Private practice, once the gold standard of physician autonomy and patient-centered care, is on the decline. Here’s what 15 leaders have to say about the private practice exodus:
Adam Bruggeman, MD. Orthopedic surgeon at Texas Spine Center (San Antonio): Let’s be honest, the practice of medicine by physicians is under a multi-front assault. We are on the brink of a fifth consecutive cut to physician pay next year. Prior authorization is expanding at exponential rates. Inflation has led to dramatic increases in the cost of doing business, particularly for staffing. Documentation, outcomes measurements and the general administration of practices continue to expand and outstrip resources. All of this is happening while Congress blocks physicians from owning hospitals and provides benefits to hospitals that purchase practices by allowing higher payments for the same services when provided in a hospital outpatient department. To say the deck is stacked against physician practice is an understatement. I am watching the various efforts to combat consolidation, which has been a cancer to our profession and to the health of our nation.
Quentin Durward, MD. Neurosurgeon at the Center for Neurosciences, Orthopaedics, & Spine (Dakota Dunes, S.D.): You don’t survive in private practice without very, very good patient outcomes. You’re dependent on your reputation in the community, and you’re dependent on doctors referring to you because they know they can trust you, and they’ve seen your work in their own patients. It’s very different when there’s an employment model, whether it’s a university-based system, a large group practice or hospital-based system, the system is the one that has the reputation. Physicians can coast in a situation like that. They can basically be much less apparent to the doctors referring to the system, or they are guaranteed referrals by doctors who are employed by the system. In my opinion, you need to be as nearly on your toes and maintain the very, very best standard you can if you’re in a private practice model vs. an employment model, because if you’re not good in a private practice model, you sink.
Marsha Haley, MD. Clinical Assistant Professor of Radiation Oncology at the University of Pittsburgh: Most physicians are employed, yet from a corporate standpoint, they are still treated as independent practitioners. For example, most physicians do not have collective bargaining agreements/union representation, which places them at a disadvantage when negotiating with large health systems. Noncompetes severely limit where and when physicians can practice. The corporate takeover of medicine by private equity can leave physicians at risk of malpractice due to understaffing and high patient ratios. Essentially, the employed physician has little control over his or her working conditions, and employed physicians need better representation.
Loay Kabbani, MD. Vascular Surgery Specialist at Henry Ford Health (Detroit): The loss of physician-owned private practice [is a concerning trend]. This one factor makes physicians vulnerable to the whims of large corporations. As physicians become more and more employed, we lose control of our practice and our patient-physician relationships. The new generation is more about timing in and out.
David Konur. CEO of Cardiovascular Logistics: As we see site-of-service differential go away in diagnostic imaging between the HOPD rates and the outpatient world, and as Medicare continues to shift its focus on cardiovascular care being treated more in the outpatient arena than the inpatient arena, we’re going to see more and more hospitals looking for alternatives to how they’re going to deal with their cardiology programs. If site-of-service differential goes away, there is going to be a huge influx of cardiologists looking to join platforms like ours, and we’re already talking to almost a dozen groups that are very interested in what that would look like, because as they read the tea leaves, they see that coming as well.
That pendulum that swung all the way over to hospital employment, we see that starting to swing back the other way. I would expect to see an increase in consolidation in the specialty. I think this partnership is a great example of the leaders within cardiovascular medicine coming together. Our platform is not a roll-up play where we’re trying to roll up a bunch of small practices from all over the place. We’re bringing together the true thought leaders that have been thought leaders for decades to fundamentally change how we deliver care in our country.
Scott Mayer. CEO of Ambulatory Anesthesia Care (Rosemont, Ill.): There’s a lot of physicians and healthcare workers in general that are trying to gain back some autonomy, some control, some freedom. The consolidators just keep getting bigger, whether it comes to platforms or health systems, it’s definitely becoming more corporate. That’s forced a lot of [providers] — especially on the anesthesia side — to be their own independent contractors.
Udaya Bhaskar Padakandla, MD. President of the Texas Society of Anesthesiologists: The trend that currently concerns me most is the vertical integration sweeping the healthcare industry. Physician practices are being bought out or acquired in a trend that is sweeping across this nation (now 90,000 strong) with Optum. Two things about it bothers me more than any other: This increasingly leads to loss of independence in the decision-making ability of physicians in patients’ best interest, and second, government watchdogs (like the FTC) are passive onlookers to this dominance of the physician workforce by a monopolizing entity. But at the same time, much smaller physician groups (with 3,000 to 5,000 physicians) get sued by the same entity for “monopolizing” the marketplace.
