How small practices are surviving and thriving, part 1

How small practices are surviving and thriving, part 1 medstat_tb_rest Wed, 07/05/2023 - 13:32

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News

Changed

Wed, 07/05/2023 - 13:38

Author(s)

Lambeth Hochwald

Key takeaways

Small-town physicians mostly love their practices; they are close to their patients and community, have the opportunity to practice very varied medicine, and feel like they make a difference. But they also struggle with many issues.

Small practices are at a disadvantage when it comes to negotiating reimbursements.

Resources such as access to specialists, equipment, and specialty meds put small-town docs in more precarious situations.

The challenges are mounting for physicians in small-town practices and rural areas, with private equity buying up many practices, the cost of overhead rising, and increased stress in attracting top talent. In the first of a two-part series, this news organization spoke to physicians in small towns around the country to identify some of the pain points squeezing small-town practices’ profits and making patient care more difficult.

Here are how physicians are working to offset the challenges and to make their small-town practices more rewarding.

Low reimbursements remain challenging

Jennifer Bacani McKenney, MD, owner of Fredonia Family Care, a private family medicine practice in Fredonia, Kan. (population 2,132), loves having close relationships with her patients and being an integral part of the community. However, she said that owning the only clinic in her town, which is 90 miles from Wichita, limits her power when negotiating for reimbursements.

“We don’t have bargaining power, so we often will end up getting terribly low reimbursements, especially for Medicaid,” she said. “We pay the price for not being part of a big health system.”

To bolster her ability to get reimbursement price concessions, her practice – which was initially started by her father and now includes four physicians – joined an accountable care organization in 2016.

“By joining other private practices around the state, we made some gains,” said Dr. McKenney, who was born in the hospital where she now works. “It enabled us to sit at the table with Blue Cross/Blue Shield of Kansas, for example, and have conversations that they listen to.”

Talent recruitment is an ongoing issue

For Ann Lima, MD, a family physician who came to Orofino, Idaho (population 3,000), 8 years ago after her residency in Ventura, Calif., practicing small-town medicine and seeing patients with a myriad of medical issues is a fulfilling challenge, but finding trained providers to join her practice remains problematic.

That’s because the physicians in her practice need to be nimble and to be able to routinely pivot from primary care to obstetrics to emergency medicine, owing to the nature of small-town practicing.

“It’s challenging in terms of finding people who are able to stay on top of all facets of hospital and acute care emergency care as well as OB and primary care,” she said. She noted that, for patients who require additional care, the nearest cities are Spokane, Wash., and Coeur D’Alene, Idaho, both approximately 3 hours away.

“It’s a challenge to find well-trained family physicians who want to do this diverse type of medicine.”

When it comes to staffing at her clinic, Dr. McKenney said it’s been more efficient to train employees from the ground up than try to find health care workers who already have significant experience.

“Right now, I have two 19-year-olds, a 21-year-old, and a 24-year-old working for me,” Dr. McKenney said of her clinic staff, which currently includes four doctors, a nurse practitioner, and 14 employees. “I hired the 19-year-old at age 17 and taught her to be a medical assistant.”

In addition to difficulty in recruiting physicians, nurses, and staff to a small-town practice, trying to find affordable housing makes it difficult to attract staffing in certain locations, said Frank Batcha, MD, a family physician in Hailey, Idaho (population 9,463), and chief of staff at St. Luke’s Wood River Regional Hospital in Ketchum, Idaho, where he has worked since the 1990s.

“We’re a resort community, so housing is unaffordable for somebody with an entry-level job,” he said. The region, a valley that includes Sun Valley, a popular ski resort with about 22,000 residents, is home to a handful of celebrities. It’s a popular destination spot and makes for a beautiful back country to call home.

“But it’s difficult to recruit physicians out of residency for this reason,” said Dr. Batcha. “We call it the scenery tax. It comes with a price.” Idaho is 49th out of 50th in physicians per capita for the entire United States.

Resources can be scarce

Another stressor for rural and small-town physicians is access to specialists, resources, and, in some cases, vital equipment.

“We have a general surgeon but no other specialty care,” Dr. Lima said. “This means that we can do acute appendicitis, we can take out gall bladders and do hernia repairs locally, but for significant trauma care and for patients who are very sick with ICU needs, we have to transfer them.”

Weather is also a huge factor that can affect ground ambulance or helicopter travel to a larger hospital.

“If there’s a storm, instead of a 45-minute transfer via helicopter, it’s a 3½ hour drive along mountain and river roads,” said Dr. Lima.

