Community-Based
Group Practice: Is the Grass Greener on This Side of the Fence? |
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By
Neil W Treister, MD, FACC
It comes
as a surprise to my patients and to many of my colleagues in "the
private sector" that I am such an ardent supporter of the Southern
California Permanente Medical Group (SCPMG) and of the Kaiser Foundation
Health Plan--especially since I left SCPMG in 1988 to practice cardiology
in the community setting and have not returned--not yet, anyway.
During
the past 15 years, I have worked in several communities, at both large
and small hospitals, and in solo practice. I also founded a single-specialty
group practice that has grown to five cardiologists. While maintaining
a private practice, I have consulted with health care organizations,
served on hospital boards and committees, worked as medical director
of a medical management company, and survived a health care MBA program
at a local university.
I have
seen great triumphs and huge disappointments in our disjointed, community-based,
entrepreneurial, fee-for-service practice of medicine. And having trained
as both an internal medicine intern and as a cardiology fellow at the
Kaiser Permanente (KP) Los Angeles Medical Center and worked as a staff
cardiologist at the "new" KP Woodland Hills facility, I feel
well qualified to share with you some perspectives of life "on
the other side of the fence."
I always
just assumed that physicians in SCPMG understood what it was like to
practice in a community-based solo or small-group practice setting.
I was therefore surprised when, during my recent conversation with a
prominent SCPMG physician, he expressed genuine astonishment at some
of my stories about medical practice in the non-KP setting. He encouraged
me to present this perspective for SCPMG physicians. Naturally, these
ideas are derived from my own personal observations and represent a
limited sample. However, I believe that my experiences are not isolated
and reflect some fundamental challenges faced by all clinicians who
try to deliver high-quality, patient-focused care in a community setting.
"Groupness"
in Group Practice: Fact or Fiction?
My practice
has almost always been busy, and I have little recollection of facing
the threatening prospect of trying to make ends meet. Therefore, unlike
the situation faced by many other physicians, financial uncertainty
has not been my greatest concern in private practice. For me, the most
difficult challenge in private medical practice is the absence of "groupness."
In the private sector, many physicians are engaged in solo practice
and thus are truly on their own. Most medical groups are small, and
those that manage to stay together do not function as true groups: instead,
they seem more like individual doctors sharing overhead costs. What
holds them together (not always for very long) is that group practice
can ensure reliable after-hours coverage and the misguided belief that
their arrangement affords them economy of scale.
That doctors
who are members of a group practice can feel alone and behave as individuals
has tremendous implications. These clinicians experience little or no
teamwork on a day-to-day basis and have no common professional culture
based on shared values and goals. Because they do not think and act
as groups, most doctors in private practice do not consistently or productively
address issues such as mentoring new physicians, developing clinical
guidelines for patient care, subjecting themselves to peer review, and
adopting reliable processes for ensuring overall quality. Physicians
who work together in "nongroups" often compete instead of
collaborate, choosing to distribute income on the basis of individual
fees collected and without any thought as to group performance.
The lack
of a group culture and regular teamwork in community medical practice
underlies what is probably my single most startling experience in private
practice: In more than 90% of cases, I am asked to render cardiology
consultation not by the ordering physician but by a nurse or ward clerk
who has read an order in a patient's medical chart. The caller usually
is unfamiliar with the ordering physician's concerns and often does
not know the patient's current health status. In some instances, the
physician who wrote the order did not discuss the case with me in person
even though he or she was present on the ward--perhaps even sitting
beside me! This situation gives the impression that the physician
is embarrassed about wanting or needing assistance in the care of his
or her patient.
I do not
believe that physicians refrain from consulting me in person because
I am difficult to talk to or because cardiology does not require physician-to-physician
communication; in fact, my medical colleagues in virtually all specialties
experience the same phenomenon. Nonetheless, this lack of face-to-face
communication can lead to wasted time and resentment. For example, cardiologists
making rounds at two, three, or more hospitals are periodically called
back to a hospital because a chart order for a consult was not recognized
promptly. This type of event has far-reaching implications for the quality,
efficiency, and timeliness of patient care as well as for collegiality
among physicians.
In most
medical groups, time and forums are rarely devoted to meaningful discussion
of patient care. Indeed, most medical groups lack the resources (time,
money, and staff) to address the need for better education and timelier
clinical information. These medical groups do not formally address adoption
of new technology or how new medications might be used consistently.
Decisions about acquiring a new piece of equipment may be determined
by how much revenue the equipment can generate and not by its appropriateness
and contribution to quality of care. In short, most physicians in private
practice lose opportunities for learning, quality improvement and personal
growth. In contrast, during my two years at KP Woodland Hills, each
physician was expected to participate in Tuesday-afternoon educational
meetings and had access to an information infrastructure created and
maintained through adequate investment.
When physicians
act alone and not as a group, decisions and outcomes are more personal.
In my private practice, for example, I had to create and run a small
business and make decisions that had tremendous implications for my
employees as well as for me. I had to decide who received a salary increase
and when. I had to choose health insurance coverage for my employees
and then pay for it out of my own pocket. I was seen as too permissive
by some and too strict by others. At times, I could not find an experienced
manager whom I could trust to oversee the front and back office functions.
When equipment or processes have broken down, I have had to put patient
care responsibilities on hold and switch over to solving business problems.
