The Elephant in the Health Reform Room: Small Physician Practices

This law does absolutely nothing for small practices.

Private Comment by A National Physician Organization leader, who prefers to remain anonymous

An elephant in the room is something nobody talks about but everybody knows is there. It tends to be a huge refractory problem that nobody wants to address because there are no glib answers.

The elephant in the health reform room is the small physician practice. About 40% of doctors practice solo or in two person groups, and 70% or so are in groups of six or less. These physicians are the cement that holds the health system together. They are the ones people talk about when they refer to their “personal physician.” They are the ones to whom you confide. They are the “go-to” doctors when you really need a doctor.

When you strip away the rhetoric in the reform law - all the high-minded talk about reform scaffolding such as accountable care organizations, cooperative organizations, communicating interoperable electronic record systems, and demonstration projects doing this and that - the success of reform comes down to small practices.

David Brailer, MD, the first national “HIT Czar” knew this in 2005, five years before the reform law passed. Before resigning as czar, whose mission was to develop an interoperable electronic health record system across the land, he observed in a 2005 New York Times interview, “The elephant in the living room of what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.”

Similarly, the whole reform law may fail unless it does something for small practices. Yet, physician survey after physician survey shows 60% to 70% of doctors look at the health reform law with deep skepticism. The law does little financially to help struggling marginal practices, to relieve these practices of burdensome distracting paperwork, or to offer realistic solutions to ease the transition to a digital future.

Instead the law is a preachy, top-down, expensive abstraction that lectures doctors about the “meaningful” use of electronic records, about the supposed joys and rewards of collaborative ventures with hospitals, payers, third parties, Medicare, Medicaid, and other government-created entities.

The law fails to address in any fundamental way the hot-button small practice issues of tort reform, year to year Medicare reimbursement (SGR), the resources needed to handle the inevitable tidal wave of entitlement patients, overhead costs imposed by third parties, or the coming monumental workforce shortages.

The reform law may work for large integrated organizations with the infrastructure and expertise to handle bureaucratic strictures, but it does not work for small elephants in the room that provide most of the care in the United States.

These small elephants will be reluctant to enter the government or big organization jungles and are likely to react by retiring, seeking other employment, becoming employees, or bailing out into concierge practices where they can deal directly with patients rather than third party intermediaries. What doctors in small practices want is more time with patients, more appreciation of the elements distracting them from their mission, seeing, treating, and curing patients.


Richard L. Reece, MD, blogs at Medinnovation and has a website under construction. www.doctorreece.com. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at rreece1500@aol.com, 1- 860-395-1501