AMA Thriving in Private Practice

Private practice physicians: how they can focus on their patients and sustain their practice

Jun 9, 2022

In the debut episode of AMA Thriving in Private Practice, AMA Vice President of Healthcare Quality, Kathleen Blake, MD, MPH, dives into the findings of the AMA-Mathematica qualitative research which informed the AMA’s private practice toolkit and how physicians can implement these vital resources to improve internal business operations, clinical workflow and team culture.

  • Kathleen Blake, MD, MPH, vice president of health care quality, American Medical Association
  • Carol Vargo, director of physician practice sustainability, American Medical Association

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Vargo: Hello and welcome to AMA Thriving in Private Practice, a ten-episode series exploring the unique needs of physicians in private practice settings. In our show, we’ll talk about efficiency solutions and how to transition into the world of private practice. We also will focus on other tips and tools to help free up time so you can focus on your patients. I'm your host, Carol Vargo, director of physician practice sustainability at the American Medical Association.

Before we meet today's guest in our inaugural episode, I want to share with our listeners a little bit about why we're doing this podcast. We know that 50% of physicians are in private practice and remain a crucial point of care for patients in many communities across the country. Our goal for the series is to support these busy, private practice physicians. We hope you find it useful to listen as you work with the various resources the AMA has available.

In today's episode, I'm speaking with Dr. Kathy Blake, a senior advisor at the AMA and a former private practice physician herself. Hi, Kathy, it's great to talk to you today.

Dr. Blake: And the same, Carol. Thank you. So, Carol, before we start talking about me, what I'd really like our audience to hear about is your background and your experience and why those are such important contributors to how you will moderate this series of podcasts.

Vargo: So, I currently am director of practice sustainability in the AMA's strategic focus on physician professional satisfaction and practice sustainability. I have been in this role, actually helping physicians implement change, understand change within the walls of their practice. But I come to that role after many, many years working at the AMA in our advocacy unit, specifically around federal regulations related to physician practices, whether it be payment, organizational networking with hospitals, health plans and others.

So, with that backdrop, I've really been able to understand the full dynamic of what is happening for a physician, both internally, as well as externally in their community. I also have a lot of experience and deep engagement with these other key stakeholders in the health care environment, whether it be health plans, large employers, vendors. So, with all of that, it's bringing a perspective that I think is really there to support physicians in all practice models frankly. But more importantly, today is what's really happening to physicians in the private practice model.

So, we have worked together here at the AMA in our professional roles, supporting physician practices, and we have much to discuss on our recent research on high-performing physician-owned practices. But first, tell us all a bit about your former private practice.

Dr. Blake: I practiced cardiology in Albuquerque, New Mexico for 25 years. And during that period of time, I was a member of the American Medical Association. And I have to say that I relied upon resources just like this to get ideas and be able to find out what other people were doing so that I might be able to bring some of those lessons back to my own practice. It was a statewide practice, 26 physicians, cardiac surgeons, cardiologists, vascular surgeons, advanced practice clinicians of all types. And we served the entire state of New Mexico. So, in addition to really being leaders in the cardiac community in our state, we also were running a business. And so, I'm hoping that part of what we talk about today will be that balance of running the business but at the same time, delivering excellent patient care.

Vargo: Yeah, I think, and we know from our work at the AMA that for private practice physicians, that balance is the key to success. So, what we're really hoping today to share and in the future is really highlighting not only the clinical care aspects but the running of the business, which I think you would agree is really half if not even more of the battle at times.

Dr. Blake: So, I think that it is a balance. The most rewarding part is to be able to take care of patients. And we used to say that if every single new patient came to us because they had been referred to us by a satisfied family member or friend or a professional colleague, that would be the ideal kind of practice. But with our research, our research was really driven, very much, by knowing that there are not just benefits but also obstacles to being able to have that kind of a practice environment.

