Solo Practice Doctors Become Endangered Species

Can alternative practice models like concierge medicine or direct primary care save them?

Tom Kisken, Ventura County Star, April 6, 2013


Ted Hole knows he’s a dinosaur.

In an age of electronic records, the 63-year-old family practice doctor from Ventura tracks hundreds of patients in paper files that layer shelves and weigh down filing cabinets.

Doctors in the large health care systems that may be the future of medicine employ administrators to deal with an avalanche of federal regulations and insurance mandates. Hole tapes a paper note to walls. “No injections on same day as visit,” it reads.

At a time when solo-practice doctors face odds that would scare an inveterate gambler, Hole is more solo than most. On days when his only employee — a nurse who has worked with him for 30 years — is out, Hole answers the phone. But it won’t stop ringing. Patients are waiting. Insurance companies need paperwork. So Hole offers a white lie.

He tells callers the doctor can’t come to the phone. He’s too busy.

More than half of the nation’s doctors worked in solo or independent practices 13 years ago, according to estimates from the Accenture consulting firm. The consultants predict that number will fall to 36 percent by the end of this year, with the decline driven by the cost of running a business.

A 2012 survey from the Association of American Medical Colleges showed one in 100 of the nation’s medical school graduates planned a solo-practice career. More than six in 10 wanted to work in medical groups, in partnerships with hospitals or at a university.

Some observers contend solo doctors will survive. They say the old-school physicians who pride themselves on medical autonomy and their bond with patients will find ways to deal with administrative burdens, federal reform and changes in the way they’re paid.

Others say the tar pits are waiting.

“They don’t have a future, not in the new health care paradigm” said Jim Lott, executive vice president of the Hospital Association of Southern California. He contends the only private-practice doctors who will survive are those who partner with hospitals and medical groups or reject insurance altogether and accept cash only(concierge medicine or direct pay practices).

“The others are just in denial and have their heads in the sand,” he said.


Hole’s office is decorated with muted blue wallpaper. It hasn’t changed since he took over the office 21 years ago.

Every morning, Hole arrives at 7 a.m. to do paperwork. He calls it “parasitic drag” as part of a rant against insurance companies and nonstop government regulation.

“Insurance companies are getting more aggressive in trying to control the medications to treat patients. The goal is obviously to maintain their profit margin,” he said one morning as he scrambled for the insurance forms to continue a prescription for an asthma patient. The request was ultimately denied.

Years ago, he would make hospital rounds every morning to see his patients. Reductions in insurance reimbursement for hospital care and the reliance of hospitals on their own doctors curtailed that practice. Now his practice revolves around his office, on the corner of a modest sprawl of medical suites sandwiched by two hospitals on Loma Vista Road in Ventura. When his patients call, they don’t need to use their names. Hole has treated some of them for so long he knows their voices.

Marlene Reinhart, who is 81, has been seeing him since 1992. She remembers how he met her at the hospital when nerve problems in her mouth made her feel as if her head was going to explode.

“He came when I needed him,” she said, trying to explain how well they know each other. “He can tell when I’m feeling low about something. He can tell when I’m elated about something. He can read me.”

She winced at the notion that his practice — that solo doctors — may be obsolete.

“How long is it going to be where I have to go to the other kind of system, where I’m just a number, where the doctor looks at me and doesn’t even know who I am?” she said. “I find that very scary.”

Perfect Storm

Juan Carlo/The Star Dr. Ted Hole files papers, answers calls, makes appointments and checks on his patients, among other duties.
Reimbursements already have been pushed down by large companies that control the insurance market and send patients to medical practices. The Affordable Care Act provides incentives for doctors to join new networks — accountable care organizations — in which they work in sync with other doctors, hospitals and insurance companies.

Bonuses are paid when the accountable care organizations reach goals for improving quality of care and reducing health care costs, which increase with unnecessary care and hospital visits. The concept is that though doctors may make less initially, the bonuses will offset the loss.

The government is also paying as much as $63,750 over six years to doctors who have installed high-priced computer systems and are meeting government standards for using electronic medical records. But a price that can reach into five figures or higher and a transition that can cost practices more money scares away many solo doctors.

