More and More Doctors Abandoning Private Practice

Fewer doctors are opting to run their own small private practices, with more seeking jobs in hospitals or larger medical groups, according to a new report.

These patterns likely reflect broader trends toward consolidation in health care, with both insurance companies and hospitals also having grown in size in recent years.

The latest biennial analysis of doctors' practices by the American Medical Association showed an acceleration of a trend away from private practice, defined as a practice wholly owned by physicians. The 2020 results found less than half — 49.1 % — of doctors involved in patient care worked in a private practice, the AMA said in a report released this month.

This marked the first time private practice was not the dominant approach since the AMA analysis began in 2012. What's more, the trend appears to be gaining steam, with a drop of almost 5 percentage points from 54.0% in private practice in 2018. The percent of doctors in private practice declined at a slower rate in previous AMA surveys, slipping to 55.8% in 2016 from 56.8% in 2018 and 60.1% in 2012.

Employment and ownership structures have become so varied that no single approach or size of organization "can or should be considered the typical physician practice," the report noted.

AMA, for example, added to its 2020 benchmark survey an option to identify private equity organizations as employers. The survey found 4% of doctors involved in patient care worked in practices owned by these kinds of firms. Other options include practices wholly or jointly owned by hospital and health systems and insurers, as well as direct employment and contracting.

There are signs that the shift away from smaller private practices will continue, with younger doctors appearing more likely to seek employment.

The survey found 42% of doctors ages 55 and older were employed by someone else compared to 51.2% of doctors ages 40-54 and 70% of physicians under the age of 40.

The AMA surveyed 3,500 U.S. doctors through the 2020 Physician Practice Benchmark Survey. The survey was conducted from September to October 2020, roughly 6 months into the COVID-19 pandemic, and therefore may not reflect its full impact.

"Physician practices were hit hard by the economic impact of the early pandemic as patient volume and revenues shrank while medical supply expenses spiked. The impact of these economic forces on physician practice arrangements is ongoing and may not be fully realized for some time," AMA President Susan R. Bailey, MD, said in a statement.

In a survey released last year by McKinsey & Company, 53% of independent doctors reported that they were worried about their practices surviving the stresses of the pandemic, Medscape Medical News reported.

Challenging Environment

It's not just money leading to the shift away from private practice, according to a 2020 report from the American Hospital Association, titled "Evolving Physician-Practice Ownership Models."

Many recent graduates of medical schools have significant debt and are more likely to opt for employment, which offers more financial stability and work-life balance, the report said.

Doctors also need to keep up with expectations of their patients that have been shaped by advances in other sectors, like banking, AHA noted. People are used to working on their own schedules, and  want to make appointments through apps, get test results rapidly and on their mobile devices, and communicate with their providers virtually.

"It is challenging to meet these expectations and make the necessary technology investments as a solo or small group practice," the AHA report said.

Hospitals face competition for doctors from insurers, which have been looking in some cases to directly employ more physicians, the AHA also notes. The report cites insurance giant UnitedHealth Group's Optum unit as the most visible example of this trend.

On a January call about corporate earnings, David Wichmann, then chief executive of UnitedHealth, spoke about the firm's "aim to reinvent health care delivery," including efforts to have its own primary and multi-specialty care practices.

"OptumCare entered 2021 with over 50,000 physicians and 1,400 clinics," Wichmann said. "Over the course of this year, we expect to grow our employed and affiliated physicians by at least 10,000. This work of building local physician-led systems of care continues to be central to our mission. "

UnitedHealth's new CEO is Andrew Witty, who had led the Optum unit.

Attractions of Larger Groups

Older doctors — those 55 and up — were significantly more likely to work in small practices than those under younger than 40, the 2020 survey found. Results showed 40.9% of doctors under 40  worked in practices of 10 or fewer colleagues, compared to 61.4% of those age 55 and older.

The large difference between age groups suggests that attrition is one reason for the shift in practice size. Retiring doctors who leave small practices are not being replaced on a one-for-one basis by younger doctors, AMA said. The same reason also appears to be a factor in the shift in practice ownership to larger systems.

Doctors in larger group practices can count on a stable business model, with a better ability to survive disruptive market trends, including those of a more extreme nature, like COVID-19, Fred Horton, president of AMGA Consulting, said.

AMGA Consulting is a wholly-owned subsidiary of AMGA, formerly called American Medical Group Association. Its more than 400 members include well-known multi-specialty groups and health care systems such as Mayo Clinic, Cleveland Clinic, Geisinger, the Permanente Medical Group, and Intermountain Healthcare as well as many smaller physician practices.

Horton, who holds a master's degree in Health Administration, said some doctors may want to participate in alternative payment programs offered by insurers, who are seeking to shift away from the fee-for-service model

"Larger organizations can dedicate more resources to continuous quality improvement," Horton said. "This is especially important for physicians who are taking on risk-based contracts, as quality can directly impact how much they earn."

