Tracy Morris

The practice of medicine is generally considered one of society's most-valued services, and in the United States respect for individualism and independence historically boosted the profession's reputation as a solid career. There are no worries about the occupation's prospects for job growth - the U.S. Bureau of Labor Statistics projects employment of physicians and surgeons to grow 18 percent from 2012 to 2022, faster than average for all other occupations.

Still, that growing demand rests uneasily on a shifting base of healthcare reimbursement changes. Getting through medical training requires a high amount of self-determination, so it makes sense that many enter the field envisioning long-term solo practice or small partnerships. But waves of organizational change threaten to clear away those still clinging to independent private practice. It might not be an understatement to say that in this new era, practices working collaboratively may not just be only the best strategy to thrive, but the only way to survive.

"Collaborating is crucial," says practice management consultant Carol Stryker. "… Practices must join forces in a formal way to bring quality of care up, drive costs down, and expand value."

Said succinctly: Size matters, especially when it comes to economies of scale.

"The bigger a physician group is, the more bargaining power they have with payers," says attorney Michael Kreager a business and healthcare law specialist. "[Plus], you'll get more for your money when you buy 100 boxes of gloves instead of only 20."

And with size comes structural changes, so with more moving pieces comes more oversight for practices.

"…Applicable labor laws change when your group of employees increases," notes Stryker. "We're all looking forward while trying to keep our footing in the present day-to-day. The need for physicians to have people on board who are charged with paying attention to every detail, keeping an eye on [human resources] and HIPAA and training, so that you're doing things right and legally - that's here and now."

But don't think that all the added layers necessary for collaboration are too difficult and that your next best option is being acquired by the local hospital.

"Selling out to a hospital means they get to direct how [their] practice operates," Stryker says. "Simply put, physicians can end up trying to keep bean counters happy."

Instead of seeing their hard-earned private practices absorbed into hospital systems, a growing number of physicians are utilizing a pair of options to bulk up and add value: independent physician associations (IPAs) and super groups.

IPAs are sometimes referred to as a "practice without walls" - several different practices joined specifically for the purpose of contracting as a group. Each practice bills under its own tax identification number. Each physician in the IPA hires his own staff, has his own rules in place, and runs his practice essentially independently.

Wayne Lipton, who formerly ran a physician-owned IPA, refers to them as "strictly insurance collaboratives." The IPA is in charge of negotiations on behalf of separate independent practices, and it comes with an overhead cost. Ownership varies: The association can be owned by doctors in the organization or not.

Part of the IPA format is a necessary concern about antitrust issues. The Federal Trade Commission (FTC) and Department of Justice enforce consumer protection laws meant to prevent price fixing among competitors. If, for example, a couple of OB/GYN practices want to band together and negotiate rates with an insurance company, the negotiations would occur separately in order to stay within the bounds of the law.

"The 'rule of reason' says that if competitors collaborate in a manner to efficiently deliver medical services and effectively reduce costs of medical services - and they follow the rules - that can be done," says Kreager. "But an intermediary is required to go between the insurance company and each of the practices in the IPA. This inefficient negotiation process is one of the drawbacks of IPAs."

Practice consultant Regina Mixon Bates stresses the basics in setting up groups of any kind, especially given the intricacies of ones like IPAs.

"You're entering into a special type of legal structure, so you have to be prepared to work through development of an operating structure that all members can be happy about - this may at times require the use and support of lawyers, accountants, and consultants who will need to work together to make sure common goals are met," she says.

If you want to continue being as independent as possible and keep running your own show, IPAs make sense. You can get better reimbursement rates than going solo without giving up as much autonomy as you might in other collaborative models. Remember, the association will be required to support overhead expenses for a negotiation liaison. For some, shifting to an IPA might turn out to be a transitional move toward an eventual super group.

An alternative to the bulky negotiating requirements of IPAs are what might be called "super groups" - several practices that join together as a single entity for more than just insurance contracting purposes. While variations abound, super groups can share many practice components - from an EHR to human resources to accounting and more - all under a single, common tax identity.

This "homogenization" is exactly what leads to economies of scale in super groups by way of efficiency and lower overhead, Stryker explains, but at a cost: less physician autonomy. For example, the group may decide to give the new entity a name that does not clearly link each physician's name with the new practice. Depending on the specifics of the group's agreement, you and your partners will be required to arrive at consensus on a number of variables that, prior to joining the super group, used to be your decision alone.

In terms of antitrust worries, Kreager says the FTC has already issued approvals to some very large groups in which the component practices were functioning partly independently, but were demonstrably integrated clinically. He says that super groups with a shared EHR system, in particular, are able to demonstrate both patient benefit and cost reduction through measurable patient outcomes across the entire group. Additionally, Lipton adds, EHR-sharing provides the potential to lessen bureaucracy that might dilute some efficiency of scale, thereby presenting another collective advantage in negotiations with payers.