Ultimately, Dr. McKenney wished colleagues better understood the challenges facing rural physicians.

“When I transfer a patient from my hospital to a bigger facility, it’s because I don’t have certain medications on hand or an MRI ready to go,” she said. “It’s not that I don’t know what I’m doing.”

In addition, when she calls for a consult or sends a patient to a larger facility, it’s always because of a lack of resources.

“As rural physicians, we are really well educated and well trained,” she said “Our issue is that we’re practicing in a place with fewer things. But, when we call upon you, just know that we’ve tried everything we can first.”

Dr. McKenney lives and works happily in the town she grew up in and said no place could have given her a warmer welcome. In fact, while she was still finishing school, the townspeople campaigned to get her to come back and practice there – hard to come by that in a big city.

Small-town physicians offered five tactics for making a small-town practice work successfully:

Develop relationships with specialists in your nearest large facility for referrals.

Consider joining an ACO to improve work flow, diversify revenue streams, and maintain independence.

Create a culture that’s welcoming to all incoming young professionals.

Host medical students and residents as part of their education. “If they learn about your community, your practice, and rural healthcare early on, they will be more likely to be interested in coming back to serve that same community,” said Dr. McKenney.

Recruit more than one physician if possible. “It’s really scary for new physicians to go out and practice on their own right out of training. Most rural communities need more than one more doctor anyway, and this gives them a built-in support system from the beginning,” said Dr. McKenney.

A version of this article first appeared on Medscape.com.

Publications

MDedge Family Medicine

Family Practice News

Internal Medicine News

MDedge Internal Medicine

Topics

Business of Medicine

Sections

Latest News

Feature

Author(s)

Lambeth Hochwald

Author(s)

Lambeth Hochwald

Key takeaways

Small-town physicians mostly love their practices; they are close to their patients and community, have the opportunity to practice very varied medicine, and feel like they make a difference. But they also struggle with many issues.

Small practices are at a disadvantage when it comes to negotiating reimbursements.

Resources such as access to specialists, equipment, and specialty meds put small-town docs in more precarious situations.

The challenges are mounting for physicians in small-town practices and rural areas, with private equity buying up many practices, the cost of overhead rising, and increased stress in attracting top talent. In the first of a two-part series, this news organization spoke to physicians in small towns around the country to identify some of the pain points squeezing small-town practices’ profits and making patient care more difficult.

Here are how physicians are working to offset the challenges and to make their small-town practices more rewarding.

Low reimbursements remain challenging

Jennifer Bacani McKenney, MD, owner of Fredonia Family Care, a private family medicine practice in Fredonia, Kan. (population 2,132), loves having close relationships with her patients and being an integral part of the community. However, she said that owning the only clinic in her town, which is 90 miles from Wichita, limits her power when negotiating for reimbursements.

“We don’t have bargaining power, so we often will end up getting terribly low reimbursements, especially for Medicaid,” she said. “We pay the price for not being part of a big health system.”

To bolster her ability to get reimbursement price concessions, her practice – which was initially started by her father and now includes four physicians – joined an accountable care organization in 2016.

“By joining other private practices around the state, we made some gains,” said Dr. McKenney, who was born in the hospital where she now works. “It enabled us to sit at the table with Blue Cross/Blue Shield of Kansas, for example, and have conversations that they listen to.”

Talent recruitment is an ongoing issue

For Ann Lima, MD, a family physician who came to Orofino, Idaho (population 3,000), 8 years ago after her residency in Ventura, Calif., practicing small-town medicine and seeing patients with a myriad of medical issues is a fulfilling challenge, but finding trained providers to join her practice remains problematic.

That’s because the physicians in her practice need to be nimble and to be able to routinely pivot from primary care to obstetrics to emergency medicine, owing to the nature of small-town practicing.

“It’s challenging in terms of finding people who are able to stay on top of all facets of hospital and acute care emergency care as well as OB and primary care,” she said. She noted that, for patients who require additional care, the nearest cities are Spokane, Wash., and Coeur D’Alene, Idaho, both approximately 3 hours away.

“It’s a challenge to find well-trained family physicians who want to do this diverse type of medicine.”

When it comes to staffing at her clinic, Dr. McKenney said it’s been more efficient to train employees from the ground up than try to find health care workers who already have significant experience.

