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Solo practice physicians: 'I'm not dead!'

The impending demise of solo physician practice has been predicted for several years now. In early July, recruitment firm Merritt Hawkins put the proverbial nail in the coffin of solo physician practice by declaring it officially dead. But like the old man in 1975's "Monty Python and the Holy Grail" protesting "I'm not dead!", doctors aren't ready to be hauled off for burial.

Call it denial, but many doctors while recognizing the dire state of solo physician practice aren't ready to give up the ghost yet.

Just weeks after Merritt Hawkins' death declaration was released, a report from the Physicians Foundation on the future of medical practice acknowledged the difficulties solo physician practices face, but, paraphrasing Mark Twain, insisted that "the reports of the demise of private medical practice are … exaggerated."

[See also: Recruiting firm says solo physician practice is dead and Young doctors' outlook on the future of healthcare is gloomy.]

The Physicians Foundation report, written by Jeff Goldsmith, PhD, an associate professor of public health sciences at the University of Virginia, acknowledges the challenges solo physicians are facing, but offers a glimpse of the future, too, by suggesting that the tide toward employment will turn to new models in the coming years.

"There's a rush towards employment because of the huge hassle and the payment issues," said Lou Goodman, PhD, president of the Physicians Foundation, "but after a while, both the doctors and the hospitals, per se, may say, 'Hey, wait a minute. This might not be the model for everyone.' And we may start going back to, maybe not small practices, but physician-directed groups."

Solutions to counteract the dwindling of solo physician practices also came up during a House Small Business Committee hearing on July 19. "The Hearing on Health Care Realignment and Regulation: The Demise of Small and Solo Medical Practices?" included testimony from four physicians and Merritt Hawkins' president, Mark Smith.

They all noted the reasons for the decline of solo practice: flat or declining reimbursement; more regulations and administrative tasks; the cost of malpractice insurance; the burden of implementing information technology systems; the debt of medical school tuition; the upheaval brought about by healthcare reform; and the instability of the Medicare physician payment system.

But despite the glum statistics – Smith said that Merritt Hawkins projected that within two years, 75 percent of all newly hired physicians will be hospital employees – the doctors giving testimony were offering suggestions for saving solo practice.

"If private practice disappears, patient access to care, local employment and tax revenue will all suffer," said Louis McIntyre, MD, chief of orthopedics at Westchester Orthopedic Associates in New York. "We need to strengthen private practice as well as the other models of healthcare delivery to ensure patient access to quality care."

"…(The American Osteopathic Association) believes that the transformation of the practice of medicine has undoubtedly impacted the ability of physicians to thrive in a small practice or as a solo practitioner," said Joseph Yasso, Jr., DO, a member of AOA' board of trustees and medical director of Heritage Physicians Group, a small physician practice owned by the Hospital Corporation of America. "However, physicians are adapting to the changing practice of medicine by becoming patient-centered medical homes and participating in shared savings programs."

The testifying doctors said that solo physicians can be helped by the elimination of the sustainable growth rate (SGR) and the creation of a stable payment process; programs to eliminate or reduce medical school debt in exchange for practicing in areas of great need; malpractice tort reform; injecting market values by having providers compete on quality and price; and allowing providers to band together so they can negotiate better.

"The attitudes of doctors are that they want to work with and for other doctors, not for corporate systems," said Goodman. "It's not that they don't like it, but they just think having that collegial peer review relationship is a little stronger if you have a physician model."

Goodman noted that for physician-directed models to work, capital needs to be freed up for doctors to develop those models.

"The models that the president used and everybody talks about are Mayo and Scott & White and Cleveland Clinic, and guess what?" Goodman said. "They're all physician-directed models. And yet - where the dollars are going and the systems that are developing are corporate models. They're huge hospital systems that are not physician directed. So I think we have to be very careful."