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Should You Divest Your Practice?

Practicing medicine in today’s health care environment is not for the faint of heart. Historically, successful practices were predicated on providing high-quality patient care; i.e., being great physicians. Slowly but surely, over the past 25 years, operating and maintaining the necessary business infrastructure has evolved dramatically, outpacing physicians’ limited time and ability to properly manage it. Sadly, this new reality may put our passion for practicing medicine at risk, increasing physician frustration and burnout. It’s not because we are bad doctors; it’s simply because we may not be the best business people. Not surprisingly, as payment models shift, and physicians face lower reimbursements amid growing expenses, many have at least considered—if not seriously contemplated—divesting their practices.

Nephrologists are not alone. The traditional practice of medicine is falling by the wayside as providers across the board look to adapt to a new practice environment. The question is how physicians will survive and what factors should be considered in evaluating the current marketplace and next steps.

Challenges to independent practice

Several developments are motivating physicians to consider different business models to practice medicine, including the shift away from fee-for-service to value-based payments. These changes, initiated largely by new federal laws and increasingly complex regulations, are requiring the medical community to:

  • Invest in costly electronic health records to satisfy meaningful use requirements. According to new data from the Medical Group Management Association, physician-owned multispecialty practices spent more than $32,500 per full-time physician on information technology equipment, staff, maintenance and other related expenses in 2015.
  • Engage in the physician quality reporting system.
  • Implement the Medicare Access and CHIP Reauthorization Act (MACRA).
  • Contemplate new integrated care agreements, including accountable care organizations (ACOs) and end stage renal disease seamless care organizations (ESCOs).

Nephrologists are particularly vulnerable to changes in Medicare since the federal program is the primary payer of kidney care. As such, not keeping up with new requirements can have outsized financial consequences as these programs shift from offering incentives focused on boosting physicians’ participation to penalizing providers who don’t meet certain requirements. For example, MACRA carries significant reimbursement implications over the next several years, with possible penalties of up to nine percent of Medicare Part B revenue for non-participation or poor performance. This year, about 171,000 providers are subject to a downward payment adjustment under Medicare for failing to demonstrate meaningful use.

Thriving in this new health care environment demands both significant capital investment and the ability to navigate increasingly complex reporting requirements and financial arrangements. These factors, combined with a new generation of nephrologists with different expectations for their work-life balance, are prompting many nephrologists to seek a new way of doing business, including joining larger organizations.

Laying a foundation for the future

According to the Physicians Advocacy Institute (PAI), the number of employed physicians grew by 46,000 nationwide from 2012 to 2015, with the percentage of hospital-employed physicians increasing almost 50 percent from July 2012 to July 2015.

The trend is expected to continue. Uncertainty clouds many aspects of health care today, including how to cover uninsured Americans. However, the federal government and private insurers are aligned in their focus to better manage care for patients with chronic kidney disease and end stage renal disease. These patients consume a disproportionate share of resources, to the tune of more than $30 billion a year. Needless to say, regardless of what happens with the Affordable Care Act, integrated care and risk-based agreements are here to stay.

In addition to the significant capital investment required, these new payment arrangements pose other challenges for many doctors, the majority of whom have little to no formal training in busi­ness or business principles. After all, historic fee-for-service reimbursement models did not require physicians to have a sophisticated understanding of the business of practice. Further, payment structures employed by the federal government and private insurers increasingly favor integrated health systems, making it more difficult for independent physicians to compete.

Times of change are challenging, but there are viable options for partnerships that will put nephrologists on a sustainable path for the future. Physicians should consider partners who are not only better equipped to participate in integrated care models but who can also more easily absorb administrative costs to comply with regulatory and reporting requirements. Having access to a larger infrastructure allows administrative experts to manage contracts and reporting requirements, helping physicians, who may already be spread thin, to continue to focus on their top priority: caring for their patients.

Health care will always be local, and patients will always need nephrologists to meet their needs wherever they are. However, today’s environment requires nephrologists to evaluate how best to partner to sustain their medical practices into the future. Now is a good time to take stock of your practice and reflect on your short- and long-term goals. This exercise will not only help you address future challenges, but it will also better position you to identify solutions.

Note: This content has been repurposed, with permission, from Renal & Urology News.

Robert Provenzano, MD, FACP, FASN

Robert Provenzano, MD, FACP, FASN

In addition to his roles as chief medical officer at Nephrology Practice Solutions and vice president of medical affairs at DaVita Kidney Care, Robert Provenzano, MD, is a clinical professor of medicine at Wayne State University School of Medicine in Detroit, where he earned his medical degree. He completed his fellowship training at Henry Ford Hospital and served as the chief of the nephrology, hypertension & transplantation section and director of nephrology research at St. John Hospital and Medical Center in Detroit. Dr. Provenzano is former president of the Renal Physicians Association and chair of the National Kidney Foundation of Michigan. He is also former CEO of St. Clair Specialty Physicians, PC, a multistate nephrology practice. He has published extensively on kidney care business models and is the chief medical officer of Nephrology Practice Solutions (NPS), a national kidney care management company affiliated with DaVita that oversees owned and managed practices. Twitter: @DrBobPro