CopyrlghL [2012 WhlLeSpace PealLhcare LLC.

r|vate ract|ce at the Crossroads

Introduct|on
ln Lhe SLorm of 8eform" currenLly swlrllng Lhrough Lhe healLh care lndusLry, Lhe pllghL of Lhe
lndependenL pracLlLloner may be besL descrlbed by Lhe old adage, hyslclan, heal Lhyself." A recenL
sLudy conducLed by our research dlvlslon lnvolvlng hundreds of prlvaLe pracLlLloners revealed LhaL 94
percenL prlorlLlzed pracLlce survlval above paLlenL care.
1hls admlsslon a decade ago would have been akln Lo commlLLlng heresy, especlally ln llghL of Lhe
PlppocraLlc CaLh! 1oday, however, all beLs are off as many prlvaLe pracLlLloners sLand aL Lhe edge of Lhe
flnanclal preclplce, whlle Lhe healLh sysLem ls belng rlpped aparL ln a desperaLe aLLempL Lo cuL cosLs . aL
any cosL!
Lven conLemplaLlng Lhe ellmlnaLlon of prlvaLe pracLlce from Lhe sysLem flles ln Lhe face of convenLlonal
wlsdom. 1hls scenarlo ls so alarmlng LhaL we should noL heslLaLe Lo challenge lL.
1hls whlLe paper ls Lhe flrsL ln a serles deslgned Lo ralse awareness abouL Lhe loomlng crlsls. lL ldenLlfles
flve crlLlcal Lrends surroundlng lL, dlscusses Lhe dynamlcs underlylng Lhese Lrends, and offers predlcLlons
abouL Lhe poLenLlal lmpacL Lhey could have on Lhe healLh care sysLem, and, whaL's more, on all of us as
paLlenLs.
1rend of Attr|t|on . "lts 4// obout 5urvivo/"
lL's all abouL survlval!" 1haL's whaL one lnLervenLlonal paln physlclan sald when
asked abouL Lhe challenge of balanclng pracLlce survlval wlLh paLlenL care. Pe
wenL on Lo descrlbe Lhe agony of waLchlng hls pracLlce belng squeezed ouL of
exlsLence, afLer havlng lnvesLed years obLalnlng an educaLlon and provldlng
dedlcaLed servlce Lo paLlenLs.
A whopplng 96 percenL of prlvaLe pracLlLloners we lnLervlewed sald Lhey belleve prlvaLe pracLlce ls aL a
crossroads1hlssenLlmenL ls Lroubllng on many levels. lrom a macroeconomlc sLandpolnL, prlvaLe
pracLlces employ more people Lhan any oLher slngle secLor of Lhe medlcal fleld. lrom a quallLy-of-care
sLandpolnL, Lhey are Lhe prlmary polnL of conLacL Lo admlnlsLer paLlenL care wlLhouL overseers. And
perhaps more lmporLanLly, from a mlcroeconomlc sLandpolnL Lhey are Lhe prlmary englne for
malnLalnlng Lhe compeLlLlve balance beLween Lhe cosL and quallLy of servlce aL Lhe polnL of dellvery.
1hls l wlll refer Lo as Lhe CosL/value LquaLlon, and l wlll dlscuss lL ln furLher deLall ln a second paper.
1he unlque quallLles lndependenL pracLlLloners have hlsLorlcally broughL Lo Lhe healLh care professlon
slnce Lhe blrLh of our naLlon are ln serlous [eopardy Loday! lmaglne a scenarlo where Lhelr conLrlbuLlons
are dramaLlcally reduced or compleLely losL, leavlng behlnd noLhlng buL a black hole where once Lhey
shown as brlghL sLars. unquesLlonably, Lhls black hole conLlnues Lo form as hosplLals and healLh sysLems
acqulre more pracLlces, physlclans Lake early reLlremenL and conLlnue Lo leave Lhe pracLlclng of
medlclne alLogeLher.

CopyrlghL [2012 WhlLeSpace PealLhcare LLC.
