It’s hard to pick the flavor of ice cream you want at the shop unless you know yourself well. I know I’m that guy who takes forever to pick something when I’m in line. Choosing to get your healthcare in a private or public setting can make you feel the same way. Once we go over the major types of medical practices, you can rest easy with finding an office that’s a great fit for your needs.
You should have a say on what kind of medical practice works best for your situation, but there are tradeoffs as the practice size increases and decreases. Before we dive into the various types of medical practices, it’s critical to know the incentives on the other side of the exam table, meaning, what do doctors have to consider when it comes to owning their practice or being employed by a hospital/corporation? In a totally private setting where the doctors own everything, they can practice exactly how they want. These physician-owners shoulder more administrative burden. Employed physicians, especially in a hospital or corporate environment, get security from a paycheck and in theory can just focus on patient care but with some more red tape involved.
According to the American Medical Association’s most recent biennial survey of physicians in Fall 2020, 49% of active physicians work in a fully private setting with complete physician ownership—that is a five-percentage-point drop from 2018. The next 40% of doctors worked directly for a hospital or health system, including smaller practices that are owned in part by a corporation. Consolidation is the best word to sum up medical practice trends over this past decade. Now let’s step away from the doctor’s side of things to understand what the medical practice pros and cons are for you, the patient.
Think of practice settings like the differences between traditional ice cream, gelato, or a sorbet. All those foods have the same purpose of appeasing your sweet tooth but in distinct ways. Along the same lines, all medical practices are supposed to heal and enhance you but the setup changes how that process works. The simplest office to grasp is the solo practice. This the clinic that your grandparents would describe like, “back in my day the doctor was also the bookkeeper and the receptionist.” In this situation, the doctor has no other partners or employed professionals other than basic staff. You as a patient mainly benefit from the doctor having skin in the game. The solo doctor takes a huge financial and personal risk to keep the clinic this way, especially with rising medical school loan payments overhead. Therefore, if the solo provider messes up badly, the patient population disappears in no time flat. As a result, you get more attention and niche expertise. Seeking this kind of practice makes sense if the doctor you’re looking for is a specialist for a particular condition you have. Like if you have a propensity for skin cancer, seeing a dermatologist who mainly takes patients for those cancers in a solo or small office could make sense. The solo practice is a dying breed though—currently 14% of physicians (and decreasing) still run things like that.
If we move up to the heaviest weight class, we find ourselves with hospitals and corporate medicine, both of which are growing. Think of the VA, Stanford’s health system, or The Cleveland Clinic as examples. Pretty much every professional at those places is employed and not, at the end of the day, beholden to patients even if that is what they are paid for. It really is the opposite of the solo practice we started with. Devorah Goldman’s December 20th editorial in the Wall Street Journal illustrates the major con of big medical settings turning into assembly lines of care. But with all that being said, people still go to hospitals and corporate health systems to get not just emergency care but also supreme access to resources, technology, and expertise that a small clinic may never offer. Red tape and zero physician autonomy are just the main drawbacks here.
With the final common medical practice styles, we can meet in the middle. Simple examples could be like a primary care clinic that has 10 internists or a cosmetic outfit that has two dermatologists and three plastic surgeons. The former example would be considered a single-specialty and the latter a multi-specialty practice. In this scenario physicians can be employees or partners in the clinic—in fact, ~69% physicians run clinics with these setups. From the doctor’s side of things, these group practices spread the financial risk among partners and usually have more administrative firepower to handle a lot of patients in little time. People can argue that group practices are the Goldilocks’s of all the clinics, because as a patient you get the best possible balance of access to better medical equipment and facilities along with the facility itself not being so large that the care gets bureaucratic and the doctors forget to respect your story.
Now that we’ve covered the basic kinds of healthcare settings, what should all that mean to you? Coming back to ice cream is the easiest way to explain things. You may love gelato more than regular ice cream or sorbet, but nothing is stopping you from getting the benefits of all three depending on your current taste, or in the case of healthcare, your specific medical needs. Obviously, your health insurance plays a huge role in places you can or can’t access but you should be taking advantage of all the practice types that apply to you. If you happen to consider yourself a reasonably healthy individual with a small handful of routine medical issues to address, you probably benefit the most from visiting small offices or single-specialty groups matching with your needs. If on the other hand you have a variety of severe and chronic issues to work through, most of your care may happen at a hospital or massive health system with the most resources for treatment options. Overall, you’re now in a better position to judge the appropriate practice setting—just remember that you get both more resources and more bureaucracy as the medical setup gets larger.
Since we’ve gone over the major types of medical practices, we can thread the needle back to health insurance. One major decision you make (or more likely your employer makes) is to pick an HMO or PPO insurance model for coverage. Even if you don’t know what those acronyms mean yet, knowing the important differences will help you choose the coverage making the most sense alongside the type of medical practice you want to visit.
Stay tuned and subscribe to Friendly Neighborhood Patient for more savvy healthcare guidance. I’ll catch you at the next episode.
