I have been a solo neurologist for over 25 years in southern New Jersey. For more than 10 years, large hospitals and other corporate entities have been acquiring private physician practices at an alarming rate. At the present time, 74 percent of physicians are employed by hospitals or other corporate entities. A decade ago, the exact reverse was true as at least two-thirds of physicians were in private practice. The Covid pandemic has not helped this trend. Amazon’s recent purchase of One Medical underscores this disturbing trend as well. This downward trend will not improve patient care. Private practice and independent doctors are more efficient and can see patients much sooner than large hospital systems. Where I practice neurology, all of the large hospital groups have wait times of almost 4-6 months for a patient to see a neurologist. I can see a patient in one to two weeks or sooner if need be. Patients should at least have a choice if they want to see a physician in solo or private practice versus a large hospital system or corporate entity (which often delivers very impersonal care). When a patient comes to my office they only see me and the decisions I make for their care are based solely on what I think is best for them and not a large health care entity. No one will care for patients like a solo doctor will. My patients are like my family. Private practice physicians, whether they are in group or solo practice have skin in the game. It is their practice and their patient satisfaction is what is most important.
This disturbing downward trend and the transition of doctors out of private practice has occurred for a number of reasons:
- Doctors who work for hospital outpatient facilities get much higher payments for their services from Medicarethan doctors who practice independently, according to a recent study. This research, based on Medicare claims data from 2010-2016, found that the program’s payments for doctors’ work were, on average, $114,000 higher per doctor per year when billed by a hospital than when billed by a doctor’s independent practice.
According to this study by Brady Post, PhD, Edward C. Norton, PhD, and colleagues published in Health Services Research the amount “Medicare would pay for outpatient care at doctors’ offices would have been 80% higher if the services had been billed by a hospital outpatient facility. The researchers calculated that in 2010, the average set of Medicare services independent doctors performed annually for patients was worth $141,000, but charging for the same group of services would have grossed $240,000 if a hospital outpatient facility billed for them. It’s been estimated that evening the payments to hospitals vs. doctors could save CMS $11 billion over 10 years.”
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During the Obama administration, there were drastic cuts in payments for physician services that hit outpatient private practice physicians especially hard. As stated above, hospitals receive at least a 30% increase in payments compared to their private practice counterparts. These payment cuts affected cardiologists the most driving all of them out of private practice into hospital based systems in my area… Some of the outpatient procedures that I perform were cut by over 50% at that time. In 2007, 70 percent of cardiology practices were privately owned and only 8 percent hospital owned. In 2018, that pattern was reversed with 73 percent of U.S. cardiologists employed and 25 percent self-employed. The United States government intentionally set out to force private practice physicians out of their offices to join large hospitals or corporate entities, They did this by imposing burdensome regulations and cutting the fees to private practice physicians.
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Physician autonomy has been eroded over the past twenty years. Doctors are forced to perform a never ending revolving door of authorizations and precertifications for procedures, radiological studies, medications etc. Often these authorizations and precertifications are not successful causing patients to receive inadequate care. The magnitude of this problem has become exponentially worse over the past two to three years.
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MIPS and other government requirements that just consume a physician’s time and do not add to patient care.
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Desire for younger doctors to have more economic security and a better work-life balance.
The American Medical Association AMA does not represent most doctors. Only 20% of physicians are members of the AMA. The American Academy of Neurology is supposed to represent me. I have not seen them do anything meaningful to stop the transition of doctors out of private practice.
Remedies for the above include the following:
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Leveling the playing field so that doctors in private practice receive equal remuneration as their counterparts in hospital systems, restoring physician autonomy and lessening the burdens of governmental regulations on smaller private practice physicians.
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Restoring financial incentives towards physicians in private practice. Through legislation and executive orders, removing the barriers of precertification’s and authorizations.
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Limiting the role that health insurance companies impose on doctors and their patients.
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Restoring free-market competition in the health care system.
In summary, allowing doctors to once again be free to do what is best for their patients without the government, insurance companies, and attorneys to interfere with this process.
I want a better healthcare system for patients, doctors, and all Americans. Restoring a proper balance of private practice physicians will accomplish this.
The following executive order I drafted will help immensely:
Executive Order on Assisting and Sustaining the Ability for Private Practice Physicians to Thrive, Restoring Provider Autonomy, and Reducing Governmental Regulations that Inhibit Them.
By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered as follows:
Section 1. Preamble. Consistent with prior Executive Orders issued by my administration on June 24, 2019 (13877) and October 12, 2017 (13813), my administration seeks to enhance the ability of patients to choose the healthcare that is best for them. At the present time, more than three-quarters of physicians are employed by hospitals and other corporate entities. As little as fifteen (15) years ago, the exact reverse was true as more than 2/3 of physicians were in private practice. Recently, for the first time, practice ownership by corporations has surpassed hospitals or health systems. Corporations include health insurers, private equity firms, and large pharmacy chains. The goal of these entities is to make as much profit as possible. Corporations and hospitals increase profits due to a number of reasons, including raising prices, seeking a better ratio of lucrative procedures, increasing productivity by asking their doctors to see more patients, and hiring lower paid and less skilled staff. The acquisitions of private practices occur with little regulatory oversight. Moreover, hospital physicians are paid significantly more (approximately 30%) than their private practice counterparts for many procedures and office visits. Private practice physicians have an ethical responsibility to their patients’ health. Private practice physicians are more efficient and can see patients much sooner than large hospital systems, corporate entities, and clinics. Small private practices give physicians the ability to provide the best care for their patients and to adapt to changes quickly and effectively. The ability for patients to choose the type of provider they wish in the setting they prefer has been eroded due to corporate greed, excessive governmental regulation, and decreased payments to private practice providers that are not competitive with hospitals and their outpatient clinics. Small private physician practices have been the bedrock of care for patients for decades. They will not continue to exist if the current trend continues. The lack of private practice physicians contributes to very long wait times, three months or longer, for patients to see a physician and contributes to a more socialized form of medicine.
