Why don't private practice physicians have more power in healthcare? 

Fourteen physicians and leaders joined Becker's to discuss why physicians don't have more power in healthcare. 

Editor's note: These responses were edited lightly for clarity and length. 

Ernest Braxton, MD. Spine and Neurological Surgery Specialist at Vail-Summit Orthopaedics and Neurosurgery (Vail, Colo.): Private practice physicians often find themselves with limited influence in the healthcare landscape due to several factors. Firstly, healthcare is fragmented, with power dispersed among various stakeholders like insurance companies and large hospital systems. This makes it challenging for individual physicians, especially those in smaller practices, to compete. Additionally, resource constraints hinder their ability to invest in technology or advocacy efforts in Washington, D.C. Regulatory burdens, such as complex billing regulations, also consume valuable time and resources, making it hard for physicians to have the bandwidth to advocate for changes on the horizon. Moreover, their dependence on referral networks and economic pressures from the rising cost of overhead further weaken their influence. Despite these challenges, opportunities exist for physicians to enhance their power through strategic collaboration and advocacy efforts. My primary voice for advocacy are through professional organizations such as the Council of State Neurosurgical Societies and the Colorado Neurosurgical Society.

Adam Bruggeman, MD. Orthopedic Surgeon at Texas Spine Care Center (San Antonio): Private practicing physicians have lost power for a few reasons. The first is the growing trend toward further specialization and subspecialization leading to a disjointed voice when meeting with regulators and legislators as to how to fix healthcare. Hospitals and insurers on the other hand have a unified voice. In addition, the continued consolidation of healthcare companies and practices has led to consolidation of wealth amongst facilities and insurers. Their outsized financial position while diminishing the financial position of physicians has further led to power imbalances.

Kenneth Candido, MD. CEO & President of Chicago Anesthesia Associates. Private practice physicians are becoming more and more rare in American healthcare. This is by design and is not random. Large systems are siphoning off private practice physicians and are buying or consolidating practices exponentially. Those who hold out find a shrinking referral base, as those formerly loyal to them are being compelled to exclusively refer within the system. It is a dirty business and a dirty, underhanded game that administrators are playing to monopolize their business models. Physicians "in the system" are punished if they refer to outside, private practice physicians. They have bonuses cut or undermined or have other sanctions placed upon them. The referral process has been weaponized. The hospital systems have created a monopolized system that demands their own "growth" to the exclusion of any competition in their areas. This monopolization is largely tolerated by the enforcement of noncompete clauses and legal loopholes that in any event do not attract the government oversight, since they are in collusion with the major health systems to eliminate privatization or care and to move rapidly towards socialization of care. The private practitioner, unless they are in plastic surgery or dermatology, are essentially dinosaurs on the road toward extinction. The old mantra of "divide and conquer" has been expertly used by the major healthcare systems to pick off the lone or small group practitioners, and has been extremely lethal and effective. 

Harel Deutsch, MD. Co-Director of the RUSH Spine Center (Chicago): It's difficult for a solo practitioner or small group to compete against much bigger entities such as health systems and hospitals. Resources for small groups are limited, and we see any increasing share of revenue is derived from facility fees and hospital fees versus doctor fees, which are declining. 

Nitin Khanna, MD. Surgeon at Spine Care Specialists (Munster, Ind.): The challenge is scale. I like to compare surgeons to professional athletes. There are only a select few that can obtain these specialized residencies and then complete a year of rigorous training. This is a high barrier to entry similar to an NBA or NFL player. Professional athletes have been adept at utilizing agents to negotiate their contracts. AAOA and AANS need to combine and do something similar. Our services and skills cannot be taken for granted. In spite of mental health concerns, the system continues to add more and more administrative and cost burdens on clinicians. The airlines, UPS, autoworkers, etc., have all been successful as a group to negotiate in some cases a 40% increase in wages.

Bert Mandelbaun, MD. Professor Department of Orthopaedic Surgery Cedars Sinai (Los Angeles): The business and economic power of our present healthcare system is based on business-to-business relationships. As physicians, we have few leaders as most are focused on patient care. To be more powerful we must develop physicians who can lead their communities, the health system and their patients concurrently.

