Jarrod Shapiro, DPM Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

Is Solo Practice Dead?

During my training and early years as a podiatrist, I’ve had the opportunity to work under several different practice types, including: group hospital-based; multi-specialty; academic and solo practitioner models. Each has its joys and heartaches. Each caters to a different physician’s personality and style. But of all of these types the solo practitioner appears to be at greatest risk, with our current healthcare crisis and changing system. Is solo practice dying?

A Little History and a Trend

Solo medical practice has existed for about as long as the practice of medicine itself.  According to the Medical Group Management Association (MGMA), the first group practice was started in 1870 by the Homestake Mining Company in South Dakota for its workers.¹  Since then, the “medical group” concept has expanded into entities such as Kaiser Permanent, The Mayo Clinic, and The Cleveland Clinic, and significant medical advances have originated from these groups.  For a while, it seemed there was a happy medium with some larger organizations and a good number of solo practitioners.  Things, though, seem to be changing.

According to one source, the number of physicians who own their own practice has been declining 2% per year for the past 25 years.²  A study by the Center for Studying Health System Change (HSC) – yes, there is such a center — found the proportion of physicians in solo and two-physician practices declined from 40.7% in 1996-1997 to 32.5% in 2004-2005.³  Follow this link to view the HSC study.  Doctors appear to be moving from small practice situations to larger health care organizations as employees.

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Is there something wrong with solo practice?  Intrinsically, the answer is no.  There are many benefits to solo practice—not only for physicians, but also for patients.  Solo practice gives the physician control over business decisions, allows those with an entrepreneurial spirit to flourish, and allows one to modify the schedule without limitations.  Additionally, many patients enjoy the personal touch a solo practice may bring. In fact, nine of ten patients in the United States see independent practitioners or small groups.²  Rural areas rely heavily on solo practitioners, as large groups and healthcare delivery organizations may not be feasible in these areas of sparse population. 

If solo practice is intrinsically valuable, then where is the problem?  The problem is extrinsic.  Medicine has increasingly become more costly.  The extra staff required to handle ever more complex insurance contracts and reimbursements, draws away from the profitability of a small practice. All physicians are watching a decline in reimbursement for their services, whether surgical or nonsurgical. Office technologies like EMR and digital radiography have steep initial investment costs that may put too much pressure on the small solo practitioner. Additionally, insurance movement towards reimbursement by core measurements and standards will add pressure to monitor clinical outcomes, which may be impractical for the solo doctor.  Add to this the increase in general business expenses such as health insurance and benefits for employees, as well as high student loan debt for new doctor's and one sees the deck is stacked against the solo practitioner. 

An analogy from Darwinian evolution may be appropriate here. The solo independent practice, once the primary method of physician employment, and once very successful, may no longer be well adapted to the new medical environment we find ourselves in.

If there are significant benefits to large groups, and our health care environment is changing in ways to make solo practice less competitive, then I have a few questions for the podiatric community. I honestly don’t know the answers to these questions (I don’t think anyone does), but they’re worth discussing.

1. Is solo practice truly becoming a thing of the past?
2. Is this a good change or are we watching the sad demise of a quality institution?
3. Would the death of solo practice translate to improvement or a decline in patient care?
4. Would the loss of the solo practice create a corporatization of medicine? 
   And if so is this good or bad?
5. For those who see this reality what steps can be taken to ensure continued growth and success?
6. Where does podiatry stand in this new environment?  Are we poised to benefit or suffer?

Change is the only constant in life, and medicine is no exception to the rule. If it’s true that solo practice is dead, then I for one will be sad to see it go.  I enjoy working for large organizations, but not everyone wants to be someone else’s employee.  And not every patient wants to be a member of a large health care giant medical delivery system. I wonder what medicine would be like if Hippocrates worked for Kaiser?

What are your thoughts about this? After reading the eZine, we encourage you to follow up with any additional comments in the PRESENT Podiatry eTalk.

Keep writing in with your thoughts and comments. Better yet, post them in the eTalk forum, where you can get in on the discussion or start one of your own. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References

1. Medical Group Practice Fast Facts
2. Isaacs, S, et al.  NEJM Feb 2009; 360(7): 655-657.
3. Allison Liebhaber, Joy M. Grossman.  Center for Studying Health System Change,
   Tracking Report Aug 2007; #18.

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