If current trends continue, solo medical practitioners could go the way of the dinosaurs.
The reasons are familiar to any entrepreneur: mind-numbingly long hours, uncertain income, an ever-changing regulatory environment and ceaselessly rising startup and overhead costs, including the skyrocketing price of providing employee health benefits.
The Center for Studying Health Care System Change reports that those factors helped drive down the percentage of doctors working alone or in two-doctor practices — as opposed to multi-physician groups or “big box” providers such as Kaiser Permanente — from 58 percent in 1970, to 40 percent in 1996, to just 28 percent by 2007.
Dr. Ruth Haskins, who opened her current Ob/Gyn practice in Folsom in 2008, is intimately familiar with both sides of the picture. It is her second private effort, coming after 11 years with the UC Davis Medical Group. Unlike the first time, however, she did not purchase another physician’s practice, choosing instead to “start the whole thing from scratch.”
It was the harder road for sure, she says, with a half dozen banks turning her down for startup financing. She eventually got the money, but only after putting up her house, life insurance policy, $30,000 in cash and her future accounts receivable as collateral. It was a gamble that prompted her to skimp and save at every turn.
“Everything we bought was secondhand or the cheapest we could negotiate,” she says. “We went bare-bones minimum, hired people fresh out of training and paid them peanuts; promised them we’d grow. I knew I could start with a cadre of patients that would follow me (from UC Davis), so I knew I could make money from the start.”
The plan worked. She has more than 4,500 patients and five employees, including a nurse practitioner. She provides them with a profit-sharing plan and health benefits for which she pays half the premium; all told, her current monthly operating costs run between $30,000 and $40,000.
Now, like other business owners, she’s learning the ins and outs of federal health care reform and admits it has been a significant challenge to fully grasp the ramifications of the Affordable Care Act.
“Generally, doctors are so busy just keeping their day-to-day business going and taking care of their patients that they don’t have the time and energy to devote to looking at it in all of its detail and drawing conclusions from it,” she says.
But there are several facets of the law that greatly concern her, both as a doctor and as a business owner. From a medical perspective, she is wary of the cost and time constraints of implementing the law’s electronic medical-records mandates. The expected influx of millions of new Medi-Cal patients also is troublesome, given the state’s lack of primary care doctors. With Medi-Cal and Medicare reimbursements shrinking all the time, she believes more doctors will simply stop taking new Medi-Cal patients, leading to “emergency rooms being flooded, because patients won’t get preventive care.”
Unlike many of her colleagues — and in direct opposition to the powerful California Medical Association — Haskins supports allowing more medical services to be provided by nurse practitioners and other nonphysician personnel.
“I really think we underuse our ancillary providers,” she says. “There needs to be a system in place to make sure there aren’t quacks taking advantage of patients’ illnesses, but to have nurse practitioners and physician assistants in urgent-care settings or emergency rooms or doctors offices or the free clinics is, I think, the direction we ought to go.”
Haskins also is concerned about her employees. Health premiums for her workers eat up $12,000 annually, even with her and two of her five workers not on the plan. (Haskins is covered through her husband’s employer.) If the law drives up premium prices, she says, it will leave her little choice but to drop her benefits plan altogether.
“I will pay you a little extra in your salary, and I will not be able to pay your premiums anymore,” she says. “That’s speaking as a business owner, not as a doctor.”
Even with all that — and even if the law eventually is struck down by the courts — Haskins believes the ACA has accomplished something critical: raising the public’s awareness of the nation’s troubled health care system.
“Everybody is a little more aware, maybe to the point of frenzy, maybe to the point of just a heightened level of paranoia among everybody — the business owner, the patient and the physicians. But that’s a good thing. At least it initiates a discussion so that people say, ‘The future doesn’t look so good.’ ”
Whether it’s enough to keep her practicing solo is uncertain. As with many entrepreneurs, she lives in constant fear that one significant rise in costs — a big spike in her malpractice premium, for example — could force her to give it all up and return to a big facility.
“It is a constant, looming threat,” she says, “that in order to keep doing what I enjoy doing, I might have to cave in and rejoin a major medical group.”