The future of private practice: Key thoughts from OrthoCarolina CEO Dr. Daniel Murrey

Practice Management

Successful private practices are focused on the forces driving healthcare today: collaboration and integration, transparency on quality and cost, systems thinking and innovation.

At the Becker's ASC 22nd Annual Meeting—The Business and Operations of ASCs in Chicago, Daniel Murrey, MD, CEO of OrthoCarolina, gave a presentation titled "The Future of Private Practice—Is it Supergroup, Employment or Neither? Thoughts from the Leader of the Country's Largest Orthopedic Group."


"A lot of the change is driven by the increasing volume of data. Big data is real and we are being asked to contribute," said Dr. Murrey. "Groups that aren't on EMR or digital radiology now have to worry about data collection. If you are in a solo practice, the idea of spending nights and weekends understanding regulatory changes and learning government updates is difficult."


As a result, many solo practitioners and small groups are joining larger groups or merging as larger physician organizations. Across the country, only 17 percent of physicians reported being in solo practice in 2014, down 8 percent from 2012, according to a report form The Physicians Foundation titled "2014 Survey of America's Physicians: Practice Patterns and Perspectives. "There were 35 percent of physicians who were physician practice owners in 2014, down from 49 percent in 2012.


But independence is still alluring and many specialists feel is the best route forward. Physicians have a fiduciary responsibility for their patients; they're obliged to work for the patient's benefit, not their own.


"In those terms, the more independent a fiduciary is, the easier it is for them to live up to their fiduciary responsibility," said Dr. Murrey. "We know there is a difference between internal auditors and external auditors. Physicians can be increasingly dependent in employed situations and asking someone to risk their employment can be difficult."


As the CEO of OrthoCarolina, Dr. Murrey champions physician independence and spends time discussing independent physician opportunities with medical students across the country. Physicians, he argued, have a unique perspective as leaders in the healthcare space and should take on a more active leadership role.


"Physicians are trained to look at the world in a certain way and that creates an affinity among them," he said. "Physicians even in competing health systems are still brethren and they have great affinity and respect for one another. That's a culture you can build on. Health systems have a culture defined by their leadership, who could be physicians, but might not be. They are more likely to have cultural complexity."


Many private practice physicians choose to stay independent for the autonomy; however, Dr. Murrey argued that only autonomy for better clinical judgments is acceptable. Autonomy gives physicians control over the practice setting; the autonomy to use any implant, even if it doesn't have the data to back it up, won't make private practice successful. The autonomy to arrive at the operating room late isn't the autonomy surgeons need.


"Physicians need to have autonomy to serve the patient's interest, but if it's to serve someone who isn't the patient, that's not the best situation," he said.


Becoming a systems thinker holds autonomous physicians accountable, and is one of the biggest transitions in healthcare today. Instead of focusing just on the surgery and radiographic outcomes, surgeons are now challenged to take responsibility for the patient's entire care experience.


"What we value is whether physicians make great decisions, learned decisions and whether the patient has a great experience," said Dr. Murrey. "That's an inward way of looking at the world. If I'm a systems thinker, I look at the world differently. How many physicians ordered tests that haven't been done? The patient cares less about whether you made the good decision to order the test than whether they got what they needed. If I'm outside the system as a private practice physician, am I asked to take responsibility for what happens inside the system? I can't just send my patients with an order out the door. I have to take responsibility to make sure the patient gets what is needed. This is a move from autonomy to accountability."


The healthcare system is currently mired with misaligned financial incentives — rewarding work done, not health improvement — and poor communication. There isn't transparent pricing and poor connectivity between providers can lead to a lousy patient experience. Care often isn't coordinated intuitively for patients.


"Unbridled autonomy and the lack of integration and coordination in healthcare is provider-focused, not patient-focused," said Dr. Murrey. "Clearly, we need a systems approach to address these issues. The demands of complexity and efficiency require scale to afford it."


Solo practitioners often don't have the resources to purchase an EMR for benchmarking and data gathering. They aren't able to communicate with other providers in a meaningful way without this technology, and the infrastructure becomes overwhelming. The larger scale groups enable transparency and accountability in healthcare for a disciplined approach.


"At OrthoCarolina, our culture is built on quality, service, community and teamwork. If you have physicians emboldened for higher quality at a lower cost, the market should reward you with value-based contracting, ACOs and bundled payments," said Dr. Murrey. "You should know how your group compares with other groups around the country and begin to take on risk. We do take risk on ourselves with seven commercial bundle relationships in mostly hips and knees, but some in spine."


The bundled payments have been a transformative opportunity for OrthoCarolina physicians to work with patients; the readmissions and complications are minimized. Every patient goes home by a day-and-a-half after surgery and their patients report good numbers on the pain scale.


"This is a process that allows us to provide better care for patients at a lower cost," said Dr. Murrey. "Ultimately the platform that will allow you to meet those requirements is the right culture and shared decision-making. Choose a strategy you can perform on; strategy is great, but it must be rooted in your organization's culture."


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