Setting offers autonomy, flexibility, but has downsides as well

Recently, AAOS Now explored why some orthopaedists are leaving private practice to become full-time employees of a multi-specialty group, hospital, or health maintenance organization (See “Is the private practice orthopaedist disappearing?”). Although the problems of diminishing reimbursements, difficulty in managing ancillary services, and unwillingness or inability to provide uncompensated care while on call are shared by all orthopaedic practices, these issues are exacerbated in solo and small group settings.

Despite the apparent trend away from the private practice setting, many orthopaedists—including Robert H. Blotter, MD and Aleksandar Curcin, MD, MBA—plan to remain in a small group practice in the future. Drs. Blotter and Curcin are both members of the AAOS Practice Management Committee, representing small group practices. Speaking to AAOS Now, they pointed out some of the main advantages—as well as the drawbacks—of being part of a small group practice.

AAOS Now: Can you give us some background about your practice and identify the main benefit of the small group model?

Dr. Blotter: For the past decade, I’ve been part of a small orthopaedic group practice in the upper peninsula of Michigan that currently has six orthopaedists. Before that, I was part of a multi-specialty group in the U.S. Navy that had three orthopaedists.

In my current practice, I have more control and autonomy compared to when I was in the military. I can control my destiny. If I or one of my partners perceives something that needs to be changed, we can do that. We may not be able to do it as quickly as a soloist can, but we can effect change fairly rapidly.

Dr. Curcin: My practice, which is located in a small community in Oregon, has seven orthopaedic surgeons. I’ve been here for 3 years. Prior to that, I was a full-time faculty member at the University of Maryland. I’ve also been part of a 16-physician orthopaedic surgery practice.

My decision to come here wasn’t necessarily driven by the desire to be at a smaller practice—it was just a good opportunity. When reimbursement, fee schedules, and medical liability became issues in the mid-Atlantic region, I looked around at what was available and this opportunity caught my attention.

Everything that I’ve got to say about my current setting is good. When a practice gets big—and big in my mind is more than 10 orthopaedists—bureaucracy, politics, and other issues start to emerge. In our small practice, it’s easy to get everyone around the table if we have a problem or an issue and get it resolved.

AAOS Now: Does your practice offer ancillary services?

Dr. Curcin: A critical number of orthopaedists in a group is needed to drive ancillary revenues from opening a surgery center or offering services such as magnetic resonance imaging.

We have our own surgery center. We were able to open it even before we had our current number of orthopaedic surgeons because under Oregon law, surgeons from other specialties are allowed to operate in our surgery center. Now that we have seven surgeons, we could probably keep the surgery center busy by ourselves.

Dr. Blotter: Recently, a couple of partners retired, leaving us with only four partners for a couple of years. We decided to enlarge our group to six to eight partners and make some other changes to remain competitive. We currently have six partners, which has helped us add some ancillary income. In addition, we are in a new office and have implemented an electronic medical records system as well as digital X-rays. We’re also working with local hospitals to increase our ancillary income and recruit more effectively.

AAOS Now: What about the dynamics of a smaller team—how does it affect the ability for everyone to work together?

Dr. Curcin: Big practices frequently have satellite offices or are so big that an orthopaedist can go for long periods of time and not see some partners, even if the practice only has one office.

When I was in Baltimore, we had multiple satellite locations. As a result, I sometimes saw a couple of the partners only when we had our monthly business meeting. At my current practice, we have one office, and we operate out of one hospital. I think that it’s a better working environment because there’s more cohesiveness and more interaction between staff and physicians.

Dr. Blotter: A small practice provides a better lifestyle than a solo practice because having partners frees you from being on call every night. You can also share the overhead, which helps your income. At the same time, you don’t have so many partners that it becomes difficult to effect change.

AAOS Now: Do you employ physician assistants (PAs) and/or nurse practitioners?

Dr. Blotter: We have three PAs and two nurse practitioners—I don’t know many soloists who are able to employ PAs and nurse practitioners. They really improve our lifestyle. They go on rounds and perform all histories and physicals. Because they take floor calls at night, we only take emergency department calls and physician calls.

Hiring PAs and nurse practitioners may seem expensive, but they enable you to see many more patients. They increase our revenue considerably. Their assistance in the operating room is also very helpful.

Dr. Curcin: We have five PAs working with us right now, and we also have a nurse practitioner. Our PAs help increase our patients’ access to care. There’s a shortage of physicians in our area. If we didn’t have our PAs, it would make it harder for people to get appointments.

AAOS Now: What are some of the drawbacks of being part of a small group practice?

Dr. Curcin: Unlike a large practice, a small practice doesn’t have the power of numbers. Large practices have an economic advantage in terms of purchasing, which is one reason why the Practice Management committee recommended that the AAOS establish a group purchasing program.

Larger practices may also have an advantage in recruiting, especially in a big city environment. They’re able to offer better pay and other incentives that many smaller practices can’t offer.

Dr. Blotter: When I was in the military, I didn’t need to be concerned about the bottom line, and my schedule was much more predictable. Now, my schedule is much less predictable, since if I don’t work, I don’t get paid. There’s no financial cushion.

Small practices face the same challenges as orthopaedists in private practice or in academic settings: being productive, working with hospitals, dealing with issues such as reimbursement and medical liability.

AAOS Now: Do you foresee staying in a small group practice?

Dr. Blotter: Yes, I think so.

Dr. Curcin: Yes. This is my third move since my fellowship, and I hope it’s the last.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org