Ортопед из Лансинга: независимая практика выживает за счет контроля над системой лечения

When Patrick Noud, MD, an orthopedic surgeon and shoulder specialist, arrived in Lansing, Mich., nearly two decades ago, independent orthopedic practice was still the norm. The region had roughly eight to 10 private orthopedic groups, ranging from small practices with one or two surgeons to larger groups with seven or eight. Today, he said, almost all of them are gone. What remains is a hospital-employed orthopedic group, and Lansing-based Michigan Orthopedic Center, where Dr. Noud practices. That change has shaped how he thinks about the future of orthopedics. For many physicians, independence has become harder to defend. Reimbursement pressure keeps rising. Operating costs keep climbing. Hospitals can offer large guaranteed salaries, built-in referral networks and administrative support that private groups struggle to match. Dr. Noud understands the appeal. He also believes something important is lost when physicians give up control of the practice around them. “When they had no control over how their practice ran, and they had no control over the people that provided the care, apathy is real,” Dr. Noud told Becker’s. For him, the case for independence is not only financial. It is personal, operational and deeply tied to the patient experience. What hospitals cannot buy Healthcare often describes the physician-patient relationship as though it exists only between two people in an exam room. Dr. Noud sees it differently. “The doctor-patient relationship isn’t just doctor and patient,” he said. “It’s all the people that care for that patient.” That includes the person at the front desk, the medical assistant who rooms the patient, the advanced practice provider who supports the surgeon, the billing staff, the administrative team and everyone else a patient encounters before and after seeing the physician. In an independent practice, Dr. Noud said, physicians can build that team intentionally. They can choose who represents the practice. They can adjust workflows. They can respond quickly when something is not working. They can shape the culture patients experience from the moment they walk in. When physicians lose control over those pieces, he said, they lose control over far more than operations. They lose influence over the care experience itself. “If the doctor can’t control any of that, then they have very little control of the doctor-patient relationship,” he said. That loss of control, he believes, is one reason burnout and disengagement can deepen after physicians become employed. “You just start to coast,” Dr. Noud said. “We’ve all heard that before, but it’s very real.” Why ownership changes the work Dr. Noud does not romanticize private practice. He describes it as demanding, complex and increasingly difficult. But he also believes ownership creates a different level of engagement. “When you have your own practice, you just have more skin in the game,” he said. That changes how physicians think about every part of the organization. Patient reviews matter. Community reputation matters. Staffing matters. Technology matters. The name on the building matters. “What the name Michigan Orthopedic Center means to the area, it just matters more,” he said. For Dr. Noud, that sense of ownership is part of what keeps medicine satisfying. Physicians who can shape something beyond the exam room are not simply delivering care inside someone else’s system. They are building something that reflects how they believe care should be delivered. That entrepreneurial element, he said, is one of the strongest arguments for independence. Without it, medicine can begin to feel like any other job. “You’re still just a worker bee,” he said. The margin problem The challenge is that independent practices are facing a business environment that grows tighter every year. Dr. Noud said his group has had to become increasingly disciplined about efficiency, cost structure and new revenue streams. “There’s not a year in which the same amount of work that we do results in the same margin,” he said. That pressure has forced the group to think differently. Private practice, he said, cannot survive by simply working harder and accepting shrinking reimbursement. It has to become more efficient, find ways to improve margins and develop additional sources of revenue that allow the practice to keep investing in patient care. For Michigan Orthopedic Center, that has meant building around ambulatory surgery, physical therapy, durable medical equipment and other ancillary services. Those revenue streams are not just about supplementing physician income, he said. They allow the practice to avoid cutting in places that could harm the patient experience. “The thing we don’t want to do is suffer patient care because of the constraints of cost,” Dr. Noud said. Why technology is becoming survival infrastructure Technology has become one of the practice’s most intentional areas of investment. Dr. Noud said independent groups can no longer afford inefficient communication systems, especially as staffing pressures increase. Practices are competing not only with other healthcare organizations for employees, but with employers in entirely different industries. That reality has pushed his group to adopt tools that reduce administrative burden and improve patient responsiveness. One example is triage. For years, patient calls often turned into a chain of inefficiency. A patient left a message. Staff called back for missing information. The message was relayed to the physician. More clarification was sometimes needed before care could be directed. Dr. Noud believes agentic AI and other digital tools can reduce those delays by gathering the right information earlier. Instead of a patient leaving an incomplete voicemail, technology can ask follow-up questions and help collect the details needed to direct care more efficiently. The goal is not replacing people. It is removing friction from work that already overwhelms them. “We can provide care quicker and more efficiently,” he said. The technology test Dr. Noud also evaluates technology inside the operating room, particularly in shoulder surgery. The field is moving quickly. Big data, robotics, augmented reality and virtual reality are all entering conversations