The demise of the independent doctor

The notion of a new doctor hanging out a shingle on a small town's Main Street is fast becoming a relic of a bygone era. Like the nation, Minnesota has seen a decline in solo and small-group practitioners, with most working instead for larger clinics and hospitals, often owned by health systems, as reported today by Elizabeth Stawicki of MPR News.

Among members of the American Academy of Family Physicians, for example, the ratio of solo practitioners in the United States fell from 44 percent in 1986 to just 18 percent in 2008. In Minnesota, according to the Minnesota Medical Association, just eight percent of the state's clinics are solo practices, while a mere six percent are practices with between two and four doctors.

The trend is changing the face of medical care not only in cities, but also in rural parts of the state.

Just ask Dr. Curt Louwagie, an ophthalmologist who began practicing almost two years ago in Marshall, Minnesota, near Cottonwood where he grew up. He works in a clinic that was purchased in 2008 from an independent physician by Avera Marshall Regional Medical Center.

"Privately held practices are becoming less and less popular because of the administrative and insurance demands," Louwagie says. "You need assistance just to manage the paperwork."

When Avera hired Louwagie, it reimbursed him for his medical school costs in return for his commitment to stay in Marshall for five years. He says it's unlikely he'd be practicing in town without Avera, given the ever more byzantine health-care system, which he says requires extensive business knowledge to navigate.

"There are a lot of people coming out of the school now with no business training at all," Louwagie says, noting that during his four-year residency, he had fewer than 10 hours of business instruction.

"You don't know if you're getting a good deal or not or how to evaluate the practice," he said. "You're already cash-strapped with six-figure student loans from medical school. Then you're supposed to get a loan of hundreds of thousands of dollars to purchase the practice in an uncertain reimbursement environment. We have 80 to 85 percent Medicare patients in our practice."

Still, Louwagie debated buying the clinic or opening his own. Either would have been a daunting prospect.

"There was so much equipment that needed to be purchased," he says. "Within the first month I was here, they updated $300,000 in equipment. That was just to get the place up to speed as a modern practice."

In the end, he decided he'd rather focus on doctoring.

"It's hard enough to keep up with medicine," says Louwagie, who has no plans to leave Marshall. "I'll concentrate on being a good doctor and let someone else worry about being a good business maker."

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