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.
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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