Some physicians prefer the autonomy, reduced load of independent practices

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When Matthew W. Levin's patients call his family practice office in Greensburg, they'll likely end up speaking to the doctor himself -- even on nights and weekends.

Family physician Shawn S. Moyer sees his patients in a 750-square-foot office near York, Pa., that has a waiting room that holds only four chairs. His office staff consists of one medical assistant.

At a time when most trends point to multiplex doctor practices and hospital-owned physician groups, Drs. Levin and Moyer have staked claim to a philosophy that smaller is better -- for them and their patients.

Both worked in physician groups in the past, but both were troubled by the waste and expense involved -- to the detriment, they believe, of the care they could provide.

Discounting his salary, said Dr. Moyer, 40, his office overhead now is less than the phone bill at the three-physician practice where he previously worked that kept a staff of 27 full-time employees including "three people whose only job was to locate paper charts."

Dr. Levin, 51, started his solo practice six years ago -- immediately taking a two-thirds cut in pay -- with one full-time and one half-time employee. His staff has grown some but he still makes sure the practice doesn't lose its personal touch. As with Dr. Moyer, his policy is to see ill patients the same day they call. Nights and weekends, he will consult with them over the phone.

"All of my patients know me."

Solo physicians enjoy their independence and cherish the extra time they get with patients but "we're a dying breed," said John Delaney, a geriatric neuropsychiatrist with a solo practice in Fox Chapel. The current president of the Allegheny County Medical Society said, "I don't think people coming out [of medical school] now are even going to think about it."

Independence sounds nice, he said, but going solo can also be lonely and you have to maintain backup coverage for times you're unavailable. "Being a small, independent practice means that you obviously have to be really careful about your expenses."

A 2008 report on health care trends by the American Medical Association noted a "significant" shift from small physician practices to group practices and hospital employment, and predicted that trend could accelerate "primarily because of the greater leverage they can exert in negotiating private payment."

Another national study reported that the proportion of solo and two-physician practices had decreased from 40.7 percent in 1996-97 to 32.5 percent in 2004-05.

Still, there are clear advantages of a solo practice, starting with the freedom to run the business as you'd like. "If you ask a physician what it is they want, autonomy usually ranks above money," said Dr. Moyer.

In a large group or hospital-owned practice, "Your schedule is prepared by a practice manager and there is a little bit of pressure to keep running people through the mill." There can be a yearly bonus at stake for maintaining a high patient volume, "which is a large percentage of their salary," he said.

Without external pressure to see large volumes of patients to meet revenue goals, solo physicians can take as much time as they'd like with patients.

When a retiree who'd suffered a stroke visited Dr. Levin this week, the doctor spent close to an hour going over each of the 10 prescription bottles the patient had brought in, some from a hospital stay, some from a nursing home he'd gone to after his stroke. The patient told the doctor he was having trouble with diarrhea; Dr. Levin noticed he was on a medication for a stool softener and told him to stop taking that pill.

The biggest downside to soloing is just as obvious. A reduced patient load -- Drs. Moyer and Levin see about half the number of patients they did while in a larger practice -- means reduced revenue.

"What I say is that I'm happy to come to work every day, but I don't always pay myself," said Dr. Levin.

He estimates his overhead expenses claim about 66 percent of his revenue, but his cash growth rate is increasing 10 percent yearly. After six years, he's seeing no more than 15 patients daily, compared with 22 to 30 when he was part of a larger practice. He said he can't afford to see Medicaid patients because the state reimbursement is too low.

Dr. Moyer said his income is only about 10 percent below what he made as part of a three-physician practice. And he's set up his own system for uninsured patients, offering comprehensive primary care for $30 a month and $15 a visit. He sees about 12 patients each day, compared with the 30 to 40 that were required at the larger practice "just to keep the lights on" as one of his partners told him.

One trait these streamlined, independent doctors often share is an embrace of technology, in some cases setting up their own electronic medical record systems to reduce paper work They also diversify, taking on outside consulting and clinical work.

For Drs. Levin and Delaney, their practice is also a family affair -- Ilene Levin and Rose Delaney both work in their spouse's office. Dr. Moyer's wife, also a physician, works in a York-area hospital.

One expected pitfall of a solo practice turns out to be a myth, they say. Contrary to what one might guess, the solo practices have not been deluged with patient calls over the weekend, even during high flu season.

"I will get maybe one, two calls on weekends," said Dr. Levin, who has 1,200 patients, compared with about 2,500 for a family physician in a large practice.

Part of the reason he gets fewer calls is that he has fewer patients.

But he also believes patients are slower to call him because they know they can reach him any time. They don't have to worry that a sniffle and headache on Friday afternoon will get much worse before they can get in to see a doctor on Monday.

"I truly believe this is what medicine should be and could be," said Dr. Moyer. "But there are greater forces at work."

Steve Twedt: or 412-263-1963.


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