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The Decline And Fall Of Elite Multispecialty Medical Groups

The failure of Geisinger Health System, which lost $842 million in 2022 and disappeared into a new Kaiser subsidiary called Risant, sent shockwaves through the health care community in the spring of 2023. Founded in 1919, Geisinger was in the vanguard of the so-called "value-based care" movement. It sponsored a regionally significant 600,000-member health plan and served as the home of an exceptionally high-quality 1,600-person multispecialty medical group. While Covid-related financial pressures, fateful management decisions, and troubled regional economic conditions all contributed to Geisinger's demise, federal health policy may have played a crucial role — and it could bring down other multispecialty groups in 2024 and beyond.

Geisinger is only the latest member of an elite group of large regional multispecialty medical groups to lose their independence and join large hospital systems or corporations. Virginia Mason in Seattle was fatally damaged by the sad end of its decades-long partnership with Group Health in 2016 and is now part of CommonSpirit. Wisconsin's Marshfield Clinic agreed to merge with Duluth-based Essentia Health in October 2022 after a lengthy string of operating losses, though the merger fell apart recently. Central Texas' Scott and White was absorbed into Baylor in 2013. Everett Clinic in Seattle, Atrius, and Reliant (formerly Fallon) in Massachusetts, HealthCare Partners (with the Everett Clinic, both part of DaVita Medical Group), Kelsey-Seybold in Houston, and a host of others are now part of UnitedHealth Group's vast Optum Health physician network. Billings Clinic in Montana, Carle Health in central Illinois, and Guthrie Clinic in north central Pennsylvania are all struggling financially and may not survive as independent organizations.

Many of these elite multispecialty groups were founded by alumni or admirers of the Mayo Clinic in the 1920s and 1930s. They grew in the teeth of opposition by traditional mainstream medicine, including the American Medical Association and state medical societies, which viewed group practice as a malignant form of medical socialism. Graduating clinicians were attracted to these special physician-led organizations by the ethos of collegiality, collaboration and high-quality, conservative clinical decision-making. They were also drawn by the charismatic medical leaders who recruited them. Though most of these groups operated hospitals and later some offered health plans, high-quality physician care was their core business.

Multiple factors contributed to the accelerating die-off of these groups in the past decade. One major contributor has been the economic decline of the rural economies surrounding many of them. This decline tilted their payer mix toward Medicare and Medicaid as well as increasing the number of uninsured and underinsured patients. In addition, rural labor markets have been especially hard hit by the post-Covid clinician shortage. They may also have lost business to wealthier regional academic health center competitors, which gained share during the past 12 years.

A major reason that two major actors in this elite peer group, Mayo and Cleveland Clinics, have survived is that they successfully branched — Mayo Clinic into the growing Phoenix and Jacksonville, Florida, markets and Cleveland Clinic into northeast Ohio, south Florida, and the United Arab Emirates.

But federal health policy also played a decisive, and destructive, role. As their local communities and regions aged, and younger people moved away, these multispecialty groups were more dependent on the Medicare Part B fee schedule, whose payments to clinicians have lagged inflation by 26% since 2001. Medicare Part B fees also serve a crucial role as the reference standard for commercial insurance and Medicare Advantage (MA) rate negotiations. So Medicare's inadequate adjustment for inflation echoed in lagging commercial insurance and MA rate payments.

The far-below-inflation Part B fee schedule updates did not merely damage the large groups; they also made solo and partnership-level medical practices untenable, forcing them into hospital employment or sale of their practices to non-hospital businesses. Thanks to Medicare's granting hospitals the ability to charge a facility fee in addition to the physician's fee for a visit, a clinician's time was worth more in a hospital than in a physician-owned practice. Because many of these elite multispecialty clinics had relatively small acute care hospital capacity, they could not offset the inflationary ravages of rising care expenses on their operations with hospital facility fees as could their larger regional hospital competitors.

The normative assumption of Medicare policymakers has been physicians will simply increase their volumes — i.E., perform more services than patients actually need — to make up the shortfall. This assumption has become a self-fulfilling prophecy, as many of the new owners of many physician practices — private equity firms and hospital systems — indeed heighten volume-based incentives in physicians' compensation plans, as well as raise rates to private payers to cover the shortfall.

