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What medical specialties allow you to have your own practice ?

gonnif

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    Just to expand further, the medical practice and hospital corporate structure has shifted drastically over the past 25 year with costs and market forces driving consolidation.
    In the early 1990s by me, the NYC suburban county had 30-40 hospitals, dozens of independent radiology centers, and thousands of solo or small group practices. Now there are essentially 3-4 corporate behemoths, one of which, Northwell, has over 20 hospitals and is a major teaching center for three, count'em three, medical schools including their own. NYU Langone has just purchased the last independent system in the county. And Prohealth, the large corporate group practice has been picking up provider after provider, along with the other two. The only other chain is Catholic Health Systems which runs a distant 4th. They have also picked up all the radiology centers which now only belong to one of these corporation. Now they are buying up all the medical buildings running their own real estate system which of course has different rents/leases if you are part of the corporation or not. Doctors are essentially pressured to refer you to someone in the health system. In the past 5 years, all my doctors have either joined a practice or have retired because of this. I lived between three of the hospital centers and the large suburban office park has now become almost exclusively medical office space. Oh, and the chains of standalone urgent/general care centers that are now developing nationally branded chains. A recent example by me was the a Walgreens that was only built in the last 10-15 years (right across the street from a CVS only built in that past 10-15 years), has just built and moved into another new one on the opposite corner. While stuck at the light in front of it the other day, I was trying to figure out why as the old and new building looked the same size. then I saw the new Walk-in/Urgent care center next to it. Yes Walgreens , along with Walmart, CVS, Riteaid and probably Costco, are all building and developing chains of these clinics.


    While you technically could open a solo practice in any field you want, your challenges will be :

    1) lack of leverage to negotiate rates and contracts with medical insurers
    2) higher liability and malpractice rates
    3) higher independent overhead (staffing costs)
    4) requirements for electronic records and prescriptions
    5) getting patients and referrals
    6) getting actual office space if you are not part of a corporate system

    Other than opening in a very undeserved rural area, I am unsure if you could make it a successful business
     
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    VincentAdultman

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      Gonnif, would your appraisal change at all if the question were about starting a group practice? Something like a 5-10 physician outpatient center.

      I know guys fromn residency who have opened up independent two man shops. It's early going for those guys, and they'll prolly add more partners as time goes on I imagine.

      My point is it's possible but lots of work.
       
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      gonnif

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        Just curious... what other schools use Northwell's hospitals?
        NYU (Northshore) Einstein (LIJ). The reason Hostra Med School took so long to get started was resistance by NYU (mostly) and Einstein until Northwell became ao big that it could dictate its own terms
         

        gonnif

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          Gonnif, would your appraisal change at all if the question were about starting a group practice? Something like a 5-10 physician outpatient center.
          My long time personnal IM ran an established 10 person practice that was decimated in the past 5 years because of this and he had to go to one of the corporate spots as an individual
           
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          DBC03

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            From what I've heard a lot of issues stem from reimbursement rates for the hospitals vs private practice (hospitals get better reimbursements, so it can be difficult to stay in private practice). Do any of the actual physicians or medical gurus know more about this?
             

            gonnif

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              From what I've heard a lot of issues stem from reimbursement rates for the hospitals vs private practice (hospitals get better reimbursements, so it can be difficult to stay in private practice). Do any of the actual physicians or medical gurus know more about this?
              Generally, Hospitals and large groups like Prohealth have significantly more leverage when negotiating reimbursements from insurance companies
               

              Winged Scapula

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                IRT: contracts and reimbursement

                The reason so many PP have poor contracts is that:

                1) they don't negotiate
                2) they don't offer a service that others can't/don't cover as many lives etc

                Our contracts are excellent but it didn't come without being proactive, renegotiating and showing the private payers that they need us. Surgery is still open to PP.

                However, I will concede that a SOLO practice is hard to do. I know some that do it but why not have a partner? The fixed costs (electricity, mortgage/lease, employee salaries, etc. are cheaper when divided by 2 or more). Plus call/vacation is a nightmare by yourself.
                 
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                gonnif

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                  huh... that is an interesting dynamic for sure. I applied to all 3 of those places without realizing that, and they're all mostly (kind of ish) in the same tier. Though, it's not clear why there would be pushback against Hofstra as it is in a different location, and I don't see how adding another med school in the NYC/Long Island area would make that much of a difference in terms of admissions.
                  That thought is rational and logical. this is politics and turf.
                   

                  gonnif

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                    IRT: contracts and reimbursement

                    The reason so many PP have poor contracts is that:

                    1) they don't negotiate
                    2) they don't offer a service that others can't/don't cover as many lives etc

                    Our contracts are excellent but it didn't come without being proactive, renegotiating and showing the private payers that they need us. Surgery is still open to PP.

                    However, I will concede that a SOLO practice is hard to do. I know some that do it but why not have a partner? The fixed costs (electricity, mortgage/lease, employee salaries, etc. are cheaper when divided by 2 or more). Plus call/vacation is a nightmare by yourself.
                    Can you comment on practices that have exclusive contract to staff certain hospital depts? For example, the smaller hospital system hase essentially outsourced its ER to a private practice which acts as staff? Is this a widespread organizational structure?
                     

                    Winged Scapula

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                      Can you comment on practices that have exclusive contract to staff certain hospital depts? For example, the smaller hospital system hase essentially outsourced its ER to a private practice which acts as staff? Is this a widespread organizational structure?
                      I can't comment on how widespread it is, but I've certainly seen it.

                      We have hospitals that contract with Radiology and Anesthesia groups, and another local hospital has contracted with a local oncology group to provide those services. In the latter, the benefit to the oncologic group was increased referral source (within an ACO/ACN) and reduced prices on chemotherapeutic agents; the benefit to the hospital was aligning themselves with large group with a good reputation and presumably more resources for their network.

                      The physicians are not actually employed by the hospital so they can still run their practice they way they want (e.g., the hospital doesn't tell them when to take vacation, how much, how to structure the pay etc). The hospital gets coverage (which is what lead hospitals to employ surgeons, for example) and the group gets stability.

                      In the end, I also envision these arrangements in terms of money: someone is making it, and its usually not the physicians.
                       
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                      DBC03

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                        Can anyone comment on the specific Medicare/Medicaid reimbursement for private vs hospital practices? It seems like there may be some leeway with private insurance depending on how well you negotiate, but would Medicare/Medicaid be set at the national level?
                         

                        Winged Scapula

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                          Can anyone comment on the specific Medicare/Medicaid reimbursement for private vs hospital practices? It seems like there may be some leeway with private insurance depending on how well you negotiate, but would Medicare/Medicaid be set at the national level?
                          There is no difference. Medicare rates are set and do not differ whether you have a hospital owned or private practice.

                          As a matter fact I know this because a multi state company recently approached our practice in regards to purchasing it, claiming they could get us better contracts.

                          When we sat down and crunched the numbers it didn't make sense because they were going to charge us a management fee and of course would be unable, by their own admission, to negotiate Medicare, tricare, other governmental contracts for us.

                          In fact, if I see a patient in the hospital I make less money than I do if I see them in my office because of the location of service; I lose out on the facility P when I do it in the hospital.
                           
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                          Goro

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                            I mean specialties that allow you to start a practice and work alone so you can control your work hours.
                            OMM/NMM. A practitioner is a well to do area can clear as much as any decent dermatologist, and with less overhead at that.
                             
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