“Right now, I have two 19-year-olds, a 21-year-old, and a 24-year-old working for me,” Dr. McKenney said of her clinic staff, which currently includes four doctors, a nurse practitioner, and 14 employees. “I hired the 19-year-old at age 17 and taught her to be a medical assistant.”

In addition to difficulty in recruiting physicians, nurses, and staff to a small-town practice, trying to find affordable housing makes it difficult to attract staffing in certain locations, said Frank Batcha, MD, a family physician in Hailey, Idaho (population 9,463), and chief of staff at St. Luke’s Wood River Regional Hospital in Ketchum, Idaho, where he has worked since the 1990s.

“We’re a resort community, so housing is unaffordable for somebody with an entry-level job,” he said. The region, a valley that includes Sun Valley, a popular ski resort with about 22,000 residents, is home to a handful of celebrities. It’s a popular destination spot and makes for a beautiful back country to call home.

“But it’s difficult to recruit physicians out of residency for this reason,” said Dr. Batcha. “We call it the scenery tax. It comes with a price.” Idaho is 49th out of 50th in physicians per capita for the entire United States.

Resources can be scarce

Another stressor for rural and small-town physicians is access to specialists, resources, and, in some cases, vital equipment.

“We have a general surgeon but no other specialty care,” Dr. Lima said. “This means that we can do acute appendicitis, we can take out gall bladders and do hernia repairs locally, but for significant trauma care and for patients who are very sick with ICU needs, we have to transfer them.”

Weather is also a huge factor that can affect ground ambulance or helicopter travel to a larger hospital.

“If there’s a storm, instead of a 45-minute transfer via helicopter, it’s a 3½ hour drive along mountain and river roads,” said Dr. Lima.

Ultimately, Dr. McKenney wished colleagues better understood the challenges facing rural physicians.

“When I transfer a patient from my hospital to a bigger facility, it’s because I don’t have certain medications on hand or an MRI ready to go,” she said. “It’s not that I don’t know what I’m doing.”

In addition, when she calls for a consult or sends a patient to a larger facility, it’s always because of a lack of resources.

“As rural physicians, we are really well educated and well trained,” she said “Our issue is that we’re practicing in a place with fewer things. But, when we call upon you, just know that we’ve tried everything we can first.”

Dr. McKenney lives and works happily in the town she grew up in and said no place could have given her a warmer welcome. In fact, while she was still finishing school, the townspeople campaigned to get her to come back and practice there – hard to come by that in a big city.

Small-town physicians offered five tactics for making a small-town practice work successfully:

Develop relationships with specialists in your nearest large facility for referrals.

Consider joining an ACO to improve work flow, diversify revenue streams, and maintain independence.

Create a culture that’s welcoming to all incoming young professionals.

Host medical students and residents as part of their education. “If they learn about your community, your practice, and rural healthcare early on, they will be more likely to be interested in coming back to serve that same community,” said Dr. McKenney.

Recruit more than one physician if possible. “It’s really scary for new physicians to go out and practice on their own right out of training. Most rural communities need more than one more doctor anyway, and this gives them a built-in support system from the beginning,” said Dr. McKenney.

A version of this article first appeared on Medscape.com.

Key takeaways

Small-town physicians mostly love their practices; they are close to their patients and community, have the opportunity to practice very varied medicine, and feel like they make a difference. But they also struggle with many issues.

Small practices are at a disadvantage when it comes to negotiating reimbursements.

Resources such as access to specialists, equipment, and specialty meds put small-town docs in more precarious situations.

The challenges are mounting for physicians in small-town practices and rural areas, with private equity buying up many practices, the cost of overhead rising, and increased stress in attracting top talent. In the first of a two-part series, this news organization spoke to physicians in small towns around the country to identify some of the pain points squeezing small-town practices’ profits and making patient care more difficult.

Here are how physicians are working to offset the challenges and to make their small-town practices more rewarding.

Low reimbursements remain challenging

Jennifer Bacani McKenney, MD, owner of Fredonia Family Care, a private family medicine practice in Fredonia, Kan. (population 2,132), loves having close relationships with her patients and being an integral part of the community. However, she said that owning the only clinic in her town, which is 90 miles from Wichita, limits her power when negotiating for reimbursements.

“We don’t have bargaining power, so we often will end up getting terribly low reimbursements, especially for Medicaid,” she said. “We pay the price for not being part of a big health system.”

To bolster her ability to get reimbursement price concessions, her practice – which was initially started by her father and now includes four physicians – joined an accountable care organization in 2016.

