• Disruptive Forces for the Private Practice Neurosurgeon

    Author: Pedro Ramirez

    The signs are clear that a disruptive force is approaching. But it is not clear where, when, or what the extent of the impact will be. Disruption in private practice can be a positive process that neurosurgeons can benefit from, only if we identify the disruption and prepare adequately. What distinguishes disruptive individuals from the status quo are a maverick spirit, a willingness to fight for what they believe is right, and the ability to motivate others to embrace their fresh ideas. In the next few years, private practices that don't think differently, quickly, and innovatively will not flourish. This article will present some of the disruptors in private practice to help us understand what is coming.

    Self-employment allows for autonomy over lifestyle. We made a career decision based on passion, prestige, money, and lifestyle. We all know that lifestyle was not our top priority. Most neurosurgeons are workaholics since that is how we made it through residency. We bring that to our practice. Private practice means being on call 24/7, no help from residents, plus added time managing the business. Private practice neurosurgeons have to design and maintain a high-quality service to be competitive. We must never lose our sense of meaning and purpose. We must separate work from personal life and enjoy every minute of our day. Above all, life is what you make of it.

    Is very difficult to maintain a balance between the different options of employment for neurosurgeons and there are several factors to consider when transitioning to practice. We have seen a shift of physicians leaning more towards hospital employment rather than private practice. Residents are rarely exposed to private practice models and have very little or no exposure to the business side of medicine. Medical school graduates have a large amount of debt, which can easily double after 7 years of Neurosurgery training. Private practice models often offer increased autonomy and greater income potential, but fewer physicians are pursuing this option. This is most likely due to the rapidly changing healthcare environment with increased regulatory and administrative burdens, high malpractice costs, and high operational overheads. Private practice has the advantage of having physician ownership not only in the form of shareholder status, but also with intellectual property. Private practice neurosurgeons also have the ability to have an ownership stake in ambulatory surgery centers.

    Disruptive decentralization is a mechanism that reduces cost in healthcare. For decades health systems have been centralized in hospitals. Private practice has to compete with hospitals that are now health care systems that provide wellness and pre-emptive care, rather than merely sick/acute care. Pursuing profit and differentiation in head-on competition amongst similar business models generally adds cost. The decentralization that follows centralization is just beginning in health care and is driven by independently owned imaging centers, surgery centers, and medical groups. Private practices contribute to the decentralization of healthcare by having relationships with multiple hospitals and healthcare systems that help broaden geographic reach while diversifying referral networks.

    The transition to value-based care and CMS' physician incentive programs will either increase or decrease payment to providers. The incentive programs, known as the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APM) will start to move all physicians toward a goal to be reimbursed not for services rendered, but instead for outcomes. High-value care will be definedby measures of quality and efficiency and providers will earn, more or less, depending on their performance against those measures. MACRA is a disruptive force in healthcare. Within any disruption is an opportunity for those who see it. Private practice neurosurgeons who learn how to effectively leverage changing demands will likely lead and profit from this disruption. But implementation of regulations will not be easy and overhead costs will be added to the practice.

    Patients are the most important players in the disruption of neurosurgery private practice. Patients expect their healthcare experience to be seamless and integrated with technology, so they can participate more in their care. Patients want to book appointments online, access care outside the doctor's office or hospital through remote patient communications such as tele-health. Enhancing the patient experience through technology is real and rapidly growing. Healthcare has a long way to go before it can be considered consistently customer centric. Information sharing offers patients qualities they look for: convenience, attentiveness, timeliness, value, and price transparency. In health care, most technological enablers have failed to lower costs and increase quality. Technology is making it easier and faster for patients to get care but is also increasing the operational cost of a private practice.

    Social media has inarguably taken the world by storm. It can be used to improve or enhance professional networking and education, organizational promotion, patient care, and patient education. Social media has also given patients the platform to vent their frustrations and to follow up on causes they feel compelled to join. This can present potential risks to private practice neurosurgeons. The distribution of poorquality information, damage to professional image, breaches of patient privacy, violation of personal-professional boundaries, and licensing or legal issues can be devastating. Private practice neurosurgeons who want to reach larger audiences or interact better with existing audiences should be active on social media but follow guidelines issued by health care organizations and professional societies to provide sound and useful principles and avoid pitfalls.

    In most industries, disruption comes from startups. Yet almost all health care innovation funded since 2000 has been for sustaining the industry's business model rather than disrupting it. Private practice neurosurgeons cannot rely on someone else's great foresight capabilities for longterm growth. We need to identify opportunities, constraints and threats. Neurosurgeons with good business intuition will identify disruptions that others can't see and will transform it into a growth engine.


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