Rx for Health Care Reform

17. Getting Down to Nuts and Bolts

209 17 Getting Down to Nuts and Bolts “Doctors do not come together well,” says Gary Matthews, a veteran health care consultant in Atlanta who has done a lot of physicianpractice mergers. “They all want to practice medicine in their own individual way. And even if they’re in a group, they don’t want to be told how to practice.” That having been said, there’s no doubt that if primary-care physicians knew they’d have to join a group or be out of business in three years, they’d start to merge with their colleagues. The question is, could groups of the requisite size be put together in that time? Matthews and other consultants say yes. But those groups would have to be assembled in a two-stage process: First, tiny practices would merge into groups of eight to ten doctors, and then these practices would join together to form larger aggregations. Normally, the medium-sized groups would cohere and recoup their merger costs within a couple of years after coming together, the consultants say. So, in three years, it would be possible to create groups that could take financial responsibility for professional services and compete within a utility-insurer market. Specialty Mix Is an Issue What kinds of doctors should belong to these groups? The answer is not as simple as it might appear. To begin with, we have to define “primary-care physician.” By common agreement, family physicians, general practitioners, general internists, and pediatricians would all qualify. Many people also regard obstetrician /gynecologists as primary-care physicians for women. But even if an ob/gyn practices only gynecology, his or her training and knowledge are limited to a relatively narrow range of medical problems. In addition, ob/gyns are in great demand in most regions. So they should be available to everyone, and they wouldn’t be if they belonged to competing primary-care groups. 210 Rx for Health Care Reform Each physician practice must be able to treat both adults and children to compete with other groups. Thus a practice that included only pediatricians or only internists wouldn’t work. A group of family physicians would meet the criterion, but internists are arguably better at treating patients with more complex medical conditions; that’s why internists tend to have larger Medicare practices than family physicians do. Also, if a group consisted only of family physicians, the number of family physicians available to other groups would be reduced. Establishing a specialty-mix formula would be difficult because of the wide regional variations in particular specialties. There’s a big disparity between the Northeast, where general internists make up 54 percent of active primary-care physicians (including ob/gyns), and the West, where they make up only 41 percent. Similarly, while family physicians and general practitioners account for 31 percent of active primary-care physicians across the country, only 17 percent of generalists are family physicians or general practitioners in the Northeast.1 Because of these disparities, the specialty-mix formula for primarycare groups would have to be adjusted state-by-state, and it would have to be flexible enough to accommodate local conditions. Wherever possible , family physicians should be included (general practitioners are a dwindling minority); but it’s also desirable to have both pediatricians and internists in the mix. Finding Merger Partners Now that we’ve established what kinds of physicians should be in our groups, let’s see what doctors in small practices must do to join together. First, they’d have to decide with whom they wanted to practice. That could be a daunting prospect, notes Kenneth Kubitschek, an internist who belongs to a nine-doctor group in Asheville, North Carolina. “Doctors are concerned about the competency of the people they’re joining with,” he points out. “If everyone has to join a group, you’ll be forced to practice with people you don’t want to practice with.” Especially in small towns and cities, physicians are well aware of their colleagues’ reputations. While Kubitschek guesses he could form a firstclass group with about twenty doctors whom he knows in the Asheville area, “a number of people would be left out if we made our own choice,” he says. This would be a problem everywhere, but it’s imperative that doc- Getting Down to Nuts and Bolts 211 tors choose their own partners from the available pool. If their choices...