“By joining other private practices around the state, we made some gains,” said Dr. McKenney, who was born in the hospital where she now works. “It enabled us to sit at the table with Blue Cross/Blue Shield of Kansas, for example, and have conversations that they listen to.”

Talent recruitment is an ongoing issue

For Ann Lima, MD, a family physician who came to Orofino, Idaho (population 3,000), 8 years ago after her residency in Ventura, Calif., practicing small-town medicine and seeing patients with a myriad of medical issues is a fulfilling challenge, but finding trained providers to join her practice remains problematic.

That’s because the physicians in her practice need to be nimble and to be able to routinely pivot from primary care to obstetrics to emergency medicine, owing to the nature of small-town practicing.

“It’s challenging in terms of finding people who are able to stay on top of all facets of hospital and acute care emergency care as well as OB and primary care,” she said. She noted that, for patients who require additional care, the nearest cities are Spokane, Wash., and Coeur D’Alene, Idaho, both approximately 3 hours away.

“It’s a challenge to find well-trained family physicians who want to do this diverse type of medicine.”

When it comes to staffing at her clinic, Dr. McKenney said it’s been more efficient to train employees from the ground up than try to find health care workers who already have significant experience.

“Right now, I have two 19-year-olds, a 21-year-old, and a 24-year-old working for me,” Dr. McKenney said of her clinic staff, which currently includes four doctors, a nurse practitioner, and 14 employees. “I hired the 19-year-old at age 17 and taught her to be a medical assistant.”

In addition to difficulty in recruiting physicians, nurses, and staff to a small-town practice, trying to find affordable housing makes it difficult to attract staffing in certain locations, said Frank Batcha, MD, a family physician in Hailey, Idaho (population 9,463), and chief of staff at St. Luke’s Wood River Regional Hospital in Ketchum, Idaho, where he has worked since the 1990s.

“We’re a resort community, so housing is unaffordable for somebody with an entry-level job,” he said. The region, a valley that includes Sun Valley, a popular ski resort with about 22,000 residents, is home to a handful of celebrities. It’s a popular destination spot and makes for a beautiful back country to call home.

“But it’s difficult to recruit physicians out of residency for this reason,” said Dr. Batcha. “We call it the scenery tax. It comes with a price.” Idaho is 49th out of 50th in physicians per capita for the entire United States.

Resources can be scarce

Another stressor for rural and small-town physicians is access to specialists, resources, and, in some cases, vital equipment.

“We have a general surgeon but no other specialty care,” Dr. Lima said. “This means that we can do acute appendicitis, we can take out gall bladders and do hernia repairs locally, but for significant trauma care and for patients who are very sick with ICU needs, we have to transfer them.”

Weather is also a huge factor that can affect ground ambulance or helicopter travel to a larger hospital.

“If there’s a storm, instead of a 45-minute transfer via helicopter, it’s a 3½ hour drive along mountain and river roads,” said Dr. Lima.

Ultimately, Dr. McKenney wished colleagues better understood the challenges facing rural physicians.

“When I transfer a patient from my hospital to a bigger facility, it’s because I don’t have certain medications on hand or an MRI ready to go,” she said. “It’s not that I don’t know what I’m doing.”

In addition, when she calls for a consult or sends a patient to a larger facility, it’s always because of a lack of resources.

“As rural physicians, we are really well educated and well trained,” she said “Our issue is that we’re practicing in a place with fewer things. But, when we call upon you, just know that we’ve tried everything we can first.”

Dr. McKenney lives and works happily in the town she grew up in and said no place could have given her a warmer welcome. In fact, while she was still finishing school, the townspeople campaigned to get her to come back and practice there – hard to come by that in a big city.

Small-town physicians offered five tactics for making a small-town practice work successfully:

Develop relationships with specialists in your nearest large facility for referrals.

Consider joining an ACO to improve work flow, diversify revenue streams, and maintain independence.

Create a culture that’s welcoming to all incoming young professionals.

Host medical students and residents as part of their education. “If they learn about your community, your practice, and rural healthcare early on, they will be more likely to be interested in coming back to serve that same community,” said Dr. McKenney.

Recruit more than one physician if possible. “It’s really scary for new physicians to go out and practice on their own right out of training. Most rural communities need more than one more doctor anyway, and this gives them a built-in support system from the beginning,” said Dr. McKenney.

A version of this article first appeared on Medscape.com.

Publications

MDedge Family Medicine

Family Practice News

Internal Medicine News

MDedge Internal Medicine

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