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Can we “Keep” our Health Care? A Requiem for Small Practices


By Mark L. Horn, MD, MPH, Chief Medical Officer, Target Health Inc.


Editor’s note: While we may be seeing an end of an era, there may be advantages to go[J1]  to a group practice, where all specialties are represented in “one building”; so if needed, a consult could occur at the time of the office visit. This happened recently during an eye examination in a multi-specialty eye care medical practice. At a moment’s request, a cornea expert consulted with a retina expert where a non-issue was resolved in 10 minutes.


While preparing a lecture reviewing Medical Homes and Accountable Care Organizations for a class of public health graduate students, a thought intruded which, in retrospect, was self-evident, but nevertheless troubling. Under many, if not most, of the proposed innovative medical models receiving serious attention it is sadly (at least for me) hard to envision the survival of the individual and small group practices that have been fundamental models of care during virtually my entire professional life.


The forces compelling a change in the system of healthcare delivery are profound and compelling. These forces predate the passage of the Affordable Care Act and will remain drivers of health system change irrespective of any changes to the ACA as a consequence of the upcoming election. For our ON TARGET audience it is unnecessary to review the cost pressures, quality challenges, and the widening sense of dissatisfaction among multiple constituencies with the current US healthcare system; these are long standing, intensely analyzed, and chronically unsolved. Physicians, other provider groups, government and private payers, and patients and their advocates, despite their varied views about what should be done, seem aligned around the need for major system change. Of note, the still widely used and liked (by many physicians) “fee-for-service” reimbursement system seems a favored target as a driver of both uncontrollable costs and suboptimal quality. It is therefore a major target for reform.


It is not the intent today to review, assess, and opine on payment systems; the goal this week is less quantitative and more philosophical.


As I researched my lecture for the students, several themes emerged as drivers of most reform initiatives. These include the need for enhanced and more convenient access, improved coordination among multiple specialties, thoughtful utilization of teams including multiple types of providers, sophisticated tracking and reporting of costs, results, and patient outcomes, and finally, the alignment of financial incentives and sharing of risk across the entire system. These are critically Important and necessary goals.


Unfortunately for the extant solo and small group practices, it is hard to see how they can access the capital and expertise required to meet the needs for expanded information technology infrastructure, sophisticated ancillary personnel, and increased financial flexibility (e.g. the assumption and management of risk). Participation in Medical Home models and evolving Accountable Care Organizations will require capabilities characteristic of large organizations but not readily available to small practices.


Does the potential disappearance of solo and small practices matter? In a time of transformational change, are these models necessary casualties? Perhaps this is the case.


Still, for those of us of a certain age, the small, intimate private practice was the model of our mentors. There was a profound personal satisfaction that accrued to physicians adopting this style of practice. This threatened “small business model” had a genuine appeal for the doctors and, I suspect, worked well for many patients. As we move towards what will seemingly be larger, more complex, and (sorry for the charged word) “corporate like” structures, we should endeavor to identify and retain the best of the past.


The other editor’s note: the various philosophies briefly mentioned, warrant an extended conversation here in, ON TARGET.  We look forward to a continuation of this discussion in future publications that welcomes the views of our subscribers.


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