Close your eyes and think of a doctor. Do you see a Marcus Welby type? A middle-aged, smiling and friendly gentleman who makes house calls? Is his cozy office staffed by a long time nurse and receptionist who knows you well and handles everything for you? If that is what you envision, either you haven’t been to the doctor lately or you are in a concierge practice where you pay a large upfront fee for this type of practice. Whether you live in a big city or a rural community, small practices are dissolving as fast as Alka Selzer. Hospitals and health systems are recruiting the physicians, buying their assets (unfortunately not worth much) and running the offices.
Doctors are leaving small practices and going into the protection of larger groups and corporations because of economic changes that have made it harder and harder for small practices to survive. The need for computer systems, increasing regulations, insurance consolidation, skyrocketing overhead and salaries coupled with low reimbursement has signaled the extinction of the Marcus Welby practice. Some older doctors are finishing out their years and will shutter their offices when they retire. Young to middle age physicians are selling out to large groups and new physicians would never even consider this type of practice. They are looking for an employed model from the outset.
Every doctor I know who is currently in private practice is weighing his/her options for survival. Doctors are learning and performing new services for which patients will pay out of pocket. Botox, anti-aging therapy, weight loss, retainer services, home visits, cosmetic services, acupuncture, prolotherapy and medical directorships are all outside of the Medicare/insurance payment world. Physicians are surviving with these creative revenue producers and doing the best that they can.
The world of medicine has changed. Health care reform is rewarding integrated care and this will be good for patients and quality. Doctors need the capital that large systems can provide to put in the electronic health record and support its use. They need the protection of health systems to pay their overhead and ensure that employees are trained. It is unlikely that large organizations can run lean offices but they can provide standards that improve care and patient experience. I am in favor of practice standards and a continuum of care between primary care, specialists and the hospital.
Marcus Welby practiced in a silo. He could remove your appendix, deliver your baby, deal with your wayward teenager and help grandma die peacefully. The truth of the matter was he had no technology, just hand-holding and about 10 medications to offer.
This is 2011 and things have changed.
*This blog post was originally published at ACP Internist*