The key trends for independent spine practice in the US


Four spine surgeons weigh in on the future of independent practice in the U.S.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

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Question: What does the future hold for independent physician practices?

Richard Kube, MD. Founder and CEO of Prairie Spine & Pain Institute (Peoria, Ill.): I believe there will be increasing pressure for independent physicians to become dependent. The market forces created by the large insurers and hospital systems will make it increasingly difficult to remain independent. There are areas, especially if working within the bundled payment and free market medical arena, that independence will be key. Rising healthcare costs are a counter market force where there is opportunity for the smaller, nimble independent group to carve out a niche and thrive.

Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: Assuming we do not go to a single-payer system, either federal or state-sponsored, there will be a role. In truth, the wave of acquiring practices is probably ebbing. Those of us left behind, I think, will be increasingly pressured to join up. Practices that can coalesce and share expenses will thrive and can always be more nimble than large system-lead, hospital-based practices.

As much more accessible and responsible entities, those patients dissatisfied with big-box medicine will find a pleasant alternative with these groups. If these large systems are seeking to drive these small residual groups out, we will again find less access to care, long patient wait times, poorer outcomes and further evidence that the system we are being driven into is fundamentally flawed.

Vladimir Sinkov, MD. Spine Surgeon at New Hampshire Orthopaedic Center (Nashua): As reimbursements decline, overhead expenses grow and government and private payer rules and regulations grow more complex every year, running a private practice is becoming more complicated and less financially sound. The current trend is for more and more surgeons to become employed and it will likely continue for some time. With the relative financial safety of employment, however, comes loss of control over the practice and, to some degree, loss of control over quality of patient care.

Surgeons who appreciate the freedom, want to stay independent and want to deliver the best possible quality of care for their patients will need to become innovative. Such strategies would include learning MIS surgery techniques and moving more cases to an ASC; having an excellent marketing strategy and bedside manner; adopting new payment models such as bundled payment and direct pay; and developing new sources of revenue within their practice.

Rey Bosita, MD. Spine Surgeon at Texas Back Institute (Plano): As the fixed costs of maintaining a medical practice increase and the regulatory environment becomes increasingly stringent, maintaining independence will become increasingly hard, especially for doctors in small practices.

EMRs, digital X-ray systems, monitoring outcomes and complications and proper medical document security all add costs to the practice of medicine. Achieving economies of scale will force physicians to grow their practices either through consolidation or continued organic growth. Small practices simply have a harder time paying for all these services that drive up overhead and actually reduce their capacity to see patients.

There will also be closer alignment between hospital systems (academic, nonprofit and for-profit) and physicians to try and capture synergy in healthcare delivery and align incentives to deliver efficient, cost-effective care. Complex payment models make competition more severe at individual points of service, since each individual patient is more valuable than before as healthcare delivery systems try and capture more downstream revenue from each encounter.

Unfortunately, new residents and fellowship graduates seem to be looking less for independent practices to join, but instead they seem to seek the multispecialty groups. They are also more willing to accept employed positions with no chance of achieving equity, control or decision-making power. In my opinion, this is a trend that will further contribute to the decrease in independent practices, especially in competitive markets.

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