For one oncologist, it was turning to alternative payment methods that helped him keep his private practice afloat.

Kashyap Patel, MD, chief executive of the Carolina Blood and Cancer Care Associates in Rock Hill, SC, said he maintained the independence of his practice amid pressure from a large health system, which had been buying medical groups in the area. That began to interfere with referrals of patients from other doctors, which are key for cancer specialists, said Patel, who also is president of the Community Oncology Alliance.

In response, Patel worked with Blue Cross Blue Shield of South Carolina on an arrangement where his practice sought certifications from the National Committee for Quality Assurance to get better rates.

The effort has allowed Patel's clinic to focus more on preventing hospitalizations and visits to the emergency room he said.

In Patel's view, his patients benefit from his efforts to remain in independent practice. A switch to ownership by a large health care organization would have put them at risk for higher medical bills, jeopardizing their access to treatment, he said. The reason? Hospitals can charge more for services provided by doctors they employ, Patel said.

"Nothing would change. I would be the same. The building would be the same, but the cost would go up," Patel said.

For its part, the American Hospital Association has repeatedly challenged arguments that acquisitions and mergers result in higher costs for patients.

Instead, AHA has raised alarms about consolidation of health insurers, a concern it shares with AMA. In a 2020 report examining competition among insurers, AMA noted doctors working in small practices can be put at a disadvantage if mergers and acquisitions leave an insurer with too much market power.

"Under antitrust law, independent physicians cannot negotiate collectively with health

Insurers," the AMA said in the report. "This imbalance in relative size leaves most physicians with a weak bargaining position relative to commercial payers."

AMA's research on the effects of insurers' wielding significant market clout has been used in effort to thwart mergers in this industry.

"Dramatic Restructuring"

The Federal Trade Commission  also has taken note of the trends discussed in the new AMA report, saying that  "U.S. physician markets are undergoing a dramatic restructuring."

The FTC in January announced a study of the impact of the consolidation of doctors groups and health care facilities. FTC is seeking data for inpatient, outpatient, and doctors services in 15  states from 2015 through 2020. To gather this data, the commission has issued orders to six major insurers —  Aetna, Anthem, Florida Blue, Cigna, Health Care Service Corporation and United Healthcare.

The  FTC is concerned that acquired practices may have to alter their referral patterns to favor their affiliated hospital system over competing hospital systems. But FTC staff also said it might be that these acquisitions result in efficiencies, such as enhanced coordination of care between doctors and hospitals "that outweigh potential competitive harms."

The research project will likely take several years to complete because of its scope, the FTC said. For that reason, the FTC said its Bureau of Economics will release a series of research papers examining different aspects of this inquiry rather than a single paper containing all of the analyses.

Private Equity "Rollups"

On the day the FTC announced the study of the impact of doctors groups, one of the panel's commissioners argued for a closer look at how private equity firms make their purchases. 

In a Jan. 15 tweet, FTC Commissioner Rohit Chopra said his agency needs to challenge their "rollups of small physician practices" as well as clinics and labs. This is a practice of using a series of acquisitions too small to trigger the federal threshold for a serious look from the FTC and Department of Justice. (The threshold for 2021 stands around the $92 million mark. This benchmark is known as Hart-Scott-Rodino notification after a 1976 law that set a reporting standard.)

Chopra attached to his Jan. 15 tweet a 2020 statement in which he called for stepped-up scrutiny of private equity firms' acquisitions of doctors' practices. Chopra noted that private equity firms have been buying practices focused on anesthesiology and emergency medicine, fields which triggered consumer complaints about surprise billing for emergency care.

"Given trends in today's markets, it is critical that the FTC find new ways to ensure the agency has a rigorous, data-driven approach to market monitoring and enforcement," Chopra wrote.

Sources:

American Medical Association: "AMA analysis shows most physicians work outside of private practice," "Shifts away from smaller and private practices pick up speed," "Competition In Health Insurance."

McKinsey & Company: "Physician employment: The path forward in the COVID-19 era."

American Hospital Association: "Market Insights: Evolving Physician-Practice Ownership Models," "New Research Confirms: Hospital Mergers Reduce Costs, Enhance Quality of Care for Patients."

David Wichmann, former CEO, UnitedHealth.

Fred Horton, president, AMGA Consulting.

Kashyap Patel, MD, chief executive, Carolina Blood and Cancer Care Associates, Rock Hill, SC.

Federal Trade Commission: "FTC to Study the Impact of Physician Group and Healthcare Facility Mergers," "Physician Group and Healthcare Facility Merger Study," "HSR threshold adjustments and reportability for 2021."

Twitter: @chopraftc, Jan. 15, 2021