The future of medical practice is—and has long been—up for debate. Some doctors decry that it’s impossible to survive in a small practice anymore. Others work in large clinics or health systems for the relative security that model offers, but complain that they don’t have enough autonomy.
Many are happily ensconced in medium-sized single specialty partnerships. A few are bucking tradition and coming up with entirely new ways to deliver care to patients.
Of late, the discussion of hospital employment has become a hot topic in medical circles.Jeff Goldsmith, Ph.D., founder of Health Futures, Inc. based in Charlottesville, Va., conducts research, writes, and speaks nationally about the changing health care landscape.
“Only 15 to 17 percent of doctors are employed by hospitals,” Goldsmith says, citing the 2012 AMA Physician Practice Benchmark Study. “It has grown if you look at the trend data, but 20 percent of doctors are still in solo practices and another 20 percent are in groups of two to four. Overall, just short of 60 percent are in groups smaller than nine.”
These figures don’t, however, factor in the age of physicians. “Only between five and 10 percent of doctors under 40 are in small practices,” says Goldsmith. “If you look forward five to eight years, the structure of medical practice will tilt in favor of larger groups.” This is, in part, due to the fact that baby boomer physicians will be retiring en masse over the next decade or so and doctors coming out of training to take their places will opt for larger groups and employed situations. “That’s certainly an economically rational decision when you have a couple hundred thousand dollars in debt,” says Goldsmith.
Back to the issue of hospital employment, Goldsmith says the institutions are not taking on physician practices because they want to or because they think they’ll be profitable. “The impetus for this is coming from the physician community,” he says. “If you take your local health system CEO out for a couple of drinks, by the third one he’ll tell you he doesn’t want to do this. But when your cardiology group comes to you and says we don’t want to be independent anymore and if we can work something out you’ll get all our caths and stents, and if we can’t work something out then they’ll all go away, there is a not-so-subtle element of coercion.” Hospitals are essentially buying ambulatory utilization. “If hospitals had not been aggressively purchasing practices [in recent years], their outpatient utilization would be declining right along with their inpatient utilization.”
Goldsmith says to expect more practice aggregation in the coming years with groups joining forces to give physicians both independence and greater choices about how they practice.
What doctors want
Jim Stone is board president for the National Association of Physician Recruiters (napr.org). Each spring, The Medicus Firm, of which Stone is president, conducts a survey on physician practice preferences. More than 2,500 physicians in 19 specialties in 50 states responded to the most recent survey. What doctors say they want in terms of a practice model has been shifting back and forth between hospital employment and working in a single-specialty group partnership.
“This last year, the single-specialty group was the preferred choice,” says Stone. But the numbers were very close. Twenty-four percent of physicians in training said they were looking to join a single-specialty group, while 28 percent were seeking hospital employment. Among practicing physicians, those numbers were almost exactly reversed at 28 percent and 22 percent, respectively. Only 2.6 percent of physicians currently in training said they wanted to open their own solo practice.
“A lot of it is driven by fear, both in terms of wanting to be part of a group or being employed by a hospital,” says Stone. “It’s fear of regulation, fear of the financial downside, and the perception that there is strength numbers, which is probably accurate.”
In their 2013 In-House Physician Recruitment Benchmarking Report, The Association of Staff Physician Recruiters (ASPR, aspr.org) reported on open job numbers. Sixty-four percent of openings were for opportunities in hospitals or other integrated delivery systems and 13 percent were for physician-owned practices at the time of the survey. By practice type, those numbers were 72 percent for multi-specialty groups, 25 percent for single-specialty groups, and less than 2 percent for solo practices.
Hospital employment: Joining the group
Don Moore, M.D., was delighted to return to Florida to practice in 1997 upon finishing his spine surgery fellowship. He’d done part of his orthopedic residency in Tampa and, having been brought up in Detroit, was looking forward to the warm, sunny weather and beaches that his new home offered. “It was like a dream come true,” says Moore. And it was all he’d hoped for, until recently.
“I was in a group and it was very exciting. We built a building. We were all fellowship trained and we each specialized in one thing that we were trained to do. Our practice had a good reputation,” says Moore. Around 2009 or 2010 when the housing market got pummeled, Moore began to notice that primary care physicians in the area were starting to struggle. “We didn’t see a problem as specialists,” says Moore.
“Around that same time, there was a significant push in the field toward regulatory medicine. We had to comply with other mandatory processes as well,” says Moore. “We didn’t have the joy of practicing medicine like we wanted to, and it became more and more challenging.” Like many physicians, Moore and his partners were working longer and harder just to stay afloat.
Added to all of this was the fact that local hospitals were hiring doctors of their own. And Moore, like many physicians, was concerned about the implementation and many unknowns associated with the Affordable Care Act.
