For Emeka Nwodim, MD, the future of independent medicine may hinge on a seeming contradiction: Physicians may have to get bigger to remain independent.
The economics that once allowed an orthopedic practice to thrive largely by seeing patients and performing surgery are becoming harder to sustain, he said. Costs demand closer scrutiny. Reimbursement pressures continue to mount. And individual practices are negotiating in a healthcare system increasingly dominated by organizations with far greater scale.
That does not mean independence is disappearing, Dr. Nwodim, a spine surgeon and managing partner and vice president of the Arnold, Md.-based Bay Area Orthopaedics & Sports Medicine Division of The Centers for Advanced Orthopaedics, told Becker’s. But preserving it may require physicians to rethink what being independent actually means.
For Dr. Nwodim, the answer is not isolation. It is collective leverage.
The old private practice equation is changing
Private practice has always required some understanding of business. What has changed, Dr. Nwodim said, is the margin for getting that business wrong.
In previous generations, practices could build successful businesses primarily around direct patient care. Today, he said, physicians have to pay much closer attention to the economics surrounding that care.
“What has transpired over the last five to 10 years is a complete swing in the pendulum of being able to rely on just those resources,” he said.
Staffing levels, compensation, supplies, equipment, imaging, ancillary services, contracts and partnerships all affect whether a practice remains financially healthy. As those pressures intensify, physicians cannot afford to ignore the details. “You can’t be wasteful in any arena,” Dr. Nwodim said.
That creates a different calculation for younger surgeons deciding between employment and private practice. Dr. Nwodim said he encourages young physicians to consider both. Employment can offer stability, consistent compensation, established infrastructure and strong referral networks. Private practice may offer less certainty upfront, but it can provide greater control over a surgeon’s schedule, patient mix, surgical practice and workplace culture.
He also cautioned against treating autonomy as all-or-nothing. Employed physicians can retain meaningful control over their work. The question, in his view, is how much control a physician wants and what trade-offs come with it.
Private practice increasingly carries another responsibility: understanding the business well enough to preserve that control. “There’s no other environment that’s going to teach you the principles of that better than the private practice model,” Dr. Nwodim said.
Running a better practice may no longer be enough
Dr. Nwodim sees the challenge on two levels. The first is inside the practice. Physicians can scrutinize overhead, improve operations and make their businesses more efficient.
The second is much larger. Across healthcare, physicians are responding separately to reimbursement decisions, regulations and payer policies.
One group fights one battle. Another confronts a different one. Another negotiates independently with the same payer.
“We keep trying to put out these little fires with everything,” Dr. Nwodim said. He believes that fragmentation limits physicians’ ability to influence the larger forces reshaping their profession. “Somehow we need to figure out how to negotiate and leverage on a macroscopic level,” he said.
For Dr. Nwodim, larger physician organizations offer one potential answer. Practices can retain some independence at the local level while gaining the scale to negotiate with payers, hospitals and other organizations from a stronger position. That is where the traditional definition of independence begins to change.
Can physicians consolidate without giving up control?
CAO offers one version of that model. Rather than growing outward from a single practice, the organization was formed by bringing together established private practices. Dr. Nwodim’s Bay Area Orthopaedics & Sports Medicine Division continues to manage many aspects of its day-to-day operations, including its staff and local management, while the larger CAO structure can be used in negotiations with payers and hospitals.
CAO, which is based in Bethesda, Md.,has been running that model for more than a decade. Founded in 2013 when more than 20 independent orthopedic practices came together, the organization now includes more than 400 providers across the Virginia-D.C.-Maryland region.
For Dr. Nwodim, that balance, local control paired with collective scale, offers a potential path forward.
“Similar models need to continue to grow, and that’s where I think we have the best hope in preserving the physician autonomy aspect of medicine,” he said.
But scale creates its own dilemma. Large physician organizations need professional management, contracts, policies and governance structures. Practicing physicians generally do not have the time or capacity to manage every aspect of an organization with hundreds of physicians. As those groups grow, their leadership inevitably takes on more of the responsibilities associated with running a large business.
The challenge is gaining those advantages without distancing physicians from the decisions the organization was built to let them influence.
“There is a sweet spot,” Dr. Nwodim said. He believes physician ownership and leadership are important to maintaining that balance. Administrators and business leaders remain essential, he said, but physicians bring firsthand experience in patient care that cannot be replicated elsewhere in the organization.
“We need to have equal stakeholding decisions that are made for patients and for healthcare in general,” he said.
Scale requires something else: trust
The structural challenge may be only part of the equation. A physician-led organization with dozens or hundreds of physicians inevitably contains competing priorities. Not every physician will agree with every contract, policy or strategic decision.
“We physicians are very skeptical of one another,” Dr. Nwodim said. His concern is that physicians can become so consumed by internal disagreements that they weaken their ability to address the larger pressures facing them.
The solution, in his view, is not unanimity. It is governance. Physician organizations need bylaws, voting structures and processes that allow disagreements to occur without paralyzing the organization. Individual physicians will not prevail on every decision, but Dr. Nwodim sees accepting that reality as part of building collective influence.
“As long as we keep fighting and bickering internally, we are going to keep losing this battle,” he said.
He believes that principle should extend beyond physicians who belong to the same organization. Separate practices and physician groups can maintain their identities while finding opportunities to collaborate on common challenges. Independence, in other words, does not necessarily have to mean doing it alone.
The stakes extend beyond private practice
Dr. Nwodim’s argument ultimately reaches physicians who have chosen employment, too. He believes employed physicians have a stake in whether private practice survives because independent practice provides an alternative employment model and, with it, competition for physicians.
“Employed physicians should know that if the private practice model goes away and they lose that competition, more than likely, their compensation will only go down from there,” he said.
For Dr. Nwodim, that makes the divide between employed and independent physicians less clear than it may appear.
“Their autonomy and their well-being are very closely intertwined with what we in private practice are experiencing,” he said.
The independent practice of the future, then, may look different from the independent practice of the past.
It may be larger. It may require more formal governance. It may depend on physicians accepting some collective decisions they would not make individually. But those compromises do not necessarily have to mark the end of independence. They may be what allows physicians to preserve it.
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