Lvldence of Lhls Lrend ls found ln Lhe 2011 governmenL reporL on PealLh
rovlder uemographlcs, whlch showed LhaL Lhe number of prlvaLe pracLlces
decreased by 17.7 percenL beLween 2003 and 2010 so LhaL Lhey now
comprlse only abouL 62 percenL of Lhe LoLal. 1hls ls a sLaggerlng sLaLlsLlc
conslderlng only LwenLy years ago Lhey comprlsed 90 percenL of pracLlces.
Many prlvaLe pracLlLloners face Lhe same faLe as Lhe dlnosaur, yeL Lhey
nalvely assume someLhlng wlll mlraculously occur Lo save Lhem. 1hls may
be a plpe dream! Cf Lhe pracLlLloners we lnLervlewed, 74 percenL belleve
LhaL Lhe sLruggle Lo reln ln cosLs and malnLaln quallLy of care ls havlng a slgnlflcanL negaLlve lmpacL on
Lhelr boLLom llne, and Lhey are serlously conslderlng Lhe alLernaLlves Lo remalnlng prlvaLe.
rlvaLe pracLlce means [usL LhaL: lndependenLly owned enLlLles ln whlch physlclans pracLlce medlclne
Lhe old-fashloned way, based on Lhelr knowledge and experLlse wlLhouL overslghL. Powever, ln an
efforL Lo conLaln cosLs, Lhe very exlsLence of Lhls secLor of Lhe medlcal lndusLry ls belng LhreaLened as
governmenL, lnsurers, hosplLals and healLh sysLems (herelnafLer referred Lo as 1he lorces") galn
greaLer conLrol over larger porLlons of Lhe healLh care Lurf. ln Lhe face of Lhls occurrence lndependenL
pracLlLloners musL conLend wlLh 1he lorces sLacklng Lhe cards agalnsL Lhem as Lhey sLruggle Lo sLay one
sLep ahead.
1here ls no doubL LhaL 1he lorces are drlvlng prlvaLe pracLlLloners ouL of Lhe healLh sysLem aL an
alarmlng raLe. 1hls unsavory dynamlc, whlch we refer Lo as Lhe tteoJ of otttltloo," has been well
documenLed by many respecLed sources, lncludlng our flrm's research. lL would be a grave mlsLake Lo
slmply sweep Lhls phenomenon under Lhe rug so lL becomes a mere fooLnoLe ln Lhe annals of healLh
care reform. AL sLake ls Lhe demlse of Lhe Lwo mosL preclous paLlenL prlvlleges: quallLy of care and
cholce.
Clven Lhe gravlLy of Lhls Lrend, we musL conLlnue Lo undersLand boLh Lhe macroeconomlc and
mlcroeconomlc lmpllcaLlons of Lhls phenomenon, slnce healLh care ls a large and growlng porLlon of our
counLry's gross naLlonal producL and a slgnlflcanL conLrlbuLor Lo our naLlonal debL.
1rend of Conso||dat|on . "Moke the 8iq 8iqqer ond Let the 5mo// 6o
xtinct"
Many slze-zealoLs wlLhln healLh care clLe Lhe conLrol of run-away healLh cosLs
as a reason Lo ellmlnaLe lndependenLs and aggregaLe power ln fewer hands.
AlLhough some economles of scale can be beneflclal, Lhe laws of economlcs
wlll prevall and consolldaLlon wlll evenLually be exLremely deLrlmenLal Lo Lhe
ulLlmaLe consumers . paLlenLs."
A recenL arLlcle ln Lhe MedClLy news enLlLled Is the hys|c|an r|vate ract|ce 8e|ng 1argeted 'by
Des|gn,' ur. Mlchael klrsh descrlbes how many prlvaLe pracLlces are slmply sLruggllng Lo survlve. Pe goes
on Lo say, l belleve LhaL prlvaLe medlclne ls belng LargeLed by deslgn, and when lL becomes exLlncL, Lhe

CopyrlghL [2012 WhlLeSpace PealLhcare LLC.
publlc wlll lose an lmporLanL healLh care resource." 1hls polnL of vlew was echoed by Lhe ma[orlLy of
physlclans we lnLervlewed, lncludlng an orLhopedlsL who barked, 1hey (1he lorces) wanL Lo make Lhe
blg blgger and leL Lhe small go exLlncL.
