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Viewpoint: A physician's toughest choice: Accept an offer or remain independent?


Deciding your next move is difficult.

“…Two roads diverged in a yellow wood, And sorry I could not travel both...”

-Robert Frost, The Road Not Taken

Physicians are now forced to make the toughest choice of all: whether to join a government-supported, hospital-run accountable care organization (ACO) or a physician-run, independent, direct-pay practice. The time for fence-sitting is at an end, with the Affordable Care Act now law and exchanges forming to provide mandated insurance or government Medicaid.

Big government and big health insurance have run roughshod over physicians and their established practices, devouring the precious little time we have in the exam room. The patient-physician relationship is at the breaking point.

The upside

On one hand, it would be easier to sell out to a big hospital ACO and work set hours for set pay. Limited on call and possibly opting in or out of hospital inpatient work would be possible benefits. Large health organizations have all the legal, insurance, billing, electronic health record system and other information technology, and staff support for a complicated medical practice.

All that government- and insurance-necessitated overhead would detract from the physician’s salary and benefits. Doctors would be limited in patient contact time and might have to strive for a “production” bonus for seeing more patients faster to make personal ends meet.

The downside

On the other hand, it would be a challenge to convert a medical office to a direct-pay or concierge model of practice. The physician would be fully responsible for his or her call and office schedule. He or she could establish either discount posted cash prices for services or a monthly retainer fee for the “buffet” of services offered by the practice. The doctor would have to assume the financial risk for this model, but that was the case with the previous practice, too. A physician could opt out of government edicts and insurance rules and again decide on the time and care a patient receives.

Deja vu all over again

Haven’t we been here before? It seems to me that when I was in training in the 1990s, health maintenance organizations came to town, and hospitals were buying physician practices left and right. By the end of the decade, they were all hemorrhaging money. The hospitals coughed up the practices to again be independent.

A decade later, however, we are back to hospitals buying up practices to become ACOs, an untested government concept without previous, small-scale trials or testing. This, too, also may blow up in hospitals’ faces as it did by 1999.

“…Two roads diverged in a wood, and I-I took the one less traveled by. And that has made all the difference.”

-Robert Frost, The Road Not Taken

All the best for health and sanity making this decision, my colleagues. Never underestimate your power or influence.

The author is a family physician in Mullica Hill, New Jersey, and a member of the Medical Economics Editorial Board. From the Board columns reflect the opinions of the authors and are independent of Medical Economics. Send your feedback to Also engage at and


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Jennifer N. Lee, MD, FAAFP
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