Small, independent private practices are closing, increasing numbers of physicians are retiring early, and fewer medical school graduates are choosing primary care.The old-fashioned practice my father and I have built is a dying entity.Parents say coming to see us for an appointment feels more like a visit with a friend than a medical encounter.I am fighting for the subsistence of rural primary care practices.Most will not survive MACRA proposed changes to the reimbursement structure.
Seven days ago, I attended an “informational listening session,” sponsored by the Center for Medicare and Medicaid Services (CMS) for rural physicians to learn more about the new MACRA proposal known as MIPS/APM (Merit-Based Incentive Payment System/Alternative Payment Model.)This new plan will penalize 7 out of 10 small practices with 1-2 physicians in this country.Why? Because they will be overwhelmed complying with fruitless statistical reporting demands that do nothing to enhance the quality of care, instead of spending precious time seeing patients.
Thinking of starting a new practice? Is the lure of independence calling to you? There are more reasons than every why independent practice is a great option. Being your own boss is not only easier than it once was, it can actually make you happier.
Independent physicians have many more options available to help them today than they used to. Affordable technology has revolutionized private practice from EHRs to easy-to-use practice management and billing software, adding flexibility to staffing and simplifying paperwork needs. And, the increased availability and ease of outsourcing has further reduced the burden of running your own practice. Physicians can now choose to outsource inbound calls, reminder calls, pre-authorizations, marketing, and of course, billing. In addition, independent providers can transition to new agile practice models such as concierge and hybrid that can offer higher incomes and smaller patient census and reduce some of the headaches associated with traditional practice structures.
Added to the fact that starting and running a private practice is now easier than ever, is the higher level of happiness experienced by independent physicians. In fact, a study done by Medscape in March 2014 reported that 74% of self-employed doctors are satisfied in their practice and that of the physicians who left employment in favor of independent practice, 70% felt happier in their new practice while only 9% were less happy being self-employed. Seventy-four percent of these self-employed doctors also said that their opportunity to practice quality medicine met or exceeded their expectations.
There are many factors contributing to these high satisfaction rates in independent physicians but one of the biggest is the control these doctors have over their practice, their schedule, their treatment of patients, and their destiny. A survey in Hospital Topics on the impact of practice arrangements on physician’s satisfaction backs this up, reporting that physicians who work for HMO’s have much less autonomy and decision-making power than self-employed physicians. And, the report by Health Affairs found that 85% of doctors in private practice felt free to control their schedules compared to only 39% of HMO physicians.
Self-employed doctors also avoided the pitfalls of employment cited by the Medscape study while the doctors working for hospitals and group practices listed administrative headaches, added rules, and a more limited income potential as reasons for dissatisfaction in their careers. It’s easy to see why the 2014 Great American Physician Survey conducted by Physician’s Practice found that over half of independent physicians would do things the same way all over again. This isn’t to say independent providers done have regulatory challenges or administrative responsibilities. However, they have more control over the day-to-day operations and administration, eliminating frustrating bureaucracy.
Better, more affordable, easier-to-use technology, simple outsourcing options, greater autonomy and control, and higher levels of satisfaction…all of these factors make private practice a more attractive option than ever. So, if you are considering starting a new medical practice, now is the time. Just remember, doing it right from the beginning will save you from unnecessary stress, making the process of opening your new practice a much more enjoyable experience.
By joining the ranks of independent physicians, you will be in control of both your practice and your life. You will be free to set your own schedule, manage patient care to your standards, work with a staff of your choosing, and have the final control over your income potential. All new practices will face challenges along the way but you will find a wealth of resources to make your life easier and guide you to success in your new venture.
Tom Giannulli, MD, MS, is the chief medical information officer at Kareo. He is a respected innovator in the medical technology arena with more than 15 years of experience in mobile technology and medical software development. Previously, Giannulli was the founder and chief executive officer of Caretools, which developed the first iPhone-based EHR.
Life 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.
Recently I wrote about the problems with Maintenance of Certification requirements. One of the phrases I read repeatedly when I was researching the piece was “the patient as customer.” Here’s a quote from the online journal produced by Accenture, the management consulting company:
Patients are less forgiving of poor service than they once were, and the bar keeps being raised higher because of the continually improving service quality offered by other kinds of companies with whom patients interact—overnight delivery services, online retailers, luxury auto dealerships and more. With these kinds of cross-sector comparisons now the norm, hospitals will have to venture beyond the traditional realm of merely providing world-class medical care. They must put in place the operations and processes to satisfy patients through differentiated experiences that engender greater loyalty. The key is to approach patients as customers, and to design the end-to-end patient experience accordingly.
Except for one thing. Patients are NOT customers.
The definition of a “customer” is a person or entity that obtains a service or product from another person or entity in exchange for money. Customers can buy either goods or services. Health care is classified by the government as a service industry because it provides an intangible thing rather than an actual thing. If you buy a good, like a car, you voluntarily decide to shop around and get the best car you can for the price. Even a vacation, especially a vacation package or a cruise, is a good. A nice dinner, while a good in the sense of the food, is also a service. You buy the services of the cook and servers.
Here is why the patient shouldn’t be considered a customer, at least not in the business sense.
