Remember the Alamo
Recently in this blog Dr. Fisher gave a quote: physician-owned practices are rapidly disappearing. Since 2019 approximately 108,700 physicians have left private practice with only 26% of American physicians so employed in 2021. In 2022 hospitals and corporations owned about 135,000 physician practices.
Dr. Glaucomoflecken of twitter fame had this to say recently as well: Every physician who sells their practice to private equity is choosing to make health care worse for everybody. I hope the money helps you sleep at night, because you have made life worse for every single patient and employee walking into your PE Daddy’s practice.
So lets get into this. I am a solo physician in a practice I own by myself. I am in that 26%. I have two nurse practitioners. There are a myriad of reasons why doctors are fleeing the ownership game. I will discuss one -but first I have to disagree with the above statement- that those that sell have made life worse for every single patient and employee. IF I were to sell I truly believe that my patients would get more good from me, and my employees would be better off – considering the alternative is bankruptcy, burnout, early retirement or death. I am no good to anyone if my practice has a new sign over it that says “Baby Gap.” So many people keep opining over the mysterious causes of the “Great Resignation.” No mystery. This is it. We went into medicine to help people, to work hard and be rewarded with respect and finances. We did not sign up for this.
Recently (literally yesterday) I had to turn down an opportunity to go with a college choir on a mission trip to Kenya. I would have taken care of the 100 men, had a single day of organized medical mission work, and taken a 2 day photo safari – all at no cost, and it would have included time with my son who is in the choir.
Why did I have to turn this down? I recognize that I will regret not going for the rest of my life, and there is literally no way I will ever be able to replicate this experience. I turned it down for 2 reasons. Money is sadly one. One of my nurse practitioners will be on maternity leave during that time, and we do not have the war chest of money built up to survive my absence for half a month (2 week trip in May, it would be exactly half of the clinic days that month.) The one NP is a bit slower so I don’t think she could handle the load alone, so it would be about a 2\3 drop in income. I believe I would have come home to bankrupt and close us.
The other issue is a regulatory one and I could find no way to overcome this. Regulations have come in – all set by large practices without regard to the solo provider – that make it impossible to be away from cell coverage. I happen to provide a lot of care for ADD patients – it’s a significant stream for us. We have 4-5 patients a day that need schedule 2 medications sent in. Midlevels in Texas can prescribe schedule 3-5 but not the 2s. In the “old” days of five years ago everyone, and I mean every single solo provider that went on vacation pre-signed prescriptions, including the triplicates. Yes, it was strictly forbidden, and yes, many doctors abused the heck out of this. So along came e-prescribing and the EPCS – the electronic prescribing of controlled substances. In so many ways it is superior to the paper scripts. But it was designed from the ground up for multiple physician practices.
At this time I have my midlevels or myself see patients for follow up and if a schedule 2 med is needed an unlicensed MD prepares the scripts and I approve them – which pushes an approval code to my phone and then instantly to my Apple Watch. I have 60 seconds to hit approve or the process has to be repeated with another message and script generated and sent again to me for approval. Little did I know that I would be reduced to a lab rat pushing the lever for a pellet at this point in my career, but I am. I have been able to approve them during procedures using my lower lip, and during the toughest conversations with patients I glance and poke at my watch like Pavlov’s dog when I feel the gentle vibrate on my wrist.
As un-ideal as this is, it is essentially insurmountable for the solo physician to go anywhere without cellular coverage. Just passing off the duties to a fellow doc that is on the same EMR and in the same practice is nothing. Do these docs have waterproof bags to carry their phone down to the beach when they are on vacation? I do. Do they check their phones every hour on vacation, and fire up the IPAD at lunch or after everyone has gone to sleep while on vacation? I do. Do they have to turn down dream vacations and cruises because there wont be dependable cellular coverage? I have. I spoke to one solo psychiatrist this week and he carries a Starlink satellite device with him so he can go on vacation in Mexico.
This is not a trend, a blip, or a passing fancy. This is a concerted and organized attack on the solo provider. I titled this blog entry “Remember the Alamo.” Those people that died in the Alamo – valiantly defending an absolutely undefendable position against overwhelming odds – were they valiant?
Or just stupid?
Would not they have done much better for themselves and their fellow rebels by retreating or surrendering and living to fight another day? Their death was symbolic and sad, but a deeper analysis states they should have done better. They should have sold to venture capitalists at a private equity firm, or Humana or Wellmed or some insurance company or gone concierge or DPC. Wait, that is me that should do those things.
I gave up my solo practice (Orthopaedic Surgery) 24 years ago. Insurance companies would not negotiate with me, and each year more of the proposed contracts required things I could not in good conscience agree to, such as not being able to take x-rays of fracture patients in my office, being available without reimbursement 24/7 to any new in network patient, providing professional medical translation at my own expense without reimbursement, agreeing to also take Medi-Cal HMO consults that reimbursed less than my overhead cost (I already was taking care of everyone while on ED call). I was working 7 days and multiple nights a week and collecting less than $1 for every $3 billed. Orthopaedic Trauma and Pediatric Orthopaedics, while both were passions, no longer reimbursed enough to cover my expenses. I couldn’t even break even. I enjoyed and appreciated the second half of my career at the VA, time with my family, patients who were appreciative, making improvements in the systems of care. I don’t think I would have been able to stay in solo practice without going bankrupt as reimbursements continued to decrease and unreimbursed tasks increased.
So well said, our government dominated 3rd party medicine is THE cause of the corporatization of medical care. We need to re-personalize care by putting the patient incharge of the funds.
The defenders of the Alamo thought they were buying time for the larger cause. There is no Sam Houston over the horizon, organizing a larger defense. Why do I say this?
Because of the fallacy noted above: “I hope the money helps you sleep at night, because you have made life worse for every single patient and employee…”
Wrong. Every patient wanted perfect, fast, cheap health care, and over the years they empowered their government, insurance companies, and lawyers to try to force it out of us. Employees always new that they were paid first, the doc last, and were reasonably on the prowl if the pay and benefits weren’t competitive, which they often cannot be against the corporate-owned pay scale. I don’t blame them.
I sure as hell blame patients. When pressed to it, they think they have a right not only to care in the here-and-now, but a right to everything that it took to get to the point where we could provide that care. Patients expect us to hold up our end of the relationship without complaint, while they are free to ignore their end at will, and resent any hesitation on our part in fulfilling their demands. How many physicians have NOT had to deal with a patient angry that we would not fill out their forms, get their referrals, or wait hours on the phone for prior authorizations which provide us no benefit, all to our own, very tangible economic loss? Patients say they want physicians; their actions tell us that they want sacrificial animals.
If a given physician still takes pleasure in, or derives honest satisfaction from continuing in this existence, then more power to them. But no one has any grounds to criticize someone for leaving when “for the money” has become the last defensible position.
Excellent article and a very accurate description of the independent practice.
Very entertaining, and true! Thank you.
I was just reminiscing yesterday about how I used to take a week off- no computer, no cell phone, no nothing.