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Comment by lr4444lr | Hacker News Reader

More like running many kinds of businesses has become more hassle than its worth.

Medical malpractice premiums are very high, insurance payouts are stingier, and medicine has become more capital intensive than ever as newer medicines and diagnostics increasingly dominate, along with an aging population that needs more intensive care.

Doctors report being more burnt out than ever. It's an attractive proposition to outsource the hard and messy stuff to a firm that knows the business angle well so that they can keep their sanity and focus on what got them interested in medicine in the first place while still getting a great salary.

I don't love the situation, but let's not pretend it happened in a vacuum.

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> Doctors report being more burnt out than ever. It's an attractive proposition to outsource the hard and messy stuff to a firm that knows the business angle well so that they can keep their sanity and focus on what got them interested in medicine in the first place while still getting a great salary.

The corporatization of medicine is one of the major causes of burnout, not an escape from it. I am not aware of any physician who enjoys things like things like "all hands" meetings with the CEO and CMO to talk about the "new vision" for the group. Or doing several different annual/biannual compliance trainings for meaningless BS. Or having to go through several layers of internal bureacracy if they want to buy a new piece of equipment. Or having zero say in the hiring process for the ancillary staff that they work with. Or having very little say in how many patients they see during the day, or during which hours, or which types of diagnoses, or how the clinic staff does intake and rooming.

The docs who are selling their practices to PE are doing so to cash out right as they go into retirement, not to outsource their admin work. Admin work is already outsourced in the private practice model. The practice hires ancillary staff for clerical work and contracts an accounting firm for help with the financials.

No, you've completely misdiagnosed why PE is involved.

It is involved because there is slack on the system in the form of downtime, and it figured out that if it just buys up all the doctor's offices, makes the doctors rush through the cases, and keeps them busy seeing patients every working minute, the practice and it's owners will make way more money.

Quality of care will decline, but unless the doctor is actively doing surgery, or something else risky, whatever money they lose due to the decline in quality will be more than offset by grinding through patients quicker.

It's almost impossible to sue a doctor for malpractice in Texas, yet the exact same problem with PE is happening there, too.

Vets are another example where this is happening - and again, it's not because of frequent $XYZ,000 malpractice settlements. Anything that's not billable hours seeing patients is considered to be damage by the system, and capitalism tries to route around it.

>It is involved because there is slack on the system in the form of downtime, and it figured out that if it just buys up all the doctor's offices, makes the doctors rush through the cases, and keeps them busy seeing patients every working minute, the practice and it's owners will make way more money.

This doesn't explain why doctors are selling though. Why aren't doctors just not selling their practices and taking a more relaxing job running things themselves? Why are they choosing the option that requires them to "rush through the cases, and [keep] busy seeing patients every working minute"? Surely if that was something they enjoyed doing, they could do that and capture all the "slack" for themselves? So why sell your office to someone else to capture all that slack while your own work load increases?

> This doesn't explain why doctors are selling though

Retiring doctors are selling because this lets them cash out their practice for way more than they'd otherwise get for closing it and auctioning off the equipment.

> Why aren't doctors just not selling their practices and taking a more relaxing job running things themselves?

The ones that are selling are the ones exiting the rat race, the downsides aren't affecting them.

So why aren't new doctors opening their own practices? What has changed in the last 20/30/40 years that are leading up and coming doctors to choose working for someone else instead of opening their own practice?

Because the ROI dropped precipitously. Governments were paying much better, insurance companies were paying much better, liability was a lot less, documentation and paperwork was a lot less.

The 80s to 00s doctor years were very good. Now the power is in the hands of the government and huge insurance companies, and to compete with them, you need to be part of a large healthcare provider group, which ends up happening as an employee.

Plus medical school debt and increasing years to become fully practicing like having to do longer residencies and fellowships.

I think they will over time if PE deals start to implode or reveal themselves to be as bad as people claim. But the reaction will take a while to happen.

With partnership-based models, it's not necessarily the case that most of the doctors who owned their practices were necessarily that entrepreneurial. Many probably joined the practice and then became partners after a few years with buy-in and sweat equity. There's some risk and business management involved, but not the same as really doing your own thing. The path was laid out. (Kind of like lawyers at big law firms.)

The real entrepreneurs were the ones who initially founded a practice from scratch. But for some specialties where PE has taken hold, you need a group of people with enough capital to do that, negotiate contracts with hospitals for admitting privileges, wait-out a non-compete from a prior practice, etc. That takes time, and meanwhile, the net share of PE held firms may still increase for a while as other firms continue to sell out.

> So why aren't new doctors opening their own practices?

For the same reason that nobody builds out a second set of power lines to compete with an incumbent power utility.

It's capital-intensive, the size of the medical market for the area is fixed, and you'll just be fighting the established practice for it in a zero-sum game.

You can win, but it's going to be way more work for less reward than just finding a PE practice that's hiring/a traditional practice with spare space that's looking for a partner.

Possibly medical school debt.

And of course nobody has sympathy for doctors with student loan debt, but the debt may still have important effects on the economy down the line.

This would be a good argument if it were only medical practices where PE was active and having a malign effect. But that's most definitely not the case.

That just means for numerous professions, running a business is more hassle than it is worth. Accounting, dentistry, massage, etc. all come to mind. Those people want to all practice their field, not deal with licenses, paperwork, insurance, and tax. Everything from burnout to higher required investment to increased regulatory hassle applies to other fields as well.

That doesn't mean that. That is what one might infer if one believed the conclusion were true. But that's only persuasive to those predisposed to believe it. Which I am not.

Regardless, running a business has always been more hassle than it's worth for people who would just rather have a job. But it has been worth it for those who prefer independence. If you wanted to claim that things were radically worse, you could take a swing at it. But given the rise in communications, computers, SaaS, and service outsourcing, there's a strong case to be made that it's much easier to run a professional service business.

And I think the just-want-to-do-the-work thing is a bit of a red herring. I was recently talking with an optometrist whose joint practice was sold to a PE firm. His precise complaint was that PE was interfering with just doing the work, which he saw as helping patients.

Did he say what lead him to sell then?

It is frustrating to me when I respond in detail to somebody's querulous points and they just abandon everything discussed to hare off in some new direction. It certainly doesn't motivate me to write a quality reply.

> Those people want to all practice their field, not deal with licenses, paperwork, insurance, and tax.

This problem has been solved for a century, in the form of the practice which employs support staff, sometimes a multi-practitioner practice which shares those staff.

PE rolling into it has been a very recent phenomena.

Regarding burnout I know individuals in the medical field who wish they could control their schedules by reducing the number of clients per day, but they simply are not allowed to because leadership expects them to turn certain levels of profit.

Doctors are burnt out because there aren't enough of them and they make a lot of money working for businesses that prioritize revenue generation.

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