Make no mlsLake abouL lL, growLh Lhrough acqulslLlon ls cenLral Lo
Lhe overall sLraLegy of hosplLals and healLh sysLems. 8uL wlll slze
LranslaLe lnLo lower cosL and lmproved quallLy of care? Could lL be
LhaL Lhls whole Lrend ls slmply smoke and mlrrors? l'm noL lmplylng
LhaL physlclans worklng ln Lhese acqulrlng lnsLlLuLlons have
unscrupulous moLlves, buL we need Lo recognlze LhaL Lhey are
worklng under a buslness-based model raLher Lhan a pracLlce-based
model, a blg dlfference Lo be sure!
ArLlcles have been appearlng recenLly ln respecLed publlcaLlons quesLlonlng Lhe loglc and wlsdom of
maklng Lhe blg blgger." As an example, l slLe a recenL woll 5tteet Iootool arLlcle by Ann Wllde MaLhews
enLlLled, Insurers Say kates Can Surge after nosp|ta|s 8uy r|vate hys|c|ans." lL asserLs LhaL lncreased
slze doesn'L necessarlly LranslaLe lnLo greaLer cosL savlngs, as many hosplLals and healLh sysLems would
have us belleve. ln facL, [usL Lhe opposlLe ls Lrue. 1he arLlcle sLaLes LhaL healLh lnsurers say, A growlng
number of raLe lncreases are Lled Lo physlclan-pracLlce acqulslLlon." 1he evldence seems Lo lndlcaLe LhaL
ellmlnaLlng compeLlLlon Lhrough consolldaLlon resulLs ln greaLer dupllcaLlon of servlces and hlgher
charges for equal servlce. lf Lrue, Lhls cerLalnly does noL help balance Lhe CosL/value LquaLlon.
1he ulrecLor of PealLh Lconomlcs and 8elmbursemenL from 8osLon SclenLlflc CorporaLlon shared wlLh
me, rlvaLe pracLlces wlll flnd lL ever-harder Lo malnLaln hlsLorlc levels of proflLablllLy when compeLlng
agalnsL hosplLals and healLh sysLems, unless Lhey flnd beLLer ways Lo leverage operaLlons and brlng
greaLer value Lo Lhe Lable." AgalnsL Lhls backdrop, our flrm has been conducLlng ln-pracLlce research ln
an aLLempL Lo uncover crlLlcal facLors for developlng a new seL of sLandards Lo help prlvaLe pracLlces
achleve performance excellence.
ln Lhe process, we worked wlLh Crlando lloreLe, Mu, owner of a promlnenL paln managemenL cllnlc ln
!acksonvllle, llorlda. uurlng a recenL lnLervlew he Lold us, 1he era of one-cllnlclan pracLlces ls a Lhlng of
Lhe pasL. 1hey wlll never survlve Lhe pressure belng exerLed by hosplLals and healLh sysLems. ln facL, l'm
consLanLly looklng beLween Lhe cracks of Lhe walls LhaL Lhey (1he lorces) have bullL, seeklng new ways
Lo survlve."
1hls sLaLemenL, from a veLeran of medlclne who dlrecLs a large, well-esLabllshed pracLlce speaks
volumes abouL Lhe pllghL of lndependenLs. lL glves us perspecLlve on whaL almosL cerLalnly lles ahead,
because Lhls problem ls noL golng away anyLlme soon.
1he message from a varleLy of respecLed sources ls clear: Lhe movemenL Lowards lncreased slze ls
maklng lL more and more dlfflculL for lndependenLs Lo compeLe. We could be enLerlng Lhe era of
ollgopolles," ln whlch fewer enLlLles conLrol ever-greaLer porLlons of Lhe healLh sysLem. Meanwhlle Lhe
[ury ls sLlll ouL concernlng how effecLlve Lhey wlll be aL lmprovlng servlces whlle conLalnlng cosLs.

CopyrlghL [2012 WhlLeSpace PealLhcare LLC.
PlsLorlcally, slnce ollgopolles never favor Lhe consumer, or ln Lhls case Lhe paLlenL, we are lndeed
Lreadlng on shaky ground!
We, as clLlzens and as paLlenLs, musL be alerL and educaLe ourselves abouL Lhe long-Lerm ramlflcaLlons
of loslng one of Lhe mosL preclous resources ln healLh care. WhaL wlll lndependenLs do when ln Lhe near
fuLure Lhey are no longer able Lo flnd any cracks beLween Lhe walls ln order Lo survlve? We refer Lo Lhls
dlsLurblng dynamlc as Lhe tteoJ of coosollJotloo.
