinking is that by using the capital equipment for more hours a day, you drive down cost. Sure the personnel cost goes up, but as long as you’re seeing the same number of patients per hour, those costs should wash while your capital costs per patient go down.
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p>However, it would seem that those costs were low — only 17% of your costs were contained in rent, utilities, capital equipment, “disposable” equipment and supplies, malpractice insurance, and so forth. Squeezing a bit more water out of those stones won’t fill your glass.
My overhead is lower than most corporate entities since they use increased personnel to run their business and market themselves. However my income was more than satisfactory, was able to attend to personal and family events, and dispose of any debts in a timely manner. There is no education in residency how to set up practice efficiently and earn appropriately. If medical schools had pain more attention we would be a different place. Instead they have portrayed a negative view of practice.
… you’re describing an under-served market for business partners to team up with doctors for private practices. If the private practice model is profitable, but doctors aren’t necessarily thrilled at the non-doctor tasks of owning a business, then it would follow that this would be the perfect kind of business to bring in a non-doctor partner. That this doesn’t seem to happen much (or does it?) could indicate any combination of several things that I can think of: 1) Doctors are willing to overcome their distastes in order to not share a cut of profits. 2) There isn’t enough profit to share with a partner (most likely because of education debt servicing needs). 3) Business-types haven’t discovered this opportunity. 4) The non-doctor administration and labor are related enough to medicine that they are still better handled by an actual doctor.
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p>It would be awesome if it was just number 3, because that would indicate an opportunity that people should take advantage of. Perhaps a business schools and medical schools should hold mixers. 🙂
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p>Just thinking out loud.
Many physicians do have office or business managers. However their concentration is mostly bottom line and keeping the doctor from being too disturbed while he is doing more income producing work.
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p>It certainly could be #3 if the vision was one of serving the patient’s needs within reasonable time frames. One would have to have faith that this strategy would produce decent income. It did for me. Many times things you do are not compensated but they do generate more visits because of good will.
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p>I did have an office manager earlier in my practice but finally decided to do this on my own. I felt if I just jumped in and understood that learning was my biggest asset, I could figure out this business.
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p>In fact my billing person was out for six weeks with major surgery at one time and I took over the billing. Not that I would recommend it, but I have to admit I learned a lot. By the way she gave me a crash course before she left on leave and when she returned she thought I earned a B- for my efforts. She quickly made up the 15% drop in receivables during the period she was gone.
… any pressure to increase your take-home amount by losing the business manager? If so, was it influenced by educational debt?
I took it as a challenge. After he left my income steadily increased for the next 20 years. I was very satisfied with what I had accomplished.
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p>My loan from medical school was $10000 in 1969. Gas cost 35 cents a gallon and Mr. Nixon had stated that bread would never reach $1 a pound. There were other loans along the way to buy equipment, sustain myself, and eventually purchase homes, and 2 offices.
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p>Through all this I was present at my family’s events, took vacations, bought and sold homes, and started to save for my retirement.
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p>I fully understand each person is up for different challenges but it seems the deck is too stacked against private practice. It should be able to continue happily alongside the bigger guys, but not as a second class citizen.
One of the biggest reasons doctors don’t go into “private practice” anymore is that many have already (in their view) taken on too much leverage by becoming doctors. When you graduate with $300,000 in debt (a not unusual number), you care about paying that down as soon as possible, not the details of practice. Furthermore, private practice involves yet more leverage, as you either need to invest fairly significantly to start yourself or buy your way into an existing practice (“Barrier to entry” is the economic term; the barrier to entry for new physician practices is high, whereas the barrier to entry to corporate practice is fairly low).
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p>Another issue is that private practice is perceived (fairly or not, you tell me) as having poor lifestyle in ways other than practice. You’re always on call; you never have time for your family, and the hassles of administration of practice eat time which would otherwise be spent doing other things you love, sometimes as much as you love medicine (Hobbies, raising kids, making art, writing, dare I say it: politics?).
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p>On the professional front, the perception is that it is hard to find coverage, and that coverage arrangements are difficult because the covering doc has little incentive to call your patients back, nor does she know anything about them when I call from the ED to ask about them (whereas when I call BigPractice, while the doc still may not know them, they can look their information up on the BigComputer). Message passing is perceived to be poor in small practices; if I want you to see the patient the next day, will that get passed reliably? BigPractice has standardized ways of handling that; in the best BigPractices, the doc on call can schedule the patient for next day, or 2-3 day, followup without needing to talk to the patient’s doc directly.
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p>I’ve had care from both solo/small practices, and BigPractices. Both have given me excellent care, with convenient hours, regular visits with my doc, available in a timely fashion, and solid disease management (my ex-wife had MS, and she received good followup and disease management from her PCP as well as her neurologist in all the places we were together). Bigness or corporate structure is not a single criterion of goodness or lack thereof; there are well-structured corporate practices (I offer Kaiser and Group Health as models, and closer to home how about Urban Medical Group?) and poorly structured ones (coughHarvard Vanguardcough).
