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Like many cities, Philadelphia is a city defined by its neighborhoods.  I practice in two neighborhoods separated by a few miles but leagues apart in every other way.  One of the hospitals is a tertiary care facility in the heart of Center City – a well to do upcoming part of town – and the other is a small community hospital a few miles South.  The patients at the two locations are quite different, and the mechanism of health care delivery is also starkly different.  Medical care at the Center City campus is provided mostly by employed physicians, and care at the community hospital is provided mostly by private practice physicians.

The debate about employed physicians vs. private physicians was one that until very recently was thought to have been settled.  To the nascent Obama administration in 2008 charged with ‘fixing’ health care, it was obvious that health care delivery in the United States was of low quality and needed change.  Enamored by models like the Mayo Clinic, the Cleveland Clinic, and Geisinger the answer clearly was large clinically integrated networks.  And just like that, with little discussion, and no evidence, the Obama administration set into motion legislation in the form of the Affordable Care Act that brought private practice to its knees. Declining reimbursement and increased overhead costs from regulations meant that percentage of private practice physicians went from 57% in 2000 to 37% in 2013.

The effects were obvious to me in Philadelphia.  As private practices closed around me I decided to open a private practice in 2013 mostly because my experience with hospital systems lead me to believe that I could deliver care much more efficiently if I was in independent practice.  Take the case of a sick patient of an employed physician.  It is rare to be able to see your own physician when your physician belongs to a large group, and so in many cases patients are directed to the emergency department to be triaged.  Patients admitted to the hospital are usually admitted and cared for by full time hospitalists who have never met the patient.

Contrast this with a patient of mine who became ill.  Patients who are sick are usually seen by me on the same day or the next day.  If a patient has to be admitted to the hospital, I am the one primarily taking care of the patient in the hospital as well.  So when the medical resident trainee who has just met the patient in the hospital pushes me to order a CT scan for shortness of breath, I know the patient well enough to know that a CT scan will be of minimal benefit in this case and that the patients chronic kidney disease may be exacerbated with the dye used in said CT scan.  Since I’m also the physician taking care of the patient out of the hospital, I pay little attention to the expected length of stay some helpful administrator has mandated be printed out next to every patient on the hospital patient list.  I discharged the patient on whatever day the patient was medically ready to go home.  I did not practice in this particular manner because I am a saint or because there was some mandate to do so, I just did it because it was the best way to take care of the patient.

The problem with a solo-practice model, though, is that it is exhausting. Most physicians of my generation raised in an environment of 80 hour work weeks, shift work, and mandatory time off regard the constantly on solo practitioners as some sort of weird anomaly.  I despaired that the model I worked in may be good for patients but was not one that was sustainable or scalable.  This was until I began going to the community hospital located just a few miles away from the center city campus.  Here I was introduced to a legion of internal medicine private practice physicians that had survived the great purge and were delivering care in a model much different than the standard employed hospital model.  These internists had office hours 6 days a week, offered labs on-site, followed their patients into the hospital to manage them, and had same day or next day availability.  When I remarked incredulously at the internist having evening and Saturday hours, a nurse that overheard me scoffed and noted that she would not even consider going to a practice that didn’t offer Saturday hours.  Many of the physicians I spoke to did not have an electronic medical record and were thus subject to reimbursement penalties.  Instead of packing it in, their response had been to shrug, work a little harder – and though life was tougher – they were surviving to provide care that from an access and continuity standpoint was superior to anything being offered by their employed counterparts.

This tale within two cities was all I needed to conclude that the general direction of health care away from the personalized care my private colleagues were delivering to large hospital employed networks – no matter how clinically integrated – was not one that was good for patients.  I thought I was in the minority, but it appears that I have unexpected company from none other than one of the architects of ObamaCare, Dr. Bob Kocher.  Dr. Kocher just penned an Op-ed in the Wall Street Journal acknowledging that it was a mistake to try to snuff out the private practice physician.

Dr. Kocher’s about face is somewhat stunning.  Here are his words from an Annals of Internal medicine Op-ed in 2010 :

Only hospitals or health plans can afford to make the necessary investments in information technology and management skills. This is not inevitable. As physicians organize themselves into increasingly larger groups—patient-centered medical home practices and accountable care organizations—they are, out of necessity, investing in information technology tools that are becoming both cheaper and more capable and investing in the acquisition or development of management skills that could provide these organizing functions efficiently for physician groups.

Physicians who embrace these changes and opportunities are likely to deliver the greatest benefits to their patients, the health system, and themselves. Physician practices that accept the challenge will be rewarded in the future payment system. Once we accomplish this transformation, the U.S. system will be more reliable, will be more accessible, and will offer higher-quality and higher-value care. For physicians, this means a profession that is more rewarding, more productive, and better able to realize its moral ideal.

