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Monday Mar 03, 2014

Private Practice Has Its Rewards, Challenges

Editor's note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the first in an occasional series of blogs that will look at the different roles family physicians can play.

When I made the decision in medical school to become a family physician, I pictured myself working in a rural private practice. In my mind's eye, this looked something like a Norman Rockwell painting. As my residency and fellowship training drew to a close and I began the job search in earnest, my idealism was met with a stark reality: Private practice seemed to be vanishing.

Peter Rippey, M.D.

During the past 25 years, the number of active AAFP members who identified themselves as employed physicians increased from 29 percent to 63 percent. During the same time, the ranks of solo practitioners decreased by 27 percent. Many of the positions I considered in rural areas were hospital owned.

I eventually found a position as the seventh physician in a rural private practice. But practicing in a rural area has not insulated me from the changes occurring in our country. The uncertainty of the health care landscape as the Patient Protection and Affordable Care Act continues to be implemented -- along with the challenges related to payment, electronic health records (EHRs), meaningful use and ICD-10 looming on the horizon -- seems to have spurred a mass exodus from private practice to employed positions.

In my area, I have seen a few older physicians retire instead of dealing with the latest round of health care upheaval. Other practices have been absorbed by hospital systems or merged with larger physician organizations. Those who are struggling to stay in private practice have seen their overhead increase and their payments cut.

At a time when everyone is clamoring about the high cost of health care, forcing physicians out of private practice seems foolish. Payment rates for private outpatient clinics are less than those for hospital clinics for the same service provided.Many clinics can provide urgent care services (suturing, fracture care, etc.) at a fraction of the cost of the local ER. It would seem in many ways that a well-run private practice could provide quality patient care at less cost.

At a time when the United States spends more money on health care as a percentage of gross domestic product than any other industrialized nation and has some of the worst health outcomes, is the extinction of private practice really a step forward?

Private practices are a vital means for health care access, especially in rural areas where the next closest option may be more than an hour away. As these practices disappear, medical students and residents will have even less exposure to private practice; fewer and fewer may consider it a viable option. This could lead to further decline in the future of private practice.

That's a shame, because I have found private practice to be extremely rewarding. I am providing high quality, efficient care for my patients. In private practice, I also get to decide what hours I work, what procedural services I provide, what my scope of practice is, when I take vacation and who I have assist me.

In contrast to some employed settings, there us less pressure to see a certain number of patients a day. I can make that decision based on how many patients I think I can manage appropriately. If I want to take a vacation or time for CME, there is no schedule to coordinate with , no need to give significant advance notice and no need to ask for permission. I simply block my clinic schedule.

I think one of the most important benefits of private practice is that all the decisions affecting the practice are made by clinicians, those who understand what it means to be a physician and what it takes to provide care to patients.

In medical school and residency, I was taught that as physicians we are stewards of the health care system. In my practice, I provide the care patients deserve while helping to control costs. But the future seems murky. My practice has had to make many stressful decisions regarding EHRs and is trying to lower overhead due to payment cuts. As a father trying to support a family and pay off a mountain of medical school debt, this uncertainty has often put an extra furrow in my brow.

I understand all too well the reasons many have flocked to employed positions, but do all these changes really mean the demise of private practice? Or is this simply a pendulum, sure to swing the other way in time? To quote the wisdom of The Clash, "Should I stay or should I go now?"

Peter Rippey, M.D., is a board-certified family physician who practices in private practice in rural Missouri. He enjoys a full spectrum practice with a focus on community and collegiate athletic coverage.


This was really a great article Peter. Very accurate. I have had the "pleasure" of being in private practice (which I loved) for many years then thru worthy circumstances had to become employed and I now am considering the pivate practice option again. The freedom that private practice offers is something I wish all physicians could experience in their practice lives. Having done both I can honestly say there is no real quality difference in the medicine produced but there certainly is a huge quality difference in both the life and patient experience parts of it all. Hard thing about it though Peter, once you've been away from private practice for 15 years it's hard to find a good resource to help you get back into it in a safe and organized fashion. I've even searched the AAFP site here and really found nothing useful. Any suggestions?

Posted by William Paronish on March 05, 2014 at 02:28 PM CST #

Very well written, and a worthwhile perspective. Most physicians value autonomy, but are afraid when told by hospital administrators that "you can't make a living in private practice." As an employed faculty physician, I get to watch a number of my residents go into practice after graduation. The least satisfied seem to be those with the least autonomy. My guess is that the way to preserve autonomy and continue to pay off loans (and make money) is going to be some form of what is now referred to as "concierge practice". I don't think it needs to be only for wealthy patients, but the cost of conforming with all the requirements of public and private insurance is making up an increasing percentage of overhead. Charges could be much lower if you didn't count on a majority of your charges being dramatically reduced. Patient satisfaction seems to go up with those as well.

Posted by Don Milligan on March 06, 2014 at 10:54 AM CST #

Dr. Milligan is correct. Not participating in insurance plans allows you to lower overhead and provide a "conierge practice" to all comers, not just the wealthy. You don't need to charge a membership fee. I have operated this way for over 15 years by being able to charge about half of what hospital employed providers charge. I have many regular patients that have insurance (most with high deductibles) and appreciate my low charges even though I am not in their network. I would argue that this is the only viable long-term option for solo and small group physicians that wish to remain autonomous.

Posted by Keith Dinklage on March 07, 2014 at 08:39 AM CST #

Great article Peter.

Posted by Meshia Waleh on March 07, 2014 at 01:18 PM CST #

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