Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Practices are getting larger to provide micropractice service

Lucy Hornstein, MD
Physician
September 13, 2012
Share
Tweet
Share

Medicine has gone down Alice in Wonderland’s rabbit hole. Looking at the size of practices today, it seems like some of them have taken red pills and the rest have taken blue ones: most of them are getting bigger and bigger and bigger, while some are getting smaller and smaller. As the giant practices gobble up their competition to become ever more gargantuan, others are shrinking down into micropractices.

Everyone has an excuse.

Accountable Care Organizations supposedly mandated by the Affordable Care Act require giant conglomerates of physicians to provide all the care (care management, actually) for whole populations in order to (somehow) spend less while doing so. That this fails mathematically seems as lost on the current crop of folks as it was on their predecessors who brought you HMOs twenty years ago. Still, it requires doctors to organize into large groups; the larger the better.

Others speak of economies of scale. Larger groups are supposed to have more buying clout for supplies and other services. That may be, though I do pretty well at Costco. They certainly have more clout negotiating with payers, though again, this has nothing to do with saving money, since they often have enough pull to rake in significantly more of it. In fact, there are many diseconomies of scale: larger groups need more space (higher rents) and more support (higher payroll). It’s much harder to make changes in how things are done when having to go through a chain of command.

Because of these and other reasons, many doctors — both primary care and specialties — are going the other way: smaller and smaller. The end result, of course, is the micropractice: one doctor, all alone, usually supported by a fair amount of technology. Answering machines (or Google Voice) to pick up the phone while seeing patients and electronic medical records (both for medical documentation and for scheduling) make the model viable.

I’ve gone both directions. When I first started out in practice, I assumed I would eventually take on partners and grow into a group of some kind. I bought an office condo, then later bought the one next door and expanded. I took on a PA, then an NP. The practice grew all right. My strategy was to get the numerator where it should be, then grow the denominator. Things didn’t quite work out, though. With each addition, my income nose-dived. There was no way I could afford to bring in another doc. Eventually both the PA and the NP left for greener pastures. The staff shrank from four back down to two, then to one. Looking back over the finances, I discovered something interesting: the smaller I was, the better I did.

Now I watch small groups merge into bigger ones and big ones merge into enormous ones. Everyone else seems to see this as progress. Everyone except the patients, that is.

Think about the Patient Centered Medical Home (PCMH). Here is what it’s supposed to do:

Provide comprehensive primary care for people of all ages and medical conditions. It is a way for a physician-led medical practice, chosen by the patient, to integrate health care services for that patient who confronts a complex and confusing health care system.

I’m already doing that. In fact, I’ve written about this before, and my conclusion stands: the goal of the PCMH is to make a large group practice function like a solo physician’s office to the patient. Think about it: same day appointments? Check. See the doctor you want when you want? Check. (I’m the only doc in the office.) Friendly one-on-one staff who know who you are when you call? Check. Much of the rest of it is by definition impossible to implement in a solo office (Team meetings? Leadership training? “Roles and responsibilities that are stimulating and rewarding”?) Some of it makes no sense at all. (“Budgeting for forecasting and management decisions”? What does that even mean??)

What’s lost in the push to get bigger are the considerable advantages of being smaller:

  • Business flexibility
  • Lower absolute overhead (smaller space; fewer supplies)
  • Patient (ie, customer) service

You know; all the good things that make both patients and doctors happy.

So let everyone else go ahead and merge into one enormous, ever-expanding group practice — sort of like mercury coalescing (cue T-2) — until the entire country is nothing more than one huge provider network. I’ll be off on my own, where my micropracticing colleagues and I will be quietly caring for patients the old-fashioned way: one at a time. Oh wait: that’s the only way they can be cared for, whatever the wonks say. They’ll be healthy and I’ll be happy. What more can anyone ask?

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

ADVERTISEMENT

Prev

AMA: Cuts to physicians who treat Medicare patients hurt jobs, patient access and Medicare modernization

September 13, 2012 Kevin 4
…
Next

What breastfeeding and sex have in common

September 13, 2012 Kevin 7
…

Tagged as: Primary Care, Public Health & Policy

Post navigation

< Previous Post
AMA: Cuts to physicians who treat Medicare patients hurt jobs, patient access and Medicare modernization
Next Post >
What breastfeeding and sex have in common

ADVERTISEMENT

More by Lucy Hornstein, MD

  • After #MeToo, have the rules changed?

    Lucy Hornstein, MD
  • A patient’s view on cancer surprises this physician

    Lucy Hornstein, MD
  • Never underestimate the power of pus

    Lucy Hornstein, MD

More in Physician

  • The physician who turned burnout into a mission for change

    Jessie Mahoney, MD
  • Time theft: the unseen harm of abusive oversight

    Kayvan Haddadan, MD
  • Why more doctors are leaving clinical practice and how it helps health care

    Arlen Meyers, MD, MBA
  • Harassment and overreach are driving physicians to quit

    Olumuyiwa Bamgbade, MD
  • Why starting with why can transform your medical practice

    Neil Baum, MD
  • Life’s detours may be blessings in disguise

    Osmund Agbo, MD
  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
  • Recent Posts

    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
    • How declining MMR vaccination rates put future generations at risk

      Ambika Sharma, Onyi Oligbo, and Katrina Green, MD | Conditions
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician
    • Time theft: the unseen harm of abusive oversight

      Kayvan Haddadan, MD | Physician
    • How one unforgettable ER patient taught a nurse about resilience

      Kristen Cline, BSN, RN | Conditions
    • The future of clinical care: AI’s role in easing physician workload

      Michael Wakeman | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 4 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
  • Recent Posts

    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
    • How declining MMR vaccination rates put future generations at risk

      Ambika Sharma, Onyi Oligbo, and Katrina Green, MD | Conditions
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician
    • Time theft: the unseen harm of abusive oversight

      Kayvan Haddadan, MD | Physician
    • How one unforgettable ER patient taught a nurse about resilience

      Kristen Cline, BSN, RN | Conditions
    • The future of clinical care: AI’s role in easing physician workload

      Michael Wakeman | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Practices are getting larger to provide micropractice service
4 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...