ACR forms Community Practice Council amid ‘fear over private practices disappearing’
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In a health care system and a specialty that is becoming increasingly corporatized, there is a danger of small practices and independent rheumatologists being drowned out by larger, louder voices.
In an effort to provide a kind of megaphone — or at least an ear — to these smaller providers, the American College of Rheumatology in January announced the creation of its Community Practice Council. According to the ACR, this new body aims to assist and educate private practice rheumatologists in a health care system filled with giants.
“There is a real fear over private practices disappearing,” Tien-I Karleen Su, MD, the newly announced chair of the ACR Community Practice Council (CPC), told Healio. “The overwhelming trend is toward more and more people working as employees in larger health care systems. Several decades ago, when many physicians first came out of training, they were able to open private practices without the same kind of challenges that they face today. They did not have to compete with large health care systems, battle insurance companies or deal with reimbursement issues.
“Negotiating contracts with insurance companies is a challenge,” she added. “The reimbursements from both private and government insurances have not kept up with the rate of inflation. In addition, there has been an increasing administrative burden, including all the new regulations and compliance challenges that were not there a decade ago. Some of the smaller practices don't have the resources to efficiently manage these regulatory obstacles.”
Perhaps this pressing fear is why, when the ACR sought applications for council membership earlier in 2023, it received significantly more interest than expected. More than 70 people applied for membership on the 15-person council. Once chosen, the members convened for the first time in April at the ACR Education Exchange, and began mapping out strategies to help small rheumatology private practices survive and thrive.
Healio sat down with Su, who is also co-founder of the Amicus Arthritis & Osteoporosis Center, in Whittier, California, and founder of the Rheumatology Private Practice Alliance, to discuss the aims of the council, the nature of its early meetings and where the group sees itself going in the future.
Healio: Could you talk more about the “corporatization of medicine” from a rheumatology-specific point of view?
Su: As part of vertical integration in recent years, hospitals and large health systems have been acquiring primary care providers and primary care practices. They are now buying specialty practices and acquiring specialists, including rheumatologists. This has a few implications for private practices. One is that referrals that we were getting before declined noticeably.
A few CPC members reported that referrals from primary care physicians that they had long-term relationships with dropped almost overnight. Another impact of corporatization of medicine is that it is difficult to compete with large health systems in terms of staff recruitment. They can offer higher pay, better retirement plans and more comprehensive health coverage.
Healio: What other recruitment challenges do small practices face?
Su: We understand that people are enticed by higher pay and better benefits. Although all businesses had hiring challenges during the pandemic, in which there was the great resignation, smaller practices had bigger challenges. Training new staff can be very costly and many small-practice rheumatologists are not familiar with implementing good human resource practices. However, I often have to remind physicians that if we are able to go through the rigors of medical school training, we can certainly learn the concepts of running a practice.
Healio: When the CPC was created, what was the reaction among rheumatologists?
Su: When the application to participate in the CPC went out early this year, there were more than 70 applicants. This level of interest was more than what was expected, indicating that there is indeed a huge need to have more solid representation of private practices in the ACR.
ACR members who were not as involved in terms of volunteering on other committees showed interest in being involved in this council. We believe that self-preservation of our practices plays some role in why there was so much interest. Many of us feel that if nothing is being done to help private practices now, we may not survive into the future.
Those of us in private practices, and especially those that left large health care systems to be in private practice, want very much to keep this sector of rheumatology alive because we personally experience the many benefits of it. When I first met the council members, I sensed that passion among each of them and I knew this was the group I wanted to work with.
Healio: What are some of the advantages of being in a small practice?
Su: One is that we can offer employees more flexibility and less bureaucracy. For example, I had an employee who left for a hospital position that paid significantly more, but she came back because we were able to offer her a schedule that allowed her to have a better work-life balance. We also are able to foster a culture that is closer-knit than one in a large organization.
Another benefit of working in a small practice is that employees can learn more skills because they are often cross trained to do things that they otherwise may not have had the opportunity to do in larger companies. Lastly, people who work in large health care systems often become frustrated that their voice is not heard. I think fellows may have the perception that large systems are more secure without realizing that there are many limitations that can affect their ability to practice medicine the way they want.
Ultimately, I believe it depends on how much physicians value autonomy. Some may be perfectly happy working in large health care systems whereas some leave after a few years because they did not realize that autonomy was something very important to them.
Healio: Work-life balance seems to be a priority for new physicians just emerging from their training. How does this factor into the equation?
Su: When I first started practicing, I thought the key to success was to hustle, hustle, hustle in order to make our practice successful. That was the mentality we had when we went through our medical training. However, there is now more recognition of burnout among physicians.