Health care politics have also played a role in the demise of freestanding medical groups. Unlike the hospital industry, which has been a unified and powerful voice on Medicare payment policy, advocacy on behalf of physician payment has been fragmented based on dozens of specialty medical societies (as well as handicapped by the fact that some specialty physicians earn $1 million a year or more). Fragmented advocacy has especially damaged the "have-not" subspecialties such as pediatrics, psychiatry, family practice, and general internal medicine, which are destined to struggle yet more in the years ahead.

The failure of the elite multispecialty medical groups, which practiced value-based care long before it became a policy touchstone, is an indictment of federal physician payment policy. A possible policy justification for holding Medicare's fee schedule underwater for the past decade was to make fee-for-service medicine less attractive vs. "value-based care" and to set the stage for the end of fee-for-service Medicare payment. Organizations like Geisinger and Virginia Mason, whose core values favored conservative medical practice, were the losers — and they paid with the loss of their independence. The policy community has loudly decried the corporatization of physician practice, ignoring the catalytic role of physician payment policies it has supported. The slow strangulation of the Part B Medicare fee schedule has been the root cause of the demise of these important groups.

As Congress seems to be preparing to cut hospitals' site-of-service payments/facility fees, it makes sense to plow every penny saved into increasing Medicare's Part B fee schedule payments for primary care and cognitive physician services, hopefully through capitation rather than fee payments. Whether this modest gain would be enough to stem the net shrinkage of physicians in these crucial specialties, or save the remaining struggling multispecialty groups, remains to be seen.

These elite multispecialty groups have not disappeared from the scene. But they are no longer governed by the clinicians themselves, and what their new owners will do with their proud heritage of clinical excellence remains to be seen.

Jeff Goldsmith is president of Health Futures Inc. And is an independent strategy advisor and policy analyst. He received no compensation for this essay and is not employed by or advises any of the enterprises mentioned above. He would like to thank Glenn Steele, Robert Berenson, Don Crane, and Trevor Goldsmith for their feedback on the article.

SS Innovations Launches Groundbreaking Inaugural Multi-Specialty Robotic Surgical Conference

SMRSC 2024 brings global medical experts and technological innovators together to explore the future of robotic surgery

13 Live, broadcasted surgeries were performed by distinguished multi-specialty surgeons, using the SSi Mantra Surgical Robotic System

Distinguished guests included the Honorable Governor of Haryana, Mr. Bandaru Dattatreya

FORT LAUDERDALE, Fla., Jan. 22, 2024 (GLOBE NEWSWIRE) -- SS Innovations International, Inc. (the "Company" or "SS Innovations") (OTC: SSII), a developer of innovative surgical robotic technologies dedicated to making robotic surgery affordable and accessible to a global population, is proud to have presented the inaugural SS Innovations Multi-Specialty Robotic Surgical Conference (SMRSC), that was held at The Leela Ambience Hotel in Gurugram, Haryana, India on January 19 and 20, 2024. The meeting was highly attended with more than 600 visitors over the course of two days.

SMRSC 2024 was a transformative event that brought together global medical experts, technological innovators, and visionaries to explore the future of robotic surgery, with a specific focus on SS Innovations' flagship surgical robotic system, the SSi Mantra. Panel discussions and scientific sessions featured distinguished national and international faculty that delved into the current and future landscape of robotic surgery globally, the integration of Artificial Intelligence in surgery, and the pursuit of sustainable tele-surgery.

An expert panel of multi-specialty surgeons from across India performed 13 live, broadcasted surgeries showcasing the SSi Mantra and its practical applications across various surgical specialties including cardiac, colorectal, urology, and general surgery, providing attendees with valuable, real-time insights.

SS Innovations Founder, Chairman and Chief Executive Officer, Dr. Sudhir Srivastava, said, "I am delighted to have launched the first-ever SMRSC 2024 that was held in the beautiful Delhi National Capital Region. SMRSC 2024 was a productive and educational event that showcased the SSi Mantra, SS Innovations' technologically advanced, affordable, and accessible surgical robotic system, and SSi Maya, our groundbreaking virtual and mixed reality development division that we anticipate will allow us to launch robotic programs using tele-proctoring and tele-surgery. We were excited to successfully demonstrate tele-surgery with no observable latency during the plenary session of the conference, from the stage to our SS Innovations headquarters a few kilometers away."

"Our highly talented team in India has managed the design, manufacturing and assembly of the SSi Mantra system and we are extremely proud to be sharing this innovation with the world. Our goal with SMRSC this year is to inspire others to collaborate as we continue to advance the field of robotic surgery."

