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‘Physician owned’ — changing connotations and roles for orthopedists
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I first became aware of the idea of physician ownership during my childhood. Our family physician and his partner moved their medical practice into a freestanding clinic they had built.
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Shortly afterward my family had some medical appointments there and the doctor asked a nurse to give us a tour.
We were all pleased with the convenience of the new location and the new ancillary services (X-ray and blood work) they could offer in one visit.
For years, physicians have been owners or limited partners in their office buildings. They built the facilities to their specifications and, in effect, paid rent to themselves. Many paid off their buildings at — and even before — retirement, and that often turned out to be one of their best retirement investments.
Few people found physician ownership of medical offices unethical. It seemed good for physicians and patients and allowed practices to be located in friendly settings.
Adding ancillaries
Adding physician-owned ancillary services seemed an obvious extension of this whole idea — patients could more easily get the studies and procedures performed when and where they needed them. And by providing those services, physicians could generate additional revenues.
But as delivery and reimbursement methods changed, the concept of physician-owned clinics has taken on new meaning, depending on one's perspective and position.
It has raised questions and challenges within different specialties, and some critics now use the term "physician owned" in a derogatory manner.
They suggest it represents a conflict of interest, leads to overutilization of services by the physician-owner and to decisions not solely in patients' best interests.
Additionally, they say, it may place certain ancillary outpatient services in direct competition with the local hospital and other physicians.
Self-interested criticism
Much of the criticism against physician-owed ancillary services arises as a defense from established interests. For example, the radiologists' national organization continues to support legislation in some states to prohibit nonradiology physicians from owning office-based imaging equipment or centers.
They argue that such ownership results in more — allegedly unneeded — studies being ordered by the nonradiologists. In turn, most other physicians with office-based imaging view radiologists as trying to monopolize imaging for their own centers.
Yet, with new digital equipment, the quality and interpretation issue is further negated, as it becomes possible to easily obtain real-time over-readings by experts who are geographically dispersed.
Our group, for example, uses prominent orthopedic radiologists in another city to over-read our films. We send them digitally and they read the images within hours of the study. They are always accessible by cell phone.
Physician offices have the choice whether or not additional interpretations are even needed.
Orthopedists can read X-rays and MRIs very well themselves, and often their patients do not benefit from an outside reading (no value added care).
And having the studies available in the office setting helps patients avoid the burden of making and meeting additional appointments at yet another facility.
Surgicenters hit a nerve
More recently, the concept of physician-owned ancillary services became even more complicated — and financially threatening to some — with the advent of physician-owned surgicenters and specialty hospitals.
Whatever the financial implications, physicians desire quality, focused and specialized care settings that are patient friendly and where they can exercise some control.
It is particularly important, given today's challenging practice environment (which now includes such things as consumer-driven health savings accounts), for orthopedic surgeons to be able to offer convenience and the potential for superior clinical outcomes to patients.
As physician-owned surgicenters and specialty hospitals expanded, the political debate drew in hospital associations and administrators. While everyone agrees we need a more efficient health care system, some organizations (eg, hospital associations and radiologists) are asserting political influence to eliminate this form of competition.
They fear that if left unchecked, the trend towards surgicenters could potentially leave them as stripped-down service providers, offering primarily emergency rooms, critical and intensive care units.
Reaction, then over-reaction
Hospital groups have responded and have brought about the moratorium on specialty hospitals in the Medicare Modernization Act.
The underlying issues of physician ownership today becomes much more threatening to all parties as private reimbursements shrink further, costs rise, and Medicare's price controls play out.
Will this challenge to perceived unfair competition to the establishment result in over-regulation or lead to better health care delivery?
We must be involved in this debate and not be intimidated by those using the banner of "ethics" and "regulation" to their advantage.
The quality and delivery of specialty care must be balanced with the patients' interests and cost efficiencies.
Our health care delivery and reimbursement systems have many aspects that are out of date.
Whether physicians truly participate in the governance of, or as owners of ancillary services, we must be aware of what motivates those around us.
While we should always make our patient interests the primary consideration, we must understand how the health care dollars get distributed and the motivations of those bent on preventing change.
Big players against us
Our profession is up against some large forces in this arena.
These include insurance companies, state and federal governments, other specialties, the American Hospital Association and existing owners of ancillary services.
Physician ownership and a need in the future for creative joint ventures and mergers will continue (see article on page 36). As long as the patients' needs remain primary and get met efficiently, we must not be regulated out of our ownership.
Do not be intimidated over or dissuaded from the concept of physician ownership. The alternative is showing up for work, being given a stethoscope and a list of patients — becoming an employee.
The rules covering the delivery and financing of health care will continue to change. Monitoring the long-term effects on orthopedic surgeons will take constant vigilance, analysis and participation.
Physician ownership and the ability to be involved in the governance of ancillary services is not necessarily a bad thing. It can benefit our patients and us. We need to make it work and withstand the inevitable criticism by always putting patient interests first.
Douglas W. Jackson, MD
Chief Medical Editor