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p>I hear your thesis, but I argue that corporate practice is as much a result of changes in health care as it is a cause. Big groups run on ethical principles, such as the ones I mentioned above, have thrived and are held up as models of health care organization precisely because they have abandoned the straight business orientation to some extent, and instead provide disease management intended to keep people out of hospitals. Kaiser is, in the final analysis, a group of physicians who want to do right, and who hire business people to advise them on how to do what they believe is right while staying in business. I really believe that a model of less business, rather than more, is a better solution.
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p>Thanks for reading.
I will start with this example to foreshadow the following on what you have said.
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p>Isolated examples of good care is unfortunately too anecdotal for my taste. However my real problem is that this “change” has occurred without real scrutiny by the users of care and those who have to deliver it. There are other solutions.
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p>Most other countries subsidize or pay all of a doctor’s education. As the example above shows and I seen it also as the hospital took over my practice(I could not find an individual to buy my practice) rules of seeing patients and administrative practices were imposed that were heavy handed directed mostly by the bottom line.
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p>Turn over in large practices with docs on salary is also an issue. We are losing the model of a long term professional relationship and parts of our care are being farmed out to other professionals. Putting more individuals between a patient’s doctor and the site of care makes a fuller engagement tenuous.
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p>This only becomes evident in those “tire meets the road moments.” It is not always obvious since 20% of patients lead to 80% of the cost. This means for most of us it is not a common event. I can’t tell you how many times either in outright expression or by their body language that people were relieved to see their own doctor in the hospital setting.
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p>You did use the word perception and this is a significant problem. Once something has entered your belief system it is hard to muster energy for a better mouse trap.
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p>”A long habit of not thinking a thing wrong, gives it a superficial appearance of being right, and raises at first a formidable outcry in defense of custom. But the tumult soon subsides. Time makes more converts than reason.” Thomas Paine
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p>In other words time will tell. I will not be so married to what I think if you can perhaps do the same.
A more uniform and less costly payment system could rid the smaller practices of much of the “hassles.” When office routines are eased and smaller practices again made more enticing coverage can be improved. Actually in my case coverage was provided across 6 independent practices.
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p>The chase of the bottom line or trying to figure out how to improve revenue or trying to impose other pursuits on top of our professional lives has produced haphazard solutions. We may be throwing out the baby with the bath water.
with some of your own. Fair enough; my examples were meant to illustrate the idea that many people don’t find a difference between big practices and small ones if the big practices are organized and run properly. Your example is of a poorly organized and run system (run on business goals, not clinical ones); I admit they exist, and should be eliminated.
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p>Your point about the bottom line is well taken; this is why my personal preference is for a system which pays salaries and rewards factors other than productivity. A bonus for meeting clinical goals, for instance – how many of your patients meet A1C goals, or cholesterol goals? More than 80%? Excellent; have a bonus. (Not just process goals-like “are on cholesterol lowering agents if they have high cholesterol”; if the patient isn’t meeting the outcome goal, how are you going to see that s/he does? Are they actually taking the simvastatin? Why not?)
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p>(I have heard, by the way, the argument against salaries-they impair productivity. Is that really the problem, or do they properly incentivize physicians to prioritize clinical outcomes over moving the meat? I’ve been salaried all of my career, and I haven’t had any “productivity” complaints. My “productivity” is about average for an ER doc with my level of training and experience).
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p>These are the kinds of goals physicians can believe in. They must also be accompanied by the ability to affect them; if you need to spend an hour with a patient going over her diet diary and discussing why Kentucky Fried Chicken may not be the best choice for her cholesterol and sodium lowering goals, you spend the hour. If you’re at a loss as to how to improve someone’s medication compliance, you have someone to consult (pharmacists are good for this) on new approaches. In the best large groups and practices (the Kaisers and Geisingers of the world, and not incidentally in the VA and US Army medical system, with which I do have direct experience) this is how it works, and these types of systems have outcomes as good or better, at markedly lower cost, than “traditional” plans and systems.
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p>Now it may be that solo practices do as well or better; I don’t know if it’s been studied (and I’m too hurried to look right now). But I know that some big system models work, and provide good quality of life for the docs who work for them (I used to work in HI, and Kaiser has good penetration there, with happy docs generally).
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p>Finally, your comment about perception is valid. And I would like to see some “quality of life” type data from docs in various practice modes; I think it’d be enlightening.
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p>You don’t seem to have any problem with anecdotal evidence or over generalizations when it serves your purpose.
I presented articles to support my concerns with actual instances reported in reasonably responsible media. Further I too am asking for more data before making up one’s mind. Unfortunately many of the decisions that have been put in place are based on very flimsy data. Most of what I have done is point out problems to be addressed. There has been a very major change made. Isn’t it fair to look into the matter more deeply instead of being saddled with something that will take years to undo?
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p>So could you be a bit more specific? Do you think that the trend away from private ownership is not real and not documented? Do you think the reported problems I referenced are invalid? Also please review the sentence after the one you cited:
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p>I am actually calling for study of this entire issue. We plunged ahead without paying much attention to the law of unintended consequences. This whole issue of preserving the doctor-patient relationship is in flux. I just thought I would look before I leaped.