Where have all the small medical practices gone?
Put me down in the history books as one of the last holdouts in small medical practice in the Twin Cities.
I was recently asked why I closed my practice.
Good question, given that I found my work-utopia in a small private office, where the doctor-patient relationship was treasured above all. It was all about people, good solid care, hard work and the honor of being part of my patient’s life.
The staff knew the patients, their families, and the little quirks that made them all human.
As a female doctor with kids at home, I elected to go into private independent medical practice in 2006 to gain control of my schedule, quash some of the ever-present sexism in the typically male-dominated office and diminish time spent in corporate meetings in which you never spoke, you looked at your shoes, and you agreed with all the ideas presented. Private practice was a great move and brought years of fulfillment.
And then came Obama’s Affordable Care Act (ACA) of 2010. This was a good thing; all Americans would have health insurance. For the small practice office though, it spelled death, especially if you were in primary care. The ACA financially rewarded large corporate health organizations that owned hospitals, clinics and physicians under one umbrella. It was the great American dream: The bigger, the richer, the better.
The Physicians Advocacy Institute reports a nationwide trend in physician employment by hospital-owned practices, with an increase by more than 70% from July 2012 through January 2018. This trend is higher in the Midwest compared to other national regions. Unfortunately, studies show this vertical growth supported higher health care costs, and no improvement in quality of care.
In Minnesota, “nonprofit” companies such as Fairview Health, Allina Health, Health Partners, Mayo Clinic Health System, Essentia Health and Sanford Health bought out small practices, purchased hospitals and conquered territories as they played the game of health care monopoly. CEOs earned millions.
But this was a much bigger animal than a corporate department store or coffee shop. These large Accountable Care Organizations (ACOs) mandate inside-only referrals to specialty providers, MRI scanners, physical therapists, hospitals and pharmacies. Based on insurance — often affiliated with the same ACO club, such as Medica and Allina, or Preferred One and Fairview — patients were forced to choose services within the club, such as their primary care clinic.
The corporate concentration overwhelmed small clinics without affiliations. ACOs made so much money that they built new buildings, often with baby grand pianos in the lobbies to comfort their customers.
The Affordable Care Act ushered in an electronic medical record (EMR) mandate, forcing all medical billing to be submitted online, as well as lengthy encounter notes from providers supporting their reimbursement claims. That was a game changer. Large ACOs could afford the most powerful and efficient EMR, while the small office had trouble exchanging information with other providers or hospitals.
The time spent without reimbursement or help from the government mandating the change was breathtaking. I paid IT geeks more than my own salary per hour. Given the upfront and ongoing cost of these systems, I wound up making less per hour than an ICU nurse.
Enter human greed.
With small practice competition eliminated, ACOs and the Affordable Care Act changed the practice of medical care to an unconscionable standard.
Phones don’t get answered, and people with acute problems can’t get into primary care clinics. To boost revenue, they require appointments to get labs done, receive test results and coax patients into follow ups “just to make sure you’re OK.”
Urgent cares owned by ACOs popped up everywhere.
And what about physician retention? How many of you lost providers in the past five years? Providers are the source of income for the ACOs. They are nothing but a commodity, a widget on an assembly line. ACOs have the power to double book, shorten appointments, and limit lunch hours. Physicians are typing into the night hours and weekends. This is a financial bonanza for administrators, who often complain of a shrinking labor force and burnout. Workers can only vote with their feet.
This system will not change until the patient, who is also a voter, demands better care with restoration of the sacred patient-doctor relationship.
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Elisabeth Slattery, M.D.