Having always been his own boss, Moore says he never understood why some doctors would work for hospitals or other large institutions. “It seemed like giving up quite a bit,” he says. But as the handwriting on the wall became clearer, Moore began to explore his options. Eventually, he interviewed with the Cleveland Clinic and decided that giving up some autonomy in exchange for not having to worry about running a business wasn’t such a bad tradeoff. Also, the timing was good as his two children were on their way to college. “We no longer had any ties to Florida in terms of schooling. My wife was on board with the move. She understood my frustration with where things were headed,” says Moore.
Still, making a mid-career move wasn’t an easy decision. “I was 16 years in one place and I loved the patients,” says Moore. “My partners were like family and I felt like I was divorcing them.” The Florida group has remained intact and they have hired a replacement for Moore.
Moore’s new practice at Fisher-Titus Medical Center in the small town of Norwalk, Ohio, is about an hour away from the Cleveland Clinic campus. He began practicing at Fisher-Titus on September 1, 2013. “Once I decided to become employed, it was a freeing experience. I’m required to do one thing, which is [take care of] my patients,” says Moore. “It’s not that I don’t care about what things cost, but I can just do what I do best. It’s amazing what’s available here at Fisher-Titus and through our affiliation with Cleveland Clinic.”
Moore says any physician contemplating a career move should examine what they’re passionate about. “Prioritize what’s important in your life. If making money is your thing, then find a job that pays a lot, and you may have to make compromises. If you don’t want to be inundated with the business aspect [of medicine] and competition, think about that,” says Moore. “And never say never. Up until December last year, I thought I’d die in Florida. People asked why I’d leave sunny Florida to go to Ohio. I’m a physician first, and this is where the Cleveland Clinic is.”
National staffing agency: Expanded options
The Cleveland Clinic has more than 3,000 physicians and scientists on staff, and yet there are even larger organizations where doctors can choose to practice.
National staffing and management companies offer opportunities in emergency medicine, anesthesiology, radiology, hospital medicine, trauma surgery and other specialties. EmCare (emcare.com) is one such organization.
“We’re the largest in the country and growing fast,” says Andy Mulvey, M.D., FACEP, Regional Medical Director for EmCare’s North Division, based in Indianapolis. EmCare staffs more than 400 emergency departments nationwide and added more than 100 in 2013 alone.
Mulvey says that 10 to 15 years ago there was a degree of skepticism among doctors about working in “corporate medicine.” Today, due to pressures on reimbursement and ever-increasing regulations applied to health care, doctors are gravitating toward large organizations so that they can take care of patients without being distracted with the administrative side of practice. “This is the way of the future,” says Mulvey.
One big advantage that a model like EmCare offers is flexibility and opportunities for career advancement. “If you’re looking for a job in Southern California and choose EmCare, if in two years you marry someone from Michigan and want to live there, there is probably something for you. It’s a national solution,” says Mulvey. Each regional office at EmCare has its own recruiting and credentialing department to support physicians. “In my office we have full-time credentialing, recruiting and scheduling personnel to support our practices. They handle all kinds of activities that physicians don’t enjoy and aren’t very good at,” says Mulvey.
The ability for ED directors to gather and exchange ideas about best practices is another benefit of this model. “Here in Indiana we have 20 contracts that we manage,” says Mulvey. “At monthly meetings with all of our directors, we go through different ideas, talk about issues and concerns, and make wish lists for things we’d like to have done.” Networking and professional development isn’t limited to management, however. Physicians who staff EmCare’s emergency departments regularly attend regional meetings where they participate in basic skills labs, receive training in ultrasound, get updates on best practices in their specialty, and engage in other continuing education opportunities.
Concierge practice: Life on the mountain
Large groups and employed situations are not for everyone, however. Some doctors who choose to maintain their independence become quite creative in how they practice by opting for concierge or subscription-based practice models. The concierge model has been around for years and, with some exceptions, tends to attract more affluent patients who pay an annual fee in exchange for nearly unlimited access to their doctors. The subscription-based practice model is newer and usually charges patients a flat monthly fee for fairly comprehensive primary care. A handful of doctors have gravitated toward small and even “micro-practices” in which they operate from small offices with minimal staff to keep overhead low.
One such doctor is family physician Julie Monroe, D.O., who most definitely charts her own course. She worked as an ER nurse while attending medical school and after residency joined the Air Force, where she practiced for four years. She then moved to the beautiful, remote community of Lake Arrowhead, Calif., in the mountains above Los Angeles and worked in a rural health clinic for another four years. It was there that she experienced the “last straw” that led her to open a solo, cash-only practice where she has been for the last five years.
“I was taking care of a young girl who was making minimum wage and going to school. She’d been sick for a couple of weeks and she had the choice of seeing a doctor or making her car payment,” says Monroe. The patient finally did seek care but then could not afford the medication Monroe prescribed. “That’s when I knew I had to do something,” she says. The rural health clinic where Monroe had been working accepted Medicare and Medicaid patients—to their credit—but had no system in place to offer discounts for uninsured individuals.
