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AAOS Now

Published 11/1/2008
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Mary Ann Porucznik

Is the private practice orthopaedist disappearing?

Changing practice patterns are affecting involvement

Once, the image of a physician in private practice mirrored “Marcus Welby, MD,” or “Dr. Kildare.” Those days are long gone and, if a report presented at the Board of Councilors fall meeting is accurate, the independent, private-practice orthopaedic surgeon may also be disappearing. That trend could have significant implications for organizations such as the AAOS and state orthopaedic societies.

In Oregon, reported Matthew C. Shapiro, MD, almost all orthopaedic surgeons belong to the AAOS, but only about 60 percent also belong to the Oregon Association of Orthopaedists (OAO).

As Dr. Shapiro began to research the situation, he uncovered a disturbing trend: Orthopaedists who were full-time employees of a multispecialty group, hospital, or health maintenance organization (HMO) were significantly less likely to join local orthopaedic associations, even if their employer was willing to pay their dues.

“In the Eugene-Springfield area,” said Dr. Shapiro, “every orthopaedic surgeon in private practice is a member of the OAO. But only one third of the employed physicians belong to the OAO. Of the 24 orthopaedic surgeons who are employed by a major HMO in Portland and Salem, only 2 belong to the OAO.”

Dr. Shapiro’s experiences were borne out by audience responses to a quick survey. More than half of those responding had noticed that the number of employed orthopaedists was increasing and that employed orthopaedists were less likely to join state orthopaedic societies.

Is the grass greener…
According to Thomas C. Barber, MD, who presented with Dr. Shapiro, many private practitioners in rural states are looking to join hospital groups, in part because recruiting is so difficult. Another trend he noted was the growth of large groups that employ physicians.

Dr. Shapiro noted the following reasons that an orthopaedic surgeon would leave private practice for a full-time situation:

  • Diminishing reimbursements, particularly from Medicare and workers’ compensation
  • Difficulty in managing necessary ancillary services, such as physical therapy, imaging, or durable medical equipment, alone
  • Need for assistance in marketing to match the competition
  • Unwillingness or inability to provide uncompensated care while on call
  • Increasing medical liability insurance premiums

As an employee, he noted, physicians can improve their compensation situation because hospital-based or joint venture ambulatory surgical centers are reimbursed at a higher level and employers may provide compensation for otherwise “uncompensated care.” Employees may have lower costs than private-practice physicians and may spend less time on management issues. Lifestyle issues—particularly the work/home balance—may also contribute to the decision to become an employee.

But there are disadvantages, he points out. Many employed physicians chafe at the loss of autonomy and authority and at the rigidity of a system that inhibits their practice patterns.

Dr. Barber noted that employed physicians and private practitioners have different attitudes on a number of issues. Both groups are concerned about medical liability issues, but employed physicians do not share the private practitioners’ concerns about the cost of coverage. Both share a need for continuing medical education, but employed physicians may have organizational time and money budgets to meet those needs. Private practitioners, on the other hand, must use their own resources.

On the other side of the fence?
The ambivalence orthopaedic surgeons may feel about being in private practice or working as full-time employees was evident in the responses to Dr. Shapiro’s final questions. Among those currently in private practice, 58 percent said they would consider making the move to being employed full-time. Ironically, among those currently employed, 58 percent said they would consider making the move to private practice.

2006 Practice Setting Based on Source of Salary (PDF)

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org