‘Long Term, Sustainable Partners’: Bucking a national trend, Munson collaborates with primary care offices

In recent years, consolidation has dramatically altered the healthcare landscape. According to a joint study conducted by Avalere Health and the Physicians Advocacy Institute, hospitals or healthcare systems acquired 8,000 independent medical practices between 2016 and 2018 alone. In the same time span, approximately 14,000 physicians left private practice behind to work in hospitals. Are these types of consolidations impacting the northern Michigan healthcare environment? And if so, what do the trends mean for local practitioners and the patients for whom they provide care?

Critics of healthcare consolidation typically cite a range of different concerns for the trend, the biggest of which is a reduction in competition. Consolidation can sometimes run the risk of creating monopolistic enterprises that largely control consumer choice and pricing – a significant worry in the already-expensive arena of healthcare. More private practices in a geographic region can mean more freedom of choice for patients and more variety in pricing and payment options.

As the major player in northern Michigan medicine, Munson Healthcare is also the central force behind the area’s healthcare consolidation trend. Over the past decade, Munson has made a strong push to bring other northern Michigan hospitals under its umbrella, building a network that now includes nine hospitals from Frankfort to the Mackinac Straits. Recently, Traverse City’s Milliken Medical Group – formerly a private practice for primary care medicine – converted to an employed practice. And in March, Munson announced that it would be opening a new primary care clinic in Frankfort – called the Frankfort Medical Group – “following moves by Benzie County-based physicians Jennifer Kuiper, Mark Kuiper, and Nancy Smith to join Munson Healthcare.”

Glenn

Despite these developments, Laura Glenn, vice president of physician network for Munson Healthcare, says the organization is eyeing an overall very conservative strategy for consolidation in the coming years. Rather than adopting a “grow-at-all-costs” model aimed at acquiring any and all northern Michigan private practices, Munson Healthcare has focused its future consolidation plan on two priorities: access to primary care and sustainability of existing primary care clinics.

“Every year, we do analyses on each of our communities and their populations to try to understand how many primary care providers we need in order to care for each community,” Glenn said. “We try to identify where we have gaps. In each region, what is the wait time for a new patient (seeking a primary care physician)? If a patient doesn’t have a primary care physician, is it because they are experiencing access issues? Asking these questions helps us identify where we have opportunities to grow and improve access to care for primary care services.”

Based on these assessments, Glenn says that Munson’s strategy regarding private primary care clinics and system-owned primary care practices (or “employed” practices) tend to vary significantly across northern Michigan. In communities like Gaylord, Grayling or Manistee, the primary physicians are predominantly Munson-employed. In Cadillac, there is about a 50-50 mix between private practices and employed practices. As for Traverse City, Glenn says the area is a rare holdout against the spread of healthcare consolidation.

“Traverse City is unique, even across the country, in that the majority of our primary care physicians here are in independent practice, and they’ve been successful in independent practice,” Glenn said.

She added that, beyond the Milliken Medical Group, there is only one Munson-employed primary care clinic in Traverse City. That clinic, Munson Family Practice, is where Munson hosts its Family Practice Residency Program. Every other primary care establishment in Grand Traverse County is an independent entity.

When asked why Traverse City has such a robust community of independent clinics and practitioners, Glenn credits three factors. First is the area’s status as a highly desirable place to live. Second is the local physician organization (called the Northern Physician Organization) which Glenn says has worked hard “to enhance and boost their revenue from payers,” which in turn has allowed for more profitable and financially viable private practices locally. Third is the residency program at Munson Family Practice, which has helped establish an unusually young network of primary care doctors in the area.

“When we do our regional assessments, one of the things we look at is the relative age of our medical staff,” Glenn said. “We need to think about where are we going to have retirements that we have to plan for, or transitions that we’ll have to plan for. By and large, our primary care community in Traverse City is relatively young, and I think that’s directly related to the residency program. We’re able to retain a fair number of our family medicine residents in the community, and that’s allowed us to have a really stable group of primary care physicians to meet the needs in Grand Traverse County.”

