Will You meet Doc on the way back from a large Group Practice?

Patients are increasingly resentful of the tactics used by health maintenance organizations in order to save money and increase profits. According to Mike Norbut of the AMNews staff, writing in its November 4, 2002 edition doctors may be quitting large groups and returning to solo practices or small groups. "The trend seems to mirror the plateauing of capitation as a payment form and consumers' shift away from the most restrictive HMO plans" he reports. The shift to large groups was most evident in the 1990s. Mergers were the rage as doctors decided to band together in order to counteract the cost-saving techniques of the business-oriented, but medically challenged invaders of their professional terrain. Those who were old enough could opt out and retire, but younger physicians, finding their incomes to be declining drastically, often had no choice but to seek a way to share the burden of mounting expenses.

And now, it's many years later. The trend back to smaller size practices was led by primary care physicians who began to realize that a big practice is not always a better one. Merritt, Hawkins & Associates is a Texas based firm that provides staff and recruits physicians for large groups. Each year they conduct a review of their results, which includes about 2,200 physicians (for year 2001). Examination of these results over the preceding 5 years revealed a 14% decline in doctors that they had placed in hospital or group settings. Conversely, approximately the same percentage was "taking jobs in solo, partnership or association settings." These doctors might pool space and equipment but each individual is on his or her own with regard to revenue. Group setting placements had dropped from 53% during those five years to only 41%. On the other hand, practices in which two physicians share space and equipment went up significantly from 9% in 1997-98 to 22% in 2001-2002.

Apparently there isn't only a shift being made by physicians participating in large practices back into smaller ones. In the past three years according to Keith Borglum, vice president of Professional Management and Marketing in Santa Rosa, California, physicians starting out for the first time in solo rather than group practices have "probably quintupled" in number. Many are shying away from HMOs, preferring PPOs and discounted fee for service. However, I find it a bit hard to agree with Borglum's statement that it's "easier now for solo and small practices to flourish." It's unlikely that my beleaguered and complaining colleagues would go along with that assessment.

If primary care doctors are the ones leading the way, what about specialists? It seems that they are not showing signs of following suit. They prefer large groups because they want to stay affiliated with academic institutions, and find better avenues for funding their research according to Leta Davenport, a recruiter with Bellwether Associates of Charleston, S.C.

Does this mean that primary care medicine is heading back to the old ways? Will home visits start to reappear? I read recently about a financially strapped young doctor who opted to avoid opening an office entirely. Instead he is only serving homebound patients. It's unlikely that he will have much competition in the near future, and there is little doubt that he will find it difficult to maintain a flourishing supply of patients who prefer to be seen at home.

I wouldn't advise my readers to get too excited about running into their favorite family physician on the way back to a solo practice, but "hope springs eternal." Either way, it's a comforting thought.

Cartoons and Poems following each article are created and copyrighted by Dr. Ackerman and cannot be copied or reproduced without his permission. Copyright © 2006 by Marvin Ackerman, M.D.

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