What Is the State of Small Practice USA

Are small practices improving, stagnant, or in decline? Articles debating the value of such practices are not of much value if the foundation of small practice is crumbling. Associations defending small practice in Washington DC may miss the point of fundamental changes required in training and in payment just to have small practice. Sadly the data is largely missing as studies have typically been about the largest and most centralized practices rather than those small and distributed where needed. Half the nation's population continues to be left behind as a side effect of Big Health focus.

There is no doubt that small practices can survive anywhere, even with dedicated efforts by large systems to move them away. This is about the ability of small practice clinicians to adapt and continue to serve their patients regardless of changes, but...

The Factors that Shape Small Practice Are Changing

Patient Changes
  • Demand is increasing in multiple dimensions as populations grow, age, and acquire more conditions needing care.
  • Patient complexity is increasing due to patient changes such as aging population increase and getting older and and patient conditions such as Alzheimer's as well as rising mental health and disease burdens in younger populations
  • As with the other factors, the changes are more dramatic where small practice is more likely
Changes in the Clinicians Needed for Small Practice 
  • The data does show that the proportions of clinicians in primary care arising from MD, DO, NP, and PA are decreasing - especially the family practice positions filled
  • But the massive increases in NP and PA graduates are difficult to evaluate
  • On the other hand the continued collapse of internal medicine primary care, the number 2 largest source of workforce, is an issue for care where needed, primary care, and the fast rising elderly - about 35,000 internists have been lost to hospitalist workforce (Hospitalist data)
  • And about 30,000 NP and PA graduates have been losto teaching hospitals to replace resident workforce lost due to many changes 
  • Data from the AMA Masterfile for 2013 as compared to 2005 demonstrates overall losses of general types of specialties, especially general surgery, general ob-gyn, general orthopedics, and other core surgical specialties remaining in core specialty. The data demonstrates greater losses where small practices are more common. 
  • MD, DO, NP, and PA clinicians are rapidly specializing to careers least associated with small practice and care where needed 
  • Physicians in small practices including core specialties and primary care are nearest retirement with those in most needed locations closest to retirement - replacements do not appear to be on the way.
  • Small practice ownership is threatened due to financial changes
  • About 6% of family physicians are found in urgent or emergent care (Graham Center) and rural/smaller hospitals are more likely to have FM docs as ER or hospitalist docs. This may also drain small practice FM docs from needed primary care. 
Changes in Payment Interacting with Training
  • Relatively less paid for primary care and basic services has shaped less primary care result from clinicians as well as fewer in the core specialties that do basic services. 
  • Clinicians that begin in primary care depart in a few years - taking their primary care experience with them (predominantly IM, NP, PA - less so for MPD, PD, FM)
  • Payment and training interact to prevent most desirable health access and small practice choices such as family medicine careers that are 90% permanent to primary care and family practice positions. Other graduates face a difficult choice to select and stay in primary care after training or entry. 
  • Shortages of clinicians have been shaped by decades of poor payment design
Payment Changes
  • Payment is stagnant, especially for small practice services
  • Small practices are paid less than larger or hospital based practices
  • Small practice owners are facing changes due to regulation and innovation, and must invest massive amounts or move out of small practice
  • Lesser pay and penalties are more likely where care is needed and there is less ability to pay for care in the populations served by small practices.
Systemic and National Changes
  • Forced mergers and consolidations
  • Bigger must be better mentality enacted as policy
  • Insurance reform has yet to address payment changes needed
  • Insurance issues more common where small practices are found
  • Declines in half of the American population with regard to income, education, jobs, local resources, and other spending areas 
Serious Issues with the Medical Literature and with Media Coverage
  • The bigger must be better mentality prevents understanding
  • There is a general lack of awareness regarding strengths, weaknesses, opportunities, threats of small practices
  • Research includes those smaller despite being different in many ways, failing the classic Apples to Oranges test of validity. This is seen in the most read and most prestigious journals. Small to large comparisons are too difficult to accomplish due to so much variation between and within groups in so many dimensions
  • Well orchestrated promotional efforts continue to push innovative workforce, innovative software, innovative reorganization, or other substitutes - instead of the workforce, training, and payment design changes needed. 

When the worst is emphasized and the best is underemphasized about small health care - most Americans suffer by design.

More attention could fuel more debate and some needed action. The real enemies are inaction and considering what has been done to be enough.

It is an impressive run of articles with some content regarding small health care, often negative but a few positive

9/16/14 AFP Community Blog The Demise of Small Practices Has Been Greatly Exaggerated

9/11/14 Commonwealth - All Health Care Is Local

9/10/14 Headlines - Small Hospital Closures Accelerate, Finances Weaker for Stand Alones

9/9/14 Commonwealth Do Health Care Costs Fuel Economic Inequality in the United States?

Open Season Upon Small Health Care

Continue on to Open Season on Small Health By Big Media

Summary of Small Health Complexities

Reference Links

Recent Works

Starting to Solve Societal Inequities - Support for a SMART Start from the Very Beginning of Life

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings

Family Medicine Needs a New Beginning - Current Preparation, Admission, and Medical School Plus Health Policy Interact To Prevent Family Medicine Choice - and Health Access Result

Too Many and the Wrong Clinicians for graphic - Additional consequences result from designs not specific to primary care or care where needed.   

And the Next Victims of Cost Cutting: Dual Eligibles - Those Most Vulnerable and Least Able to Defend Themselves Are Next

ALS Disease Focus Is Not a Top Priority - Have fun, but Minor Incidence Diseases Are Below the Major Diseases, and Far Below Health Care Caused Disease, and Causes of Early Death, and the top 10 priorities for most Americans - and America as a Nation  

Hotspotting Has Many Spots To Consider - Simple Interpretations Are Inaccurate, Many Different Characteristics Shape the Outcomes, Not Just Geographic Location

Retail Clinic Recoil - Many Side Effects Can Be Anticipated, And More to Come

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice - No Other Type of Clinician Comes Close to the Location or the Scope

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...

Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.


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