Governments push for larger groups. It didn't work in the US so why should it here? The best size is the size you like best

By David Elkins

Whether physicians like it or not, most provincial governments are moving toward consolidating practices into larger and larger groups. Before control slips away from the profession entirely, it makes sense to try to determine what the ideal practice size is. Solo? Two or three doctors? Four or five? Big group? Just what is best for a medical practice?

The answer is simple, say practice consultants, there is no general 'right' size. The right size is the one that's right for the individual practitioner.

Doctors in the US have had considerable experience with groups of various sizes. In the 90s the prevailing attitude south of the border was that bigger is better. HMOs were in their hey-day. 'Economies of scale' were supposed to offer the best possible care to the largest number of patients at the lowest possible cost. It didn't work; administration's attempts to squeeze costs down caused patient and physician revolts. Services deteriorated and operating costs, initially lower, climbed as competition among HMOs for patients heated up and additional services were added. Insurers balked and sent premiums skyrocketing. Companies slashed healthcare coverage and workers suffered. Meanwhile, administrators � especially those at the top � creamed off huge bonuses and, in the case of publicly traded outfits, rewarded themselves with stock options that had no relationship to performance.

When the bottom fell out beginning in 2000, regulators and shareholders asked the hard questions to which they discovered, there were no answers forthcoming. The battles have now moved to the courts and US physicians who got caught up in the frenzy are seeking greener pastures once again in smaller practices. Downsizing is the order of the day.

DO WHAT YOU LIKE
So what is the right size for your practice? Solo practice can be lonely and naturally enough solo-physicians often contemplate taking on a partner. Doctors stressed by too many patients take on a partner to reduce the workload. If the volume's truly there, this may be a good idea but it might make more sense to take a deep breath and hire what practice management experts like to call mid-level personnel. Read: nurse practitioner. Another good reason to go from solo to partnership is to share weekend and night coverage. This makes sense too. Still, taking on a partner involves considerable risk. What if your patients don't respond to the new medic? What happens when disputes arise? There aren't easy answers. If your practice has grown too big for one, a better alternative � if you can manage it � might be stop to taking new patients and to reduce the current number.

How about going from two doctors to three? A partnership of two FPs in Regina did just that in 1997. The patient volume was there and the doctors were tired of being on call every other weekend. The new partner, a newly licensed female GP graduate from the University of Saskatchewan, fit right in. She bought her way into the practice over five years by gradually increasing her income share from 60% to 100%. With a young woman on board, there was some shifting of existing patients between physicians. New patients liked the choice of physicians the practice offered. The increase in practice size could still be handled by one on-call doc, which meant one weekend on in three instead of every other week. Last year they considered adding a fourth doctor but rejected the idea in part because the increased patient load would likely mean call duties every other week, once again.

On the positive side, four-doctor groups say they like the congeniality of having four on board. For one thing, this often softens the possible quandaries and difficult decisions that regularly arise with the familiar old two-against-one confrontations.