I think the days of solo practice and small group practices are numbered. ... Every single physician will have to be part of something larger. The cost trends have just been too steep to overcome alone." ("More docs say: Super-size it," Oct. 4, p. 24). What? Had I gone back in time? Was it 1997 again? Or were these the ghosts of physician practice-management companies past coming back to life?
Your article on the growth of physician practices was a useful review of this issue. However, the death of solo and small practices has been heralded for years. First, it was managed care, which was going to herd physicians into groups, or at least physician-hospital organizations. Then it was the PPMs and management services organizations, which failed despite billions of dollars and plenty of strategic intent. Remarkably, when those owned practices were spun off, the physicians did not organize themselves into large practices but rather went back to their small practices.
There are at least three hypotheses as to why solo and small practices have remained robust:
No. 1: Doctors are idiots. Physicians just don't know what is good for them.
No. 2: Doctors are stubborn. They may know that they could be better off in a larger group, but they just don't want to be.
No. 3: The benefits of larger practices may not be as real as many have contended. Unless you are as big as Harvard Vanguard, you probably won't have much negotiation leverage with health plans; with size comes complexity, more administrative duties, delegated decision-making, and perhaps lack of autonomy.
What a colleague and I are finding in our research is that the primary value of size and scope is that larger practices have the opportunity to capitalize on ancillary services.
The bottom line: As in the mid-1990s, the message to physicians is not "grow or die." It is that the market can support a multitude of practice sizes and structures.
Chairman of the Department of the
Business of Health
Johns Hopkins University
More to it than malpractice
Democratic vice presidential candidate John Edwards espoused the same "fix" for medical malpractice costs as put forth in your editorial ("The hidden debate topic," Oct. 4, p. 17), but it isn't a solution unless the legal fees that eat up half of the tort awards are addressed.
The editorial mentioned the need for a 10- to 20-year plan to reform the healthcare system. Absolutely correct, but with old congressmen holding power in Washington and no bold congressmen, I doubt any top-to-bottom house-cleaning on healthcare will occur, regardless of who is elected president.
Malpractice is but one operating cost associated with U.S. healthcare. Regulatory compliance, the largest single cost, takes 32 cents of every healthcare dollar, eating away at what can be used for actual healthcare delivery. Straw by straw over 40 years, regulations have increasingly burdened consumers, providers and payers, with the Health Insurance Portability and Accountability Act the most recent example. Consolidating and simplifying this regulatory nightmare will likely take 10 years.
I've been around health insurance and managed healthcare for a very long time but have only identified 40% of healthcare operating costs. Marketing accounts for about 8% of the total. While figures aren't available for lobbying, redundancies in managed-care oversight, for-profit conversions or medical malpractice, I'm sure those items collectively push healthcare operating costs past the 50% mark.
Reform must seek to reserve at least 75 cents of our healthcare dollar for delivering actual healthcare and would result in up to $350 billion being shifted back to actual care were the effort totally successful.
The cost of all health plans would drop and perhaps lend our timid Congress the courage to finally make health insurance available to the nation's 44 million uninsured.
Founder of ConserviCare
Singing editorial's praises
I am a nursing student in Arizona and in one of my classes we are required to write a journal on topics related to the healthcare field. I came across the editorial "Singing the access blues" in the Aug. 30 edition (p. 17). I just wanted to thank you for writing it. I just wish there were many more people who felt the same way.
Key link: the supply chain
The recent scrutiny of healthcare group purchasing organizations has been and remains an important and legitimate issue for hospitals. At the same time, however, all of this attention to GPOs has become one more in a long series of distractions that obscure the critical importance of a finely tuned internal supply chain.
How, when, where and why products move around a hospital facility would initially seem to be a dull and unimportant subject. But hidden in the mundane are serious ramifications that affect patient care, nursing productivity and nursing job satisfaction. When nurses cannot access the supplies or equipment they need to care for their patients, they must often leave the nursing unit to search for what they need. While they are off searching the hospital, their frustration levels rise and their patients' care is compromised. Hospital chief executive officers may not hear about these issues because, unfortunately, nurses have learned to live with the situation. But nurses should not have to put up with it and neither should CEOs.
The internal supply chain of many hospitals rivals the global supply chains of some Fortune 500 companies in its complexity and the number of times a product is touched on its way to its ultimate consumption. To say that most hospitals' materials management departments are occupied with product price issues would be accurate and that emphasis on price is not misguided. The issue is not to spend less time on product price issues but rather to make more time to focus on improving performance and efficiency in the internal supply chain.
Lynn James Everard
Healthcare Supply Chain Strategy and Consulting
Coconut Creek, Fla.
Your article on the 100 Most Powerful People in Healthcare does a very nice job of summarizing some very complex issues and weaving together all of the important cast of characters (Aug. 23, p. 6). Nice work.
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