1rend of D|sconnect . "with 1odoys Metrics lts Like l/yinq in the uork"
1o slow or sLop Lhe tteoJ of otttltloo," prlvaLe pracLlLloners musL do more
Lo help Lhemselves. 1haL ls, Lhey musL become more adapLlve Lo lnnovaLlve
Lools and Lechnlques for leveraglng Lhe Lhree lllars of erformance":
eople, rocess and 1echnology. 8uL where are pracLlLloners Lo Lurn for
help ln becomlng more compeLlLlve?
Common sense would suggesL Lhey Lurn Lo Lhe healLh care lndusLry.
Powever, Lhe physlclans we lnLervlewed overwhelmlngly expressed Lhe
vlew LhaL Lhey aren'L seelng Lhe leadershlp emerglng from Lhe healLh care lndusLry Lo help Lhem
compeLe, especlally as lL relaLes Lo Lhe quallLy of daLa and meLrlcs. We querled hundreds of physlclans
abouL Lhls lssue and found:
- 32 percenL of Lhose surveyed belleved Lhe meLrlcs avallable had moJetote voloe"
- 33 percenL sald LhaL Lhey had some ot llttle voloe"
- 13 sald lL was extteme voloe."
1hus 83 of Lhe populaLlon lnLervlewed belleves LhaL Lhe daLe and meLrlcs avallable Loday are medlocre
aL besL! Cne pracLlce manager from a large paln cllnlc ln Chlcago sald ln exasperaLlon, WlLh Loday's
meLrlcs, lL's llke flylng ln Lhe dark."
1o galn perspecLlve on Lhls lssue, we lnLervlewed several execuLlves from suppllers of medlcal devlces,
elecLronlc medlcal records (LM8s), and bllllng servlces. When we asked Lhelr oplnlon abouL Lhe quallLy
of daLa and meLrlcs avallable Loday, Lhey all seemed Lo agree LhaL hlgh quallLy daLa and meLrlcs are
plenLlful. Cne vlce presldenL from a promlnenL LM8 flrm clalmed LhaL, uaLa and meLrlcs are avallable,
buL pracLlces are [usL noL lncllned nor educaLed Lo use Lhem properly."
1hls senLlmenL, whlch Lo a cerLaln exLenL may be Lrue, does noLhlng Lo help correcL Lhls dlsparlLy.
Clearly, wlLh Lhe advenL of Lhe Pl1LCP AcL ln 2009, LM8's have become Lhe de facLo posLer-chlld for
lmprovlng pracLlce performance. Powever, our researchers found LhaL Lhe poLenLlal for LM8's Lo
accompllsh Lhls goal ls llmlLed aL besL.
1o Lhls polnL, we asked physlclans Lo whaL degree Lhey belleve Lhelr LM8s conLrlbuLed Lo lmprovlng
operaLlng performance. Surprlslngly,

CopyrlghL [2012 WhlLeSpace PealLhcare LLC.
- 30 percenL of Lhe respondenLs clalmed LM8's had a negaLlve lmpacL.
- Cf Lhose 100 clalmed Lhey had a negaLlve lmpacL on boLh Lhe cllnlcal and operaLlonal aspecLs.
lor Lhose pracLlLloners LhaL dld experlence lmprovemenL,
- 70 percenL graded Lhe lmprovemenL a mere 10 Lo 23 percenL.
- Cnly a handful of Lhe 30 percenL who ranked Lhelr lmprovemenL above 23 percenL fell lnLo Lhe
73 Lo 100 percenL lmprovemenL caLegory.
- When Lhe group above 73 percenL was asked Lo whaL exLenL Lhe LM8's daLa and meLrlcs drove
performance lmprovemenL, more Lhan 90 percenL saw llLLle correlaLlon.
