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Professionalism: For Small, Solo Practices, Support Is On the Way

Butcher, Lola

doi: 10.1097/01.NT.0000526504.98791.4d
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The article discusses the challenges that US neurologists in solo and small group practices face and discusses AAN resources to help support them.

For 12 years, Elaine C. Jones, MD, FAAN, was a poster child for small independent neurology practices.

Undaunted by the challenges that frustrate many small and solo practitioners, she had been an enthusiastic proponent of technology, an expert on the government's incentive programs, an advocate for neurology patients and providers at the state and federal levels, and a go-to example of success in solo practice.

But the relentless changes — more regulations, new threats, financial pressures — wore her out. She came to feel that one false step could be disastrous: “If I got a ransomware attack, if I had a security breach, if I made a bad financial decision,” it could have a major impact, she said. “The margins were becoming so small and the requirements for business in health care were becoming so big, I just got tired of dealing with it. And I had options where I didn't have to, so I stepped out.”

On February 28, Dr. Jones closed her practice in Bristol, RI, and pivoted her career in a new direction. A few years earlier, she had started supplementing her practice income by providing teleneurology consults through a national telemedicine company. She now works for the company full-time. She's enjoying the work, the flexible schedule, and the break from running a small business.

“Ultimately, it probably won't be the only thing I do because I miss getting to know my patients over time,” she said. “I really enjoy that part of neurology so I will get back to it at some point.”

Dr. Jones said she doesn't want her experience to send the message that small practices cannot survive. She believes small and solo practitioners in neurology can thrive, and, as a member of the Academy's board of directors, she encourages them to stay the course. [See more of her story, “Why One Neurologist Stepped Out.”]

In fact, Dr. Jones is not a minority. Neurologists practicing in solo and small practices — defined as solo practice neurologists or neurologists in neurology groups with five or fewer neurologists — account for a substanial portion of the nation's neurologists. A review of practicing US neurologists who belong to the Academy revealed that approximately 12 percent are solo practitioners and another 18 percent work in small group practices.

“These practices have been under attack for the past seven to 10 years,” said James C. Stevens, MD, FAAN, the Academy's president-elect, who chaired last year's AAN Solo and Small Practice Task Force. The “attack,” he said, is an outgrowth of an ongoing string of payment and policy changes designed to rein in health care costs while improving the quality of care. As policymakers and payers experiment with various ideas on improving the value of care, new regulations and reporting requirements have become a burden for all physician practices, with solo and small practices hit hardest.

That has fueled a long period of consolidation, Dr. Stevens said, as physicians seek to escape the pressure by joining larger practices or hiring on with health systems. If that trend swallows up small neurology practices, patients living in wide swaths of rural America will have no access to the care they need, he said.

“That's where the smaller groups or solo physicians provide an incredible service to our population,” Dr. Stevens said. In fact, helping solo and small practices to continue to thrive is the focus of an AAN initiative. “For those members who desire to practice in that model, we want to do everything we can to allow them to do so — and to do so successfully,” Dr. Stevens said.

The task force found that while many need help to run their practices more efficiently or would like to advocate for reduced regulatory burdens, they are too busy running their practices to figure out how to do so. And most members in solo and small practices do not have time to access the vast amount of practice information and resources available from the Academy.

In response, the task force recommended several initiatives to support those members. One is a new outreach program in which the Academy is sending staff members to small-practice offices to learn about the kinds of support they need and to connect the practices with resources the Academy offers.

“Understanding [their] issues will help the AAN better advocate on their behalf, fine-tune current resources, and develop additional tools that will assist members in running a more successful practice,” said Sochenda T. Nelson, the Academy's program manager for Practice Management Solutions.

During these visits, Nelson interviews neurologists and clinic staff to learn about the practice's operations, identify challenges and opportunities for improvement, and share AAN resources that might be useful.

The site visits, made at the request of members in solo or small practices, are currently being offered at no cost to the member.

“We are going to be monitoring it to see how successful this program is and then decide what to do with it in the future, depending on the feedback we get from our members who participate,” Dr. Stevens said.



The task force also found that relatively few solo practitioners participate in the Academy's advocacy efforts. They account for 7 percent of the graduates of the Palatucci Advocacy Leadership Forum and make up less than 10 percent of the Neurology on the Hill participants.

In response, Academy staff created a new email address — — to make it easy for members to quickly reach staff when they have questions about coding, payers, health care information technology or practice management issues, according to Amanda Becker, senior director of policy and practice innovation. Staff respond to questions promptly and connect members to expert guidance, she said.

In addition to the site visits Nelson is conducting, an AAN webinar— “Thriving in Small and Solo Neurology Practices”— was presented last spring. It is available for viewing on the AAN website. Likewise, a course titled “Business Strategies for the Small Group and Solo Practitioner” will be offered at the Academy's Fall Conference, Oct. 20-22, in Las Vegas.

Many of the resources that Academy staff are developing for participation in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program are targeted toward small practices, Becker said.

Staff are also looking for ways to make it easier for solo and small-practice neurologists to participate in advocacy efforts.

“When you're operating on a shoestring and running as fast as you can to stay ahead of the payroll, it's hard to take time off to go to ‘Neurology on the Hill’ or to participate in advocacy initiatives,” said Allen Gee, MD, PhD, FAAN, who works in a three-physician practice in Cody, WY.