Vargo: So, moving into the study and we've worked on this together but from your perspective, talk a bit about the motivation for our team, why we launched this study that we recently published at the AMA. And why it was important to analyze the kind of data on what makes a physician practice high performing?

Dr. Blake: So, I think that there are two ways of looking at challenges and the challenge is the sustainability of private practices. And one way is to identify the practices that are performing at a very high level and be able to find out what are some of the common approaches, themes, culture that have allowed them to perform at a very high level.

The other side of the coin, of course, is to look at practices that have not been able to sustain themselves in the long run. I think that lots of the literature looks at those challenges but not so much do we see a close examination of the success stories. So that was one of the motivations.

The second is that we know that 50% of physicians or very close to 50% are working either in a private practice for which they are an owner or they are working in a practice that is owned by physicians. So even though the numbers have dropped over the last 20 years, it's still very high. And there are a lot of people, patients, in America, who depend on the private practices in their communities to receive their care. So we thought this was worthwhile from the standpoint of size of population, challenges and opportunities.

Vargo: Kathy, you also like to say that when it comes to private practices, no one size fits all. Can you explain to our listeners what you really mean by that and why that is?

Dr. Blake: So, this is really partly the result of our research and finding out from these physicians that there were always some unique aspects to their community that drove the type of practice that they had, the number of clinicians, the way that they practiced team-based care, the relationships they had with hospitals. So, context really did matter.

The second part about no one size fits all is I think that there's been a very strong push, move towards saying that health care can be standardized. Or we might, in the old days, we would've called it the Focus Factory—that health care could be delivered with the use of templates, algorithms, computers. And I think that pendulum is starting to move back, hopefully, closer towards the middle to say that some of it can be standardized. In fact, a lot of the routine preparation, a lot of the workflow tasks, but that fundamentally, health care is a person-to-person relationship-based endeavor. And that relationship at its core is between the physician and their patient.

Vargo: I agree. And I also think markets matter. I think a lot of practices are not one size fits all because they're practicing within their own community and their own market, which really lends to this more tailored care.

Dr. Blake: I think markets do matter. And I think the features of the population do matter. So my practice in New Mexico, 78% of our patients, adult practice, so adult patients, had diabetes and that was 20 years ago. So, the approach that someone practicing in New Mexico would have to take might be quite different than the physician who is in, let's say, Minnesota or Maine. So not one size fitting all I think is a very apt description, both from the business as well as the clinical standpoint.

Vargo: Great. So given this discussion, talk a bit about any shared attributes across the practices that we found in the survey.

Dr. Blake: So that's really the other side of the coin, and those are the … what I call the usable lessons learned that others might want to consider applying to their own practice. These were physicians who acknowledged that this was hard work, that they did have to stay absolutely at the top of their game clinically, at the same time that they were running a business. And so, one of the shared attributes was being able to juggle those joint, you might say responsibilities.

The second goes along with that, which was that they had real pride, personal pride in the practices that they were growing, might have founded, wanted to see last, even beyond their own retirement. And so, they did not see themselves as having any kind of halo effect except the halo that they made for themselves.

The other part was that they really valued being able to make decisions quickly. Well informed decisions but that they did not have to go through a number of committees or layers within an organization. The kinds of bureaucracy, others might call it structure, that larger organizations have to have for them to be able to function. Our practices that we interviewed, they were 15 physicians or fewer. And we did that on purpose. We knew there were a lot of them, and we also knew that the people we would talk to and interview would have a very personal, well-developed sense of what their practice was like.

Vargo: So that nimbleness is absolutely critical but there's also some potential downsides, for example, is having your own private practice really considered somewhat high risk, particularly in today's climate?

Dr. Blake: So, I think of it as there is risk and benefit, no matter what type of practice a physician chooses to go into. And so, for some, and I think it's important to say it now, for some, they find the integrated health system to be the right fit for them. For others, it may be practicing in an urban environment or in a rural environment. For some, it is practicing in a group that they may eventually become a part-owner or partner in. So, it's not that there is risk in one domain or another but I think there's real reflection that has to take place about where you are comfortable yourself taking that risk, and realizing that there are trade-offs. So, what are some of the risks?

