Should Doctors Work for Hospitals? Tough Question.

A physician I have known for many years recently told me about his decision to enter the world of concierge medicine. His reasoning was telling, saying that it came down to a very simple decision on staying independent or becoming a hospital employee. He liked being an independent solo practitioner, and that was his primary motivation – to maintain independence in a time of consolidation. 

Richard Gunderman, writing for The Atlantic, tackled this question head on in a recent piece titled, “Should Doctors Work for Hospitals?” The article reflects on the dramatic shift in physicians either seeking or being forced by market pressures to join hospital systems as employees.

Barring occasional periods of hospital consolidation, the independent practice of medicine has defined the American healthcare model almost as long as physicians have existed. There are many reasons for that, including the desire to control how you manage your own business and the freedom, as well as responsibility, to provide care as you see fit. These are touchstones on which medical care has operated for decades.

There are no doubt many benefits to joining larger groups. The chief one is perhaps better exchange of information, either personally or via information technology, to better manage patients and provide better care. Although, I must confess that as an emergency physician I have seen very little benefit from the millions of dollars spent on cutting edge hospital information systems. None of them have made me more efficient, nor have any allowed me to provide better quality care through the use of improved algorithms and pathways to best practices. At best, the notes look better and are more easily searchable. At worst they require the clinician to be a high-priced data entry tech.

The Atlantic article raises other concerns, including the fact that after purchasing a physician practice hospital systems are able to charge a “facility fees” for the same office visit or procedure at, in some cases, double the cost. The tragedy is that if the physician had been able to collect a slightly higher fee in the first place they would probably have never considered being acquired by a hospital system.

There are certainly other advantages to joining a larger entity. One especially important one is the ability to negotiate better rates as opposed to being in solo practice. Hence my friend’s decision to join the ranks of concierge doctors, which require a yearly fee for the ability to see your provider for longer office visits and rapidly when needed due to the management of much smaller panels of patients.

We have seen consolidation of physician practices before, followed by wholesale divestment of these practices as the environment changed. The argument for consolidation today is that we have much better tools and data to manage costs and quality across large health systems.

Managing physicians is always a delicate process. We need to respect the years of training and sacrifice that physicians have invested and the core belief of most physicians that they are there to serve our patients. Striking that balance in the right structure requires numerous levels of ongoing communication on what is best for the patients, system and providers. A delicate balance indeed.