When I entered private practice eight and half years ago, I had no idea there were so many different practice settings to choose from. Needless to say, since then, private practice itself has changed. In 2007, 70 percent of cardiology practices were privately owned and only 8 percent hospital owned. In 2018, that pattern is reversed with 73 percent of U.S. cardiologists employed and 25 percent self-employed. As a result, early career physicians entering private practice now face several options, each with their own benefits and drawbacks. Here is a look at the common business models and points to consider:

Solo practice: It is estimated that 12 percent of all cardiologists today are in solo practice. The obvious advantage is complete autonomy. However, the disadvantages are several, including high overhead cost, lack of scheduling flexibility or coverage, lack of resource support (IT, billing, staffing, etc.), increased call, and lack of ability to subspecialize. As a result, quality of life is significantly impacted.

Group private practice: Of these, there are two common options: single specialty and multi-specialty. Single specialty group compensation is usually higher. According to Medical Group Management, self-employed cardiologists make roughly $80,000 more in compensation than their employed counterparts. In each type, size matters.

The advantages of larger group settings include increased flexibility, lighter call or coverage, greater ability to subspecialize, and more financial stability. Forty-five percent of cardiology groups today consist of 10 doctors or less. Twenty-four percent of groups consist of 11 to 25 doctors. However, larger scale groups (more than 10) are more likely to suffer from less cohesiveness. The size of the group may also affect how one practices. Smaller groups need every cardiologist to participate in most activities. The larger the group, the more likely one can subspecialize in an area of interest.

One disadvantage of joining large multispecialty groups is governance. Sometimes the business structure of these groups is dominated by primary care. A modification of this model is to create specialty "pods" designed to help specialties like cardiology, which have unique practice and compensation models. Specialty pods create a higher degree of autonomy and also allow their cardiologists to be involved in organizational governance. This can also be a good career path for cardiologists who have an interest in leadership development.

Hospital-owned practice: A hospital-owned group is often financially tied to the hospital, which can be good or bad. Interestingly, research suggests that this may also drive up costs. Current analysis shows that prices paid by private plans increases with physician employment and physicians refer to hospitals despite the quality or cost of health care provided. In its assessment of the top five major mistakes made by hospital-owned groups, Beckers Hospital Review listed as a mistake the exclusion of physicians from some element of governance such as physician advisory, financial or quality committees. Physicians in these setting should be wary of initial contracts vs. renewal contracts with less perks and more restrictive covenants. Cardiologists should also be aware of billing changes and whether bonuses are paid on productivity or value-metrics.

Integrated Health Systems: An integrated health system is defined as a network of organizations providing health care to a population, which can either be independent or associated with a health care plan such as Harvard Vanguard or Kaiser Permanente. According to the SK&A report released in 2017, the largest integrated systems in the U.S. include:

1. Ascension Health (St. Louis, MO)
2. Community Health Systems (Franklin, TN)
3. Catholic Health Initiatives (Englewood, CO)
4. Hospital Corporation of America (Nashville, TN)

Some argue that the power of these networks is scale – the larger the better. There is also the theoretical benefit of access to better technology, enhanced expertise and access to capital. Doctors joining this type of network are advised to have an escape clause if the alliance is too restrictive or they are unhappy with the results.

As an early career cardiologist, you may have several options in private practice and each has its own disadvantages and advantages. The decision ultimately revolves around which model suits your needs professionally, financially and personally.

This article was authored by Riya Chacko, MD, cardiologist at Crouse Medical Practice Cardiology in Syracuse, NY.