President's Perspective May 2015

Richard Derner, DPM FACFAS  
Bring Out Your Dead
Monty Python and the Holy Grail
Richard Derner, DPM, FACFAS
ACFAS President

Is private practice dead? I have been in private practice for more than 24 years and have seen many changes. Shortly after joining a busy, one-doctor practice in 1990, there was a significant shift in reimbursement for surgical procedures. HMOs and PPOs were on the rise, even capitation, and physicians needed to plan how to deal with these new challenges. Some physicians changed their methods in caring for patients, seeing many more patients per day, while other physicians continued to treat patients as if nothing changed.

Since those years in practice, managed care continued to gain strength resulting in the reduction of reimbursements to physician and hospitals in an attempt to tame the skyrocketing costs of healthcare. The writing was on the wall that this couldn’t persist as costs continued to increase. More information regarding the quality of care in other countries seemed to demonstrate that our system, once thought of as the best in the world, was not.

A change was therefore, deemed necessary. The first noticeable change started with primary care physicians. More and more primary care doctors left solo practice and became employees of hospitals or hospitalists. The days of the one-doctor primary care office were dissolving. According to most analysts, this would happen regardless of the implementation of the Affordable Care Act or not.

As a result, with the enactment of the Affordable Care Act, there appears to be a move from fee-for-service to value- and population-based reimbursement. Physicians will still be able to maintain some autonomy with either single-specialty or multispecialty mega groups more than they would as hospital employees. The days of hanging a shingle may very well be over in time with our new healthcare environment.

“I’m not dead yet…I’m getting better.” “No you aren’t, you will be stone dead in a moment." This classic exchange from Monty Python and the Holy Grail can be related very closely to today’s healthcare and the single-doctor practice. Once a vibrant part of our healthcare system, the single-doctor practice will just be a footnote in history. The Marcus Welby MD, persona is gone and most likely will never return.

Foot and ankle surgeons are late to join this fray in the healthcare chess game. Many other specialties have joined hospitals and have formed large multispecialty groups or large single-specialty groups. The advantage of these large groups allows the use of one National Provider Identifier number, creating increased bargaining power with supplier and especially insurance companies. We as foot and ankle specialists are now evaluating these prospects and starting to make move toward the future. Unfortunately, none of us know exactly what the future will bring or what will be the best option.

One of the College’s six strategic initiatives is to work closely with practice management experts to help you navigate these uncharted waters, but this is not an easy question to answer. Every physician will have his or her own preferences for how they want to practice—or perhaps retire—and all of the answers may not be available or easily accessed, which makes this even more frustrating.

“I’m getting better!” as the wounded soldier says in Holy Grail, may unfortunately not be the case for some solo practitioners. This problem is more challenging, and personal, than any nonunion or complex foot disorder This problem may require drastic measures to improve our present course.

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