As we approach 2014, the wa-tershed year for the Patient Protec-tion and Affordable Care Act(PPACA) implementation, great un-certainty remains about healthcarereform’s ultimate impact on physi-cian practices.

Everywhere we look, it is beingreported in the media that PPACAand all of the financial pressures inhealthcare are making it increas-ingly difficult for physicians to re-main independent. Statistics revealthat PPACA is pushing physicianstoward a number of emerging prac-tice models, including accountablecare organizations (ACOs), privatepractice medical homes, largealigned groups, community healthcenters (CHCs) and concierge prac-tices.

A survey conducted by BrachEichler in July 2013 among nearly150 physicians in New Jersey re-vealed that nearly half of the physi-cians surveyed said they were con-sidering changing their practicestructure in the upcoming year.Specifically, half of the respondentssaid they plan to integrate with an-other healthcare organization, suchas another single specialty or multi-specialty practice, an individualpractice association, a hospital sys-tem or a joint venture. Physiciansstated that the main drivers for achange in practice structure includethe need to reduce expenses, in-crease cash flow, increase opera-tional efficiencies, bolster marketshare and compete more effectivelywith other organizations that arealready integrating with partners.

While no one is able to even be-gin to accurately quantify the num-ber of physicians who will integratewith hospitals or restructure theirpractices in other ways, it seemsthat most healthcare experts tendto believe that the movement to-wards physician employment willnot only persist, but continue toswell.

It is yet to be known whetherthis trend toward employment willwork better than it did in the 1990s.So far, compensation growth hasrapidly outpaced reimbursementgrowth in many specialties, creatingpotentially unsustainable practiceeconomics.

The reaction to changes in prac-tice structures varies greatly. Thosephysicians who are long establishedin private practice tend to view thetrend of practice consolidation witha degree of sadness. They know thatwhile the integrated business modelmay benefit physicians financially(at least in the short-term), the neteffect is a definite loss of autonomyfor physicians as a whole.

In fact, hospital employment is

expected to remain much loweramong physicians established inprivate practice, as compared toyoung and recently graduatedphysicians. According to the Amer-ican Medical Association, 81 percentof physicians who own their ownpractices are over age 40, and a sur-vey from April 2013 indicates that60 percent of physician practiceowners are not interested in sellingtheir practices. Certainly, thechoices of younger physicians arelikely to have a long-term impact.However, the physician populationcurrently is disproportionatelyolder—and becoming more so.

Perhaps a more definite trendamong physician practices is aggre-gation into larger groups. A recentstudy from Health Affairs foundthat, among physicians filingMedicare claims, 35.6% worked ingroups of more than 50 in 2011, upfrom 30.9% in 2009. These largergroups can be either hospital-ownedor independent. With physician-owned practices growing larger,physicians will likely have more op-portunities to work in such a prac-tice without taking a stake in own-ership. Hospitals andphysician-owned groups may thusincreasingly compete for youngerphysicians seeking employment op-portunities (as well as those still insolo and small practice). Independ-ent physician groups, whose strat-egy is not tied to supporting inpa-tient demand, may have moreflexibility in meeting healthcarepurchasers' demands for higher careefficiency and value. However, theirsmaller size and limited capital maypose a challenge to these growthprospects.

Clearly, these are stressfultimes for physicians who are at-tempting to guess the future ofhealthcare. As physicians gauge thefuture of their careers, only 16 per-cent report a generally favorableoutlook. Thirty-six percent reporteda generally negative outlook, while48 percent remain cautious.

Perhaps the most important ac-tion for physicians as they stepthrough the many necessary prac-tice decisions in the coming monthsand years is to identify businesspartners who are truly physicianadvocates and who will look out forthe physician’s best interest, inde-pendent of all other parties. Forthose physicians who are consider-ing hospital employment, that willmean seeking out a healthcare at-torney who is well versed in the ar-eas of hospital employment con-tracts and restrictive covenants,and who can provide guidance onareas of potential conflicts of inter-est.

For example, there are likely tobe conflicts of interest inherent inthe way medical malpractice claimsare handled. A physician whodoesn’t think he or she has doneanything wrong will probably notbe in a hurry to settle a claim. Aphysician does not want a quick fixthat is going to be reported to theNational Practitioners Databankand impact his or her reputationthroughout his or her career. Butthe hospital is likely to think dif-ferently. The hospital will want tomake the best business decision,and often that may mean opting forthe more expedient settlement.

Physicians must not allow oth-ers to dictate what they need to doto take care of a patient. No matterwhat the future holds for physiciansin terms of practice structure, physi-cians need to be leading the way insetting the standards for patientcare. And in order for that to hap-pen, physicians need to work to-gether to make sure that their in-terests are heard in a collectivefashion.

It is essential that physiciansdevelop and prioritize the messages

they feel need to be conveyed to ourelected officials, legislators andstate regulators. One way to stayinformed is to become involved withthose groups and organizations thatare able to represent your interests,whether they are local medical orspecialty societies or business part-ners that are willing to hear yourconcerns and work with you to com-municate your needs to the appro-priate parties.