A common challenge presented by the formation of a super group is when patients feel that their tried-and-true practice experience has changed flavors. Perhaps the new, larger group elects to use a call center to handle appointments, or maybe there are related changes in the checkout process, both of which might be upsetting to long-time patients. There may be a learning curve involved.

If you can give up a little more autonomy and enjoy working with others in parallel leadership fashion, super groups may be the answer for your practice. Collaborating together in this way can mean additional bureaucracy and mindful communication processes, which Lipton says, depending on your preferred work style, might dilute the efficiencies-of-scale benefits for you or your staff.

"When transitioning into a super group, the flavor of the practices changes," says Lipton, who now serves as managing partner of an independent concierge medicine provider. While you should be prepared for some culture shift, you can smooth the transition by entering into this arrangement with practitioners who are on the same philosophical page as you and your staff, he says.

To truly find strength in numbers, Stryker stresses the human elements.

"Doctors should keep control of the organization; they need to be the executives and continue to drive the group's priorities," she says. "Unfortunately, most aren't drawn to caring about business operations, and that's OK - so long as the people in those operational roles clearly work for the doctors."

And don't forget that collaboration comes with some sacrifice as well.

"For economies of scale to actually materialize, you've got to understand who the owners are, who the business people are, and let them do their work," says Stryker. "You have to acknowledge that you've given up some autonomy. You've got to play well with others."

is a freelance writer based in Houston, Texas. She's been a writer and editor for healthcare industry publications and websites, as well as a consulting writer for practices ranging from solo physicians to national corporate networks. She can be reached via 

This article originally appeared in the September 2015 issue of 

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Collaboration, feedback loops, patient experts - terms like these are cropping up more and more in medicine.

Most recently, Internet-empowered patients have been banding together to make waves in the arenas of rare disease research, like patient-initiated studies on spontaneous coronary artery dissection; and to increase awareness of treatment options and guidelines, as is the case with patient-requested updates to the National Comprehensive Cancer Network guidelines.

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Gathering and valuing patient feedback can help improve the quality of care physicians provide, and it can make physicians aware of changes they can make to improve their practices.

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In response to an open invitation to "rant away" on Facebook, patients ranging in age from 20-something to 75 shared their biggest pet peeves about doctors.Here is your opportunity to be a fly on the wall and learn what you might want to avoid saying - or doing - next time a patient comes to your practice.Tell us if you've heard these same issues from your patients or if these are rare cases in the comments below.To view the slides in PDF format, click here.

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Are your patients relying too much on inaccurate information from Dr .Google? Here are some resources to recommend that will help steer them in a better direction.Resources:
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The Association of American Medical Colleges' Center for Workforce Studies reported the United States is in the midst of a perfect storm: an aging physician workforce, millions of baby boomers becoming Medicare-eligible, and millions more younger people becoming insured through the Affordable Care Act. The predicted aftermath is a shortfall of 45,000 primary-care physicians by 2020. The broadcasting of this and related statistics is partly responsible for an increasing buy-in by all stakeholders - including government, healthcare delivery organizations, provider education programs, the payer industry, and the general public - on the utilization of advanced practitioners.

NPs, PAs, and advanced practice registered nurses (APRNs) are hot items in the medical hiring world because of the increasing necessity of their skilled presence in private practice. Many already recognize that bringing these high-quality and cost-effective care providers on board can be a superior alternative to adding a physician.

But not everyone is well-versed in either the field's economic realities or the capacity of advanced practitioners to positively transform a growing practice. How does a private practitioner blend these professionals into a cohesive staff team and rest assured that patients will welcome them as bona fide medical professionals?

The key, says Jean Hansen, CEO of Kansas City Internal Medicine, a multi-clinic practice, is "communication - upfront and often." Hansen recommends detailing the benefits of an advanced practitioner through a meeting or other communication to staff as soon as the decision is made about a new addition to the patient care team.

Transparency in hiring, whenever possible for a practice, can promote trust in administrative decisions and enrich staff loyalty. An astute practice manager works proactively to avoid any questions like, "What is the new hire bringing to the clinic that we don't already provide?" or to answer the question as soon as it arises. Do not presume existing staff are knowledgeable about advanced practitioner training and abilities, especially if this is the practice's first time to hire one.

Aside from the readily apparent benefit of having a less costly, additional decision maker on board, some staff might be assured to hear advanced practitioners bring legal benefits, as well. Dawn Morton-Rias, president and CEO of the National Commission on Certification of Physician Assistants, explains, "Practices experience greater liability without credentialed, licensed providers on board. In recent years, the legal tolerance level for non-credentialed providers has become very low."