I have been unlucky enough to be sued for malpractice and felt very
much alone navigating that complicated process with little help from
the people around me. To this day, I look wistfully at electronic medical
record systems, knowing that investing in such a system in the near
future would not be feasible for our practice.
In my
experience, hospitals and physicians seem to be in conflict much of
the time, and hospital-physician relationships are unclear at best.
Hospitals are seen by physicians as their rightful domain--an entitlement--and
physicians do not understand the many challenges and compromises that
must be made. Physicians also do not understand why they cannot dictate
important decisions about capital outlay and daily operations. Hospitals
see physicians as selfish and shortsighted. Only a few physicians meaningfully
contribute to how hospitals address patient care decisions; instead,
most physicians approach these issues by asking, "What can I get
to make my practice better?" The result of this situation can be
underlying distrust and lack of any meaningful collaboration; rarely
does better patient care result. I have repeatedly seen hospitals and
physicians together tolerate illegible writing, medication errors, and
disruptive physician behavior.
The physician's
time in the community setting is unprotected and can be characterized
as "feast or famine." A cardiologist making rounds at one
hospital who has 14 patients yet to see at two other hospitals tends
to have mixed feelings about running into an internist friend who might
have just admitted a patient with atypical chest pain. Or a cardiologist
whose service is quiet might be afraid of what another cardiologist
would say at seeing a colleague wandering through the emergency room
to see if any cardiac patients are waiting there.
Benefits of Collaborative
Medical Practice
From a
broader perspective, I am deeply troubled by the waste and inefficiency
in the private practice setting. Outpatient tests are repeated and other
services duplicated because we lose records or don't share them with
other offices. We spend an enormous amount of time and money trying
to extract information from other doctors' offices or from our own offices
at different locations. We must bill a wide assortment of payers, each
of which requires slightly different information. In addition, hospitals
and managed care organizations update credentialing on a regular basis,
each with a unique form that must be filled out by hand. In the private
sector, specialty groups underuse nurse practitioners and physician
assistants, who can improve both efficiency and quality of care.
Our private
practice model imposes a phenomenally large cost to the country. For
some of the for-profit health plans with whom we work, less than 80%
of each premium dollar (ironically termed the "medical loss ratio")
is spent on medical care;1 the rest is allocated to administration,
marketing and profits. As a member of the health care community, I find
distressing that these unnecessary layers of costs take chunks out of
the health care dollars and rarely add the value that they promise.
I am well aware that KP spends nearly 95% of each health care dollar
on patient care.1
Another
point is perhaps the most important. Having trained and worked in the
KP system, I find the incentives under fee-for-service medicine very
disquieting. If you are paid a fee for service, you can immediately--and
rightfully--start worrying about whether you are yielding to the temptation
to order more tests and create more visits--services that have immediate
effects on your income. And another disquieting fact is that the tests
and treatments you order often have substantial costs for your patients.
I have found myself debating the cost effectiveness of my recommendations
from the patient's perspective--a difficult, slippery slope. In addition,
without good practice guidelines or adequate information systems, physicians
having to make these decisions are hard-pressed to do so adequately
and consistently.
As a result
of lack of consistency in medical decision making, some practitioners
do far too much, and some others do far too little. I have known cardiologists
in private practice who administer treadmill tests annually, echocardiography
regularly, and Holter monitoring routinely without evidence supporting
the medical value of these tests in many cases. In contrast, when paid
on a capitation basis for the same patient, these same physicians realize
that such tests aren't needed "in this particular case." I
found that in the KP system, I did not worry about how much money my
decisions were costing the patient or whether I was personally benefiting
from the services I performed. At KP, I practiced in a purer and more
ethical environment--one that is very difficult to achieve in the usual
private practice setting.
Conclusions
The private
practice world is very different from the Permanente Medical Group workplace.
In my tenure at KP, I experienced a highly consistent group culture
that helped me make better decisions on a regular basis. The incentives
were conducive to unbiased and patient-oriented choices. I had ready
access to help from experienced people who were on the same team. Neither
my colleagues nor I had to contend with the distractions inherent in
running a business.
I admit,
my perspective might have been clouded by 15 years' separation from
KP Woodland Hills and might not reflect the current environment at that
(or any other) KP facility. Moreover, I was particularly fortunate to
train and work with some very special friends and role models, such
as Jack Braunwald, Peter Mahrer, Joe Ruderman, Al Dreskin, Lew Seager,
and Jeff Weisz. Perhaps my SCPMG experience was unusual. Nonetheless,
if you are a PMG physician longingly peering over the fence and marveling
at the green grass at the community hospital, you should understand
that what you are seeing might be artificial turf. You may underestimate
what you have and how it has molded and conformed to your personal and
professional values and goals. The fit in the private sector might not
be as good.
I left
KP Woodland Hills in 1988 and do not regret my decision; I have learned
much from the rich variety of my professional experiences in the "outside"
world. However, I now practice cardiology part-time, which is the compromise
I make to work in a "system" that is disjointed and inefficient.
And--as I say each time someone asks--I am sure that if I ever go back
to full-time clinical practice, it will be with SCPMG or in a similar
organization that embodies the values and professionalism that are so
important to me in my practice.
Reference
- California
Medical Association. 10th Annual Knox-Keene health plan expenditures
summary, FY 2001-02. [Sacramento (CA): California Medical Association;
2003] Available from: www.calphys.org/assets/applets/0102_knox_keene_report.pdf
(accessed October 22, 2003).
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