around shoulder arthroplasty. He is not opposed to innovation. He is skeptical of adopting technology simply because it is new. “Ultimately the most important thing is improving patient outcomes,” he said. For Dr. Noud, a technology has to do at least one of three things: decrease complications, improve outcomes or meaningfully increase efficiency. That standard becomes especially important as new tools arrive faster than long-term outcomes data. Some technologies clearly improve accuracy and reproducibility. The question is whether that improvement matters clinically, and for whom. That is why Dr. Noud thinks differently about technology depending on the surgeon and the case. In shoulder replacement, he said, most procedures are performed by surgeons who do relatively few shoulder replacements each year. For those lower-volume surgeons, tools that improve accuracy, precision and consistency may be especially valuable. “For me, a high-volume surgeon, there has to be a reason why that makes sense,” he said. Where precision matters One area where he sees promise is augmented reality in shoulder replacement. Dr. Noud has been involved with a company’s augmented reality system designed to overlay anatomy and assist with implant positioning. He said the value becomes clear in cases where deformity makes orientation difficult and small differences in placement can matter. “If being off by 5 millimeters can be the difference between achieving good fixation of a shoulder prosthesis versus not, it’s really important to be five millimeters more accurate,” he said. He does not see these tools as something every surgeon needs for every case. Rather, he sees them as resources that can be deployed when anatomy, deformity or technical demands make them especially useful. The strongest technologies, in his view, are not the ones that require massive infrastructure for every operation. They are the ones that can be used selectively, efficiently and practically. That practicality matters because innovation does not exist in a vacuum. It exists inside a healthcare system where cost determines whether technology ever reaches patients. The cost conversation too many leaders avoid Dr. Noud believes physicians have a responsibility to think about cost, even when they are not employed by hospitals. Independent surgeons still rely on hospitals, ASCs and industry partners. New technology can only help patients if the system can afford to use it. “Technology doesn’t exist if there’s not somebody to utilize it, and they can’t utilize it if the cost is exorbitant,” he said. That requires partnership. Physicians need industry to develop better tools. Hospitals and surgery centers need sustainable economics. Patients need access. If any part of that equation breaks, innovation stalls. Dr. Noud said physicians should not view hospitals as enemies, even as they fight to preserve independence. They still need to work together to bring useful technologies into practice responsibly. “The physician has the responsibility to work with both industry and the hospital system to make sure that these amazing technologies are usable for the patient from a cost standpoint,” he said. The long game For young surgeons weighing private practice against employment, Dr. Noud’s advice is simple. Do not judge the decision by day one. “This is a marathon, not a sprint,” he said. Hospital employment often looks better at the beginning. The salary may be higher. The benefits may be stronger. The patient pipeline may already exist. The infrastructure is already built. Private practice rarely offers that level of security immediately. But Dr. Noud believes the more important question is where a surgeon wants to be later on in their career. In an independent group, he said, physicians can build revenue streams, develop leadership roles, shape culture and expand the practice in ways that employed models often do not allow. “Our offers look kind of puny compared to what it looks like from a hospital system,” he said. “The question isn’t where you are on day one. It’s where you’re going to be eight to 10 years into your practice.” That path is not easy. At Michigan Orthopedic Center, physicians take on leadership responsibilities beyond clinical care. Dr. Noud serves as the “de facto” CFO. Another partner functions as CEO. Others lead technology, ancillary services and other parts of the business. They meet regularly on finances, operations and strategy. It is more work. That is the point. “Sometimes it’s onerous and difficult, but it’s worth it, because you’re building a business,” he said. The future of independent orthopedics Dr. Noud believes the migration of procedures into ASCs may eventually change the employment equation. Hospitals have spent years acquiring specialty groups in part because physician ownership helps keep procedural volume and revenue within the system. But as reimbursement shifts and more orthopedic procedures move into lower-cost sites of care, the economics may become less favorable for hospitals trying to own every specialist. His hope is that this creates more room for partnership rather than employment. “I’d love it to go back to the situation where the specialist is self-employed,” he said. He does not expect the pressures on private practice to disappear. Reimbursement will remain difficult. Costs will continue rising. Technology will keep changing. Hospitals will keep competing. But he believes independent orthopedics still has a future for physicians willing to work beyond the operating room and exam room. Because independence is not only about ownership. It is about control. Control over the team. Control over the patient experience. Control over technology decisions. Control over the culture of care. After nearly two decades watching private orthopedic groups disappear around him, Dr. Noud still believes that control is worth fighting for. “You work so hard as a physician to go through undergrad and medical school and residency and fellowship,” he said. “To do all that and then feel like you have no control is disheartening.” For him, the future of independent practice will belong to surgeons who understand that medicine is no longer just about seeing patients. It is about building the system around them. At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.