“Healthcare Reform,” “PPACA” and “ACOs” all have one certain thing in common: cost-saving change. Though debate swirls about politics, timing and the particulars of change, it seems clear that the changing demographics of our country (aging baby boomers) in our economic climate is not sustainable as is. And it’s no surprise that a compensation system based on how much is done and how much it costs leads to greater expense. An economic reward system that drives costs up as more and more people are set to join the ranks of the insured (through mandated health insurance and expanded Medicaid) simply underscores the timing of the change. What does that mean for physicians?
Physicians are asking three key questions:
- Is there a future for small or solo practices?
- Is fee for service really gonna change?
- What can I do right now to adapt?
The Future of the Small Practice
The only solid answer is “less.” It really depends on complex things like the demographics of where the doctor practices and the number of competitors close by. That said, as change happens, the hardest hit will likely be the smaller practices, since they lack the personnel and financial resources to weather the change and to invest in adaptation. Many small practices will likely experience change in such a way that the best they can hope for is to survive, rather than thrive. Even worse, solo practitioners already know what it’s like to handle all the duties as a physician, keep track of business operations and keep the patients flowing into the practice. Exhausting. Without substantial support and resources, it’s just not realistic for most solos to expect to keep up.
Even larger practices are not often run like a business. The professionals that generate the revenue often manage as well. Moreover, most medical practices do not market or do any serious “back office” magic (revenue cycle management). As such, change hits small practices especially hard. Implementing even new EHR requirements can be consuming for a small practice. How will it be as changes are made to reduce cost and improve quality? How will it be when practices begin to see there is opportunity in change, that they may actually make more money in a risk based compensation environment? Rougher. Like a herd of buffalo when attacked, circling together is a good strategy.
That said, the vision has to be clear. Why circle together? Most medical practices are combining and growing to guard market share, not to manage costs or measure and demonstrate quality. This is probably the biggest reason why we see larger practices in single specialties, not multi-specialty or primary/specialty based practices. Most physicians that are adapting by joining larger practices are doing so for the same reason why buffalos circle together—the threat of change. Though size alone is no panacea, larger practices are definitely in a better position to adapt.
Let’s face it: few are running after change in healthcare right now. Few see the opportunity and are leading the charge. Most are waiting or are just setting the stage. And most large practices are, at best, a good platform where change can be implemented and costs can be shared and spread among a larger pool.
Will There be a Change to Fee for Service Payment?
Yep. Simple as that. It’s already happening. Bundled payments are in place, even in Florida. Capitation is old hat for many now.
When? Over time… Not right away. Even ACOs aspirants are selecting just one sided risk, testing the water as they see how well they do to reduce costs, improve quality and “earn” their right to bonus money. Physicians that think fee for service will thrive for decades are kidding themselves, at least in the insured market. Is there a basis for it in a “second tier” or concierge sort of environment? Probably.
What Can I Do Right Now?
First, accept that we are approaching a new paradigm of healthcare delivery. The current model of disease/injury crisis management has prepared no one for the move from intervention to prevention. And yet, systems that are solidly based in wellness and prevention stand to profit most from the change we all face.
Second, look to shore up you business model. That means:
- Look to join a larger practice that is committed to thriving in the future risk-based compensation scenario. If the practice is there just to thrive in a fee for service environment and has no commitment to thriving in a risk based compensation model, keep looking;
- Market. Most practices do not market at all, and yet consumers are selecting medical care in the most unlikely environment—the internet;
- Look at anything concierge-like. Most of the public conversation centers around the insured market, mostly the Medicare Shared Savings Program (which has spawned the ACO concept). What about the rest of the consumers? As the insured market gets squeezed (remember that consumers are feeling the pressure too with heightened copays, deductibles and benefit limits), you can expect growth of the “second tier,” those who want more and are willing to pay for it;
- Build in wellness and prevention. Not all practices lend themselves to wellness related services that can reduce healthcare costs, but those that do must look at ways to offer cost-saving, wellness and prevention-oriented services;
- Enlist the patients. The concept of “partnering” with patients is strange, but consider the amount of savings and the enhancement of outcomes if physicians could incentivize healthy patient behavior. Though absent from the public policy conversation, health care businesses that build in patient accountability stand to win big in a payment system that rewards clinical outcomes and cost savings.
Change is frightening. Even “good” change is frightening. Just look at all the upset stomach meds sold at airport kiosk counters. Physicians have a terrific burden at this time. They not only hold our health in their hands. They are expected to have skills and time to help create a new environment in which care will be delivered. Denying change in the healthcare sector is a waste of time and energy. Looking for ways to thrive in it and even drive it is wise.