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Tuesday Sep 25, 2018

Why I'm Building a Solo Practice -- Again

It shouldn't be this hard.

[blueprints, model house, construction hat]

Three years ago, despite obvious trends to the contrary, I decided to go back to the practice model where I truly belong: independent, solo family medicine.

Early in my career, I spent two years in a multispecialty group practice where I was expected to see 30 (or more) patients a day. It wasn't for me, and the time-limiting approach wasn't ideal for patients, either. I spent the next 16 years at a small, independent group practice that offered more freedom and autonomy, but it still wasn't quite the same as the solo practice where I started my career.

So here I am, starting over more than 30 years into practice. Has it been worth it? I'm practicing at the highest level of my training, devoting more time to each patient and making decisions based solely on what's best for patients without being beholden to a health system and its financial goals.

I've been here before. When I completed residency in the 1980s, I was a solo doc for several years, doing full-scope family medicine, including obstetrics and inpatient care. It was tough but rewarding work.

Building a solo practice has been even more challenging the second time around. In today's economy, there is a dearth of capital to help launch an independent practice. In the past, a physician might have had a relationship with a local banker, but now decisions are more likely to be made from a corporate headquarters and less likely to consider the significant economic impact a single physician can have on a community.(www.lafp.org) Many banks don't seem to understand health care financing and aren't eager to get involved.

When you get an independent practice up and running, more challenges await. Payers have not kept up with the costs of running a practice. For example, when I was a new-to-practice physician, Medicare paid $3 for a lab draw, and private insurers paid $12. My expenses have increased, but the reimbursement is now even lower; Medicare pays $2.76 and private payers pay $3.

For some perspective on inflation, a U.S. consumer should expect to pay nearly $7 today for something that cost $3 in 1986. Just don't expect payers to do the same.

An independent OB/Gyn last year told the Los Angeles Times(www.latimes.com) that her rent was increasing 3 percent each year, and her utilities had increased 18 percent in the previous year. Still, one payer was reimbursing her at the same level as it had seven years earlier. When she protested, the payer told her to take it or leave it. Her practice was small, she was told, and it wouldn't affect the payer if she dropped her contract.

There are options for small practices. Accountable care organizations give small, independent practices the ability to come together and have more influence based on quality improvement and value.

Small physician practices should matter not only to physicians and patients but to payers and policymakers, too. Studies have shown that small, physician-owned practices have lower costs, fewer preventable hospital admissions and lower readmission rates(www.ncbi.nlm.nih.gov) than larger independent and hospital-owned practices. In fact, large hospital systems with integrated delivery networks have increased costs without evidence of improving quality.(www.nasi.org)

Despite those jarring truths, hospitals have bought out independent physicians at an alarming rate. Among all specialties, the number of doctors who were practice owners or partners shrank from 62 percent of the physician workforce in 2008 to 35 percent in 2014.(physiciansfoundation.org) Growing administrative and regulatory burdens likely have tipped the scales even more in the four years since that Physicians Foundation survey was taken.

According to AAFP survey data, 71 percent of Academy members were employed in 2017. Of those, 49 percent worked for hospital systems, compared to 17 percent in group practices.

The AAFP has advocated for site-neutral payments, which lower costs for patients, level the payment playing field for physicians and leave less incentive for hospitals to buy out independent practices.

So what incentive do family physicians have to join me here in the shrinking minority? Well, aside from autonomy, lower costs for patients and higher quality, how do you feel about lower rates of burnout? According to a recent study in the Journal of the American Board of Family Medicine, that independence and autonomy contributed to physicians in small, independent practices having a lower burnout rate than their peers at larger practices. Specifically, 13.5 percent of physicians in the small practices studied had experienced symptoms of burnout, compared to a national rate of 54.4 percent.

An Annals of Family Medicine study recently showed that a broader scope of practice, which is more likely in independent practice, also lowers burnout risk.

Clearly, with lower costs and better outcomes, payers should be motivated to support small, independent practices. Unfortunately, the health care system has undervalued primary care for years. There was once such a large primary care base that it was easy to take for granted. When the resource-based relative value scale was implemented in 1992, it incentivized physicians and health systems to emphasize complicated procedures rather than prevention. The subsequent widening gap in payment between primary care and subspecialty physicians has contributed to the primary care physician shortage, and access has become a challenge for patients.

Payment reform is essential for FPs, especially for those in solo and small practices. The AAFP is advocating that spending on primary care increase by 15 percent. Insurers must find ways to pay family medicine and primary care better and differently. One example is the alternative payment model developed and proposed by the Academy.(38 page PDF)  

Despite the challenges, I have no regrets about my change in practice models. Every day I come to the office and have time to take care of my patients. No, I will not make as much money as some of my colleagues, but close. (Survey data indicate the pay gap may be closing(www.healio.com) between employed and independent health care professionals.) I have the satisfaction of taking care of my patients by placing their needs first. I am not beholden to a hospital that needs more CT scans or that wants me to refer procedures I am qualified and capable of doing just to feed its system. I can practice to the highest level of my license and ensure that my patients have only the right, appropriate care they need.

I look forward to seeing my patients every day, and I love what I do. Would I like to be more appropriately compensated? Of course, but I do have the privilege of working for the best interest of my patients every day without interference, and that has been a blessing.

I am working hard. Experts say it takes four to five years to fully develop a practice. I am betting my retirement that I will succeed.

Erica Swegler, M.D., is a member of the AAFP Board of Directors.

Posted at 02:59PM Sep 25, 2018 by Erica Swegler, M.D.

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