The SSi Mantra Surgical Robotic System is the first surgical robotic system to be made in India, and one of the only systems in the world to be distinctly cost-effective with broad-spectrum surgical applications including cardiac surgery. It has been granted regulatory approval in India, and Guatemala and is clinically validated in more than 40 different types of surgical procedures. More than 650 surgical procedures have been performed using the system to date. SS Innovations is currently seeking regulatory approvals in the United States and Europe that it anticipates receiving in 2024 and 2025.

The surgeries performed showcasing the SSi Mantra included a LIMA Takedown by Dr. Sudhir Srivastava at Medanta - The Medicity, Gurugram; a Robotic Atrial Septal Defect Repiar by Dr. Sathyaki Nambala at Apollo Hospital, Bengaluru; a Radical Prostatectomy by Dr. Sudhir K. Rawal at RGCI&RC, New Delhi; a Radical Nephrectomy and a Radical Cystectomy by Dr. Amitabh Singh and Dr. Aashish Khanna at RGCI&RC, New Delhi; a Radical Hysterectomy and CA Rectum Surgery by Dr. Somashekhar SP at Aster CMI Hospital, Bengaluru; Two TAPP Inguinal Hernia Repairs, a Rectal Prolapse Repair and an Incisional Hernia Repair by Dr. Magan Mehrotra at Apex Hospital, Moradabad; a Cholecystectomy by Dr. Ganesh Gorthi at Continental Hospitals, Hyderabad; and one Complex Cholecystectomy by Dr. Deep Goel at BLK Hospital, New Delhi.

SMRSC 2024 aims to foster collaboration, knowledge exchange, and innovation in the realm of robotic surgery by uniting thought leaders, practitioners, and industry experts. The conference endeavors to set the stage for the future of healthcare with the SSi Mantra Surgical Robotic System. For more information about SMRSC, please visit https://www.Ssinnovations.Com/SMRSC_2024/.

About SS Innovations International, Inc.SS Innovations International, Inc. (OTC: SSII) is a developer of innovative surgical robotic technologies with a vision to make the benefits of robotic surgery affordable and accessible to a larger part of the global population. SSII's product range includes its proprietary "SSi Mantra" surgical robotic system, and "SSi Mudra", its wide range of surgical instruments capable of supporting a variety of surgical procedures including robotic cardiac surgery. SSII's business operations are headquartered in India and SSII has plans to expand the presence of its technologically advanced, user-friendly, and cost-effective surgical robotic solutions, globally. For more information, visit SSII's website at ssinnovations.Com or LinkedIn for updates.

About SSi MantraSupporting advanced, affordable, and accessible robotic surgery, the SSi Mantra Surgical Robotic System provides the capabilities for multi-specialty usage including cardiothoracic, head and neck, gynecology, urology, general surgery and more. With its modular arm configuration, 3D 4K vision open-console design and superior ergonomics, the system engages with the surgeon and surgical teams to improve safety and efficiency during procedures. The SSi Mantra system has received Indian Medical Device regulatory approval (CDSCO) and is clinically validated in India in more than 40 different types of surgical procedures. The company expects to seek regulatory approvals from the US Food and Drug Administration (FDA) and CE Mark in Europe in 2024 and 2025.

Forward-Looking StatementsThis press release may contain statements that are not historical facts and are considered forward-looking within the meaning of the Private Securities Litigation Reform Act of 1995. The words "anticipate," "assume," "believe," "estimate," "expect," "will," "intend," "may," "plan," "project," "should," "could," "seek," "designed," "potential," "forecast," "target," "objective," "goal," or the negatives of such terms or other similar expressions to identify such forward-looking statements. These statements relate to future events or SS Innovations International's future financial performance and involve known and unknown risks, uncertainties and other factors that may cause our actual results, levels of activity, performance, or achievements to be materially different from any future results, levels of activity, performance or achievements expressed or implied by these forward-looking statements.

For more information:

PCG AdvisoryStephanie Princesprince@pcgadvisory.Com(646) 863-6341

Wright Medical Group

About Wright Medical Group

Wright Medical Group, Inc. Engages in the design, manufacture, and distribution of biologic products. It provides surgical solutions for the foot and ankle market and its products include large joint implants for the hip and knee, extremity implants for the shoulder, elbow, hand, wrist and foot and biologic products, including bone graft substitutes. The company was founded by Frank O. Wright in 1950 and is headquartered in Arlington, TN.

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