1hus, lL appears from our research LhaL LM8s are noL Lhe panacea for lmprovlng performance LhaL many
suppllers clalm. AlLhough, approxlmaLely Lwo ouL of Lhree pracLlLloners wlll percelve some degree of
operaLlng lmprovemenL when lncorporaLlng LM8s, Lhe lmprovemenL wlll be
moderaLe aL besL. 1hose ln Lhe remalnlng group who may percelve slgnlflcanL
lmprovemenL wlll noL aLLrlbuLe lL Lo Lhe quallLy of daLa and meLrlcs ln LM8s.
1o be falr, LM8s were never meanL Lo provlde operaLlng daLa and meLrlcs,
buL LhaL seems Lo be whaL physlclans are looklng for. 1hey seem Lo wanL, and
expecL LM8s Lo do more Lhan slmply be, a Lechnology subsLlLuLe for whaL
once was an adequaLe paper-based sysLem. 1hls conundrum ls exacerbaLed by Lhe Pl1LCP AcL ln whlch
governmenL lncenLlvlzes pracLlces Lo purchase LM8s. WhaL Lhey dldn'L plan on ls LhaL many pracLlces go
Lhrough several LM8 sysLems ln a desperaLe aLLempL Lo flnd one LhaL works besL for Lhelr needs. CfLen
Lhls Lrlal-and-error process Lo flnd Lhe LM8 LhaL besL flLs Lhelr speclalLy wasLes valuable Llme and
money.
lrom our research lL ls evldenL LhaL LM8s are noL an easlly adopLed panacea, slnce Lhey do noL provlde
any of Lhe crlLlcal daLa and meLrlcs prlvaLe pracLlLloners deslre Lo compeLe agalnsL 1he lorces. So
reLurnlng Lo our orlglnal quesLlon, where do Lhey Lurn? Large pracLlces can posslbly geL help from
consulLlng flrms, buL Lhls soluLlon ls ofLen flnanclally ouL of reach for small Lo mld-slzed pracLlces. lor
Lhese pracLlces Lhe answer aL presenL seems Lo be nowhere"!
We refer Lo Lhls unseLLllng dynamlc as Lhe tteoJ of Jlscoooect." 1o reverse Lhls Lrend we may need Lo
reLhlnk Lhe LradlLlonal Lask-based" approach of Lhe pasL and conslder a 21
S1
CenLury lnsLrucLlonal-
based" approach LhaL seamlessly lncorporaLes daLa and meLrlcs as parL of an overall soluLlon. Such a
sysLem would allow physlclans, especlally Lhose wlLh small Lo mld-slzed pracLlces, Lo become more
adapLlve.
1rend of Commandeer|ng . "kodico/ chonqe kequires uisruptive lnnovotion"

CopyrlghL [2012 WhlLeSpace PealLhcare LLC.
now LhaL Lhe Supreme CourL has recognlzed Lhe Affordable Care AcL as consLlLuLlonal when lL ls
consLrued as a Lax, our undersLandlng of Lhe role LhaL prlvaLe pracLlce wlll play ls furLher compllcaLed.
1hls declslon acceleraLes Lhe movemenL Lowards soclallzed medlclne and, more alarmlngly, posslbly
Lowards naLlonallzaLlon. LlLher movemenL wlll dramaLlcally LhreaLen Lhe survlval of lndependenL
pracLlces.
1he defenders of Lhe Affordable Care AcL can be found ln all corners of medlclne, as well as LhroughouL
socleLy-aL-large. lor example, ln a recenL lssue of MeJclty News, an apparenL proponenL of Lhe acL, ur.
!ohn Mandrola, lamenLs LhaL, 1he less-ls-more dlscusslon geLs beaLen down by raLlonlng, whlle goal-of-
care-dlscusslons brlng up deaLh panels." 1o a large exLenL hls asserLlons are correcL. 1haL's because free
markeLers are concerned LhaL lf 1he lorces galn Loo much conLrol, Lhey could, ln an acL of desperaLlon,
enacL raLlonlng and/or panels of care.
Whlle Lhe debaLe rages on, we need Lo seek advlce from LhoughL leaders who have proven Lrack records
of successfully enacLlng change wlLhln healLh care and oLher lndusLrles. We should noL rely slmply on
Lhe lnflnlLe wlsdom" of governmenL offlclals Lo leglslaLe change as Lhey see flL.