I think if you're starting right from scratch as a solo practitioner, that feels like that could be a very high-risk choice to make. So how do you balance the risk? You balance the risk by seeing is there support from the community? Is there a need for your kind of practice to be in that community? Are there relationships that you have already established that will help you really get up and running quickly? Who will be your advisors? So, for every risk you need to look at what will be the antidote, so to speak or help balance that risk.

I think the other part is the risk of who are you working with? Because I would say certainly from my own experience, the most important driver of my professional satisfaction was the quality, the reliability and the congeniality of the physicians and other clinicians with whom I worked. They were like my family. And I think we heard that from a number of the practices interviewed for this study. And so, there is the risk in both or all settings that you may, shall we say, be more compatible with some of the people you'll be working with than others. But looking for that shared culture and compatibility, that has to be there. And if you don't evaluate a practice on that basis, I think that you're putting yourself at high risk for disappointment.

Vargo: That's a great point. And I think now, even when physicians are struggling with the ongoing COVID pandemic and workforce shortages, I think that really is ... Recruitment and retainment is what we're hearing is really job number one at this time, so that you can sustain that level of confidence and trust in your team. So, the AMA obviously is working to continue to support practices on that journey. Let's turn a little bit to what the opportunities arose from the research to support private practice and what the AMA is doing to address that.

Dr. Blake: Sure. And I think that really goes to the core of why we did the research in the first place. What opportunities could we uncover that we could then present to others who would be in a position to implement them? So, one of the opportunities is to really leverage the electronic health record system that has now been a part of almost all practices in America for more than 10 years. And the physicians in these practices told us, remember they're high performing practices. They told us they knew that they were not using the full horsepower, the full capability of the electronic health record system. So being in a position to convey that concern and be able to address it through tools and resources, I think, is one of the opportunities.

Another area was being able to have the leverage in terms of economies of scale, ability to negotiate that would come with being, for example, part of a larger group. It might be an ACO or it could be an IPA but these were opportunities that sometimes were available and that they felt they could potentially leverage.

The third comes back, really goes back to the passage of the Affordable Care Act and there's language in the act that sets up what's almost like a regional extension service, very similar to what's been done for the Department of Agriculture on a county-by-county basis. And this was to have an extension service where physicians could get resources to be able to leverage the EHR, to be able to implement practice improvement capabilities, be able to do performance measurement. That language, that law section of the law has just never been funded but that was clearly an opportunity that seemed pretty obvious to us. And opportunities also for networking, and sometimes these physician practices, they describe what I might almost call a sense of loneliness or sometimes feeling as though they were a bit invisible. And so, the AMA has recently recognized, seated at the House of Delegates, the Private Practice Physician Section. And so, I'd urge our listeners to look at the AMA website and look at the information about this section and consider very seriously becoming a member.

Vargo: Thank you. Let's discuss sustainability because I think this is so important. Why is sustainability especially important for private practices and what is the AMA doing to help these practices become more sustainable?

Dr. Blake: So, I think of sustainability as really comprised of resource allocation. Do you have enough resources coming in to be able to cover your practice expenses and be able to provide salaries, not just for physicians but also for your clinical staff, for your administrative staff so that you're able to recruit and retain the people that are needed to have a strong practice? So, in terms of sustainability, many of these practices were able because of their nimble decision-making, to be very judicious in terms of the types of expenses that they took on. At the time, they also wished that they could have the leverage associated with perhaps being part of a buying group, where they could buy PPE and get some economies of scale. And they, also for sustainability, wanted to be able to recruit people to come to the practice but they needed the exposure, whether it be medical students, residents, fellows, so that people would know that this model was available to them. So, sustainability, I think of it as you might call it technical resources, financial resources, people resources, human resources.

Vargo: And extend upon that, with what we at the AMA are doing to help practices in terms of the resources we're helping with.