Dr. Kocher’s remarkable admission may indeed be a genuine desire to get it right, but it is important to mention (as he does in his op-ed in the Wall Street Journal) that he is a partner at Venrock, a health care venture capital firm in Silicon valley, and that he is on the board of a company called Aledade.  Aledade – a company founded by another former regulator turned entrepreneur Dr. Farzad Mostashari – seeks to organize independent physicians into accountable care organizations (ACOs) for a monthly fee.  So after helping create a regulatory construct for paying physicians – the ACO – while in government, Drs. Mostashari and Kocher have now started a company that has ‘unparalleled regulatory expertise’ to help the private practitioner succeed and stay independent by joining/forming a physician ACO.  How very kind of them.

Not surprisingly, Dr. Kocher and Dr. Mostashari now regularly write editorials that would make it easier and more lucrative for physicians to join ACOs.  Indeed, when it appeared that Medicare may not allow providers to participate in multiple cost reducing pilot plans at the same time and force them to choose between Comprehensive Primary Care plus (CPC+) and ACOs, Drs. Mostashari and Kocher lobbied to allow practices to choose both so as to not keep physicians from choosing to enroll in ACOs.

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Keep in mind that this new faith Dr. Kocher et. al. have in the primary care physicians is not free.  Adelade’s fee can range from $500 – $3500 per month, and physicians must continue to collect, report and transmit data in order to qualify for shared saving payments from the government. Of course, the jury remains out on whether ACO practices that are incentivized to not admit anyone to the hospital are actually providing higher value care than physicians who aren’t thinking about dollar savings when deciding to admit a patient to the hospital.  Regardless, the good folks at Venrock have helped raise $35 million in two rounds of financing for Adelade, and thus there are 35 million reasons Drs. Kocher and Mostashari will continue to do penance on their apology tour as they now seek to champion the cause of the private practice primary care physician by enslaving them in their latest model.

Anish Koka is a Cardiologist in Private Practice in Philadelphia.  He loves regulations that make it harder for him to take care of patients.  Follow him on twitter: @anish_koka

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10 replies »

  1. Thx Paul, I’m not sure why there isn’t more coverage of these conflicts of interest. Dan Diamond had Mr. Mostashari on for an hour .. no real ?s about whether the regulations put into motion had the desired effect. Apparently the victory was widespread adoption of the emr, no matter that what ended up being adopted slowed physicians down and negatively impacted the pt-physician encounter. A large portion of the media has a priori accepted certain facts – bundled payment is good, capitation is good, FFS is bad, performance metrics will take us to the promised land. It is frustrating, to say the least.

  2. I’m getting old, so its been a while since I’ve been in medical school :). There was no conversation of cost when I was in medical school. Its hard to miss once you leave training though.. Guidelines, and opinions in medical journals are very much driven/influenced by cost now. I’ve noticed the adoption of the next big med or device has a higher bar now. Entresto – the new HF drug, has had sig. slower adoption mostly b/c of its cost, I think.
    I would be all for sensible tort reform – again, the medical societies and politicians seem to have given up on this. I’m not sure why.

  3. Certainly may have had a part. I’d be fully supportive of high deductible plans combined with legislation that allows for payments to physicians pretax.

  4. Great article, as usual Anish! The contrast between small private practice and the large conglomerate system is spot on. How about we (this may be you and me by the end) refuse to be enslaved by anyone? I think we need to do our own thing, our own way, refuse to back down, and continue taking care of patients as long as possible. I suspect after the exodus of physicians begins, patients will be beating down our doors with cash in hand. That was my clinic, today. I am still reeling, but they were very sick kids in need of care. There will be a future. Our kind of hands-on, high quality, lower cost medical care has value and will always be needed, my friend.

  5. As you said “Health care cost as a percentage of GDP was actually flat from 2009-2013″……the reason was the proliferation of high deductible plans linked to health savings accounts….adopted by corporate health plans across the country….usually giving the employees the option of these plans vs. more traditional “full coverage” plans.
    Rand Corp. studied this:
    Here is a quote from the Rand link: “An increased emphasis on consumer choices is also expected to encourage cost and quality competition among health care providers, resulting in lower prices for services.” And I add, these are in the much maligned “fee for service” system.

  6. Anish – Thanks for your informative response.

    I am also encouraged by the slowdown in medical cost growth since 2008. I’ve commented numerous times about how the current cost of the Medicare program is over $100 billion per year less than what the CBO projected it would be by now when they made their long term forecast in 2009. That’s in spite of the ACA, I think, rather than because of it.

    The most encouraging point I took from your response is that your generation of doctors was trained to be more cost conscious than earlier generations. I always perceived that the older doctors didn’t consider it part of their job to know or to care about costs unless the patient brought it up as an issue important to him or her. I’m also glad that doctors were able to fairly quickly adjust practice patterns after the results of the COURAGE study became widely known. I know that most doctors aren’t in medicine for the money though I want to see them all earn a very comfortable living for the value they provide for patients and the years of training they have to undergo to acquire the necessary expertise to practice medicine.

    I hear you and the other doctors about the negative impact from burdensome regulations and the push for electronic records which add cost to the system and reduce physician productivity as measured by the number of patients they can see each day. My own primary care doctor pegs that productivity reduction number in his practice at 15%.

