[Editor's Note: Today's guest post was submitted by Mary Ellam, a reimbursement rate negotiator and consultant for private practices with NGA Healthcare. We have no financial relationship.]
We all know that the need to maximize profits and volume has depersonalized the healthcare industry. Effective and thoughtful medical care can’t thrive in an environment overrun by payer politics and a business model built to push physicians to their breaking point. When the number of obstacles facing the modern physician seems to grow every day, how do we adapt? Here are some of the major challenges private practices are facing and how to overcome them.
The 3 Greatest Obstacles Facing Private Practices
#1 Private practices are getting absorbed by the large health system and there are fewer than ever before
Independent practices have proved that they provide better outcomes at a lower cost than large health systems. But private practices are disappearing more and more each day.
According to AMA’s Physician Practice Benchmark Surveys, for the first time, physician-owned private practices are no longer in the majority. In 2016, 55.1% of physicians were working in privately owned practices compared to 60.1% in 2012. The reality for younger physicians is even bleaker with ownership among physicians under 40 being at about 27.9%. Why are medical professionals moving away from the private model?
As more boomer physicians retire, the latest generation is unlikely to take on the risk of running their own independent practice. For a newly trained, fresh out of medical school physician, positions in highly profitable hospitals offer too much stability and lucrative pay in the short term to turn away. With offers from large organizations that can help them repay their seemingly insurmountable student loans, it’s easy to sign on the dotted line. But at what cost?
#2 Physician burnout is real, and private practices are more susceptible to it
Over the last few decades, the workload that is required of an individual physician has escalated dramatically without any corresponding increase of pay. Much of this uptick in workload can be attributed to the transition to inefficient and burdensome EMR systems.
A study from Annals of Family Medicine concluded that primary care physicians spend more than half of their average workday on clerical work like documentation and data entry. With 6 hours of an 11-hour workday being spent on the computer rather than on their patients, its obvious why we are seeing more and more physicians take their work home with them.
This administrative burden typically falls on the backs of physicians and hiring extra hands to alleviate the weight isn’t always a financially realistic option.
To combat this, we should be looking for ways to maximize profit with a smaller pool of patients so physicians can focus their energy on providing the best care possible without being stretched too thin. This is where we can turn to the deep pockets of insurance payers for the answer.
#3 Insurance companies keep growing in size and negotiating power
Year after year, insurance companies have been absorbing their competitors and merging to maximize their own profits. By paying into lobbying efforts and playing the political field, they have leveraged themselves into a position where they can increase premiums at will while neglecting to increase the rates for the physicians.
They claim that mergers help them reduce the cost of healthcare and eliminate waste, but in reality, they are shifting the costs to the providers while hoarding more of the profits for themselves. Insurance companies’ profits keep skyrocketing and they are leaving the providers and patients that they represent in the dust.
Over the last decade, inflation has risen by over 20% while Medicare reimbursement has increased by less than 5%. (NGA Healthcare 5 Year Forecast). Each year, payers are increasing their premiums by double digits, yet we rarely see these increases passed on to the physician groups.
The issue most physicians run into is the nightmare that is dealing with insurance payers. One of the major benefits of partnering with or being acquired by larger organizations is being able to avoid that headache altogether, but the solution is to hold payers accountable and negotiate your reimbursement rates.
The Simple Solution That Most Practices Neglect
Mary Ellam
Physicians need to realize they hold more leverage against payers than they realize; even in a smaller group of physicians.
More often than not, practices are shackled by contracts and rates that are far below market value. Physicians assume that these rates are set in stone, but securing a professional rate and contract negotiator would ensure that the physician stops leaving money on the table. Money isn’t the answer to everything, but it is the solution to many of the problems that private practices are facing.
Most practices are not getting the reimbursement rates they deserve. The key to obtaining better rates is finding an understanding of your leverage and holding the insurance payers accountable.
Understand the Leverage You Have
Before negotiating better rates for your practice, you first need to take a look at your practice and identify what sets you apart from the other providers in the market such as:
- What services do you bring to the table that can be used to establish your value and give you leverage when talking with payers?
- Do you offer a service that keeps patients from needing to go to Urgent Care?
- Are you a specialist that can't be found in the area?
These are all questions to ask yourself and your team or to ask a professional rate negotiator who performs this analysis on your behalf. Working with a third party analyst outside of your practice is incredibly valuable when seeking out an honest analysis of your practice that is bias-free.
Hold the Insurance Payers Accountable
Educating and empowering independent practices is crucial to leveraging a negotiation strategy with payers. It is a simple solution to these three systemic healthcare problems that every private practice should pursue in order to remain independent. By creating a strong analysis of your practice that highlights its unique value and how it will save the insurance payer money in the long run, you will create a powerful argument for more favorable rates.