It's also important to remember the needs of the newly hired advanced practitioner in the transition. Observable parts of the onboarding process will communicate messages to everyone involved. With each step, keep in mind the goal of a high-functioning team. Choices that appear unsystematic can appear arbitrary or haphazard. Hansen explains that advanced practitioners are integrated in similar fashion as physicians. "They are a provider who is credentialed with the payers, as well as oriented to our electronic health record, physician protocols, and business practices," she says.

NP Sharon Lockridge's role at a suburban occupational medicine clinic in Texas is strictly clinical, which frees up the physician to accomplish more administrative duties. The team approach also enables a two-pronged staff management process, which includes observation and review of clinical skills plus acculturation and social functioning of individuals. She credits the working environment's family-like atmosphere in part to the communication habits of the physician-administrator.

"He's very customer-oriented and clearly communicates that's our priority," Lockridge says, "and we maintain a policy of 'praise in public, correct in private' for everyone." She describes how a medical assistant (MA) initially felt threatened by the addition of the NP position, "But once the physician explained the difference in our roles, including my greater liability, the MA relaxed into the team again."

The next step in successful integration is patient education. Even more than with your staff, make no assumptions that your patients are fully informed about advanced practitioner training, skills, or roles in the clinic.

Practice management consultant Brian White of Tennessee-based Competitive Solutions, LLC, explains, "Proper communication can help prevent patients feeling as if they've been cast off to the ancillary provider. Once patients understand the role of the NP or PA, they will be receptive to the care provided by those individuals."

Before taking time to educate staff or patients, two administrative tasks are crucial to integration success:

• Develop clarity about the roles the advanced practitioner will perform within your practice;

• Decide who will be charged with being the primary point of communication about the new hire.

Morton-Rias has years of experience helping patients and staff fully embrace advanced practitioners. She estimates that in situations where things are not working out, where integration hits a rough patch, unfocused orientation of the new hire can often be blamed. If your staff are unable to clearly grasp their individual roles in the full team, that message comes across loud and clear in many ways, including patient adaptation to changes.

"You need to know the facts, yourself, about the professionals you're bringing on board," Morton-Rias says, "so you can communicate with confidence." This is important particularly in this era of Internet-savvy patients; some will want specific details on advanced practitioner training and licensure requirements.

Clarity of roles is also paramount. "To the extent that staff is comfortable, patients will be accepting. If the physician is under duress, patients pick that up," Morton-Rias says.

Well before recruiting begins, consider the following questions about advanced practitioners' roles:

• Will the advanced practitioner be managing her own panel of patients?

• Will the physician and advanced practitioner work as parallel colleagues?

• Will the physician and advanced practitioner function as collaborating teammates, actively coordinating care together?

Another bonus to onboarding advanced practitioners: You can sample before hiring. Morton-Rias strongly recommends preceptorships, and Lockridge gives high marks to locum tenens providers as ways to try out potential long-term hires.

"It's the perfect way to gauge your practice's capacity to provide support for every person on the team," Lockridge says. "Any signs of dissonance can be valuable learning experiences."

Advantages to hiring advanced practitioners

 The larger pool of prospects is a bonus for hiring time, even if turnover rate is higher, as some studies suggest.

 Even as advanced practitioner compensation is on the rise, they are still paid roughly half of a physician's salary. Patients can appreciate that the presence of advanced practitioners may equal lower cost of care.

 Adding one advanced practitioner can double patient volume and result in increased revenue.

 Comprehensive training of advanced practitioners assures a broad role capacity that can be well-utilized by resourceful practices.

 Studies indicate patients give advanced practitioners higher marks than physicians for interpersonal care such as listening and rapport.

 Credentialed, licensed providers lessen legal risks in general.

is a freelance writer based in Houston, Texas. She's been a writer and editor for healthcare industry publications and websites, as well as a consulting writer for practices ranging from solo physicians to national corporate networks. She can be reached via editor@physicianspractice.com.

This article originally appeared in the March 2015 issue of 

Want to grow your patient base and still be able to have quality relationships? Consider advanced practitioners. 

Advanced Practitioners Grow Practices, Patient Rapport

Dawn Morton-Rias, president and CEO of the National Commission on Certification of Physician Assistants, emphasizes, "Patients have choices; they return to a practice because of relationships. Patients demand not just well-trained professionals, but people they can relate to. That's not to say office staff aren't personable, but patients can Google providers in 10 seconds, and they expect a different level of interaction."

She describes a practice in Maine that expanded from two physicians to eight practitioners, allowing them to remain open seven days a week. "In that practice, the PAs maintain their own panel; they are the patients' provider of choice."

Pushback from other staff is expected, she says, so she recommends the "try before you buy" scenario to bring advanced practitioners on board:

• Bring a student in for a four-week rotation. They'll benefit, too, from close supervision while testing out their skills.

• Offer licensed advanced practitioners small part-time positions, for a few hours a week. This can include double-booking on those days so productivity remains high. Keep an eye out for positive results.

Adding advanced practitioners to your practice can grow your patient base and still allow for good patient relationships.