Fewer doctors going it alone

By GUY BOULTON
http://www.jsonline.com

There’s a good chance that your doctor works for a health care system – and there could be an even better chance of that in the coming years.

The health care systems in the Milwaukee area are all vying to put more doctors on their payroll. The systems long have employed primary care doctors. But now they increasingly are hiring cardiologists, gastroenterologists and other specialists.

In the process, the health care systems are moving a bit closer toward being fully integrated systems.

Some health care analysts contend that model – in which primary care doctors, specialists and hospitals are part of the same system – could improve the coordination of care and lessen the fragmentation that marks the U.S. health care system.

The move to hire specialists slowly is taking hold throughout the country. And there are several examples in the Milwaukee area. They include:

• Aurora Health Care, which employs about 670 doctors throughout eastern Wisconsin, has made a bid to buy Advanced Healthcare, the largest multi-specialty group practice in the Milwaukee area. About half of Advanced Healthcare’s 250 doctors are specialists.

• Froedtert & Community Health and Columbia St. Mary’s, which plan to consolidate their operations later this year, also have offered to buy Advanced Healthcare.

• ProHealth Care, which employs about 104 doctors, is in negotiations to buy Medical Associates, the second-largest group practice in the Milwaukee area. About 60 of Medical Associates’ 100 doctors are specialists.

• Wheaton Franciscan Healthcare, which employs about 260 doctors in the Milwaukee and Racine areas, is working to hire more doctors. The health care system added 40 doctors last year and 53 so far this year.

More than half of the primary care doctors in the Milwaukee area now work for health care systems. That sets the market apart from most. Nationally, most doctors still work in small practices.

An estimated 73% of all patient visits in 2003 were to practices with four or fewer doctors, according to the National Ambulatory Medical Care Survey.
Eliminating a competitor

For the health care systems, having doctors on their payrolls gives them a source of referrals. That’s because the doctors generally refer patients to specialists who practice at hospitals within the same system.

Health care systems lose money on their medical groups, offsetting the losses through their hospitals and other services. Standard & Poor’s, which rates bonds issued by non-profit hospitals, estimates the losses might range from $10,000 to $100,000 a year for each physician.

But specialists can generate considerably more revenue than primary care doctors. Further, hiring specialists brings an additional benefit: The health care system no longer has to worry about a potential competitor.

Hospitals now compete not only with other hospitals, but also with the doctors who staff their hospitals, said Preston Gee, senior managing director of Phase 2 Consulting, a health care consultancy in Austin, Texas.

Procedures and tests that once were done only in hospitals increasingly are being done in physician offices, imaging centers and ambulatory surgical centers.

Advanced Healthcare, for instance, owns two ambulatory surgical centers and has a stake in two others that it owns jointly with Medical Associates and Froedtert & Community Health.

For doctors, working for a health care system frees them from the complexities and hassles of running their own practices.

Working for a health care system also holds the promise of more set hours and a bit more time with families.
Small practices in decline

Many doctors still prize their independence and have no interest in becoming part of a health care system. Further, employing doctors can bring its own problems.

“Doctors are accustomed to being fairly autonomous,” said Scott Weltz, senior vice president of Bowers & Associates Inc., a Milwaukee company that advises employers on ways to control health care costs.

But solo practices are becoming increasingly rare. The same is happening with small practices. And Loren Meyer, president and chief executive officer of Wheaton Franciscan Medical Group, said physicians are becoming more open to working for health care systems.

Since the start of last year, Wheaton Franciscan bought or hired physicians from 14 local practices. Those practices had a total of 24 doctors.

The health care system also has hired specialists in neurology, cardiology, orthopedics, oncology and other specialties. It now employs about 150 specialists.

Potential changes in how hospitals and doctors are paid also are behind the emerging trend.

One is the prospect of basing part of doctors’ pay on their ability to provide quality care at a lower cost. Another is the prospect of paying doctors and hospitals a set rate for a so-called episode of care.

That would mean payments to doctors and hospitals would be tied to how each other performs.

Yet doctors’ practice styles vary and so, too, does the cost of the care they provide. Some doctors order more tests, for instance, or prescribe different medications.

Putting doctors on their payrolls gives the health care systems more control over how the doctors practice, Weltz said.

At Wheaton Franciscan and other health care systems, for instance, part of a doctor’s bonus is tied to his or her meeting certain quality measures as well incentives for efficiency.
Communication failure

Hiring specialists also could improve the coordination of care.

Communication problems among doctors, medical records that aren’t forwarded and poor hand-offs are common problems in the U.S. health care system.

In surveys, 17% of people report test results were not available at the time of an appointment and 14% said a doctor had to reorder a test that already had been done.

Just hiring more specialists by itself won’t improve the coordination of care.

But some of the country’s most admired health care systems – such as the Mayo Clinic and the Cleveland Clinic – are integrated systems.

That’s not lost on the health care systems that are moving to hire more specialists.

“Integrated systems certainly are shown to be a better way of providing care,” Meyer said.
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