Thomas Pliura, MD. Physician and Attorney (Le Roy, Ill.): Private practice physicians have lost their power in healthcare because their patient bases have dried up…as the hospital systems have gobbled up the patients through their extensive network of non-physician practitioners, the few physicians who have remained in private practice have been gobbled up. Additionally, those physicians who left private practice to be bought out by large hospital systems. Virtually all of those doctors are coerced into signing binding noncompete provisions that prohibit these physicians from leaving the employment status to go back to the private practice of medicine. These physicians are led to believe the grass is greener on the other side of the fence, but when they go into an employed setting, that is not always true. But they are handcuffed by these restrictive noncompetes.

I hold the opinion that one of the worst things for the public is non-compete clauses. The FTC is looking closely at this subject, and maybe they will pass federal legislation to prevent the use of non-compete provisions in healthcare. They create artificial shortages in medicine. They create monopolies in medicine. They are not in the best interest of patients or the public.

Scott Russo, MD. Professor of Neuroscience and Director at the Icahn School of Medicine (New York City):

A) Despite providing significant amounts of care to patients unable to pay, they are not recognized to some degree as not-for-profit and do not have the same status as not for profit hospitals. And received no financial benefits for this unreimbursed care.  

B) Lack of leverage with the insurance companies. 

C) Inability to leverage size and keep costs down with suppliers. This is why clinically integrated networks are becoming more commonplace.   

Kristopher Schroeder, MD. Professor of the Department of Anesthesiology at University of Wisconsin School of Medicine and Public Health (Madison): I don't imagine that there is a single answer that would be appropriate to cover all of these physicians. It may be that workflow and the expectation for specialty engagement exists to a greater extent in academic medicine. It may also be that those in academic medicine may have more of an innate interest associated with engagement in these activities or an increased leadership support infrastructure that provides the resources required to fully participate. It may also be easier for private practice organizations to fragment physician groups and thereby diminish the collective power of the group. Whatever the case, there is ample evidence that promoting and empowering physicians improves organizations and there should be efforts to ensure that those working in private practice are encouraged to contribute to leadership efforts.  

Thomas Schuler, MD. Spine Surgeon and Founder Virginia Spine Institute (Reston): Private practice physicians focus on their patients and work responsibilities, not political action.  Work demands stretch these physicians thin. Unfortunately, they do not focus on the large scale political picture since they are consumed by the daily obligations to patient care.This results in the private practice doctor's perspective and interest not being represented on the political stage. Furthermore, hospitals and insurance companies spend much money on lobbying to achieve their control and ultimate financial success. Organized medicine does not represent the private practice physicians adequately. The individual physicians are left without a voice and without power in healthcare. 

Matthew Searles. Partner at Merritt Healthcare Advisors: Many private practices don't have any bargaining power with the payers and they often cannot achieve the scale or afford required investments in technology that will allow them to adapt to changing payer models.

Khawar Siddique, MD. Co-CEO of DOCS Health (Los Angeles): You can thank the government for that (independent physicians are not allowed to negotiate together because it is considered collusion). Secondly, physician groups like the American Medical Association have proven to be ineffective.

Vladimir Sinkov, MD. Surgeon at Sinkov Spine (Las Vegas): Private practice physicians have more power in healthcare than their employed counterparts. Private practice physicians at least have some control over what insurance contracts they sign, where they practice, which hospitals they chose to go to operate or admit patients and what schedule they have. Employed physicians frequently relinquish those decisions to their administrators. All physicians, however, have been gradually giving up their power to control the healthcare system. The main reasons for that include a lack of understanding of the financial aspects of the current healthcare system and the resulting unreasonable fear of financial loss as well as desire to 'just practice medicine' instead of getting involved in policy decisions. The rest of the healthcare entities (federal and state governments, health insurance companies, hospital systems) exploit these 'weaknesses' and continue to assert more and more control over the physicians — the actual providers of healthcare.    

Leigh Wilson. Former Manager of a Neurotology Practice in Portland, Ore.: In general, private practice physicians are not organized into groups for contracting reimbursement levels with insurance companies and cannot create groups without forming partnerships. Consequently, each practice contracts for insured rates on a solo basis with limited numbers of patients, which prevents them from receiving a higher reimbursement. Private practice is ultimately too expensive in overhead incurred by staffing required to meet regulations imposed by insurance companies and the federal government. Power takes numbers and private practitioners, in general, want to be just that, in private practice — hence no power to contract for higher reimbursements.

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