Small-Practice Update: Three Key Steps to Survive and Thrive in the New Healthcare Era

Neil Chesanow


October 18, 2010

In This Article


Despite much-touted reports predicting the demise of the small physician practice, experts maintain that small practices can be profitable and rewarding if doctors are willing to make some key changes.

The prognosis last August from 3 White House representatives -- that the small physician practice is a dinosaur incapable of adapting as healthcare change sweeps across the land -- sparked an outcry but also a backlash. "We're not ready to write off the small practices," J. Fred Ralston Jr., MD, president of the American College of Physicians, told Medscape Medical News. "We think there needs to be more than one delivery model."

The 2010 article, published in the Annals of Internal Medicine, said, "The economic forces put in motion by the Affordable Care Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger groups."

For a small practice with month-long waits for an appointment; charts that are incomplete, illegible, or frequently lost; prescriptions that are hard to read, easy to misinterpret, or just plain wrong; or an inability to share patient data in a timely manner with those who need it, the prognosis is indeed likely to be terminal.

The key is for small practices to identify and acquire the tools needed to adapt and grow in changing times. Here are 3 actions you can take to help survive and thrive even though the rules of the game are about to change.

Action Item 1: Hire an NP or a PA

With healthcare on the brink of momentous change, increasing patient volume will be necessary for many small practices to survive and thrive. That's one reason to consider adding a nurse practitioner (NP) or physician assistant (PA) to your staff: A midlevel provider can improve access for new and existing patients.

"The delivery of healthcare is hampered because it's a one-to-one transaction: a doctor looking into the eyes of a patient one at a time and deciding what to do, and no one has been able to get out of that paradigm," says Jeffrey J. Denning, a partner in the Practice Performance Group in La Jolla, California. "The doctor is the highest cost in the equation and the rate-limiting step. If a doctor is doing anything that someone else at a lower pay grade could be doing, there's an efficiency to be had. Adding an NP or [a] PA is an example."

"When a patient has an appointment with me, a nurse does the intake, brings the patient into the exam room, takes all the vitals, gets the presenting symptom or complaint, and I do the rest," explains Theresa Oakley, a PA in the Family Medicine Residency Program at Southern Illinois University School of Medicine in Quincy, Illinois, a 9-provider practice with 18 medical residents. Oakley sees nearly all patients with same-day appointments, improving access. "The patient rarely sees a physician on the same visit," she says. "I'm there to see the patient in the absence of a doctor. If I have a question, I always have access to a supervising physician."

The top 5 specialties employing NPs were obstetrics/gynecology, family medicine, internal medicine, cardiology, and pediatrics, according to a 2008 Physician Retention Survey, jointly sponsored by Cejka Search and the Medical Group Management Association. For PAs, they were orthopedic surgery, family medicine, internal medicine, dermatology, and occupational medicine.

"Midlevel providers are wonderful because they can capture a history, perform an assessment, and have worked with the doctor so much that they know what he's looking for in the patient," says Kathryn Moghadas, principal of Associated Healthcare Advisors in Winter Springs, Florida. "A midlevel can also spend more time educating the patient about her condition and adherence to treatment, as opposed to the doctor, who may be looking at his watch every 5 seconds and trying to get out of the room. Using a midlevel is better for patient relations and for capturing all the data on a given patient."


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