Joe Peluso. Administrator at Aestique Surgical Center (Greensburg, Pa.): Large scale consolidation/mergers that have been seen in other industries such as healthcare hospital providers, banking, retailing and pharmacies with the promise of improved efficiencies, financial stability, personalized car, and regional dominance has taught us that we shouldn’t be sold on the notions that organizations become too big to fail or bigger is better. Through these transactions independent entities have been left struggling to compete and have left communities with fewer choices, reduced access, increased costs, reduced services and closures which have affected the overall quality of life and economics of communities.
Amit Patel, MD. Gastroenterologist at GI Alliance of Illinois (Evanston): The most disruptive trend for physicians is the decrease in reimbursement coupled with the increasing expenses. It is particularly concerning for Medicare patients. The economics makes it almost impossible to care for these patients. For example, it is difficult for a Medicare patient to obtain spine consultations and treatments. It also affects the specialties and number of physicians in regions.
It is also leading to the closure of private practice offices, and hence less options for patients. This is not limited to Medicare. Commercial insurers also base their reimbursement to physicians on Medicare rates and with the decrease year after year leading to a critical break point. Reimbursement is a major factor in the decrease and in some regions lack of obstetric care. Only time will tell to what extent this will continue. There appears to be no solution from our legislators, who neglected the issue in the annual budget this year.
Evan Pollack, MD. Internist in Westchester, Pa.: I do not feel that physicians strive to have their practices taken over by corporate entities. If one follows the trajectory, most of the practices that are taken over are struggling financially; some are on the verge of going out of business. I would say that it is mostly out of necessity that physicians sell their practices and become salaried employees. Presently, over 70% of physicians are employed, and physicians coming out of training are comfortable with that arrangement. In order for physicians to regain their power, they would need to be in control of their own practices once again.
Jason Rosenberg, MD. Pain medicine specialist and neurologist at SC Pain & Spine Specialists (Myrtle Beach, S.C.): What scares me about the future of medicine is the loss of the independent physician. I’d like to think AI would be to blame, yet this is not the case. Inflation with resultant increased cost of conducting business, salary battles with local health systems over trained employees and declining reimbursements are some of the major factors. Add in the demands from private insurers with prior authorization and now post authorization, the hurdles to practice medicine independently only grow larger.
Vladimir Sinkov, MD. Founder and CEO of Sinkov Spine Center (Las Vegas): Physician autonomy has declined significantly since the advent of Medicare in the 1960s. When physicians become employees, they are often asked to see more patients, which reduces the quality of care. No matter how skilled a physician is, seeing more patients per day inevitably lowers the quality of care. Access to care also decreases if physicians are owned by entities that limit who can see them. Overall, healthcare costs go up because the entities that own physicians focus on maximizing profits. This applies to both for-profit and nonprofit hospitals and insurance companies.
Jeremy Shiner. Founder and CEO of Myriad Systems: Providers increasingly feel they’re losing control over care quality and patient outcomes — the very reasons they entered medicine in the first place. Instead of a simple consolidation trend, we’re seeing a bifurcation in healthcare. While large hospital systems and corporate entities offer accessibility and advanced medical equipment, there’s also a growing push for more personalized, patient-centered care in physician-led practices. Patients are driving this shift as well, seeking stronger relationships with their doctors and, in some cases, premium concierge care.
Easwar Sundaram Jr., MD. President of Texas Institute for Neurological Disorders (Dallas): The disruptive trend is without doubt failing small or medium-sized group practices and individual practices under the weight of declining revenues and rising costs. Private equity is the thing in vogue, and very soon all physicians will be employed either by mega-insurance companies or private equity. There will be consolidations all over, with just large groups with less access for patients.
Michael Warne, CEO of Associated Gastroenterologists of Central New York in Camillus: Private practices like ours are laser focused on delivering high-quality, personalized care and building tight-knit community ties with other providers and patients, especially as colon cancer and other complications are on the rise. Private practice [doctors] aim for high-prioritizing patients, working with our primary care colleagues, and pushing awareness. But, the system is no ally. Operational expenses are through the roof while reimbursements stay frozen. Despite the grind, private practices and ASCs are battling every single day to keep quality care first and stay independent in a brutal healthcare landscape.
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