Other pressures include the rising administrative burden of running a business and the availability of jobs in medical groups in which doctors have time to lead lives outside work.

“It’s kind of like the perfect storm,” said Troy Fowler, of the Merritt Hawkins physician recruiting firm. “Many physicians are saying, ‘I’m seeing more patients than I ever did. I’m working longer hours and making less money.’”

Some large health systems have bought out smaller practices in a nationwide trend. In Ventura County, clinic systems ranging from Kaiser Permanente to the Ventura County Health Care Agency have opened new facilities or renovated old ones.

A foundation linked to St. John’s hospitals in Oxnard and Camarillo has started a group of primary-care doctors. The hospitals are also teaming up with a coalition of more than 250 local doctors in a partnership designed to grow into an accountable care organization.


Extinction is not a foregone conclusion. Dylan Roby, a health policy professor at UCLA, noted that solo-practice doctors have been adapting to changes in insurance and reimbursement for 20 years.

They will survive by joining loosely formed networks that allow them to integrate with hospitals and specialists but maintain some autonomy, Roby said. He predicted others will form concierge medicine practices where patients pay for care not through insurance coverage but through regularly paid membership fees.

“I don’t think private-practice doctors will have to go away,” he said. “I just think they’ll have to adapt.”

Doctors worry that if they don’t join a group or an affordable-care organization, large insurance companies won’t contract with them, said Dr. Jim Hornstein, a solo-practice physician in Ventura.

Hornstein has no immediate plans to join a new network or to dramatically alter a 25-year-old practice in which his duties include checking supplies of office toilet paper. He’ll keep his overhead low, maintain a staff that handles administrative duties and focus on caring for his patients.

His confidence in survival is driven in part by Obamacare provisions that are expected to provide coverage to 32 million Americans nationwide and 40,000 people in Ventura County.

“There’s going to be plenty of people to go around to fill up all of our practices,” he said.

Other doctors are already changing. After 13 years as an independent pediatrician in Oxnard, Dr. Imelda De Forest said her costs kept rising and her income kept falling. So she joined 10 other doctors in a Ventura medical group.

She believes money will determine whether solo doctors will survive.

“The bottom line is who can afford it,” she said.


Private-practice doctors worry medicine controlled by groups means they’ll lose autonomy. They think their patients will be less like family and more like widgets on an assembly line.

They worry about a health care system that increasingly ties reimbursement to care called evidence-based. The label means medications and other treatments match standards verified by research.

The result is doctors have fewer choices in treatment, said Dr. Geoffrey Drew, a solo-practice physician from Thousand Oaks. Doctors won’t find ways to deal with mystery illnesses because they won’t be allowed to try.

Drew’s answer to the pressures is succinct. He’s retiring. At 65, he plans to work as a mission doctor in his native South Africa.

“With all of these bureaucrats looking over our shoulders, innovation and modification is going to be virtually impossible,” he said. “ … It’s going to cause medicine to be stifled and stagnant.”

But if solo doctors worry about what is being lost, many others focus on what is gained. They note that health care reform emphasizes the importance of dealing with chronic illnesses and keeping people out of hospitals and emergency rooms.

Integrated care means doctors work together to figure out what a patient needs without repeat appointments or duplicated tests, said Dr. Paul Phinney, president of the California Medical Association and a pediatrician affiliated with Kaiser Permanente.

If a patient comes to a primary-care doctor with a mysterious mole, a medical assistant can take a digital photo and send it to a dermatologist. The doctors can confer on a speaker phone while the patient listens. In one visit, the doctors can decide on the best treatment.

“That makes the care of the patient not only more convenient but more cost-effective,” he said.

Phinney thinks integration can improve care.

“It’s not going to be Marcus Welby anymore,” he said, referring to the 1970s television doctor. “It’s going to be something new and different.”

 READ MORE on Ventura County Star

About Concierge Medicine Journal

Concierge Medicine Journal (CMJ) curates breaking concierge medicine news, and editorial opinion on a wide variety of topics relevant to the practice of Concierge Medicine.

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