AuLhorlLles who come Lo mlnd lnclude Mr. !ames Champy (www.[ameschampy.com), co-auLhor of Lhe
New otk 1lmes besL seller keenqineerinq the corporotion. Pe recenLly auLhored Lhe book
keenqineerinq neo/thcore, whlch lncorporaLes Lhe prlnclples of
reenglneerlng, fleld-LesLed for more Lhan LhlrLy years. ln lL he clLes
examples ln healLh care where radlcal change has been made by uslng
reenglneerlng prlnclples.
AnoLher experL worLh heedlng ls Mlchael orLer
(www.mlchaelporLer.com), Lhe emlnenL Parvard professor and
leadlng auLhorlLy on value-based managemenL and compeLlLlve
sLraLegy. ln hls recenLly auLhored book keinventinq neo/th core, he
descrlbes how Lhe dellvery sysLem can lmprove value. ln hls chapLer called ldenLlfylng Lhe 8ooL Causes"
he asks, Why ls compeLlLlon ln heaLh care noL worklng." ln lL he dlscusses why hls Lheory of Zero Sum
CompeLlLlon whlch applles wlLhln oLher lndusLrles should also apply wlLhln Lhe healLh care lndusLry,
even Lhough many people clalm healLh care ls dlfferenL."
LasLly, Lhe esLeemed Parvard professor ClayLon ChrlsLensen (wwww.c|aytonchr|st|anson.com), auLhor
of lnnovotors Prescription, presenLs a Lhesls LhaL radlcal change requlres dlsrupLlve lnnovaLlon ln
order Lo be meanlngful. 1he book has a chapLer enLlLled ulsrupLlng Lhe 8uslness Model of Lhe
hyslclan's racLlce," ln whlch he descrlbes ways Lo dlsrupL Lhe LradlLlonal buslness model for
lncorporaLlng operaLlng pracLlces Lo lmprove resulLs.
Lach lf Lhese lndlvlduals agrees on a few polnLs regardlng reform wlLhln healLh care:
- 8adlcal change ls requlred: anyLhlng less wlll noL produce lasLlng resulLs

CopyrlghL [2012 WhlLeSpace PealLhcare LLC.
- 8ellance on Lhe free markeL sysLem ls Lhe only long-Lerm soluLlon LhaL wlll be flnanclally
susLalnable.
- CovernmenL ls noL Lhe soluLlon, or as !ames Champy so apLly puLs lL, We musL noL rely on Lhe
angels of governmenL Lo solve Lhe healLh care crlsls."
All Lhree lndlvlduals seem Lo reach one over-archlng concluslon: Angels of
governmenL" are noL change agenLs and Lherefore Lhey are noL quallfled Lo lead
LransformaLlon. 8aLher, we musL llsLen Lo reasonable, responslble argumenLs
presenLed by experLs llke Champy, orLer, and ChrlsLensen. 1hese experLs eaL,
sleep, and breaLhe change, and Lherefore Lhey are well quallfled Lo develop
vlable, long-Lerm soluLlons. unllke many pollLlclans, Lhese lndlvlduals wlll ensure
LhaL Lhe lnLegrlLy of Lhe sysLem remalns lnLacL by maklng free-markeL soluLlons goal one."
1he volces of physlclans need Lo be heard. 8uL unforLunaLely 80 percenL of Lhe physlclans we
lnLervlewed percelve Lhelr lobbylng power Lo be dlmlnuLlve compared Lo LhaL of hosplLals, healLh
sysLems, lnsurance companles, and pharmaceuLlcal companles. 1hey reallze how lmporLanL lL ls for Lhelr
oplnlons Lo be respecLed ln Lhe halls of Congress, buL Lhey feel Lhelr lnpuL ls falllng on deaf ears.
