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How Business Pressures Shape the Social Evolution of Modern Private Practice--A Case Study

How Business Pressures Shape the Social Evolution of Modern Private Practice--A Case Study

My Burlington, Vt., private practice used to be a low-budget, low-profile operation. A couple of chairs, a desk, a file cabinet and a couch created a fully equipped office. Most billing transactions were simple: Exchange a bill for a check. No "networks" linked me with unknown clinicians. No network bureaucrats from St. Louis or Minneapolis or even Burlington invaded my patients' privacy. How and why my practice has changed are emblematic of the forces, changes and opportunities influencing today's private psychiatrists.

Since finishing my psychiatric residency at the University of Vermont, I have had a private practice in general adult psychiatry on the outskirts of Burlington. For the first seven years I shared a building ("The Old Stone House") with two other psychiatrists, who were good friends from the residency program. Later, a psychologist and another psychiatrist moved in, unhappy refugees from the university. Our relationship was more a neighborly affiliation than a partnership, as we set our fees independently of each other, billed separately, and had individual phone numbers. For the first five years of my private practice, I held once-a-week consulting positions with the state disability service and with a county mental health center in New York State. I also taught residents and helped out administratively in the university's department of psychiatry.

By the early 1990s, the Stone House group had begun to drift apart. One of the original three members became the staff psychiatrist for Burlington's first health maintenance organization. The other original member developed a growing child psychiatry consultation practice in New York State. The psychologist also had a thriving consultation practice, as well as an expanding academic role in a nearby college. The ultimate dissolution of our increasingly fragmented group happened for aesthetic reasons, however, in the eighth year of our association when our two child psychiatrists moved into the top floor of a Burlington building with panoramic views of Lake Champlain.

During this period of group transition, managed care had begun to make its first noticeable inroads into northern Vermont. The local HMO was becoming more prominent, and the area's largest employers (IBM, General Electric, the University of Vermont) all signed managed care agreements. As a consequence of my decision to join selected managed care organizations, the paperwork demands on my time escalated; treatment reports and other managed care-generated correspondence began to pile on top of my traditional paperwork load of office notes, provider correspondence, billing, and so on.

My two remaining colleagues at Stone House kept minimal and irregular schedules. The moving away of my practice neighbors gave "solo" private practice a new, and lonely, meaning to me. I began to think about how I might restructure my practice. Unlike my Stone House colleagues, I poured more of my time and commitment into my office practice and felt quite gratified "just seeing patients." I missed collegial contact, though, and I needed office help.

Around this time, a large psychology-based group practice in the area was going through its own evolutionary upheavals. A child and family psychologist who has been a good friend and softball teammate of mine for nearly 15 years wanted to leave the group he had been part of for several years. After a series of informal conversations, we decided in an after-softball, late-night meeting in a local Ben & Jerry's to form our own group. The initial group consisted of my psychologist friend, two other members of his group: His wife (a drug and alcohol counselor and certified mental health counselor), and their friend (a pastoral counselor who also was a mental health counselor), a woman who quit her job as billing manager of their former group to become our office manager (and my personal insurance savior) and myself.


In late 1994 we began a series of regular breakfast meetings, started looking for office space and added another psychologist. In March 1995 we moved into office space built to our specifications. We decided upon a name for our group: Cedar Brook Associates, because there were cedar trees by our front entrance, and somewhere nearby flowed a brook whose name (Allen Brook) was already associated with a nearby office building and a local group home. By consensus we designed our logo, selected our carpeting and picked out our offices.

The five of us held several important ideas in common. We believed that in the evolving managed care environment, being in a mixed specialty, one-site-fits-all (or most) group mental health practice would be competitively wise. We looked forward to sharing cases with trusted colleagues. As a psychiatrist, I could bolster the practices of my nonpsychiatric colleagues by allowing them to take referrals they otherwise might turn down (i.e., if medications were needed). As a corollary, of course, my own practice would be more secure, as I would be assured a steady stream of consultations and medication reviews.

We also wanted our new group to be socially egalitarian and free of artificial role distinctions. (For example, I would not assume any financial or administrative role, like "medical director.") In the 1990s, this cross-discipline egalitarian ethic has gained strength in Vermont, as evidenced by the growing popularity of yearly multidisciplinary conferences and by the successful passage of a mental health parity bill by this year's legislature, after an intense and costly coordinated lobbying effort by all mental-health guilds and citizen groups in the state.


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