1. Patients are not on vacation. They are not in the mindset that they are sitting in the doctors office or the hospital to have a good time. They are not relaxed, they have not left their troubles temporarily behind them. They have not bought room service and a massage. They are not in the mood to be happy. They would rather not be requiring the service they are requesting. Which leads to number 2:
2. Patients have not chosen to buy the service. Patients have been forced to seek the service, in most cases.
3. Patients are not paying for the service. At least not directly. And they have no idea what the price is anyway.
4. Patients are not buying a product from which they can demand a positive outcome. Sometimes the result of the service is still illness and/or death. This does not mean the service provided was not a good one.
5. The patient is not always right. A patient cannot, or should not, go to a doctor demanding certain things. They should demand good care, but that care might mean denying the patient what the patient thinks he or she needs. The doctor is not a servant; she does not have to do everything the patient wants. She is obligated to do everything the patient needs.
6. Patient satisfaction does not always correlate with the quality of the product.A patient who is given antibiotics for a cold is very satisfied but has gotten poor quality care. A patient who gets a knee scope for knee pain might also be very satisfied, despite the fact that such surgery has been shown to have little actual benefit in many types of knee pain.
Google has had multiple mobile initiatives, including the GoMo campaign where the company provided free tools to help small businesses build websites that worked on mobile devices without the dreaded pinching, resizing, and squinting. That campaign had limited success because the technology didn’t quite work as elegantly as possible, but just last week Google took its most aggressive approach yet by declaring that they were going to start penalizing websites that did not have mobile capabilities.
Once referred to as mobile-friendly website design, geeks refer to it simply as responsive website design now. So how does one get a mobile-friendly, er, responsive website?
When providers and their staff don’t have the time or tools to effectively communicate with patients, a slew of issues can result: from physicians missing important cues and misdiagnosing patients to preventable hospital readmissions and poor outcomes because patients didn’t understand or follow care guidelines.
The problem has become endemic. According to one study, 80% of what doctors tell patients is forgotten as soon as they leave the office. Beyond that, 50% of what the patient did recall is incorrect. In addition to impact communication and follow up have on care and outcomes, patients are expecting a different experience than they once had. Nearly two thirds of patients now say they would consider switching to a physician who offers access to medical information through a secure Internet connection.Continue reading…
It’s been two years since I first started my new practice. I have successfully avoided driving my business into the ground because I am a dumb-ass doctor. Don’t get me wrong: I am not a dumb-ass when it comes to being a doctor. I am pretty comfortable on that, but the future will hold many opportunities to change that verdict. No, I am talking about being a dumb-ass running the businessbecause I am a doctor.
We doctors are generally really bad at running businesses, and I am no exception. In my previous practice, I successfully delegated any authority I had as the senior partner so that I didn’t know what was going on in most of the practice.
The culmination of this was when I was greeted by a “Dear Rob” letter from my partners who wanted a divorce from me. It wasn’t a total shock that this happened, but it wasn’t fun. My mistake in this was to back off and try to “just be a doctor while others ran the business.” It’s my business, and I should have known what was happening. I didn’t, and it is now no longer my business.
This new business was built on the premise that I am a dumb-ass doctor when it comes to business. I consciously avoided making things too complicated. I wanted no copays for visits (and hence no need to collect money each visit). I wanted no long-term contracts (and hence no need to refund money if I or the patient was hit by a meteor or attacked by a yeti). The goal was to keep things as easy as possible, and this is a very good business policy.
At the conclusion of a recent doctor visit, he gave me his cell phone number saying, “Call me anytime if you need anything or have questions.”
In disbelief, I wondered if this was a generational thing – and whether physicians in their late thirties had now ‘gone digital’.
My only other data point was our family pediatrician, who is also in her late thirties. Our experience with her dates back nearly seven years when my wife and I were expecting twins. A few pediatricians we met with mentioned their willingness to correspond with patients’ families via email as a convenience to parents. The pediatrician we ultimately selected wasn’t connected with patients outside of the office at that time, but now will exchange emails.
I am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.
So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.
1) Doctors are People
No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.
Celebrating its 40 anniversary this year, Robert M. Pirsig’s Zen and the Art of Motorcycle Maintenance bears several distinctions. It is listed in the Guinness Book of World Records as the eventual bestseller that was rejected by more publishers than any other, 121. It went on to sell more than 5 million copies, making it the most popular philosophy book of the past 50 years. And it focuses on a truly extraordinary topic, which its narrator refers to as a “metaphysics of quality.”
Quality is a hot topic in healthcare today. Hospitals and healthcare systems are abuzz with the rhetoric of QA and QI (quality assessment and quality improvement), and healthcare payers including the federal government are boldly touting new initiatives intended to replace quantity with quality as the basis for rewarding providers. Yet as Pirsig’s narrator, Phaedrus (see Plato’s dialogue of the same name), comes to realize, quality is very difficult to define.
In fact, giving an account of quality is so difficult that it drove Zen’s author mad. And this is a man whose IQ, 170, would make him one of the most intelligent people in any health system. The problem, of course, is that there is a big difference between intelligence and wisdom, and in the quest for wisdom, mere intelligence often leads us dangerously astray. Something similar is happening in healthcare today, where schemes to improve quality often precede sufficient efforts to understand it.
For example, we seek to gain greater control over healthcare outcomes through measurement, only to discover, to our chagrin, that people are massaging the data to meet their numbers. We create new programs intended to increase patient throughput, only to discover unintended perverse effects on the quality of relationships between patients and physicians. Initiatives intended to reduce error rates turn out again and again to stifle innovation.Continue reading…