April 1997
Volume 61 |
Number 4
|
| |
|
| Practice Options:
Solo, Group, Academic Modes of Practice |
Kenneth I. Mirsky, M.D.
In this and following issues, the ASA NEWSLETTER
will be publishing articles about some of the various practice
options available to anesthesiologists today - inside the operating
room and in other venues.
Solo or group practice and academic settings are the mainstays
of anesthesia practice. Frequently, the different modes of practice
in anesthesia are often distinguished not so much by the types
of patients treated as the economics of the practice - the business
of medicine.
Outside the protection of a training program, nonscientific and
nonscholarly issues may take precedence. If the fundamental concern
is maintaining a secure place to practice, considerable effort
is directed into nurturing that practice. The way to keep any
business viable is to satisfy the customers; for the anesthesiologist,
customers are not only patients, but also surgeons, hospital administrators
and managed care organizations. In addition to these external
concerns, there are internal issues such as how anesthesiologists
organize themselves in the various modes of practice.
Internal Departmental Issues
Solo Practice
The solo practitioner, as the only anesthesiologist on staff
in the hospital, often has nurse anesthetists to supervise in
the operating room, has administrative responsibilities and is
on call all the time. There may also be additional responsibilities
and opportunities such as running the intensive care unit, respiratory
therapy and pain management services.
Any sense of isolation in a solo rural practice might be less
now with the availability of the Internet and other computer network
links. Arranging vacation time can be done through a locum tenens
provider.
Some hospitals with no anesthesiologist might offer additional
stipends or other incentives to lure a physician to practice there
and may guarantee some level of income and benefits. Properly
managed, a solo practice may be rewarding.
Group Practice
Some groups still consist of anesthesiologists who function as
solo practitioners and bill individually for their services. Accordingly,
the individual who controls case assignments can, by anticipating
the payer mix, wield considerable power. This may lead to jostling
among group members for patients with higher-paying insurance:
thus, poorer patients may be left to the most junior personnel.
There have been pressures for groups like this to form a legal
entity. Not infrequently, groups of solo practitioners do not
cover other's patients in the postanesthesia care unit. "Independent
contractors" who cover for each other are often advised to
incorporate for a number of reasons, including tax regulations
regarding retirement funds; hospital administrators must be able
to deal with a single entity such as a formal group rather than
multiple individuals.
Groups can be formed as limited liability partnerships or professional
corporations. The members of a partnership might not be protected
when judgments are entered against other partners. A corporation
with shareholders offers an individual's assets more protection
when another shareholder is held liable for debt. The advantages
of being a partner or shareholder in the corporation are to have
a say in how the organization is run and how receivables are distributed.
If you wish to consider incorporating, an attorney with experience
in medical practices should be consulted.
Once a group is organized, there are many ways to structure it.
Leaders and members of groups exist with varying amounts of power.
Committees may be formed within the group to analyze business
planning and other issues of growth and stability; e.g., some
groups have salary committees. Other groups divide the total income
equally. Still others may have a mechanism to reward "productivity."
The term productivity may include such variables as teaching,
research or intensity of cases.
New people are usually brought in as employees of the group for
a trial period and paid a predetermined salary. Groups have different
plans and time frames for employee advancement to partner or shareholder,
and these should be spelled out in detail to potential candidates.
Some groups are comprised of only physicians; others utilize
the anesthesia care team approach by supervising nurse anesthetists
or physician assistants. It is important to be aware of not only
federal Medicare guidelines but also state regulations regarding
ratios of physician to nonphysician providers.
A few years ago, articles in the New York Times and
the Wall Street Journal described difficulties that anesthesiology
residents were having finding practice opportunities. These articles
may have crystallized fears that groups were already having, as
managed care organizations and hospitals applied pressure to accept
decreasing fees. With self-preservation in mind, many groups eliminated
partnership tracks that would have led ultimately to ownership.
ASA, which had provided space at its annual meetings for people
offering and seeking practices, suddenly saw offerings dry up.
What had previously been a robustly attended area was reduced
to a kiosk with practice offerings stapled to it. Perhaps the
media drove some of the sense of despair. It seems that more partnership
tracks are being offered again as the resident pool is diminishing.
