Having been associated with a large California primary care group in the 1990s, Roxanne Tyroch, MD, was on the brink of securing a partnership before life led her in a different direction. She forewent the opportunity due to her husband’s job relocation and delved into academic medicine for nearly a decade.
After that, Dr. Tyroch was an employee of a hospitalist group with no opportunity for partnership. But once her five-year noncompete agreement ended, she took a step back and realized that private practice was calling her name.
“Private practice attracts people who have creative ideas. These physicians are willing to invest time into developing their vision into something concrete. They likely have a natural interest in the business aspect of medicine,” said Dr. Tyroch, an internist who owns and operates a solo practice called Intellimedicine in El Paso, Texas. She also is member at-large of the AMA Private Practice Physicians Section (AMA-PPPS) Governing Council, which seeks to preserve the freedom, independence and integrity of private practice.
It takes astute clinical judgment as well as a commitment to collaboration and solving challenging problems to succeed in independent settings that are often fluid, and the AMA offers the resources and support physicians need to both start and sustain success in private practice.
“After being in this for nine years and having confronted many obstacles to survival, I remain happy in my private practice,” Dr. Tyroch told the AMA in an interview in which she discussed the practice landscape and how telemedicine helps her reach more patients in the El Paso area.
Supporting telehealth is a critical element of the AMA Recovery Plan for America’s Physicians, as disccussed by AMA Director of Congressional Affairs Jason Marino during an episode of “AMA Update” in which he detailed the latest advocacy efforts on Capitol Hill for Medicare payment reform and telehealth.
AMA: How has the landscape changed for physician private practice since the COVID-19 pandemic began?
Dr. Tyroch: Private practice is challenging for those of us who have chosen it—we provide the same service yet make less money than practices that are associated with hospital systems. There have been some movements towards equity in this space, but we need to advocate clearly for fair reimbursement for all that reflects true market value, factoring inflation and the staffing crisis.
Staffing shortages have created a real challenge to offer a competitive salary under the current conditions. Vertical consolidation, Stark Law and Fortune 500 practice purchases are all changing the practice landscape at a rapid pace. But despite this, the rewards are tremendous and I’m happy.
AMA: Did your private practice experience any struggles with the pandemic?
Dr. Tyroch: I still do. My practice is not the same. I used to have three times as many staff as I have now due to availability and high hourly rates required to compete for staff.
Before the pandemic, I would call the staffing agency and say: “My staff will be absent next week. I need a substitute on Tuesday.” Boom, I’ve got three people ready for that opportunity. Now I don’t even ask. There’s no way they’ll have somebody on a moment’s notice like that.
AMA: Like so many other physician practices, you now routinely offer telemedicine, but you limit your telehealth services to Texas. Tell our readers about that.
Dr. Tyroch: I’ve always been interested in telemedicine, even before I opened my practice. For the last decade, I would go to national conferences and learn as much as I could about it. But back then Texas was quite strict about how it could be conducted before the pandemic. You'd have to overcome the logistic hurdle of having clinical presenters at the patient’s end who were taking the vital signs of the patient or putting an otoscope connected to the computer in the patient’s ear. So, this was a very difficult logistic to overcome and not lose money.
At that time, telemedicine was really designed for rural medicine. But after the pandemic, we're still learning how to do it correctly. I'm very glad I don’t need a presenter, but I’m held by the Texas standard to provide the same standard of care as if I were seeing the patient in the office. I’m bound to have the same outcomes.
If I don’t know you, I don’t know your community, I don’t know your local consultants and I can’t do a physical exam, this really does limit my ability to provide you with the same standard as if I were seeing you in the office. So, I limit telemedicine to individuals who are in my geographic range and I’m familiar with their environment. If push came to shove, I could either get them in here for a physical or I could send them to somebody who I know could take the ball and run with this patient’s problem.
AMA: What do you like about telemedicine?
Dr. Tyroch: What I like is that people can see me on their lunch break. They don't have to waste the time driving down, look for a parking space or wrestle with traffic. They can see me on the weekend or evening even when I don't have staff. Patients with physical limitations and transportation hardships are well served by telemedicine.
They can see me if they're in between jobs or lost their insurance. They pay cash for telemedicine until they get their insurance again. Patients upload pictures of their COVID tests, their blood pressure logs, pictures of their skin, auto accident photos and labs from other specialists. I really like it.
AMA: How did you come up with this branding—Intellimedicine for the practice and Galaxy Health for your self-pay telemedicine packages?
Dr. Tyroch: I get such mixed reviews on these names. I had watched many physicians struggle with the EMR onboarding. When people went from paper to EMRs, they spent so much money on people doing data entry. Staff duty expansion was expected of all new hires to enhance the value of each employee, avoiding the staff duty fragmentation that I saw occurring in people's offices. So, I was really blessed to be opening a practice at the time that I did.
I did a demo with Athenahealth, and they gave me the confidence that together we could really make this happen. All the things that I felt maybe I wouldn't be able to manage had been addressed by them and solutions were developed. It was really important to me that my patients feel like I have their back. That I'm there for their physical and emotional needs.
So, I did my best to merge features of highly personalized medicine with modern practice features. It is a cashless business. I engage in a great deal of portal medicine. I'd heard countless stories of embezzlement happening in practices in El Paso, so all these things, I just felt like I was kind of creating something that was different.
AMA: Tell our readers about your experiences serving in the AMA House of Delegates and as member at-large of AMA-PPPS Governing Council?
Dr. Tyroch: It has been an honor and a privilege to serve as a Texas delegate to the AMA, which I've done for a lot longer than I have the PPPS governing council. During my time here, I've authored resolutions—such as one for COVID-19 loan forgiveness—through both the delegation and the PPPS and I do feel like these have made an impact. We are proposing solutions that will allow physicians to continue to provide our beloved patients with high value care.
I have finished my first year as a member of the PPPS governing council. The talent, experience, comradery and creativity in this group is tremendous. We're really making a difference.
AMA: What tips do you have for physicians who might be considering private practice?
Dr. Tyroch: Talk to people in private practice and develop an inventory of questions that pertain to your specialty and your geographic area. Keep notes of these interactions. Hire consultants if you've decided that you're going to open the door and enter private practice as a business owner.
If you're joining partners, they've already done a lot of the groundwork for you. So, respect that and forge a good relationship with your partners moving forward.
The AMA Private Practice Physicians Section can also help when people have questions. And one thing that is really important for success is to understand your locale—what’s going on in your region.
AMA: What else is important to highlight about private practice?
Dr. Tyroch: My message to those who are wondering if this is the right path for them is that the best way to predict the future is to create it. We have so much collective, creative power and talent among the AMA membership. Reach out to other members of the PPPS and candidly share your ideas and your vision and see where it takes you.