1he lnablllLy Lo lnfluence Lhe debaLe helghLens Lhelr fears. ln facL, several physlclans we spoke wlLh
abouL Lhe polltlcs of meJlcloe openly shared Lhelr concerns abouL Lhe movemenL of medlclne away
from free markeL soluLlons. 1hey descrlbed Lhe devasLaLlng effecLs lL could have on Lhelr pracLlces, as
well as on Lhelr llves, wlLh remorse abouL Lhelr lack of power Lo halL lL.
lmaglne Lhe growlng frusLraLlons on Lhe parL of pracLlLloners who have llLLle lnpuL lnLo Lhe declslon-
maklng process LhaL dlrecLly lmpacLs Lhelr professlon. Whlle Lhey duLlfully aLLend Lo paLlenLs, Lhey hear
ln Lhe background Lhe proverblal Lraln rumbllng down Lhe Lracks Lowards Lhe lnevlLable wreck. ln Lhelr
mlnds Lhls Lraln has catastrophe wrlLLen all over lL!
lL's noL a preLLy plcLure. Congress conLrols mosL of Lhe levers and lndependenLs reallze Lhelr faLe may
hlnge on how pollLlclans see Lhe world. Meanwhlle, hosplLals and healLh sysLems conLlnue Lo pressure
Lhem Lo sell ouL and [oln 1he lorces. 1hls dlsLurblng dynamlc we refer Lo as Lhe tteoJ of
commooJeetloq."
1rend of Marg|na||zat|on . "consider 4// 4/ternotives in Order to kemoin viob/e"
8unnlng a prlvaLe pracLlce Loday ls akln Lo belng Lhe capLaln of a small shlp losL ln Lhe
mlddle of a ragglng ocean sLorm. As Lhe crew sLeadfasLly Lraverses Lhe waves of change,
Lhe physlclan-capLaln desperaLely Lrles Lo sLay afloaL and avold becomlng a casualLy of
Lhe SLorm of 8eform."


CopyrlghL [2012 WhlLeSpace PealLhcare LLC.
l wanL Lo lssue a warnlng Lo Lhose of you who have noL personally experlenced radlcal sLrucLural change
wlLhln an lndusLry. 1here wlll be casualLles! 1hey are an unavoldable consequence of Lhe dynamlcs of
radlcal change. AlLhough casualLles as a resulL of change are noL necessarlly bad, lf Lhe overall
performance of Lhe sysLem ls lmproved, lL wlll creaLe wlnners and losers.
1hls leads us Lo our lasL Lrend, whlch ls causlng greaL consLernaLlon amongsL prlvaLe pracLlLloners.
ayers are conLlnulng Lo undermlne pracLlLloners' value, especlally aL lower levels of medlclne, by
reduclng relmbursemenL schedules. 1hls Lrend may acLually be Lhe rooL cause for many physlclans
feellng dlsconLenLed and dlslllusloned. Some even feel dlsconnecLed from Lhe sysLem alLogeLher.
ln facL, our research found LhaL over 90 percenL of Lhose surveyed ldenLlfled payers as Lhelr number one
enemy, wlLh governmenL runnlng a close second. 1hls Lrend of undermlnlng physlclans' value makes
Lhem feel lsolaLed and Lrapped. 1hey llve wlLh Lhe consLanL fear LhaL Lhey mlghL be lefL behlnd lf Lhey
don'L so someLhlng. Cr as kandy Pammond, a leadlng consulLanL ln veln pracLlce appllcaLlon, exclalmed,
hyslclans have power ln numbers, however, Lhey have been made Lo feel powerless by Lhem (1he
lorces)."
lor many pracLlLloners seeklng more ferLlle relmbursemenL ground wlLhln medlclne Lhere ls an
alLernaLlve: movlng up Lhe medlcal food chaln. ln facL, physlclans are movlng lnLo speclalLles aL an
alarmlng raLe. Cur research found LhaL over 70 percenL of Lhe speclalLy physlclans we lnLervlewed had
mlgraLed from oLher areas of medlclne. When asked why, Lhe ma[orlLy slmply replled . money"!
1hls movemenL lnLo speclalLles has especlally lmpacLed lnLervenLlonal areas such as paln, veln,
cardlology, radlology, and oncology, where a deluge of Lechnologlcal and procedural advances have
occurred. ln facL, one could say LhaL lnLervenLlonal speclalLles are Lo lmprovlng quallLy of care and
reduclng cosLs as Callfornla was Lo Lhe gold rush . noLhlng buL opporLunlLy!
lnLervenLlonal medlclne has become Lhe Mecca for reduclng or ellmlnaLlng surglcal procedures, avoldlng
complex Lheraples, shorLenlng recovery Llmes, and promoLlng prevenLaLlve care. 1hls has slgnlflcanLly
helped Lo lmprove Lhe quallLy of care whlle reduclng cosLs wlLhln Lhe sysLem, whlch ls exacLly whaL
reform ls all abouL!