Academic Settings
Academic institutions and teaching hospitals, like
others, have been forced into contracts with managed care plans
whose bare-bones payment schemes do not provide funding for training.
With less money coming in to pay for residents and fewer residents
entering training programs, more and more cases are being done
by attendings who have less nonclinical time available for research.
Advancement within academic departments is based
on research and publication. With less time and money,
it will become more difficult for researchers to publish and gain
promotion within the tenure system. Involvement with state and
national anesthesia societies, lecturing and article reviews help
create visibility in the academic community. Nontenured clinical
tracks may be offered, but contracts for these are often on a
year-to-year basis.
External Issues
Patients and Their Care
Patient care and safety are always of utmost concern. Anesthesia
services in all modes of practice must be provided in a safe,
timely and courteous manner. Failure to provide a full range of
quality anesthesia services is cause for major upheavals in anesthesiology
departments.
Patients often recognize extra warmth and comfort. It is rewarding
to have patients request a certain anesthesiologist for themselves
or their loved ones based on positive prior encounters. Surveys
of patient satisfaction are often continuously undertaken by hospitals.
Every aspect of a patient's experience can be evaluated, analyzed
and used when contract renewal time comes.
Surgeons, Other Hospital-Based Physicians, Other Colleagues
When surgeons, internists and anesthesiologists have different
approaches to the perioperative care of a patient, statesmanship
must diffuse the situation, remembering that patient safety is
fundamental. It is crucial to have a record of providing excellent
care to reinforce the fact that everyone is working for the patient's
benefit and everyone benefits when the patient does well.
Hospital Privileges, Administrations, Contracts
After gaining privileges to practice at a hospital, the key is
to become and remain a good citizen of the hospital community.
Neglecting meetings and committees can be as detrimental as refusing
to come in for a case since both engender criticism and can open
the door for a new, more cooperative group. Information is distributed
and policies are implemented at meetings whether or not the anesthesiology
department is represented. Without knowledge and representation,
any department can be put into disadvantageous positions.
Hospital mergers have variable impacts on their medical staffs.
Some anesthesiology departments in hospitals of newly formed systems
have remained independent and some have been forced to merge.
Partly as a result of the turmoil wreaked by managed care's relentless
inroads, the practice you may join today may be different from
the practice that will be in place a few months down the road.
While some hospitals have an "open staff," without
limiting who can get hospital privileges, more and more hospitals
now offer one group an exclusive contract to provide anesthesia
care for the entire hospital. This may appear to give the group
some degree of stability and permanence. However, clauses are
often included that give the hospital administration the right
to terminate the contract, perhaps without cause and with only
a few months' notice. Some contracts also include waiving the
rights of the individual or group to appeal within the medical
staff hearing system and with hospital privileges tied to having
a contract in place; a group that has been "swept clean"
from a hospital often has little recourse.
A recent trend has been for staff privileges to be dependent
on Board certification. New members of the medical staff may be
given a certain time (perhaps five years) to pass their written
and oral Board examinations. If they do not become Board certified,
their privileges are rescinded automatically.
Managed Care
Managed care penetration has created stress in the relationships
of anesthesiologists with their hospitals and with
each other. Anesthesiologists may be pressured to join managed
care plans that are beneficial for the hospital but are less so
to physicians. Some plans do not even negotiate with the hospital-based
physicians and instead prefer to come to an arrangement with the
hospital alone; the hospital then determines how much each physician
group is reimbursed.
There are many instances of physicians joining together to form
their own organizations to compete with managed care corporations.
Involvement in these ventures is necessary to educate policy-makers
and rate-makers, who probably are not aware of some of the unique
disadvantages under which anesthesiologists have been working.
Summary
Challenging patients who can stress the keenest clinician appear
in all settings, sometimes in the middle of the night when extra
hands may be scarce. The most trying problems and elusive answers,
however, are more likely to be faced in the nonmedical aspects
of maintaining a lasting practice - in any mode.
Kenneth I. Mirsky, M.D., is an attending
anesthesiologist at J.F.K. Medical Center, Edison, New Jersey.
He is Vice-President of the New Jersey State Society of Anesthesiologists.
E-mail the author.
return to top
Home >Newsletters
>April 1997Home >Test |