Can physicians maintain their autonomy in today’s healthcare system?

This story is one in a series examining the impact of healthcare ownership trends on the practice of physicians. Click here for the main article on employment trends, and here for a sidebar on how private equity in particular is driving employment trends.

When Rebecca Berens, MD, was only 4 years old, she was already suffering from burnout.

Berens, a Texas-based family medicine practitioner, spent the start of her career working for a federally accredited health center (FQHC) and, subsequently, a county health department. The work aligned with its mission to address underserved populations. But working for large systems has been expensive.

At the FQHC, Berens, 32, had to see 21 or more patients per day. Her appointments were made one after the other and she saw a patient every 10 minutes.

“When you see so many people back to back, you start to feel like you’re just a robot,” Berens said. MedPage today. “You just top up drugs and order tests, and there isn’t really the time or space to think of a case.”

If a patient needed more time, Berens often did not have the authority to grant it. She could not book a duplicate patient without obtaining the approval of the administrators, and she often had to make multiple requests just to exercise her best clinical judgment.

“I felt like I was constantly fighting so many little battles day in and day out, just to do the basics,” Berens said.

When Berens had her first child, she knew something had to change. She was still committed to the values ​​of her workplace, but didn’t want to endure the long hours, bureaucratic hurdles or the added stress now that she had a baby at home. So she opened her own direct primary care practice.

“I think it was just a reassessment of my priorities,” Berens said. “I thought to myself, how do I want my career to work? “

As the number of physicians employed by large healthcare systems grows steadily, physicians like Berens are looking for ways to maintain autonomy in their practice of medicine in an increasingly consolidated healthcare landscape.

For some, autonomy means breaking away from the mainstream health system and embarking on alternative health care delivery models such as direct primary care. But others have found ways to retain ownership of their work – and their lives – by operating within the system.

The world of direct care

Berens opened her direct primary care practice in January 2020. She charges patients a flat monthly membership fee of $ 99 per patient or $ 150 for a family of two (adding $ 50 for each additional family member) , without co-payment, co-insurance or deductibles. This monthly rate includes office visits, virtual visits, physician text services, and certain procedures. Patients pay separately for drugs, lab work, x-rays, and other tests, but she may offer some at lower rates.

Now, instead of seeing more than 20 patients a day, Berens sees two or three in person, and texts or calls five to ten more (although she still plans to expand the practice). Rather than compressing a visit into a 10-minute time slot, it can offer patients up to an hour and a half.

“I am able to do a lot more navigation in the health care system,” Berens said. In addition to spending more time with patients during their visits, she has the time to seek out transparent pricing specialists to refer them to, or even learn about conditions that she can treat on her own. Because Berens has more time to research and do more of the checkup internally, she refers patients less often.

Berens also said she had more autonomy over her scope of practice. Procedures such as IUD insertions, skin biopsies, or joint injections – which she couldn’t do when working for larger systems – have become common in her practice.

“I don’t have anyone else to tell me what procedures I can and cannot do,” Berens said.

The movement to lead primary care has grown in popularity in recent years, especially among physicians who feel disillusioned with the current system. There are currently about 1,200 of these practices in the United States, which serves more than 300,000 patients, according to the Direct Primary Care Coalition.

Berens still treats an underserved population. The majority (70%) of its patients are uninsured and many of them are self-employed seeking affordable health care. The freedom to devote more time to patient care, as well as having their own schedule, improved their job satisfaction.

“Autonomy was a big part of the reason I decided to go into direct primary care,” she said.

Maintain control in private practice

Not all physicians feel the need to abandon conventional models of practice in order to remain independent. Carolynn Francavilla Brown, MD, a family doctor with her own practice in Colorado, said being self-employed was imperative for her ability to practice medicine.

“Self-reliance was really the reason I decided it was essential to have my own practice,” said Francavilla Brown, who also sits on the American Medical Association’s private practice board. (AMA), in an interview. “I felt like I could treat patients better by doing things my way.”

