The state of physical medicine: Maintaining independent practice

Independent physician practices across specialties, including physical medicine and rehabilitation, face mounting financial and administrative pressures that have driven many small practices to be acquired by large health systems, private equity firms or other consolidating entities, fundamentally shifting outpatient care toward an efficiency-driven, bottom-line model that many physicians feel compromises patient care. John C. Cianca, M.D., FAAPMR, president of the American Academy of Physical Medicine and Rehabilitation, said he is fortunate to have established his independent practice before consolidation pressures peaked, while many of his colleagues have found themselves with little choice but to surrender autonomy and join larger, institutionalized practice environments.

Medical Economics: Based on your own experience as an independent practitioner, what are the biggest challenges right now to maintaining independent practice?

John C. Cianca, M.D., FAAPMR: That is actually a giant challenge for many of my colleagues, in so far as survival, being financially viable, of being able to keep pace with the demands of a health care system that is, let's say, challenging, meaning the administration thereof and the payment of it. Many, many small practices have been bought in some way or another, either by large institutions or by private equity or by other groups, so that in some respects — well, there definitely is power in numbers. And that could be at the level of still an independent practice that's just bigger. But it also could be at the hands of somebody else who's overseen that practice, and saying that in a kind way, because it really has changed the way that kind of care, outpatient care, is being delivered. It has become very bottom-line focused, very much an efficiency model, and that's challenged the care part of it, if you will. So I think many of my practitioners have had to, not by choice, have had to fold themselves into a situation that was different, less autonomous, is a better way to say it, than it had been. I, on the other hand, have gone the other way and have become more and more independent. I was probably fortunate that I started that before there was a critical need to make a change. So many of my colleagues have gotten caught up in this sort of churn of outpatient practices becoming big institutionalized practices.