Will small primary care practices survive health reform?

A friend and family physician colleague of mine owns a private practice with three other primary care physicians and a physician assistant. Not long ago, she mentioned that she and her partners have been struggling to maintain their incomes in the face of rising equipment, personnel, and administrative costs, combined with declining payments from health insurance plans. Basically, she said, everyone's salaries have been going up except the physicians' - she takes home about the same amount she made after graduating from residency more than a decade ago. In order to boost the practice's income, she and her partners explored an agreement with one insurance plan to receive a bonus for providing care coordination services (which they do anyway, for free), only to be told that their practice was too small to qualify.

My friend's story, I think, is not atypical of the challenges facing small family practices today. Although last year's health reform law contains some programs designed to support primary care, including more funding for training programs and significant (albeit temporary) increases in Medicare and Medicaid payments to improve access, there is widespread concern in family medicine that the law did little to support the small practices (those with 5 or fewer clinicians) that see the majority of patients in the U.S.

An editorial authored by White House officials in the Annals of Internal Medicine suggested that small practices would eventually be absorbed by "vertically integrated organizations" and prompted the president of the American Academy of Family Physicians to send a letter to the White House defending the ability of small or solo practices to provide high-quality primary care in the new health environment.

More recently, the health reform pilot program that shares Medicare savings with physicians who meet certain quality-of-care goals in accountable care organizations (ACOs) has come under fire from physicians who fear that small practices won't have sufficient resources to form ACOs and will therefore be left at a competitive disadvantage against large hospital-owned practices or health corporations.

So is the future of primary care in the post-health reform era destined to be one in which small private practices become extinct, and family doctors who don't practice at community health centers or enter concierge medicine are all salaried employees for hospital systems or health maintenance organizations? And if so, will it be possible to persuade medical students to make this their career of choice?