Will Independent Physicians Go Extinct?

Richard Gunderman goodLife is tough for physicians in solo and small group practice.  The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases.  “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive.  And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.

Of course, such requirements are not being imposed solely on solo and small-group physicians.  In many ways, they affect all physicians alike.  Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues.  Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.

Such challenges are not just raining down –  they are pouring down on the heads of physicians.  Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business.  And the problem is not just the money.  It’s also the time.  Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data.  We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.

Not surprisingly, independent physicians appear to be going the way of the dinosaurs.  One study found that only 17 percent of today’s physicians are in solo practice, a figure that stood at 54 percent in 1980.  Moreover, the percentage of physicians who describe themselves as independent practice owners has dropped from 62 percent in 2008 to just 35 percent last year, manifesting an acceleration in the pace of decline.  Conversely, over the same period, the percentage who say there are now employees of a hospital or medical group has increased from 38 percent to 53 percent.

We recently spoke with Georgia Blobaum, a medical practice administrator in Lincoln, Nebraska.  Blobaum has worked with many independent physicians who are now spending so much time trying to comply with mandates of the federal government, insurance companies, and hospitals that they have little energy left to care for patients.  “My heart really goes out to these doctors,” says Blobaum.  “They find the whole thing just so wearying.  They want to do right by their patients, but big organizations are making life so difficult for them that many are just throwing up their hands in frustration.”

Blobaum says many hospitals and health systems are seizing this decline in morale as an opportunity to snap up small physician practices.  “They know how discouraged physicians get when they contemplate all the work necessary to implement their own electronic health systems.  Then in comes a hospital who says that they will take care of all the IT and paperwork, and pay the physician more than they are currently making to boot.  Only two to three years later do physicians realize that their new employer is just piling on even more requirements and cutting their salary.”

“What is even worse,” Blobaum continues, “is that these physicians are giving up their autonomy.  I was talking recently to an oncologist.  He said that if he sells his practice to the local hospital, it will penalize him unless he refers all his patients to its facility and the physicians it employs.  But he thinks this is not always the best thing to do.  He knows his patients and he knows his colleagues.  If he thinks a particular physician is a good match for a patient, he wants the freedom to refer to that colleague, without regard to who he or she happens to work for.  For this reason, he will not sell.”

“Too often,” says Blobaum, “health systems deliver independent physicians an ultimatum:  ‘Either you join us as an employed physician, or we will replace you with other physicians who are eager to have your job.’”   Blobaum believes this is one of the greatest sources of the decline in contemporary physician morale – physicians are being made to feel alone, isolated, and unable to continue to operate independently.  “As a gastroenterologist told me recently,” she continues, “physicians are growing so accustomed to being told what to do that many have seem to have become paralyzed.”

Physicians in Nebraska are so concerned that they have formed a new organization of independent physicians.  Called OneHealth Nebraska, it helps to lower the costs of operating a medical practice by pooling resources.  For example, it will offer consolidated credentialing, so each physician does not need to fill out pages of forms for every hospital and insurance company.  It will also offer its members access to group purchasing and training, quality and compliance monitoring, and practice management services.   The hope is that independent physicians can keep practicing independently.

So far, the group has signed up more than 300 Nebraska physicians, and it is continuing to grow rapidly.  Blobaum explains it this way: “What we are talking about here is not a union, with collective bargaining and the right to strike.  But it does represent the unification of physicians around something many of them believe in deeply; namely, the mission of preserving  the independent practice of medicine by enabling physicians to continue to focus their attention on delivering high-quality, patient-focused care.”

“Our members believe that physician independence is a crucial ingredient in the recipe for high-quality healthcare,” says Blobaum.  “We admit that the pressures on physicians to give up ownership of their medical practices are huge, but we also believe that it is important to for them to maintain their independence.  By banding together and pooling their experiences and resources, physicians can put themselves in a much better position to put the interests of patients first, which is ultimately what makes practicing medicine rewarding in the first place.”

<em>Richard Gunderman is a frequent THCB contributor and professor of medicine at the University of Indiana.  Matt Albin is a professor of medicine at the University of Indiana.</em>

21 replies »

  1. Dr Tom I wished more doctors thought outside the box like you. There are resources out there that can help reduce the financial burdens placed on physicians, but it’s up the practice to take action. Unfortunately, I think a lot of doctors are burned out and have been beaten up so much that they’re afraid to make the wrong decision, so they opt to make no decision.


  2. I actually don’t think it is a matter of IF independent physicians will go extinct, but a matter of WHEN independent physicians will go extent. In this technological age, the rate of change is exponential. New technological breakthroughs are not only given us fancier smart phones, but better quality medical care. And with this advancement, physicians may have less value; just as the emergence of self-check-out technology has made many grocery store cashiers obsolete. As a surgeon and recovering luddite, I have accepted the fact that the world is becoming more and more technologically advanced. And this means that I have to take full responsibility for all aspects of my life: my own personal health, the proper functioning of my work at http://www.facialfeminizationsurgeons.com, my relationship with my patients, my relationship with myself, my knowledge in the health department. Yes, one day, and it may be soon or it may be in a few decades, there may very well be technology available that has the capacity to do everything that I do at work. That would render me useless, and mean that I’d have to go out there and find a different job.
    I have no problem with this technological revolution and evolution, and I think that any physician that tries to keep society from advancing for the sake of their own vocation is a primitive luddite unworthy of association. I choose not to associate myself with those who are trying to force their own dogma on others.

