Moving Out It has become increasingly challenging to stay in business as a private-practice primary-care physician. In recent years, hospitals have purchased large numbers of independent and physician-owned practices. The descent in the numbers is striking. A  2014 Physicians Foundation survey of 20,000 U.S. doctors found that 35% described themselves as independent, down from 49% in 2012 and 62% in 2008. The previously independent doctors typically accepted salaried roles inside larger institutions, often affiliated with a local academic medical center, while retaining their group identity to the outside community. Why has this come about? The first, primary reason is that in the Affordable Care Act (ACA) purposefully provides strong financial incentives to favor hospital ownership of medical practices, ostensibly to improve outcomes, care productivity, and patient experience. Initial evaluations of aggregate changes to outcomes have been mixed and hotly debated, and it would be premature to draw firm conclusions about long-term outcome metrics until the system truly stabilizes from its present state of continuing substantial flux along organizational, payment and legal axes. However, what is not debatable is that doctors now receive substantially better reimbursement rates from health insurers and Medicare for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. This differential, coupled with the recognition that private HMOs have aggressively cut back what they pay primary-care physicians in recent years, has compelled many doctors to move on.

Secondly, the implementation costs of EHRs are very high. Although federal incentive payments nominally have helped to defray startup costs, government incentives were capped at about $44,000 per doctor for systems that cost at least $100,000 and often closer to $200,000, presenting financial burdens for doctors, especially in small-to-mid-sized private practices. A report in November 2014 from the Agency for Healthcare Research and Quality found that the average five-physician primary-care practice would spend $162,000 to implement the system, followed by $85,000 in first-year maintenance costs, plus subsequent maintenance and upgrade costs. Many private practices often find it difficult to pay such sums, especially if they fear that the new systems are not permanent, thus requiring new significant outlays. So again, they increasingly go under a hospital’s umbrella, where an extant EHR is already provided with no further expense to the practice.

Thirdly, although this may be less important to some physicians, technical support for EHRs appears to be significantly more responsive to hospitals, particularly to those affiliated with highly regarded academic centers, than it is to independent practices. This is not a minor point, given that many of the most prominent EHRs do not routinely have a local presence, of course in conjunction with the frustrations and non-usability of EHRs already discussed.

A Faustian Bargain? Nonetheless, many small private practices would still ideally prefer to remain autonomous, even if it meant a modest hit in the pocketbook. Retained independence would allow the physicians to practice in ways that they have adopted over many years, that fits their world view of good doctoring, with a minimum of external influences or burdens. This push-pull tug-of-war between absorption and autonomy has created a golden opportunity for web-based EHR vendors to provide technologic `solutions`, which have become very popular in the last few years. Notable among these companies is Practice Fusion, whose free software includes the full EHR package, with charting, scheduling, e-prescribing, billing, Meaningful Use certification, training, support, and a personal health record for patients. Practice Fusion’s blog proudly (and legitimately) notes that their system dramatically reduces the IT burden for practices. This system has recently been named by several well-established ranking organizations as the No. 1 EHR system for value among ambulatory professionals, for customer satisfaction among primary care providers, and for helping doctors achieve Meaningful Use (which of course leads to payments). Moreover, all of this is for free. So, is this the magic bullet for small practices? Well, just perhaps. Think back to the sponsored alerts described above – brought to you by the same vendor Practice Fusion as described in the essay `Franz Kafka, meet Joseph Heller`. This is the quid pro quo – the EHR vendor that helps most to keep private practices independent, to retain `the old ways` of long-term continuity of care, will pay its bills in part by an interesting model. As a society, do we want to pay for private practices to remain autonomous by this (or similar) means? At the very least, we need to be aware of the present path of least resistance. Some, including Nicolas Terry (the authority on the intersection of medicine, law and information technology featured in the essay `Legal Recourse: Slim and None`), have advocated that we keep third party or commercial interests entirely out of the EHR picture, via legislation. I would wholeheartedly agree, but then many private practices would still require a comparable replacement to what Practice Fusion now provides to stay afloat. Where will – or should – the money come from to pay for this? This screams out to me for attention, discussion, and resolution, by society at large, the sooner the better.

Lost Horizons However, what may be lost in this migration worries me a great deal. Continuity of care with a single provider is gradually being diminished, if not amputated. No matter how excellent an EHR might ever be, it seems highly unlikely that a physician would confidently deduce the interpersonal dynamics of how best to nudge an unfamiliar patient towards helpful behavioral, relationship or lifestyle modifications. Medical care in these newly minted outpatient clinics is becoming more like shift work, more compartmentalized and fragmented. Critically, with the loss of continuity of care by a primary physician (or small group) over an extended time-period, who within the medical profession will be deeply vested in maximizing an individual patient’s long-term health? Who will help to fight the system on the behalf of their patients? Who will identify well-matched specialists for complicated procedures, and go the extra mile to ensure smoothly coordinated care? And perhaps as importantly to patients, who will be vested to ensure that after procedures, patients will have a minimum of side effects, especially if these occur later or are not routinely quantified? A much smaller percentage of the physicians within large hospital settings, I believe. This recognition by many patients has accelerated the interest in solutions that are entirely out of the present system, a parallel tier, either into concierge care, or a variant in which a physician is identified as a `captain of the ship` overall care coordinator.

Indeed, it was just announced that starting this coming August, Harvard-affiliated Mass General, which was founded more than 200 years ago to treat the poor, plans to open a concierge medicine practice. For $6,000 a year (and whatever their insurance pays), patients in its new Concierge Medicine Practice will get round-the-clock access to their doctors, as well as personalized nutritional, exercise and wellness counseling. So this evolution by Mass General, one of the nation’s top hospitals, vividly confirms a significant pent-up patient demand for a separate track that will allow for more `meaningful` and less administratively-driven patient-physician interaction, even at a substantially elevated price.