Ultimately, the changes that aremade in your practice should beyour decision. They should reflectthe mission, vision and values inyour practice. Going forward, physi-cians must find their voice, as therecan only be strength in numbers.Independence, strength, autonomyand success will come not from suc-cumbing to someone else’s conceptof healthcare, but rather from fol-lowing your own. The real key toevolving your practice will be find-ing the right business partners tomake that happen.

Patricia A. Costante is Chairmanand CEO of MDAdvantage InsuranceCompany of New Jersey.

2013 Winter PhysiciansNews.com PHYSICIANSNEWS 7

L&A LAWLOR AND ASSOCIATESPhysician and Executive Healthcare Search

PRACTICE OPPORTUNITIES

MAMMOGRAPHY - RED BANK, NEW JERSEY

Riverview Medical Center seeks a 2nd woman’s imaging candidatefor a Hospital employed position located in a year round shorecommunity, Red Bank, 1 hour from New York and Philadelphia.Great schools! Great Beaches! Great Parks! Practice has tremendousradiology support staff and S-O-A technology; no call, no weekends.The Woman’s Center is doubling the size of their existing facility tobe completed within at the end of 2009. 100% full rangeMammography position available or an 80/20% split with otherfacets of woman’s imaging. Very strong financial package withopportunity for part time or a full time position.

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Premier Private Practice of five seeks a general orthopedic surgeonand will consider other orthopedic subspecialties due to stronggrowth. Practice established in 1968 and enjoys impeccablereputation, new candidate will be busy immediately. Enjoy the warmsouthern hospitality and home to the world famous Masters GolfTournament. Quick track to partnership, call of 1-5 with excellentfinancial compensation. Located within two hours of Charleston,Savannah and Hilton Head.

ORTHOPEDIC TRAUMA SURGEON - BALTIMORE, MARYLAND

Join as the 2nd orthopedic surgeon, employed by a 450-bedcommunity based Hospital, at an academically oriented tertiary carecenter. Combined orthopedic and trauma practice at MIEMMSLevel II Trauma Center. Call is 7 nights a month with a strongfinancial package. The Department of Orthopedic Surgery providescomprehensive musculoskeletal surgical care with special emphasison reconstruction, sports medicine and orthopedic trauma.

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EMERGENCY MEDICINE STAFF PHYSICIANS -EASTERN PAJoin this 750+ bed institution in one of Pennsylvania's busiest EMDepartments, treating over 105,000 patients annually and serves apopulation of 400,000+. Employed situation, excellent salary.

GENERAL SURGERY; GASTROENTEROLOGY;OTORHINOLARYNGOLOGY AND UROLOGY -LITTLETON, NH Great opportunity to join the medical staff of an "award winning"hospital in Littleton, NH. Employed position, excellent salary +bonus OR work 2 years employed and Hospital will set you up onyour own. Located at the Northern edge of the White Mountainsand an easy drive to Boston, Montreal and Manchester. great qualityof life and affordable housing; no state income tax and the cost ofliving is low.

INTERNAL MEDICINE - NORTHERN VERMONT A wonderful opportunity to join 15 primary care physicians on thestaff of a well -respected Medical Center. Our client is looking torecruit 2 physicians. These are employed positions offering acompetitive salary and wonderful comprehensive benefits. You havethe choice to take call or not to take call. You may practice in theMedical Arts building (next to the Hospital)…. Located on LakeChamplain, 30 minutes from Burlington. One hour to Montreal.Enjoy a great quality of life.

OBSTETRICS - ST. ALBANS, VERMONTA wonderful opportunity to join the staff of a respected MedicalCenter. This is an employed position offering a competitive salaryand wonderful comprehensive benefits. Call is 1:4. Located on LakeChamplain, 30 minutes from Burlington. One hour to Montreal.

OTORHINOLARYNGOLOGIST -

NATIONWIDE TELEMEDICINEPHYSICIAN POSITIONSlooking to enhance your income?

We are working with a qual-ity company offering Nation-wide Physician coverage for24/7/365 Telemedicine care.Join this elite, well-respectedand exclusive Physician net-work and earn excellent moneyworking from anywhere. Thereare opportunities throughoutthe U.S. in Emergency Medi-cine, Family Practice and Inter-nal Medicine. This does not re-quire relocation and no specialequipment is required. There isno cost to the Physician fortraining, Malpractice Insuranceor required Licensure.

Physicians have the flexibil-

ity to choose their desired vol-ume of scheduled availability,based on their current profes-sional practice. You will alwaysbe able to review the patient’smedical record prior to a con-sultation that may, at your dis-cretion, include diagnosis orprescription for a non-con-trolled medication. Applicantsshould be: licensed in their re-spective states; Board Certifiedin their specialty and verifiedthrough the National PhysicianData Base (NPDB) and theAmerican Medical Association(AMA) for medical licensure.Bilingual is a plus.

Please contact Margie Quinlan of Lawlor and Associates for more information at 800-238-7150; fax 610-431-4092; or mail:

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Visit us on the web: www.lawlorandassociates.com

MEDICINE & BUSINESS:PROTECTING PHYSICIANS’ INTERESTS IN A

RAPIDLY CHANGING HEALTHCARE ENVIRONMENTBy Patricia A.Costante