Dr. Blake: There are so many resources related to how do you evaluate a practice arrangement? How do you determine if it's right for you? What are the different arrangements? What are the different payment models that gets to the revenue and the risk-bearing that we talked about earlier? What are the contracting considerations—whether you're dealing with a health plan or with a private employer that's doing direct contracting? How do you partner with hospitals, health systems, ACOs? And newer on the radar screen is the whole issue of private equity firms. And then we know health care is highly regulated. And so, we give you resources about those regulations, what you can do, what ought to give you pause. And quite honestly, when you need to get local, specific practice advice.

Vargo: And what I think about is great about these resources is they're really written by experts, whether external legal experts or also just people, physicians we know who have given us their insights. And all of these materials are free and open access, which I think is also really important. So, we have a toolkit. Can you talk a bit about our toolkit and what is in it, and how is it valuable to private practices?

Dr. Blake: Right. So, the toolkit is based on, or the contents of it are based on, some of the things that people told us through research, the study we did with Mathematica. Some of it is based on research that we've done through surveys of physicians more broadly. It's also, we set our priorities based on what we hear from the Private Practice Physician Section. And so, what people have told us over and over again is they want reliable kind of, I can go to the bank with this kind of information about contracting and about making sure that I stay carefully within the regulatory requirements of private practices. So, I think people will find that very helpful.

I have to give a shout-out for the Behavioral Health Integration work that Carol, you and I have worked on a lot together. Because what we've heard certainly in recent years is that that is a big concern for patients but also for physicians. The behavioral health needs, I think, have been amplified through everyone's experience with the pandemic. We don't think those will go away. We think there will be a need to continue to address those challenges. And so, the AMA has developed a lot of resources about how physicians can integrate behavioral health care in their practices.

Vargo: That's great. From your experience as a physician, formerly in private practice, and now as a senior advisor at the AMA, can you really speak to your thoughts on how resources like our toolkits, like our other resources, how can physicians use those to really help them be sustainable in their endeavor?

Dr. Blake: So, I'm going to make an analogy, which is that if I was still running my large statewide private practice, I'll be honest, I did not have time to read a book, a 300-page book about all the different aspects of private practice. So, one of the things that we've been really sensitive to is that the most important resources that physicians have are their time. It's a non-renewable resource. And the second is their attention. How much attention can they give to something? So, I do think that resources in the toolkit, also the AMA Steps Forward platform, these are meant to be immediately usable. We scrutinize them to make sure there is no waste we hope of your time or your attention or energy. And quite frankly, we set it up so you can pick and choose. You do not have to read, shall we say, the whole book.

Vargo: Right. I think we have things like checklists. We actually, in some instances, have printable downloadable checklists that you or your practice manager can literally just put up on a bulletin board right in front of you. This is the feedback we received that I think private practice physicians find so valuable. And also, really our hope for this podcast going forward, that we're just providing you some interesting information, as well as usable information in a format where you're either driving home from your car or in your car or taking time out in the morning when you're on the treadmill, just to listen in and learn more. So that's our goal going forward.

So, as we're wrapping up Kathy, any final thoughts or comments given all the expertise you have and your really deep commitment to this practice model? What would you like to share with the listeners, if anything else?

Dr. Blake: So, I would like first and foremost to share with them, and it's actually true for physicians in all models of practice. The AMA has your back. And if there is something that we have not identified or you cannot find on our website, we want to hear from you about that. Because we want the tools and resources to be useful to you. So, please. It's a bidirectional conversation with you and with the AMA. I think that would be my final, really, comment but also my request.

Vargo: Really important. Thank you. And it's as always great talking to you, Kathy, and thank you for sharing more about what you've called, really, truly the bread and butter of private practice. For tools to support your practice’s sustainability, including the AMA toolkit Dr. Blake mentioned, visit again, I'm Carol Vargo and until next time, this has been Thriving in Private Practice. Thank you so much for your time and for listening today.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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