Helping Small Practices Survive Health System Change

This is a tough time for family physicians in many small or solo practices. They're working as hard as they can, struggling to keep their doors open while the health care system shifts and changes beneath their feet.

Many are wondering how to transform their practices into patient-centered medical homes, or PCMHs, with the limited resources they have at hand. And now, to top it off, they're worried about the advent of accountable care organizations, or ACOs, and whether practices like theirs will be able to participate or be left behind. Faced with these challenges, many simply don't know what to do.

If this describes you, I want you to know the AAFP hasn't forgotten you -- not in the programs and services we offer, and definitely not in the national debate about health care reform and ACOs.

I personally can empathize with what you're going through. I started in a small practice years ago but had to leave it because our local hospital couldn't survive the new diagnosis-related group payment method. So I've known firsthand the heartache and uncertainty of trying to run a practice in the midst of system change.

Physicians in small and medium-sized practices currently constitute the majority of the AAFP's active members. In fact, the 2011 Member Census shows that 58 percent of active members are in practices with five or fewer physicians. But the Member Census also shows that more than half of active members are either employed or in large group practices: 62 percent have no ownership stake, and 42 percent are in groups with six or more physicians.

The dynamics and the needs of members with small and medium practices and those who are employed or in large groups are considerably different, with only moderate overlap. There's not an AAFP Board of Directors meeting at which we don't challenge ourselves on how we can do more for these demographic groups -- indeed, for all of the Academy's membership segments -- with the finite resources available to us. The plight of private practices is also a personal issue for many Board members because their own practices fit this model.

Because of the AAFP's demographics, our advocacy in Washington is based on a "no one size fits all" approach. In other words, we advocate regulations and legislation that take into account our members' tremendously varied modes of practice -- and we always stand up for small practices.

A good case in point is our response to CMS' recently proposed rule for ACOs under the Medicare Shared Savings Program. The proposed rule was, in our view, simply not supportive of small practices. Most troubling was that it created a set of regulations that these practices just couldn't meet.

We were blunt in our comment letter to CMS, urging it to "drastically reconsider its proposed Medicare ACO policies and instead offer greater flexibility so that small- to medium-sized primary care practices will be more eligible to participate." Failure to do so, we warned, would "deny the potential benefits of the ACO model to patients throughout the country, most of whom receive care from small and medium size physician practices."

We also criticized the proposed rule's over-regulation of ACOs. "If CMS focuses only on the essentials and allows ACOs to take shape in ways that make the most sense in their respective markets," we wrote, "then small- to medium-sized practices will have more opportunity to participate, and Medicare patients will reap the rewards of their doing so."

Another good example of standing up for small practices was my testimony (12-page PDF; About PDFs) during a May hearing of the Health Subcommittee of the House Energy and Commerce Committee. The subcommittee was exploring alternatives to the sustainable growth rate formula for Medicare payment.

In my testimony, I advocated a blended payment system that would support broader use of primary care. I noted that the AAFP supports moving the health care system to a PCMH base, but I also told the subcommittee that transforming to a PCMH is expensive and time consuming. "Without payment reform," I said, "it is probably beyond the economic reach of many small- and medium-sized practices, especially in rural and underserved areas that do not have the resources that may be in place in other parts of the country."

Member demographics also are front and center when the Academy develops products and services, many of which are created with small and solo practices in mind. We learn what members need through surveys and from members who call, from chapters and from AAFP meetings, including the Congress of Delegates.

When your practice needs help, I encourage you to search the AAFP website first -- you might find exactly what you need, and chances are it's free. (Don't forget that you can also call (800) 274-2237 to talk with Academy staff, especially regarding coding and insurance issues that often plague smaller practices.)

I'd like to draw your attention to a few website offerings that might be especially relevant for you right now:

I could go on and on, but I hope you get my drift. Your AAFP is there for you in many ways and in many venues, whether it's standing up for you in Washington or providing a "storehouse" of resources you can use to help your practice thrive.

In advocacy and in practice support, the AAFP hasn't forgotten the small and solo practices that so many Americans rely on for health care. And we never will.