In the past decade, however, he attended the Palatucci Advocacy Leadership Forum, a weekend-long training program, served for six years on the Academy's Government Relations Committee and more recently joined the Practice Committee.

“My personal experience is that the connections and the conversations that I've had through that work have enhanced my revenue and helped me be more productive, rather than losing from taking time away to attend those events,” he said.

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After completing a fellowship in neurophysiology at Brown University's Rhode Island Hospital, Elaine C. Jones, MD, FAAN, worked at a hospital for a few years before opening her own practice in 2005. The practice quickly outgrew its first location—rented space in a primary care clinic—so she bought and moved into her own building in 2008.



“And then it just exploded,” she said. “It was a fabulous business. It was fun, it was patient-oriented. We could do what we thought was right for patients and what was right for us.”

At first, “us” was Dr. Jones and an office manager who was also a nurse. As the practice became busier, a secretary/receptionist joined the team.

“I had amazing staff, and I could not have done it without them,” Dr. Jones said. “We all took ownership in everything—it was a family business kind of thing.”

The federal government had not launched its Physician Quality Reporting Initiative (PQRI) and no one was even thinking about an electronic health record (EHR) incentive program when Dr. Jones set up her practice in 2005. But she believed technology was key to efficient medical practice, and she used an EHR system from the outset. Thus, she was well-positioned to participate in PQRI (which evolved into the Physician Quality Reporting System) as well as the Medicare and Medicaid Electronic Health Record Incentive Programs.

“I qualified for meaningful use (incentives) every year, and I got all my bonuses from them every year,” Dr. Jones said.

While many physicians groused about the government's prods to practice in new ways, Dr. Jones thought the goals were good. Physicians should be focused on the quality of care they provide, and EHRs can support them in doing so.

In hindsight, however, Dr. Jones sees the EHR incentive program as a tipping point. For her, the challenges of being a solo practitioner started to outweigh the benefits. “I think meaningful use was the beginning of the end,” she said.

Regulations and reporting requirements, not just from the government but from private payers as well, started to snowball. Dr. Jones was spending less time with patients and more time worrying about EHR security assessments and gathering patient records that insurers wanted to audit. She spent more money on outside expertise to handle things that were too complicated to address on her own, but the margins on her business were lower than in the early years.

When Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, Dr. Jones was enthusiastic about the Academy's plans for supporting members as the Quality Payment Program starts paying physicians in new ways. But as the details of the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) started to emerge, Dr. Jones felt her energy for the next phase of private practice wane.

“I decided I could not reinvent my practice at this point,” she said. “I just felt it was an explosion of what I had been struggling with in the past, and there was too much that I could not do.”

The trigger came when Dr. Jones experienced some health issues that she suspected were related to stress.

“I suddenly said, ‘I am working too hard and it's going to get harder. I need to do something different,’” she said.

Telling her two staff members was difficult; telling her patients was even harder. Dr. Jones had seen about 1,000 patients in the past year, and she needed to give three months' written notice to each of them. With a shortage of neurologists in Rhode Island, helping them find another neurologist was a challenge.

“Some of these patients I have been seeing since I was a resident in training at Brown, and they have followed me everywhere for 20 years,” she said. “It was very traumatic for all of us.”

“It's been rough for a few years,” she acknowledged, “and I think it will continue to be rough. But it's a great way to practice medicine, and I do think it's a model that will survive. So, stay the course.”

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Allen Gee, MD, PhD, FAAN, is in a three-physician practice in Wyoming, a state that one research study presented in July at the Alzheimer's Association International Conference predicted could well become a neurology “desert” by the year 2025. While Dr. Gee's office is in Cody, the other office is 200 miles away in Casper, and clinicians see patients in several locations across the state. “Through telemedicine and outreach clinics, we cover a substantial area of Wyoming,” Dr. Gee said.



Having practiced in solo and small practices in Wyoming for 17 years, he understands why most neurologists opt for a different work situation.

“We struggle to recruit community neurologists, given the pressures and given the opportunities to work at institutions in employed scenarios,” he said. “We're going to have to continue to aggressively participate in the transformation of the delivery of neurologic care.”

His transformation strategies include increasing patients' access to care by using physician extenders and teleneurology, which he expects will grow significantly in the foreseeable future. His strategy for running a successful small practice is to offload non-clinical responsibilities to outside partners.

“Our success, in many ways, is built on the recognition that we can't do it all,” he said. “That's where a lot of the stress and anxiety that small practices experience comes from.”

His practice participates with a company that provides both technology and support for a cloud-based electronic medical record, revenue cycle functions, and other services for nearly 100,000 providers. That gives Dr. Gee and his colleagues access to rules from all insurance companies, billing support, security and privacy compliance and other services.

“The company guaranteed that we would meet meaningful use in the past and that we comply with MACRA,” Dr. Gee said, referring to the new payment system coming from the Medicare Access and CHIP Reauthorization Act.

Dr. Gee's practice is also joining a management services organization (MSO) that will provide coding and other administrative support that would otherwise require hiring additional staff members or consultants.

Dr. Gee, who served on the AAN Solo and Small Practice Task Force, believes small practices can be more nimble and innovative than larger practices, which offsets the pressures they face to a certain extent.

“It is a stressful time and we're being overwhelmed with layers of bureaucratic rules and reporting and security and privacy threats,” he said. “So we're going to have to be creative. But we're not at all threatened or concerned that we won't be able to continue to be in private practice.”

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