Comparative Analysis: Physician Practice Evolution

EXAMPLE PAPER

Learner’s Name

School of Business, Technology, and Health Care Administration, Capella University

BHA4002/BHA-FPX4002: History of the United States Health Care System

Capella Instructor’s Name

Date

Note: This is an example paper written on the evolution of physician practices. The actual assessment is a comparative analysis of the evolution of hospitals.

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Comparative Analysis: Physician Practice Evolution

In this comparative analysis report, the evolution of physician practice is reviewed from the 1800’s

through the 2000s. The purpose of this report is to show the progress of how physician practices, their

staff and payment systems have changed over the last three centuries. The irony is that they have

changed, and they have also gone full circle as explained below.

In the 1800 and 1900 centuries, the relationship with the physician was very personal and patient-

centered. The physician knew everything about their patient, and the patient knew everything about their

hometown physician. As medicine evolved, physicians became more specialized, and focused on specific

diseases. This often removed that personal relationship between physician specialist and patient. The

irony is that the 2019 COVID pandemic put a spotlight once again on the primary care physician-patient

relationship, but in a much broader context. The pandemic showed us the importance of the primary and

community healthcare (P&CHC) systems focus (Lauriola, et al., 2021). The pandemic revealed a

weakness in P&CHC worldwide, i.e., it put a focus on hospital and intensive care beds and not on

community and primary care. In Lauriola et al. (2021), the authors propose that the pandemic has shown

us that P&CHC is where the focus needs to be though local community problem-solving to safeguard

communities, which brings us back to the primary care physician and infrastructure at the community

level, but in a context of global world health (Lauriola et al., 2021).

Comparative Grid and Analysis

In Appendix A, the table entitled The Physician Practice Evolution and Changes shows how the

physician practice has progressed. There are several major milestones that stand out in the table which

includes the evolution of the physicians’ offices, the training of their staff, and how they were paid

compared to payment systems today.

The Physician Practice

In the 1800s, physicians would often go to see the patient at their home (Nespor, 2009).

Physicians were solo practitioners around the turn of the 19th century. By the mid-1900s physicians were

more likely to be in a group practice of two or more providers (Kroth & Young, 2018). In the early 1990s,

healthcare markets began to consolidate nationwide due to rising healthcare costs and reduced

reimbursement. By the 1990s group practices began to integrate horizontally into Independent Practice

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Associations (IPAs) (Kroth & Young, 2018). The IPAs then vertically integrated with hospitals and formed

Physician-Hospital Organizations (PHOs). The PHOs were established to retain and gain market share

through managed care contracting and used shared purchasing groups to achieve cost-savings (Kroth &

Young, 2018; Williams & Cuneo,1997).

Physician Staff

In the 1800s, the physician most often worked as a solo practitioner without an assistant. If they

had an assistant, it was someone that they personally trained (Nespor, 2015). By the 1960s, due to

population growth and the demand for health services, physicians time became a scarce commodity, and

the nurse practitioner movement began (Kroth & Young, 2018). This movement persists today because of

population demand and the projected physician shortages (AAMC, 2021).

Payment Systems

From the 1800s to the early 1900s, physicians were paid in small amounts of cash, or in food

and services from their patients (Allen, 2016). As healthcare costs rose between 1960-2000, physicians’

fees declined. The physicians’ reimbursement changed from fee-for-service to discounted fee-for-service

and capitation (Kroth & Young, 2018). Capitation is a flat prepaid fee to providers per member per month

(PMPM) from the managed care organizations (MCOs) (Kroth & Young, 2018).

Comparative Analysis Summary

In the 1800s, the physician’s office was often their home. By the 1960s offices were centrally

located and often group practices with two or more physicians. In the 1800, physicians extenders did not

exist. In the 1960s and still today the educational programs for NP and PA are well established and the

physician extender, working under the supervision of the physician, is common.

One of the biggest changes in the physician practice has been in the reimbursement for their

services. In the 1800s, physicians received payment in cash or food and services. Blue Cross (BC) was

established in 1929, Medicare and Medicaid in 1965 as fee for service payers. However, by the early

1990s markets consolidated and managed care organizations were on the rise promoting care quality and

cost containment.

