Physician Independence Not Incompatible With Reform

Plenty of people will tell you that the independent physician is a rapidly dying breed. A few reasons they cite:

• Coding, billing, and collections are getting more complex.
• It costs a lot of money and effort to achieve meaningful use standards.
• Learning team-based medical practice is difficult.
• Young physicians don't want the hassle and long hours of running a business in addition to seeing patients.

I could go on and on. It's true that challenges like these aren't going away. Indeed, they're a necessary part of the transformation of healthcare into a more predictable, more high-quality endeavor.

That doesn't mean they don't cause a lot of upheaval. Some of this upheaval means lots of formerly independent physicians are giving up the business side and joining as employees with hospitals, health systems, and health plans. Some physicians equate that outcome as "giving up."

The challenges of adaptation are real and seismic for every healthcare organization, and they're exceedingly more difficult to deal with for small independent physician groups.

As a result, many independent physicians are throwing up their hands about their ability to remain so in an environment that appears to actively discourage physician independence. These are the practices that are acquired on a daily basis by the nation's hospitals and health systems, whose leadership seems to often equate physician acquisition with physician alignment.

From the physician's point of view, the bottom line is, well, the bottom line. Businesswise, it's difficult, and arguably more stressful, to maintain your independence. There's a degree of safety in employment.

As an employed physician, your job and standard of living isn't quite as dependent on the whims of the federal government or the difficulties of contracting with commercial insurers. Then again, you can't make your own decisions.

So says Russell Libby, MD, the president-elect of the Virginia Medical Society and a frequent commentator on what I write in this space each week. He says giving up your independence as a physician is just that: giving up.

"I'm not sure what employment achieves other than consolidation" he says, arguing that consolidation doesn't necessarily achieve benefit to the community. "That doesn't mean there aren't examples of that, but in a partnership, community benefit is a consideration as it evolves. When you look to be acquired, it's because you're giving up."

I'm not sure that the majority of his professional peers agree, but it's nice, as a healthcare consumer, to know that there still is a choice. For now, even Libby agrees that independence appears to be the tougher road in the future, albeit a more rewarding one.

As an independent physician, you can't afford to sit on the sidelines as the industry changes, he adds. And he concedes that while employment could be the right choice for some physicians, there are big downsides.

"If you're employed you're much more a cog in the wheel," he says. "You don't have to worry about how the machine works, and you are insulated. But you're going to be scrutinized in ways you haven't been scrutinized before, which will directly impact your compensation."

Libby, a pediatrician in a 16-clinician multispecialty practice in Fairfax, is, with his partners, in the process of evaluating a potential business partnership with a local hospital. But the deal would stop far short of employment.

"You have to face the fact that you have to develop an approach to team care and understand how to evolve systems that don't necessarily stratify and create questions of authority and that are geared toward solutions," he says of the effort.

He cautions health systems to be wary of envisioning large-scale physician employment as a panacea—something we write about frequently at HealthLeaders.

"[Employed] docs will come in and out of their jobs, and won't be fixtures in the community," he says. "Hospitals trying to 'own' their community will find their strategy will not necessarily pay off if they can't trust some of the care to those outside of the hospital. That will be necessary to do ACOs."

As the massive shakeup in healthcare continues, Libby envisions a point at which independents and employed docs will reach a new equilibrium, but he's not necessarily optimistic that independence will win out. He's sanguine about the prospects, but isn't convinced that employing a greater percentage of physicians will lead to higher quality healthcare.

"There will be a saturation point, but you disenfranchise the medical community when you remove the incentives for them to be responsible business owners," he says. "Medicine is a business. [Hospitals and health systems] will stop being so enamored of hiring physician groups and will realize that they are better off partnering with us.