During the administration of Barack Obama, there was a deliberate intent to drive physicians out of private practice and into large hospital systems and clinics. Excessive governmental regulation and reduced payment to physicians in private practice provided the impetus for this change. This was done through legislation (Merit Incentive Payment System or MIPS) and rule making (Misvalued Code Initiative). Some physician’s payments for certain procedures were reduced by over fifty percent. Physicians who work for hospital outpatient facilities get much higher payments from Medicare than physicians who practice independently. A recent study published in Health Services Research examined Medicare claims from 2010 through 2016. They found that the program’s payments to doctors’ work were, on average, $114,000.00 higher per doctor per year when billed by a hospital than when billed by a physician’s private practice. In December of 2021, a study in the Journal of General Internal Medicine, reported several challenges related to MIPS, including irrelevant measures, administrative burden, frequent programmatic changes, and small incentives. MIPS measures do not correlate well with patient outcomes or lower rates of postoperative complications.
Physician autonomy has significantly deteriorated over the past twenty years. Doctors and their staff are forced to perform a never-ending revolving door of authorizations and precertifications for medications, tests, surgeries, and procedures. Often these precertifications and authorizations are denied. Patients are unable to receive the necessary care they need which can cause severe harm to the patient. Physicians who work for corporate entities and hospitals are not able to make referrals outside of their practice or ownership system. The amount of time that physicians need to fulfill MIPS requirements takes away from valuable time needed to be with patients and erodes physician autonomy.
Large hospitals and corporate entities have been buying out private practice physicians and their offices due to the unfair competitive advantage they hold over them. The enforcement of federal anti-trust laws that govern anti-competitive practices is necessary. The goal of this executive order is to once again allow physicians to do what is best for their patients without the government and insurance companies to interfere with this process. Reducing governmental regulations and increasing payments to private practice physicians can accomplish this. My administration strives for an America where free market capitalism, entrepreneurship, and individual liberty are valued.
Section 2. Policy. It is the policy of my administration to ensure that patients have access to the type of healthcare of their choosing and that unfair competitive practices that allow large hospital systems, corporate entities, and private equity firms to thrive, are removed. Excessive government regulation also needs to be removed. Financial incentives make physician practices attractive acquisition prey for corporate entities that want to increase their profits. A major goal of hospital systems is to increase their patient base to maintain a steady stream of revenue from tests, procedures, and other specialty services. Payment to private practice physicians must be competitive with other types of medical care that is offered to patients, such as hospitals and corporate entities. The congressional ban on physician-owned hospitals should be lifted to encourage greater competition. The Federal Government aims to eliminate the bureaucracy of medicine that imposes unnecessary barriers to private practice physicians keeping them from thriving.
Section 3. Increasing the Competitiveness of Private Practice Physicians (a) Within 120 days of the date of this order, the Secretary of Health and Human Services shall issue an advance notice of proposed rulemaking, consistent with applicable law, soliciting comment on a proposed rule to nullify the MIPS requirement for small private practice physicians and providers of 5 or less.
(b) Within 90 days of the date of this order, the Secretary of Health and Human Services, in consultation with the Attorney General and the Federal Trade Commission, shall issue a report describing the most effective means to enforce anti-trust laws that govern anti-competitive practices. They shall provide recommendations for such action, which includes, but is not limited to enforcing the Sherman Act and the Clayton Act.
(c) Within 120 days of the date of this order, the Secretary of Health and Human Services, in consultation with the Department of Justice and the Attorney General, shall issue an advance notice of proposed rulemaking, consistent with applicable law, soliciting comment on a proposal to ban authorizations and precertifications for medicines, medical testing, radiological studies, surgery, procedures, or other care deemed necessary by a provider or physician to appropriately care for a patient. This ban will apply to all health insurance issuers, including commercial and Federal, third party administrator plans, and self-insured group health plans.
(d) Within 60 days of the date of this order, the Secretary of Health and Human Services, in consultation with the Attorney General, the Treasury, and the Department of Labor, shall formulate a report on the viability, operability, and sustainability of small private practices. This shall include financial incentives or other means to ensure the prosperity of private practice physicians already in practice and to help stimulate younger physicians to join small private practices. In coordination with prior executive orders of my administration, competition and free-market capitalism shall be encouraged. This report should also focus on site-neutral payments and the means to effectively pay small private practice physicians in their offices.
(e) Within 90 days of the date of this order, the Secretary of Health and Human Services shall analyze and issue a report on MIPS reporting criteria that do not contribute to the quality of a patients care. Those measures deemed to be of little or no value should be eliminated. If it is felt that the Merit Incentive Payment System itself is of little value to practicing physicians, then the program should be eliminated. My administration intends to work with Congress to remedy these maladies.
(f) Reinstatement of executive order 13813 (Promoting Healthcare Choice and Access Across the United States), which was subsequently revoked by President Joe Biden.
Section 4. General Provisions. (a) Nothing in this order shall be construed to impair or otherwise affect:
(i) the authority granted by law to an executive department or agency, or the head thereof: or
(ii) the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.
(b) This order shall be implemented consistent with applicable law and subject to the availability of appropriations.