ln facL, an execuLlve ln one of our cllenLs recenLly commenLed, ln
Lhe foreseeable fuLure, Lhe LhoughL of rlpplng open Lhe body wlLh a
knlfe Lo LreaL a problem, oLher Lhan ln a dlre medlcal emergency,
wlll be consldered barbarlc." 1hls bold sLaLemenL can be
subsLanLlaLed by several sLudles, all of whlch conclude LhaL many
surglcal procedures wlll soon be replaced by mlnlmally lnvaslve
Lechnlques.
unllke Lhe oLher Lrends descrlbed ln Lhls paper, marglnallzaLlon by
payers has a poslLlve slde. lL brlngs more speclallsLs Lo Lhe Lable Lo
perform mlnlmally lnvaslve procedures, Lhereby lmprovlng quallLy

CopyrlghL [2012 WhlLeSpace PealLhcare LLC.
of care whlle reduclng cosLs. 1hls ls free-markeL nlrvana!
Powever lL ls also clear LhaL lf physlclans wanL flnanclal freedom, Lhey musL achleve lL Lhrough Lhelr own
lnlLlaLlve. Movlng up Lhe medlcal food chaln Lo more ferLlle relmbursemenL ground ls one opLlon raLher
Lhan slmply slugglng ouL a survlval aL lower levels of medlclne. Powever, keep ln mlnd LhaL noL all
physlclans are able Lo mlgraLe up Lhe food chaln.
As one leadlng cardlovascular surgeon observed, 1aklng a bllnd eye Lowards resolvlng Lhe healLh care
crlses ls noL an opLlon. Powever, we musL conslder all alLernaLlves ln order Lo remaln vlable." 1hls
sLaLemenL sums lL all up. 1he healLh care crlsls musL be addressed and aL Lhe same Llme pracLlLloners
musL conLlnue Lo look Lhrough Lhe cracks ln Lhe wall Lo flnd ways Lo survlve. 1hls double-edged dynamlc
ls referred Lo as Lhe 1teoJ of Motqloollzotloo."
Conc|us|on
CerLalnly evldence abounds LhaL ptlvote ptoctlce
stooJs ot tbe ctosstooJs." ln facL, many
pracLlLloners over Lhe nexL few years wlll declde
wheLher Lo do noLhlng and conLlnue Lo sLruggle, sell
Lhelr pracLlces so Lhey can move on or reLlre, or
change and adapL. 1hls crlsls has everyLhlng Lo do
wlLh 1he lorces sLacklng Lhe cards agalnsL
lndependenLs whlle aggregaLlng more power.
Arguably, 1he lorces' approach ls noL susLalnable ln
Lhe long Lerm, unless one belleves LhaL Lhe angels
of governmenL" can solve all healLh care llls. 8uL we
need noL be dlscouraged. As Lhe renowned and self-
proclalmed soclal ecologlsL" eLer urucker has sald,
Lvery soclal and buslness problem ls a buslness
opporLunlLy ln dlsgulse." lf Lhls ls Lrue, and l belleve
LhaL lL ls, flxlng healLh care ls Lhe opporLunlLy of a
llfe Llme. l sLrongly Lhlnk, as do many oLher experLs,
LhaL Lhls ls boLh a soclal and buslness problem.
1herefore, accordlng Lo urucker, lL ls llkely Lo be a
buslness opporLunlLy ln dlsgulse."
1he flve ma[or Lrends llsLed above - Lhe tteoJ of otttltloo, Lhe tteoJ of coosollJotloo, Lhe tteoJ of
Jlscoooect, Lhe tteoJ of commooJeetloq, and Lhe tteoJ of motqloollzotloo have poLenLlally devasLaLlng
consequences on us as paLlenLs. 1he lmpacL of each Lrend ls growlng as Lhe prlvaLe pracLlce secLor
conLlnues Lo crumble under Lhe welghL of economlc and pollLlcal pressure. lf prlvaLe pracLlce ls sLlll Lhe
hub of Lhe healLh care unlverse, waLchlng lL collapse lnLo a black hole wlLhouL a flghL would be morally
and eLhlcally unconsclonable.