    The truth is, no matter who you are, an accomplished physician who is on the verge of losing his job to majestic hardware and software, or any other form of profession, you need to continue learning. If you stop learning, you stop growing. And if you stop growing, you are decaying.

    As long as we continue in our pursuit to sharpen our skills, learn new things, and identify what the world and society wants and demands, we will have a vocation. Now the choice is up to us. We can choose either to accept the nature of reality and society, and work even harder to keep up with the demands, or we can try and force politicians to pass laws and oppress others.

    I don’t know about you guys, but I would much rather the world not rely on the whims of venal politicians. I say we let the market decide whether or not physicians deserve a place in the arena of health services.

  3. BTW, I love TechnoRapture. The phrase.

    If I ever use it I’ll credit you.

  4. My wife recently told me that if I wasn’t always wrong I’d be always correct.

    Can’t argue with that.

  5. Um…that was buzzword bingo, SJ. To translate it, it seems that if independent practitioners only do the right things, and avoid the wrong things, everything will turn out hunky. Business blather disguising the TechnoRapture.
    Counterargument would be to write Tom’s phrase in traditional English.

  6. In my mind this is a BIG dou’h! Idiot docs! You did it to yourselves; your group the AMA backed that obamacare debacle. You should have read it first; you would have seen that it expressly didn’t want independent MD’s running around. That would have messed with the scenario of big brother dictating who gets what kind of health care. Seesh, a little late to the dance folks!

  7. The small independent practice can survive and thrive if they make an effort to automate their practices and leverage cost effective software and service platforms. The goal is to offset costly internal processes, integrate their data into larger systems, and make their practice more attractive to the consumer.
    If small practices can operate as a node within a larger network of providers, they can take advantage of organized medicine and maintain autonomy. With this autonomy they are free to offer high margin consumer centric services for their patients (hybrid model), and enjoy the benefits of being independent.

  8. With any luck if the self quantified movement takes off there will be a demand for flashy concierge doctors with shining teeth to treat the numbers and heal the patient.

  9. I was par tof a multispecialty big grp. Forced to work with doctors who wanted to put hours in only. A doc actually said,” Katharine, these aren’t your patients, they are Multicare’s patients!” when I expressed concern about apathetic doctors. I left after that.

    I have a private practice for twelve years now. No ACA or medicare patients. I am a specialist. I keep waiting for the environment to close down around me as is so foten predicted.

    Guess what?! My practice is jammed and I had to hire more docs! So I guess I will keep doing what I know is right for me and my patients. Maybe there will always be a place for my type of doc.

  10. At Geneia, we too are concerned about the state of physicians today. That’s why we commissioned a study to determine the level of physician dissatisfaction – and it’s alarming.

    Just a few of the most compelling findings, 67% of physicians know a colleague who is thinking of leaving clinical practice and 87% believe that the “business and regulation of healthcare” has changed the practice of medicine for the worse.

    That’s why we partnered with Medstro to launch an online competition to solicit the best ideas from physicians about how to restore the Joy of Medicine.

    To learn more about the competition, visit https://medstro.com/groups/joy.

  11. And so, the dinosaurs became extinct, as the slow, unimpeded ice age descended upon the land.

  12. The idea of a national organization of independent physicians is a good one, and I have thought for years how vital that is.

    Give me liberty, or give me death.

    Indeed, patients are saying that also, as they have become the enemy of the hospital-insurer-doctor mega systems, who are aligned to kick patients out as part of the gig and competition to shorten los.

  13. Watch iora health, qliance, medlion, Paladina health networks continue to grow. And these are DPC pure plays, not hybrids like Onemedical. Then there’s the cherry lickers in concierge medicine. Have yah talked to a PCP lately. Sentiment at all time low. Many docs don’t recommend profession to their children. What am I missing, p.s. I take payment via square.

  14. based on what, Gregg? I’ll happily wager your mortgage payment that that tsunami that’s keeping you up won’t happen

  15. “PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.”

    When I was with the REC, I HATED dealing with PQRS. I call it a “Quadrant 3 activity” (“urgent, but not important”). The PQRS measures that can’t be fully automated should be dropped. Or pay the docs extra for participating (fat chance, I know).

  16. I believe that the oppressive complexity of our system (MU, ICD-10, E/M coding, ACO’s) will force physicians, especially those in primary care, to choose one of two options: join a large group/hospital system that can manage the complexity with a large staff trained to do so, OR leave the system behind. This is evident in the increasing numbers of doctors opting to go the DPC route. That was the choice I was forced to make when I left my old practice, and opted to go DPC. Unless the government does something to simplify things, the exodus of doctors from their system will speed up and create greater problems. We may be at the start of a big crisis in the making.