Can the Nephrologist Continue to Survive in Private Practice?

From the Editorial Board

Kenneth A. Liss, DO

Hypertension & Nephrology Associates

Eatontown, New Jersey

 

Liss Kenneth HR (2)I was honored to be asked to be a member of Nephrology Times editorial board because it represents a journal that plays an important role in educating nephrologists, fellows, and residents. In addition, unlike most members of editorial boards who represent some of the most prestigious academic institutions, I am a member of a five-practice single specialty group in central New Jersey. While my fellow board members’ service to the education of the nephrologic community is invaluable, I would like to think that my perspective is unique and somewhat atypical of what is normally found in journals.

Lately the changes in the delivery of medical services have been coming so fast and furious that I am afraid that the private practitioner is ill equipped to be successful. Last month Congress finally acted to pass legislation to end the sustainable growth rate as a measure for physician reimbursement. Although most of us are surely relieved to see this conundrum put to rest for the time being, the other side of that legislation may present an even more difficult challenge to practitioners who wish to provide quality care to  patients while being fairly compensated. I refer specifically to the idea of payments being linked to quality measures. In free market systems, success is typically linked to quality. While most of us embrace such a system, there is trepidation that the way quality is measured will not reflect the input of medical experts, particularly the private practitioner. In response to the Affordable Care Act and the impending quality measurement standards, hospital systems are rapidly consolidating and purchasing practices in order to dictate the flow of care. Practices have likewise merged into “megagroups” in an effort to control costs and negotiate payments from third parties.

The entire delivery of healthcare is subject to events that seem to be out of the control of the practitioner. As a nephrologist in private practice, the task seems particularly daunting. In order to compete effectively nephrologists must continue to grow their ESRD population while keeping costs contained. This is becoming more challenging, as reimbursements are not keeping up with overhead. This has forced nephrologists to expand their patient load while seeking out other sources of revenue. Investing in vascular access surveillance facilities, partnering with dialysis chains, and expanding clinical research opportunities have been met with mixed reviews.1 Unfortunately, relying on an ever-expanding bureaucracy of third parties for reimbursement of services has only added to our overhead. Regardless of their success, it seems unlikely that this was the original motivation for ambitious internists to pursue a subspecialty in nephrology.

I understand the motivation for a graduating renal fellow to join a corporation such as a large hospital system, a dialysis chain, or a pharmaceutical company. The idea of job security and improved quality of life can be alluring. For my part, I was motivated by mentors who valued a rigorous intellectual challenge and comprehensive care for patients with a myriad of medical problems, while continuing to make their own business decisions. It may seem trite, but the idea of failing or succeeding on my own merits is an ideal that I value most of all.

As the system for fair compensation to medical practitioners becomes more complicated, I hear a familiar refrain from many of my colleagues. They are coming to begrudgingly accept a single-payer system. Nephrologists have generally accepted government payments for services since the early 1970s and have seen this part of their compensation grow as the population ages and the government continues to support end stage renal disease care. Rather than improve care, a single-payer system will likely make the private practitioner virtually unable to compete for their share of the contracting kidney disease healthcare dollar. Larger conglomerates will have the resources to control the flow of care, regardless of the wishes of the patients. Dialysis bundling virtually assures the fact that an individual nephrology group will be unable to successfully run their own dialysis units.

As private practice nephrologists, my partners and I continue to believe that the best care is delivered through a system where our medical decision-making and educated patients are paramount. We continue to support initiatives to educate our patients to partner with their doctors in managing their blood pressure, blood glucose, and cholesterol. Additional critical issues include dialysis access surveillance, renal bone disease, home dialysis modalities, and a stringent adherence to a healthy lifestyle following renal transplantation. For my part, when my autonomy for doing what I believe is in the best interest of my patients is taken away, it will be time to work on pursuing a lower golf handicap. For the time being I hope to stay in double digits.

 

  1. Nephrologist Compensation Report 2013. Medscape