For Dr. Mitzi Rubin, a Cobb County family practice physician in mid-career, the cost to convert patients’ medical records electronically may have been the last straw.
Not that she resisted the concept – in fact, she was eager to embrace it. “My father practices in the Virgin Islands, and his office has been on EMR [electronic medical records] for years now,” she said. “But I could see the transition was going to be difficult.”
She was a member of an independent family practice group in Kennesaw that had yet to go electronic, and she knew that such a change was a major investment for any practice, large or small. With private insurers and the federal Affordable Care Act pushing physicians to adopt EMR to maximize reimbursement, Rubin figured in late 2010 that it might be a good time to fundamentally alter how she practiced medicine.
So a year ago, she left the four-doctor group in Kennesaw and set up shop in east Cobb County. This time, instead of managing the business end of her practice, Rubin signed on with the WellStar Medical Group, a consortium of about 500 doctors in 30 specialties affiliated with WellStar Health System. The group runs physician practices around Cobb and several other counties in northwest metro Atlanta.
Since day one, Rubin said, her practice – WellStar Family Medicine – has been paperless. The WellStar Medical Group runs all aspects of the practice, from purchasing and maintaining equipment (including the electronic medical records system) to hiring nurses and office staff, billing patients and negotiating contracts for payment from insurance companies.
(It also handles media inquiries, and had a public relations specialist sit in on the interview for this story.)
Rubin became a salaried employee of the group, getting paid every two weeks just like everyone else in the office. Many of her former patients chose to go with her to her new office. And by mid-2011, the practice added a partner, an internist-pediatrician.
“I loved my patients and I love what I do,” Rubin said. “But I hated the business end of it. I had to make the change.”
She’s not alone.
Although specific figures are hard to come by, health policy experts agree there has been a clear trend over the past few years for U.S. physicians to give up practicing solo or in small, independent offices. This is especially true for doctors working in primary care.
An American Medical Association survey sample of physicians in 2007 found that while 61 percent of doctors in all specialties were self-employed, more than half of those under age 40 were not.
Is independence being sacrificed?
Female physicians, as well as younger male physicians, are much more likely to join large groups, hospital systems, health insurance companies and other medical models where they work for salaries, experts say. By doing so they don’t put as much at risk financially and have more time to spend with their families.
This appears to be particularly true in family medicine practices. According to a survey by the American Academy of Family Physicians in 2008, 64 percent of its members were being paid salaries as their primary source of income, compared with about 20 percent who were on contract or who were paid strictly on a fee-for-service basis. About 30 percent worked for a hospital or hospital system.
Though the trend is new, the concept is not. Hospital systems across the country started buying up physician practices 20 years ago. But that movement largely fizzled out when hospital officials determined there wasn’t enough money to be made.
Things are different now. Dramatic changes in health care policy and financing, competition among commercial insurers, and hospital system consolidation have rekindled interest in metro markets nationwide.
The speed with which the change is taking place worries some doctors. If hospital groups and insurance companies are keeping track of how many patients doctors admit, the length of hospital stays, and how well chronically ill patients are cared for, that information will eventually be used to determine not just how much physicians will be paid, but also how they practice.
But Jay Wolfson, professor of public health and medicine and a health finance expert at the University of South Florida, argues that those measurements are already influencing physician practice, and will do so even more in the future.
The 2010 health reform law provides incentives to set up accountable care organizations (ACOs) that pay bonuses to doctors and hospitals when they show improved patient health and effectiveness of treatment. The only question is whether doctors will want to join an ACO run by a hospital or one run by physicians, Wolfson said.
Because physicians control the WellStar group, Rubin said, she feels secure in her independence.
Among other things, the move away from managing a business has allowed her to spend more time with patients. She and her partner can now offer them the services of an in-house nutritionist and diabetes control coordinator. There is a laboratory on site, and the staff is trained to call and discuss lab results with each patient rather than rely on recordings or the mail. Doing all that would have been financially impractical without the services of the WellStar group, Rubin said.
Gaining leverage with insurers
Dr. Ruth McClatchey Cline, a partner in the decades-old Athens Obstetrics-Gynecology practice, felt the same pressures as Rubin to change her practice model in 2010.
The driving force for Cline and her partners was the problem of contract negotiations with insurance companies. Each year, it seemed, health insurers – especially those covering patients in managed care – were squeezing physicians into accepting lower reimbursement rates.
After 15 years in practice, Cline said, she was seeing her income decline each year. “At age 32, I made the most money I have ever made,” she said. It has been flat or declining over the years since then, she said. Moreover, the staff at her practice hadn’t received a raise in three years, while their costs for health insurance and other benefits continued to rise.
Cline said that when another long-established Athens doctor group was unable to negotiate a contract with one of the state’s largest insurers – and instead the insurance company signed up a competing group in town – she and her partners decided they’d had enough.
A year ago, Cline’s practice signed on with Atlanta Women’s Health Group, a consortium of about 80 ob-gyns, most of whom deliver babies at Northside Hospital in Atlanta.
Cline and her partners still send their obstetrics patients to St. Mary’s Hospital in Athens, but the Atlanta group runs her practice, where she is on salary and eligible for quarterly bonuses. Now, rather than negotiating payment rates for just their own patients, she and her partners have the bargaining clout of a group that has upwards of 100,000 patients and delivers more than 9,000 babies a year.
There was some confusion during the transition and ramp-up for electronic medical records in the first half of 2011. But the second half confirmed the wisdom of the switch to a large group affiliation, Cline said. The staff is happier and more efficient than ever – thanks to the training and help they get from being a part of a larger operation. Most importantly, she can concentrate more on patient care.
“I feel very confident about the future,” she said. “And I haven’t felt that way for a while.”
Mike King is a medical and health policy writer based in Atlanta. He worked at The Courier-Journal in Louisville, Ky., and served as the editor of The Atlanta Journal-Constitution’s science and medicine staff.