The newer generation of physicians are more aware of the importance of work-life balance. This is particularly true because the rheumatology workforce is becoming increasingly more female. So, one strategy is for practices to offer part-time positions and as much administrative support for physicians as possible in the practice.
Healio: What else do small practices need to be doing to compete with larger systems?
Su: Larger health care systems can bring in ancillary revenue, which can help offset the higher compensation they offer to their physicians. It is more difficult to do that in a small practice, so we are trying to help practices find strategies to bring in ancillary revenue that can better support their overhead and compensate their staff and physicians more competitively.
These strategies include infusions, in-office dispensing, innovative care models such as membership models and conducting clinical trials. We also want to provide resources to help small practices to operate more efficiently.
Healio: Could you talk about the challenges to private practice in urban, suburban and rural areas?
Su: Taking Los Angeles as an example, there are many large health systems in the area, including the University of California Los Angeles, the University of Southern California and Cedars-Sinai. They deliver care all over the area and into the suburbs of Santa Barbara County. This has impacted both urban and suburban rheumatologists and their referral base. How do private practice rheumatologists make themselves stand out and survive in this kind of climate?
We have to communicate to patients more clearly what makes us different. For example, in small practices, we often can deliver more personalized care. We can pivot faster and solve problems quicker. When patients call our offices, they do not reach a call center and sit on hold for a very long time. Instead, they reach directly to our office line and can get their answers quickly.
Healio: How about in rural areas?
Su: The demand should be considerably higher because the supply of rheumatologists is low, but recruitment can be challenging because many new physicians are less attracted to working in rural areas than they are in urban or suburban areas. At the CPC, we are trying to figure out ways to draw fellows and trainees to those underserved areas. One attractive feature is that rheumatologists practicing in rural areas often have a lot more autonomy, even if they work in large health systems, because they are the only person with that kind of expertise in the region.
Healio: Did you select members of the CPC who could be a voice for rural providers?
Su: Yes, each of us on the council has different backgrounds and different things that we are interested in. We were cognizant to select representatives from different regions of the country. The group is also 50% female and 50% male. We wanted people who faced different types of challenges and who had different viewpoints on the work-life balance.
Healio: What have you accomplished so far?
Su: We started off by making a long list of all the things we wanted to address. However, we understand that this is going to be a long-term project, and that solutions will not happen overnight. We have had two meetings thus far and the excitement among the council members to make a positive impact for private practice rheumatologists was palpable.
Despite our diversity, we share a common vision that allowed our discussions to be productive and enjoyable. We were able to narrow down to a few issues that we plan to work on in the next few months. The next step after that is to connect and collaborate with other committees within the ACR to work on these issues.
Healio: Can you give some examples?
Su: One important issue is for us to establish a stronger voice for private practice within the ACR. The perception among most private practice rheumatologists is that the ACR has focused more on academic rheumatologists, so it is important that we help ACR communicate to their members that we are here, we care about you, and we are going to do something to help you.
The second item is to build a resource library for private practice rheumatologists on the ACR member website that can serve as a go-to place for rheumatologists to thrive in their private practice journey.
Healio: Why now? What prompted the formation of this council at this particular time?
Su: My partner in my own clinic has been practicing since the 1980s. He was able to operate for many years without the need to collaborate. However, in recent years, he has been saying that private practice is going to die. I am more hopeful, but we both recognize that private practices are facing more challenges than ever. That said, our challenges are not unique, and so we are starting to recognize the need to collaborate when it comes to negotiating power and shared resources.
At the same time, it seems that the ACR also realized that fears and concerns among private practitioners were not being addressed. Many private practice rheumatologists have voiced that ACR has focused too much on those in academia and private practices are like the forgotten children. CPC members do not believe this is intentional and that it is our job to help bridge that disconnect.
Healio: What are the next steps?
Su: We are excited that we will be able to leverage the ACR’s reach. We can reach out to fellows who may be intimidated to start their own business. We can use the infrastructure of the organization to form networks of trainees, fellows and people who are currently running private practices or want to join private practices. We have some great ideas such as sharing our own practice journey on podcasts and journals that have a wide rheumatology audience as way to educate and inspire.
The one important message we want to deliver to our rheumatology colleagues and fellows is that despite the challenges faced by private practice rheumatologists, we still find tremendous joy and autonomy offered in our jobs. These benefits motivate us to passionately advocate for the sustainability of private practice.
Reference:
The ACR Announces New Community Practice Council; Applications Now Open: https://www.the-rheumatologist.org/article/acr-announces-new-community-practice-council-applications-now-open/
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