As far back as we can remember, the hallmark of American medical care was that solo physician who greeted you by your first name and inquired about your family. He/she then directed you to the exam room and patiently discussed your concerns. After going over treatment recommendations and addressing your concerns, he/she finally waved good-bye.
Today the experience of an office visit is starkly different. Because of shrinking reimbursements and time constraints and the demand for productivity, physicians are able to spend only a few minutes with a patient, before they rush out to see the next patient. “We simply don’t have the time,” physicians confess.
Sadly, the solo physician is a dying breed. Residents fresh out of residency are no longer motivated to start a practice of their own. Instead, they are enticed by offers from hospitals or multispecialty physician groups where they don’t have to worry about overhead costs or administrative requirements. “Work-life balance is better this way,” they agree.
In a large part, the shift from small to large practices has been driven by health care reform. Competition and poor reimbursements have fostered the growth of larger physician practices that share resources and are able to strengthen their negotiating position with insurers. Hospitals are following this trend and are buying up physician practices to increase leverage with insurers and to integrate care for patients.
In addition, Medicare pays much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. Even 15 minute doctor visits pay more when done by a hospital-based doctor than a privately owned medical office. It is no surprise then that hospitals are buying doctor practices to take advantage of this difference.
Furthermore, employers, insurers, and government are burdening physicians with extensive reporting requirements for patient cost and quality that are difficult for small groups and solo practitioners to manage. Solo and small practices may lack the resources that are needed to collect, manage, and report data, particularly in the age of electronic health records.
It’s time to bring back the solo physician and small practices. Health care reform has not taken into account patient experience and effectiveness of the medical visit. Patients and physicians deeply value the personal relationships that smaller practices can nurture. For younger patients, physician interaction is key to understanding the importance of diet and exercise in preventing chronic medical problems including obesity, diabetes and hypertension, which have risen over the past decade. Patients need time to build that rapport and relationship with one primary physician so that they are motivated to follow preventive care recommendations. For older patients, the care of a personable, nurturing physician is key to managing chronic medical problems and end of life concerns. The value of smaller practices is also particularly seen in rural areas, where the closest hospital could be miles away.
An important study by Lawrence Casalino et al., funded by The Commonwealth Fund, revealed that patients of physicians practicing in solo and small practices have lower rates of preventable hospital readmissions than those in larger practices. The study explained, “It is possible that small practices have characteristics that are not easily measured but result in important outcomes, such as fewer ambulatory care–sensitive admissions. For example, there is evidence that patients in smaller practices are better able to get appointments when they want them and better able to reach their physician via telephone, compared to larger practices. It is also possible that physicians, patients, and staff know each other better in small practices, and that these closer connections result in fewer avoidable admissions.”
We need to help solo physicians and small practices survive. We need to implement health care reform that gives independent, private-practice doctors an equal footing and encourages small physician practices to share resources and come together to have leverage with insurers. Government needs to develop payment models that include grants or loans for solo practices to invest in necessary infrastructure so that they can alleviate mounting overhead costs.
Most importantly, we need to empower patients to lead healthier lifestyles. The key to better health lies in the care of that personable and nurturing solo physician.
Dr. Kavita Kewalramani is an Internist who started a solo practice in New Providence, New Jersey in August 2015. Her practice is unique and integrates primary care, medical weight loss and lifestyle & disease management programs. Visit K Primary Care & Medical Nutrition Center website for more information.
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