Rawlin

Dr. William Rawlin, who leads the residency program at Munson Family Practice, acknowledges that the trend industry-wide is toward healthcare consolidation. In most urban areas, he says, the major hospitals own close to 100% of the primary care clinics. However, Rawlin also agrees with Glenn that there are unique factors in Traverse City– including the family medicine residency program – that have led to a subversion of the trend. As part of the residency program, Rawlin even has conversations with his residents about the pros and cons of working in private practice versus employed practice, just to make sure they are considering all potential options.

The biggest advantage for employed practitioners, Rawlin says, is having the full support of a large institution. Where private practice doctors have to shoulder a wide range of responsibilities on their own – from human resource functions to purchasing insurance coverage, all the way to advertising – Munson handles those steps for its employed clinics. At the same time, employed practices tend to have less autonomy and control than their private practice counterparts – something that doctors at hospital-owned clinics could feel deeply during the COVID-19 pandemic.

“Our clinic could potentially be turned upside down (by COVID-19),” Rawlin said. “If there is a surge in local cases, we could be turned into an overflow clinic or a second urgent care. In addition, every one of our employees in each employed practice has been enrolled in a labor pool, and some of us may end up being deployed to other hospitals within the Munson Healthcare system. So that creates a lot of flux for us, in terms of just not knowing where we might have to go.”

For her part, Glenn is glad to have Traverse City’s robust private primary care system intact right now, as well as the network of employed practices Munson has built throughout the broader northern Michigan region. These practices and doctors, she says, are giving Munson’s hospital system a fighting chance in combating the threat of COVID-19.

“Primary care is more important right now than ever,” Glenn said. “What they’re helping us to do is manage patients with chronic conditions and try to keep them out of the hospital. And then they’re also playing a role with patients who are symptomatic (with signs of COVID-19), but who are not sick enough to come into the hospital. Their role in managing those cases – that plays a really key function at this time when we’re trying to reserve hospital capacity for patients with emergent situations and for COVID patients requiring hospitalization.”

Going forward, Glenn says Munson has no plans to try to “realign” Traverse City’s numerous private practices and independent clinics under hospital ownership. However, she adds that if a local private practice were to approach Munson Healthcare about becoming an employed entity – as was the case with the Milliken Medical Group – the organization would have those conversations. Munson’s overarching goal with primary care is to ensure that it has “long-term, sustainable partners” throughout the region.

“If independent practice works and they’re able to be successful, we want to support them in that and collaborate with them as providers in our community,” Glenn said. “Our broader concern is ensuring that we have adequate primary care access across our region, and that we’re working collaboratively with our primary care physicians – whether they’re employed or in independent practice – to ensure quality care for the community.”

Some types of independent clinics would never be in a situation where merging with another partner – be it Munson or anybody else – would be on the table. Such is the case with Traverse Health Clinic, an independent nonprofit community health center that offers primary care along with other services like pediatrics, women’s health, behavioral health and addiction recovery. As a Federally Qualified Health Center (FQHC), Traverse Health Clinic receives funding from the U.S. Department of Health and Human Services (HHS) to provide community health services to anyone and everyone – particularly patients with low incomes. FQHCs cannot make any major changes – including mergers with or acquisitions of other healthcare entities – without the approval of the HHS.

Stanley

Mi Stanley, communications and marketing manager for Traverse Health Clinic, says that having a diversified healthcare community that includes an FQHC is very beneficial – particularly during a crisis like COVID-19.

“Community health centers fill a specific need and niche in the healthcare landscape,” Stanley said.

That need and niche includes acting as a safety net for people with lower incomes and who might have difficulty getting healthcare through private offices, Stanley said.

“It’s our responsibility as a community health center to be a resource for those folks,” she said. “We never turn anyone away because they can’t pay, and we know that with COVID-19 and the economic impact it is having in our region, so many people have lost or are going to lose their employment and, potentially, their healthcare benefits.”

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