What do you think are the biggest obstacles facing private practices? What do you think is key to fixing these problems? How have you negotiated better rates? Is it worth hiring a “professional rate and contract negotiator”? Comment below!
I’m a happily employed physician in a small private practice, but if I were ever to build one from the ground up, I would kick insurance and medicare to the curb and take cash only.
This isn’t a realistic solution for many specialties, but I’m surprised more physicians don’t do this. When your income is dictated by a profit seeking third party, you never truly work for yourself.
We have a three podiatrist practice, and we are about to add a fourth. We agree with those challenges, but the burnout can be mitigated by dictation equipment and scribes.
More importantly, the issue of contracted rates with insurers is dead on. We hired a third party negotiator, and were able to get slightly better rates from UHC and Humana. (This came at a cost of increased scrutiny of getting paid – increased denials). However, we live in an area where Anthem represents a majority of our population. Anthem has repeatedly told us that they are not reviewing contracts at this time (we asked them at four different times throughout the year…so they simply aren’t reviewing contracts period). So, the majority of our payments have not improved.
It seems that one possibility is that physicians need to somehow unite to obtain some form of negotiating power (without saying unionize), otherwise physicians will continue to be pushed around by insurers. That is one strength of being associated with a hospital system…but the cost is lost independence. We would love to hear other ideas as well.
Am in texas and a solo physician.
Love my solo practice.
Where did u find a negotiator from? How did it work, would u be willing to share the details.
Biggest obstacle seems to be
1. terrible guidance to new graduates to establish new practice.
2. Hopeless AMA and other organisations to help small practices or new graduates
3. terrible regulatory environment for docs from federal, state and private insurances, millions of papers.
4. even hospital credentialing is ridiculous.
Patient care is the easiest part!
Sure thing! The company name is Vivinx (previously Commonwealth Billing) out of Louisville KY. There are several around the country, but we’ve tried in the past when we were a solo practice, but got nowhere. There’s another company out of NC that has a good reputation, but unfortunately I have forgotten the name. Good luck!
Every private medical practice in our town is being purchased by the hospital system. Now, you pay for the doctor only to see a mid level provider, long wait times for appts, and spend 1/2 a day in the waiting room. You can sense that staff aren’t happy. Completely broken system. It really sucks as my wife and I are getting to the age where we need competent, caring doctors. I had to tell a young PA to please put down the i-pad and look me in the eye during a routine exam.
I run a small Orthodontic private practice and I know the level of care we try to provide, so it is very frustrating dealing with corporate practices. Simple tasks like transferring records that used to require physically mailing models and paperwork, can now be done electronically. It used to be that Orthos took pride in continuing a patients care by promptly sending very good records and many times following up with a phone call. Today, we have to call numerous times to get records sent via email! When they do arrive, they are typically incomplete. Corporate money is ruining medicine and dentistry. It is only a matter of time before they push through a mid level dental provider that will work for less than a doctor (under the guise of “access to care”). Should be access to crap. There just isnt enough money in doing fillings for more than one person to make a living. We have a doctor, an insurance company and a corporation all wanting a piece of the procedure. Drives the costs through the roof. Hopefully young docs will recognize this and turn the tide back towards a private practice setting and be rewarded for the risks. It isn’t how much you make, its how much you keep.
I joined a large multi-specialty private practice. We have tremendous negotiating power compared to the small office that has little bargaining power. I would recommend banding together with a group of doctors to fight the corporate machine taking over medicine completely.
I left the corporate medical model after 3 long exhausting and unfulfilling years and started a solo practice. I never borrowed any money and built it on a shoestring, also waiving any salary for 6 mos, and am starting my 4th year next month, with steady growth every year!
As mentioned by someone else, and not discussed in the post is why bother with insurance at all!!!! I have a cash practice and opted out of Medicare and while here in the Midwest this is still a fairly novel approach, I am continuing to grow every year, partially because I provide a service that nearly no one in a 2-3 hour radius of me provides (Functional Medicine)! I see lots of Medicare and other 3rd party insurance patients who realize that they have to vote with their dollars to get the health care they want, not the disease care that everyone else thinks they deserve!!
Insurance companies are as big a part of the problem with medicine today as is the very corporate medical model I left behind. Medicine is supposed to be between a patient and their doctor! Until we as a country come to terms with the idea of “people over profits” we will continue to have the miserable disease care system that we have and if COVID 19 has shown us nothing else, it has shown just how fragile and insecure this whole model actually is!!