Can Independent GI Practices Survive & Thrive?

In response to rising pressure and uncertainty, many physicians are turning away from the independent practice model. Given this trend, is the future of independent GI practices bright or dark?

Ask a Gastroenterologist is a weekly series of questions posed to GI physicians around the country on business and clinical issues affecting the field of gastroenterology. We invite all gastroenterologists to submit responses. Next week's question: As a gastroenterologist, what do you think is the most exciting challenge in the current healthcare market?

Please submit responses to Carrie Pallardy at by Thursday, June 19, at 5 p.m. CST.

Three gastroenterologists look forward and share their thoughts on the road ahead for the independent practices in the field.

Question: Do you think independent GI practices have a sustainable future?

Ketover mugshotScott Ketover, MD, President, Digestive Health Physicians Association, President, CEO, Minnesota Gastroenterology (Plymouth): Absolutely. The continued viability of independent GI practices is not only critical for millions of patients who count on physicians in these practices to diagnose and treat virtually all types of digestive conditions such as acid reflux disease, Crohn's, ulcerative colitis, swallowing disorders and hepatitis, as well as colon cancer and liver disease, but also for our healthcare system as a whole. I say this not only as a gastroenterologist treating patients in my own GI practice in the Twin Cities, but also as the President of DHPA whose nearly 1,000 physicians care for 1.5 million patients each year in independent GI practices across the country. DHPA's core mission is to educate policymakers and to work collaboratively with our fellow gastroenterologists across medical settings to ensure that the high-quality, cost-effective and integrated GI care furnished in independent practices remains a viable option for patients.

Make no mistake, high-quality GI care is delivered in many settings: hospitals, academic medical centers and physician practices. Even so, independent practices provide critical access to specialized and cost-effective GI care. As a specialty, if we have a chance of eliminating colorectal cancer as a major public health problem — and DHPA has taken the National Colorectal Cancer Roundtable's pledge of reaching 80 percent screened for colorectal cancer by 2018 — then we must protect patient access to colorectal screening in their communities. We know colonoscopies save lives. That means we must be sure that millions of patients across the country continue to have the option of turning to independent GI practices for their cancer screening.

Independent GI practices also offer something unique in many communities — they bring together physicians of different specialties in a team approach to delivering integrated care. For one example, DHPA member practices (like many other independent GI practices) include pathologists who are trained in gastrointestinal pathology, devote their practice to diagnostic evaluation of gastrointestinal tissue, and benefit from easy access to the gastroenterologists in their practice whether through a shared electronic medical record or personal communication.  Ultimately, it is the patient who benefits when physicians of different specialties are true teammates in a single medical practice.

On the cost side, there is a growing recognition on the part of the medical community and policymakers that care furnished in independent medical practices must be protected. That is why more than two dozen national medical societies, including DHPA, recently joined in a letter opposing proposed federal legislation that would eliminate the in-office ancillary services exemption to the federal Stark law. Not only would the legislation remove specialized cost-effective pathology services from GI practices, it would shift millions of patients into the higher-cost hospital setting.

In fact, a recent Health Affairs report found that hospital ownership of physician practices is often associated with higher prices and spending. Eliminating the integrated model of care furnished in physician practices would negatively impact healthcare spending and increase total cost of care. And just last month, in testimony before Congress, the Medicare Payment Advisory Commission acknowledged that payment rates in physician offices and ASCs tend to be lower than in hospitals and that one of the consequences of hospital acquisition of physician practices is shifting patients into a more expensive setting.

So, do I think that independent GI practices have a sustainable future?  Absolutely. I know that the 1.5 million patients who count on the outstanding, convenient and cost-effective care delivered each year by gastroenterologists in DHPA's member practices are counting on it. And the sustainability of our healthcare system depends on it, too.

Dr KornfeldHerbert R. Kornfeld, MD, gastroenterologist, Hollywood Presbyterian Medical Center (Los Angeles): Yes, independent GI practices have a sustainable future, despite imminent and ongoing regulatory changes and patient population shifts. Those of us who practice on our own do so because we're independent-minded and avoid a group philosophy. By design, as independent providers, we are solely responsible for our patients; we are not interested in caring for other physicians' cases we're not familiar with. We make decisions about the direction of our practice.

We're not sure to what extent the Affordable Care Act will affect independent gastroenterology practices and the field as a whole. The changing payment model will certainly promote the care of more individuals at a lower reimbursement level, which will stress any practice. New ACA rules may dictate that physicians invest in infrastructure to remain compliant in reporting and coordinating care. This could be costly and would seem to encourage physicians to become hospitalists, form partnerships or join groups in order to share resources and office space expense. Independent gastroenterologists will have to continue to cooperate with hospitals and regulators and should have a plan for how to coordinate care amidst the changing landscape. I've been privileged at Hollywood Presbyterian Medical Center for 25 years and appreciate open communication with the hospital's administration, which assures me I'll continue our successful working relationship through the shifts in healthcare.

The older generation of gastroenterologists, including myself, gets their own referrals. We do our own consultations and see our patients from beginning to end. It is viable for those of us committed to our independence to continue to practice without groups to maintain our autonomy. We demand it.

Dr. SciarraMichael Sciarra, DO, Ambulatory Center for Endoscopy (North Bergen, N.J.): The future of independent GI practices is really a question of the ability of private practices to maintain a presence and profit in the ever evolving landscape of medicine in general.

Those practices that can adapt will survive and in fact flourish. The ability of solo practices to attract new physicians is daunting and may hinder success if the practice cannot handle the demands of increasing volume to cover costs and maintain profitability. Those practitioners unless diversified in other interests such as ASCs, open access or concierge medicine may not be viable and will face options of merger with other groups or purchase outright and become employees. The role of the ASC provides a revenue source apart from the practice and can bolster revenue through recycled dollars. The concept of recycling revenue is that with one patient contact, revenue can be captured multiple times. This is practiced routinely by primary care physicians when they perform in-office procedures and have ancillary testing such as EMG and ultrasound.

Capture procedures and revenue which otherwise would go elsewhere. The ASC is a viable and legitimate way of achieving these goals. I believe the independent GI practice has a future and I encourage those practices to stay the course. The tide may shift once again and return patients to the private office where a more selective and personal doctor-patient relationship can occur, which I believe is what patients prefer anyway.

More Articles on Gastroenterology:
How Will Bundled Payments Affect GI? 3 Gastroenterologists Chime In
Reimbursement Changes in Monitored Anesthesia Care in GI: How Would Endoscopy Centers Be Affected?
Physician, ASC & HOPD Payment: 24 Statistics on GI Biopsy Procedure Reimbursement

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