In an era of ongoing collaboration between care providers, the hospital-owned physician practice is increasingly common. However, models like Heritage Medical Associates', which combines the scale of a large network with the independence of a private practice, offer another dimension to predicting the future of private practice.
Heritage Medical Associates has grown in just over 20 years from a 10-person internal medicine practice into a veritable Middle Tennessee giant — the largest independent, multi-specialty physician group in the area.
With more than 100 physicians, 10 specialties, laboratory and imaging services and a dozen sites of care, the practice operates like a mini-hospital in some ways, according to Dr. Paul Gentuso, Heritage chief medical officer.
"When you think of why so many physicians are beginning to be employed by the hospital now, I think it's because the younger generation is looking for security, and the older generation was looking for opportunity," Gentuso says. "That's not a slam on the younger physicians, because the world is a little less secure now in regards to the business of medicine."
Beyond the security of steady patient flow and a paycheck, large practices offer a level of administrative management that reduces regulatory and technological pressure on physicians constantly expected to do more with less. With scale come human resources, a finance and billing department, and counsel retained to handle compliance. Without it, there is an increased crunch on smaller practices.
Even so, there are physicians for whom autonomy is a priority. Gentuso calls it the "eat what you treat" mentality — the ability to control income and practice medicine with a spirit of entrepreneurship.
"They're forgoing the advantages of being in a large group for other things that drive them," Gentuso says. "They're more pioneerish, or they just can't stand the idea of being owned or affiliated. But that's becoming rare. That's why I think the independent medical practice model really works. We have the security at Heritage for the younger doctors, but we're giving them an opportunity to really go for it."
There is safety in numbers, but there is no official benchmark guaranteeing a successful practice. A strong primary care contingent has worked well for Heritage, Gentuso says, because primary care is attractive to insurers, health systems and new integrated care networks borne of the Affordable Care Act. But there are opportunities elsewhere, notably the single-specialty practice.
"Nashville is full of these large, single-specialty groups — the radiologists, the urologists, the surgeons — and they don't have primary care, but they have that specialty locked up in the region," Gentuso says.
Since its inception 22 years ago, Heritage has added many such specialties to its own service offerings. There was a desire to take care of the whole family, so the practice added pediatrics, obstetrics and gynecology. As Heritage realized additional specialties meant better records-sharing and improved care, along came neurology, rheumatology and behavioral health, among others. Having a stronghold in the full continuum of care is attractive to health systems and payers, Gentuso says.
Along with the early specialties, Heritage added laboratory and imaging services, which offer a variety of benefits for the practice. Beyond the one-stop-shop convenience for patients, managing an independent lab ensures quality and nearly instantaneous health record updates. Additionally, diagnostic testing is an important source of ancillary revenue, but one facing increased competition as hospitals also move many of their lab services to the outpatient space.
"We're going head to head with the hospitals on this, which makes it challenging because we have to be careful with price structuring," Gentuso says. "I don't think we ever set out to compete with hospitals. But in some way, we are more than ever."
In the sea change of health care, Heritage is trying to stay ahead of the curve, adapting access points and pricing to reflect patients' more consumeristic approach to care. Responsible for more of their own costs, patients are seeking additional options to obtain care that is faster and cheaper than what many physicians are used to providing.
"It puts the doctor in the position of having to defend everything prescribed," Gentuso says. "When people are asking if they can get by without a test, that's a question you never would have heard when the insurance was picking it up. I don't think fee-for-service was as bad as some of the political commentators have made it out to be; it makes doctors out to be awfully mercenary. But if we live in a capitated world, we can manage that. I like that at-risk model. I believe it allows us to practice responsible yet efficient medicine."
Heritage is working to improve access after hours and on weekends, and the practice wants to engage with urgent care facilities and retail clinics, either by creating those service lines or developing strategic relationships with established companies.
"We have a lot to do to improve, but I'm optimistic about the future of the large, multi-specialty group," Gentuso says. "We have great partnerships with the health systems, but I'm glad we're not owned. I'm not spiking the ball and I'm not thumping my chest, but I do believe there is no reason to be frightened about the future."
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