Francavilla Brown, 37, was certified in obesity medicine after completing her residency. She started interviewing some of the big companies in her area, but said none understood the value of obesity medicine in primary care. Francavilla Brown wanted the flexibility and control to give her patients the care they felt they deserved.

“I didn’t think I would ever be able to really improve the lives of patients with 15-minute appointments,” she said. “I wanted to focus on individuals on my own, as opposed to a kind of metrics-based health care that doesn’t really consider the individual patient sitting in front of us.”

But spending more time with patients – and maintaining autonomy in clinical practice – meant thinking strategically about your business model. Francavilla Brown said the key to keeping her practice afloat has been both to reduce costs and to be flexible about desired income.

Francavilla Brown cuts rent costs by occupying a small office space, which she has reduced to a minimum by optimizing the use of telehealth in her practice. Additionally, support staff is an important place to keep costs down.

“We have a much smaller staff,” said Francavilla Brown. Doctors in his office often take vital signs themselves and are responsible for recalling their patients for follow-up appointments.

Francavilla Brown’s practice also employs premedicine students. She has hired students who are considering medical school or other healthcare careers to help with administrative work – and who will often work for less pay than someone with more experience.

Francavilla Brown said providing experience for premedicine students, which can be difficult to acquire before medical school, is a way to give back to aspiring providers. “At the same time, it has been a very good staffing solution,” she said.

Autonomy in company medicine

While many physicians have chosen to run their own practices to remain independent, some believe that working for larger systems actually provides sufficient autonomy.

Nancy Fan, MD, an obstetrician-gynecologist at St. Francis Hospital in Wilmington, Delaware, who is also part of the AMA’s Organized Medical Staff Group, decided to work for a healthcare system after more than a decade to have their own practice. His current hospital is part of Trinity Health, a nonprofit system that has more than 90 hospitals in the United States.

Fan, 53, said she believes she has a lot of autonomy as a salaried provider, acknowledging that she may have more freedom than the average salaried doctor. While some clinical protocols come from top to bottom, these are generally the best practices that she would adhere to anyway.

There are also administrative protocols, but these are decisions that she prefers to leave to someone else.

“A lot of people last 5 to 10 years [and] are… completely exhausted by the administrative burden that comes with running your own practice, ”Fan said. “Medicine doesn’t prepare you for this. “

Before starting his job, Fan and a co-owner ran an independent firm for 12 years, employing around 10 to 15 people. It started to take its toll when Fan and her partner had to make tough business decisions that she didn’t want to make, such as whether to provide their employees with a higher deductible health plan to keep costs down, or if they could afford to provide disability benefits.

“I was starting to have choices that all business owners have to make,” Fan said. “But it weighs a bit on your mind, knowing that you provide the wages of 10 to 15 people. It is their livelihood.”

In addition to the administrative burden, Fan said running his own practice was a financial challenge. Obstetrics and gynecology is a labor-intensive specialty, she said, due to the need for additional staff to oversee all procedures. Staffing became a major cost that it could not reduce.

Fan and his partner had to work to their maximum output not only to generate the desired income, but also to provide benefits to their staff. Both had young children at home, and work became a burden on their families.

“It was good to do it logistically, for a little while,” Fan said. “But year after year, I was like, ‘You know what, I don’t want to spend my whole life doing this.'”

So when Fan changed jobs, she gave up her freedom to choose her staff or to do things entirely on her own judgment. But she also said there’s a trade-off – and sometimes giving up some freedom actually offers more autonomy.

“If you’re talking about autonomy, it’s really about control,” Fan said. The amount of authority to cede is a decision all physicians must make, she said, but when it comes to the administrative component, the trade-off for her was easy: “I have no problem giving up on this. control ”.

Last updated on October 14, 2021

  • Amanda D’Ambrosio is a reporter on the MedPage Today Corporate and Investigative Team. She covers obstetrics and gynecology and other clinical news, and writes articles on the US healthcare system. To follow