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Conclusion

In conclusion, the evolution of the physicians practice has been progressively positive, and the

improvements have established higher quality of care in medical practices today. The changes in the

physician’s medical practice have been and will continue to be dynamic and persistent. However, the

medical industry is unable to ignore what the 2019 COVID pandemic has revealed, i.e., the importance of

the primary and community healthcare (P&CHC) systems focus. Although, the primary care and specialty

care physicians will continue to manage patient care and prevention at the community level they will need

to do so within a broader world-health context.

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References

Allen, E. (2016, April 28). Paying the doctor in 18th-century Philadelphia. Library of Congress.

https://blogs.loc.gov/loc/2016/04/paying-the-doctor-in-18th-century-philadelphia/

Association of American Medical Colleges. (2021, June 11). AAMC report reinforces mounting physician

shortage. https://www.aamc.org/news-insights/press-releases/aamc-report-reinforces-mounting-

physician-shortage

Berenson, R. A., & Rich, E. C. (2010). US approaches to physician payment: The deconstruction of

primary care. Journal of General Internal Medicine, 25(6), 613–618.

https://doi.org/10.1007/s11606-010-1295-z

Kroth, P. J., & Young, K. M. (2018). Sultz & Young's health care USA: Understanding its organization and

delivery (9th ed.). Jones & Bartlett.

Lauriola, P., Martín-Olmedo, P., Leonardi, G. S., Bouland, C., Verheij, R., Dückers, M., van Tongeren, M.,

Laghi, F., van den Hazel, P., Gokdemir, O., Segredo, E., Etzel, R. A., Abelsohn, A., Bianchi, F.,

Romizi, R., Miserotti, G., Romizi, F., Bortolotti, P., Vinci, E., Giustetto, G., … Zeka, A. (2021). On

the importance of primary and community healthcare in relation to global health and

environmental threats: lessons from the COVID-19 crisis. BMJ Global Health, 6(3), e004111.

https://doi.org/10.1136/bmjgh-2020-004111

Nespor, C. (2009, March 11). 19th century doctors in the U.S. Melnick Medical (History) Museum.

Nespor, C. (2015, October 28). Doctors’ offices. Melnick Medical (History) Museum.

https://melnickmedicalmuseum.com/tag/doctors-offices/

Williams, W. C., III, & Cuneo, K. F. (1997). Physician-hospital organizations and PHO executives. What

lies ahead for the PHO? Physician Executive, 23(2), 13–15.

http://web.b.ebscohost.com.library.capella.edu/ehost/

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Appendix A

The Physician Practice Evolution and Changes

Theme 1800s 1960s 2000s

The Physician’s Office

• Often the providers home

• Often the patients home (Nespor, 2009).

• Single Physician Office (Nespor, 2009).

• Small group Practice of 2-4 physicians (Kroth & Young, 2018).

• Independent Physician Associations (IPAs).

• Consolidation of market with larger physician groups contracted with Hospitals, i.e., Physician Hospital organizations (PHOs). (Kroth & Young, 2018).

The Physician Assistant

• None with formal training.

• Trained by the physician to assist them (Nespor, 2015).

• Office staff, may include RN, LPN, or MA

• Often trained by the physician to assist them (Kroth & Young, 2018).

• Specialization, Physician extenders, Nurse practitioners (NP) and Physician Assistants (PA)

• Lab Technicians, Radiology Technologists (Kroth & Young, 2018).

The Physician Payment Systems

• Small cash payments

• Goods, such as coffee, tea, wine, and beer; and services such as carpentry, painting and so on were offered as payment (Allen, 2016).

• Fee-for-Service: Private pay.

• Early insurance payments form BCBS (1929),

• 1965 and beyond, Medicare and Medicaid (Kroth & Young, 2018).

• Medicare Physicians Fee Schedule (PFS), Resource-Based Relative Value Scale (RBRVS),

• Capitation, one fee per member per month (PMPM) (Kroth & Young, 2018).