Multi-specialty Groups: The Strange Bedfellows of Medico-political Necessity
Come with me if you want to live.
A funny thing happened on the way to the bottom line. As new fiscal interventions (and inventions) undermined profit and increased bureaucracy in medicine, the survivalists developed new strategies. Some became hospitalists or joined large groups in their specialty. This offered protections, but there were drawbacks. Hospitalists have no patient base of their own, so if having a practice based on a doctor-patient relationship that lasts longer than a few hours is important to you, this won’t work.
The large groups, primarily arranged according to individual specialties, meant large internal medicine groups, large surgery groups, large pediatrics, OBGYN, cardiology, etc. groups. If you think about being in such a large group of your specialty, it begins to seem like being in a small town where the number of competitors increases. Unless you’re a rock star, this could mean a decrease in income. Sure, it has the satisfaction of a job well done within the enduring doctor-patient relationship, and it has the security of seasoned veterans ready to teach you, assist you, and even save your rear end, but it’s a strange convoluted competition that is intramural. That is, your patients are more likely to see the other doctors in the group, which is not very different from advertising. Certainly you’ll benefit from this on the flip side, but if you find it difficult to compete, you won’t be happy.
Can’t we all just get along?
A new construct that takes the “smaller town” motif to the next level is the large multi-specialty group. In this, there is a group of doctors of each specialty practicing under a much larger, shared overhead of a constellation of specialty groups. It has all of the good features of the large single-specialty group in that there is help and assistance within your specialty, decreased costs of practicing (translated, higher net income), and you’re never at the mercy of someone calling in sick—even if it’s you. The business is set in stone, usually based on a base salary and productivity supplements, so you can budget even while doing the minimum but can have that pool installed if you do more. You still have your own patient base, so you can still capitalize on your personality and skills. Surgeons and internists living side by side. Disturbing?
Like cats and dogs? Getting along?
Yes. It’s a must. After all, this was invented to protect what was perceived as a much more sinister enemy—managed care medicine under the dictates of 3rd party payers. However, it’s good to be the king! If the multi-specialty group is large enough, it can call the shots. If there is one family doctor for every 5,000 people—say, 10 in a town of 50,000—then imagine the clout a group would have if 7 of them were in your multi-specialty group. Such power allows your group’s administrators to call their own shots when negotiating with insurance companies. Of course, the changing ratios—smaller percentages of a town’s doctors because of being in larger cities—can be Kryptonite to this superpower, but even then they’re still going to be able to leap tall buildings in single bounds better than the 2-person group in the next block. This is because insurance companies like their bottom lines just as much as you do, and offering them a one-stop center for all of their subscribers’ needs means less commotion, paperwork, and overhead for them.
You scratch my back, I’ll scratch yours: busy breeds busy.
The best thing about large multi-specialty groups is the referral engine that it creates, which also is intramural, so that makes it totally nepotistic. If the family doctor gets a report of an abnormal Pap smear, he’s going to send his patient to see the OBGYN down the hall. If the gastroenterologist snags a malignant polyp, she’s going to send her patient to the oncologist and the surgeon on the next floor. If the internist has a difficult diabetic patient, he or she will be referring to his or her buddies in nephrology, endocrinology, ophthalmology, and cardiovascular surgery. Dedicated referral paths means more likelihood of your patients seeing who they need to see, appointments being kept due to group EHR follow-up algorithms, better and more complete medicine accruing for more people, while all the time letting you get away with being unapologetically more profitable.
If you’re entering private practice anew, the large multi-specialty group is a great way to not only get busy quickly, but also to make valuable networking connections with other specialists. After all, you may not remain in the group and one day may need that “buddies” list to continue happily extramurally.
Me? I’m a “leg” man, myself.
A multispecialty group prides itself on…well, multi-specialties. If you’re a cardiovascular surgeon, for example, and only want to do cosmetic vein work, you can have this niche in a large multi-specialty group. The subspecialty group-within-the-group—in this example, cardiovascular—can have each one of their group gravitate to specific procedures or services. You can’t do that out in private practice, because there you will take everything and anything you can; in the large multispecialty group, you won’t be as impacted by the bottom line of such concierge thinking. And the whole group gets the bragging rights for not only being multi-specialized, but being very, very multi-specialized.
Come with us if you want to live.
Just as the multi-specialty group is an innovation of evolution when necessity becomes the mother of invention, so too the other medical interests jockeying for position are mothering their own offspring. “The Kryptonite can shine very brightly” (ancient expression from the city of Kandor). At some point, the risk of being in a large multi-specialty group falls victim to why you chose it in the first place—you didn’t want to be controlled, except by people just like you. When the dollars make sense, however, the large multi-specialty group may get bought out by the 3rd party payer or the local hospital. You’ll either stay or walk, but if you walk, you better back up that buddies list before you do!