    I’m curious about whether you can provide some insight as to roughly when medical school training started to put significantly more emphasis on cost related issues. While we patients want our doctors to do the right thing for each of us, we all also implicitly need them to help to be wise stewards of society’s limited resources by trying to keep unnecessary and even futile care to a minimum. Sensible medical tort reform could also be helpful to that effort.

  7. Great points Barry. No question there is tremendous waste in our system. But allow me to push back. Health care costs have moderated – well before the ACA. Health care cost as a percentage of GDP was actually flat from 2009-2013. 2014 saw the first uptick because (and this is what cms concludes not me) of expanded ACA enrollment. So more folks are insured, but we have made the cost issue much worse. I now believe that if the folks currently managing things cant fix this – and they show little insight into the problems in order to do so – this system needs to be drastically reworked/repealed.
    So whether it is because of the national cost conversation, the decline in private practice, or just because folks like me trained in an era of cost containment practice differently – something appeared to be working with regards to cost containment.

    With regards to solutions: I’d favor solutions that preserve private practice, and am against solutions with regulatory burdens that raise the cost of care and have little to do with patient care. Again, I’m not a policy guy- but one direction that seems to make sense is direct primary care. I’ve written elsewhere about legislative obstacles that currently exist that I think should be removed.

    The title is of course inflammatory, so excuse that..

    Lastly, I am very cost conscious. I think its a fallacy to assume all or most physicians in private practice who practice in a fee for service world are driven only by dollars. I do believe this generation of doctors is more aware than any other with regards to cost for a variety of reasons, and though I can’t prove it – has had much to with the bending of the cost curve. I bring up the example of elective coronary stents over and over again – but its important. Elective coronary stenting was reduced by 50% between 2007 and 2015. This happened in a fee for service world. Doctors are not the caricatures we are made out to be – for the most part we try to do the right thing by the patient. We just need the right tools – in the case of stents it was the widespread acknowledgement that the COURAGE study drove home suggesting medical therapy was a viable option to coronary stents. We would get a lot further if we had more trust in our physicians, and had real in the trench physicians helping guide policy.

  8. I appreciate the argument that the private practice physician can take care of individual patients better and often faster than employed physicians. My own NYC based cardiologist is in a small group practice (five doctors) and has provided me with exceptional care for the last 17 years that I’ve been one of his patients. A couple of years ago, his practice was bought by a large hospital system but, so far at least, I haven’t noticed any difference in the quality of care I receive though I do note that both the list prices and Medicare reimbursement rates shown on my EOB forms are considerably higher than they were before the hospital bought the practice. Fortunately for me, he is far enough along in his career, he can stand up to the hospital’s medical director when he has to so he can continue to do what he views as the right thing for his patients including referring them outside of the hospital’s network when he thinks it’s appropriate.

    On the other hand, medical cost growth rose faster than the overall economy for the last several decades and is now approaching 18% of the GDP. That’s unsustainable. At the same time, prior to the ACA, the number of people without health insurance continued to grow and approached 50 million people before the ACA became law. Most of the people who lacked health insurance wanted it but couldn’t afford it. That’s a big problem that the free market showed no evidence of addressing, let alone fixing.

    So, as a patient, I love my doctor and the care he provides to me. As a taxpayer, though, I’m concerned that the rapidly rising cost of healthcare is crowding out other worthwhile priorities both public and private. It also troubles me to see so many people without health insurance mainly because they can’t afford it without subsidies to help them pay for it. While private practice doctors do a fine job of taking care of their patients one at a time without much regard to the cost of individual services, tests, procedures, or drugs that their patients might need, a few constructive ideas on how to address the overall healthcare system’s cost conundrum would be helpful.

  9. No doubt, this article hits on all the right notes. Problem is that I agree that independent practice does do a better job than factory consolidated medicine. But the messengers, Farzad and Kocher have direct conflicts of interest and use their political connections to be sure their version of independent practices thrives in the current regulatory schemes. They encourage complexity so their services are needed and thus make sure they get exactly the right language and “blindspot” fixes to be sure they get paid.
    I am in a small private practice, thriving in a big city that has 2 monster corporate medical systems. I would just like to be left alone. We recently were one of the 62 hospitals out of over 3000 on Medicare Compare that are better than national average in complications after total hip and knee. Maybe medicare can bonus me for that. Just tell me to keep doing what we are doing. But instead, I am penalized because we do not do MU, as it gets in the way of our care and a horrible waste of time and effort. Andy S doesn’t seem to care about that since I am no one with no connections but have outstanding outcomes.

  10. Wow….well written and clear contrast between the large network vs. private practice of medicine…..this part alone needs wider distribution….NY Times or WSJ? Most of the public go glazy eyed when they hear about ACA, ACO, PCMH etc etc…..this draws a clear picture.

    And thank you for pulling back the curtains on Dr. Kocher’s motivations….though his reversal (from supporting the current blind faith of the central planning cognoscenti that large networks are THE answer to lower costs and better quality) is very welcome.