Monroe opened her small practice in 2008 with one medical assistant and two exam rooms furnished partly with what she could find on eBay. She’s since expanded to three exam rooms and has two full-time medical assistants. No insurance billing means the office can operate with a lean staff. “It’s working out pretty well,” says Monroe. “We’re not-for-profit and get some donations from the community.” Four fundraisers have been held to support the clinic since it opened and a local women’s group has raised an additional $12,000. But overall the practice is fairly self-sufficient.
Some grant money helped with the start-up phase of Monroe’s practice, but she says that source of funding is difficult to come by because organizations that offer grants don’t “get” her practice model. “We’re not trying to help people get on Medicare and Medicaid. I’m just taking care of them,” says Monroe. The practice charges a flat $35 for each office visit. Monroe sees 20 to 25 patients a day. Patients who need inpatient care are seen by hospitalists.
Monroe has worked out special rates for her patients with nearby Mountains Community Hospital and their affiliated radiologists for imaging, and works with another group that offers MRIs for $350 and CT scans for $225 if patients pay cash for those studies. She is also set up to offer free vaccines for children up to age 18 through a state-sponsored program and has a contract with Council Connections (councilconnections.com), which allows her to offer low-cost laboratory diagnostics and medication dispensing. “I can do complete fasting labs, CBCs, cholesterol, thyroid and liver testing for $26 through Quest Diagnostics. We draw and they pick up,” says Monroe.
Lake Arrowhead’s economy is based largely on tourism. Jobs are not plentiful and wages in the area are not high. “With Obamacare, a lot of people worried that I’d close,” says Monroe. “But if you look at California’s plan, people can’t afford the monthly premiums. If they’re just scraping by they can’t pay $300 to $500 a month for insurance,” says Monroe. In other words, there will likely still be plenty of people in the area grateful that they can see a doctor for $35. “We’ll keep going. There will always be a need,” says Monroe.
Asked what advice she might have for physicians considering a practice similar to hers, Monroe says they should determine what the needs are in the community and crunch the numbers. “Figure out how much you want to make after taxes and what can you afford to pay in overhead,” she says. Monroe says she’s extremely satisfied with her practice. “Patients are so grateful that there is someone on the mountain who cares and where they can receive quality care. It’s just amazing,” says Monroe.
Micro-practice: Who needs an office?
Farther north in the Golden State, geriatrician Leslie Kernisan, M.D., MPH, has a micro-practice. That term, reportedly coined by family physician Gordon Moore, M.D., describes a medical practice that is very small, very lean, and often operated without any staff at all. In Kernisan’s case, it also means operating without an office.
Before launching her micro-practice in October of 2012, Kernisan was the associate medical director at a federally qualified health clinic for older adults in the Bay Area. “My practice time was limited to just a few clinic sessions and house calls,” says Kernisan, who was responsible for overseeing several clinical and quality projects for the organization.
Although she was technically working part time, the work was stressful and routinely required extra hours. Kernisan felt she didn’t have enough time for her two young children and for other projects related to the care of older adults that she wanted to pursue.
Today, she makes full use of technology to deliver care to older adults and work closely with family-member and non-family member caregivers to ensure that patients remain as healthy as they can be as they age. “I do house calls and visits to assisted-living facilities,” says Kernisan. She also corresponds with patients and caregivers by phone, email, and through a sophisticated portal on her website (drkernisan.net). “My patients are elderly and often have difficulty coming to clinic, so this works well,” says Kernisan.
Rather than charging an annual or monthly fee for her services, Kernisan keeps it simple by charging $200 per hour. She does not accept insurance or Medicare. “I believe in the Medicare system, but they don’t reimburse for phones calls or care coordination,” says Kernisan, explaining why, given her practice model, she had to opt out.
Kernisan’s primary focus is on how to improve the lives of older adults with an emphasis on how caregivers factor into the equation. “I spend a lot of time blogging and writing about geriatrics and how to leverage technology,” says Kernisan. For example, one recent post on her blog, geritech.org, is titled Helping Caregivers Organize Information. In it, she offers four key categories of data that should be tracked so that older patients receive good care and have the best possible quality of life. Kernisan also lectures for lay and professional groups about the care of geriatric patients.
Kernisan spends about a quarter of her time on clinical care and the remainder researching, writing and educating. “It’s important for us to find practice models that are sustainable. Different people have different ideas about what works,” says Kernisan. “I am a bit of a geriatric health care redesign wonk, so my practice is my own little laboratory. It’s a way to keep a foot in the clinical trench while I write and work on caregiver education.”
You have options
Statistics tell us stories about what the trends are, but keep in mind that a dream job for one doctor might be a nightmare for another.
Whether you are starting your job search looking for your first practice right out of training or considering a mid-career move, take time to seriously think about where you want to live, how you want to deliver care, and what will be best for your family if you have one. Engage your brain to make this important decision, but don’t forget to listen to your gut and your heart.
Karen Childress is a frequent contributor to PracticeLink Magazine.