The Current Trend in Health Care Delivery Systems to Large Group Practices: Is Bigger Really Better? The Resilience of the Private Solo Practice
March 31, 2011 1 Comment
- By Scott W. Tunis MD FACS
One of the clear trends in healthcare delivery systems in the United States over the past decade is the evolution of large group practices. Doctors are increasingly joining large group practices, a greater number are becoming employees of hospital owned and based practices, and many are creating multi-specialty groups. There are fewer solo and small group practices, fewer physician owned practices, and fewer independent practitioners in all specialties. According to a national study from the Center for Studying Health System Change in 2005 only one half of all physicians practicing in the United States owned any fraction of their practice, and that number is diminishing.
There are several reasons for this trend. Increasing government regulations, decreasing insurance reimbursement, and increasing costs of medical technology, among a myriad of other factors, have created an environment conducive to physicians to join large groups. New physicians entering the work force are opting out of private practice, late career physicians are retiring early, and mid career practicing physicians are abandoning private practice to join large groups as salaried employees.
There are distinct potential advantages to being a provider in a large corporate practice. A physician is no longer a small businessman in addition to being a physician and is free to concentrate on delivering care to patients. In addition, large practices can share expensive technology, negotiate with third party payers for better reimbursement, and realize other economies of scale in administration and fixed costs.
For many patients, however, the trend toward an” industrial medical complex” with large corporate entities employing physicians raises many issues and concerns. Foremost among them is patients’ desire to see the physician of their choice, one with whom they may have developed an ongoing relationship, rather than being assigned the Doctor on call which can commonly be the case otherwise. In the emerging health care scenario the storied “physician patient relationship” may go the way of the house call. Another major concern among patients is that medical, diagnostic, and treatment options, which most will agree are best determined by the physician and the patient in consultation, may instead be determined by financial constraints imposed by the accountants and administrators in charge of large practices. Simply put, there is concern that corporate practices are motivated by their bottom line to deliver as little care as possible for the highest reimbursement, and that the physicians in their employ are financially incentivized to do the same.
For many patients and many physicians, bigger is therefore not always better. Solo and small group practice is alive and well in the United States, with most surveys indicating that more than one third of all physicians remain in solo or two Doctor practices, despite the pressures to centralize. The so called “boutique” or “micro-practice” is particularly successful in situations in which the physician has special experience in a narrow field of a specialty, or who has expertise in performing a procedure that is not performed by other practitioners in the community.
With 26+ years of private practice experience, having been in several practice arrangements ranging from a current solo practice to a practice with over 50 Doctors, my experience has been that solo practice allows me to practice the best medicine. And that, in the final analysis, is the most important thing. Solo practice is certainly requires more hours and more administrative and entrepreneurial skills than an employment situation. Despite those demands, I believe that overhead can be controlled more effectively, waste and redundancy is minimized, and the bureaucracy of a large practice is eliminated. Administrative, legal, and compliance duties can be subcontracted, freeing a physician to focus on medicine. Smaller can be more efficient, administratively as well as medically.
A highly functioning solo practice can provide state of the art medical technology, electronic medical records, e-prescribing, and access to consultation as efficiently as large practices. In many surgical subspecialties such as Plastic and Cosmetic Surgery, Dermatologic Surgery, and Ophthalmology procedure specific technology can be provided that is not available in large group practices.
There will always be a certain sector of the public who will continue to seek out solo and small practices for the personalized and immediate care they provide. Although the United States has yet to implement health care reforms as highly government controlled and regulated as the Canadian system, current legislation if not repealed certainly will move U.S. health care in that direction. The evolution of health care can then be expected to limit the choices, timeliness, and services provided to patients. This may well make the small, efficient, non-capitated fee for service practice even more desirable to the discerning health care consumer. Whatever model of health care reform evolves, there will likely be a dichotomy in the types of physician providers. There will be large physician groups providing generic care, many of which will be hospital based, and there will be solo or small practices which perform more traditional and specialized care.
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Scott W. Tunis MD FACS, a 1981 graduate of the University Of Virginia School Of Medicine, and a past Chief of Ophthalmology at New Hanover Regional Medical Center, has a solo practice in Ophthalmology specializing in Laser Vision Correction and Cataract Surgery in Wilmington NC
