DIN White Paper #2
Flexible Fractional Practice Models for Microsurgical Specialists
A Call to Expand Regional Access and Provider Mobility Through Technology and Policy Reform
Authored and reviewed by the DIN team, May 2025
Introduction
Millions of patients in underserved areas struggle to access microsurgical specialists – ophthalmologists, dermatologists, ENTs, urologists, etc. – due to a misalignment between where specialists practice and where patients live. Recent findings show that only 5.6% of ophthalmic surgeons practice in rural communities despite 17.4% of patients living there, forcing rural residents to travel long distances or go without care (Ophthalmology Advisor, 2023). Similar disparities exist in fields like dermatology and urology.
Meanwhile, many specialists feel trapped in rigid, traditional practice setups that limit their flexibility and reach. This white paper explores how structural challenges in today’s healthcare system constrain both providers and patients, and why new flexible practice models are needed to expand specialist microsurgery services into broader and underserved communities.
Structural Challenges Limiting Specialty Care Access
Several entrenched factors make it difficult for microsurgical specialists to serve patients outside major population centers:
Rigid Practice Models: Most specialists work in fixed locations (private offices or hospitals), bound by strict schedules and employment terms. These traditional models leave little room for providers to offer services in multiple communities or adapt their practice to areas of need. Rural patients often face “inflexible scheduling and long in-clinic wait times”, compounding their access issues (Commonwealth Fund, 2023). With care centralized in cities, patients in remote areas must travel hours for routine visits, relying on family for transport and incurring high costs. Such rigidity in care delivery means those unable to travel simply go without specialist care.
Private Equity Consolidation: Over 25% of urologists in some states are now employed by private equity (PE)-backed groups, and ophthalmology and dermatology show similar trends (Khullar et al., 2023). While consolidation can bring efficiency, it often prioritizes profitability over access. PE-backed practices tend to concentrate in dense, high-revenue markets, closing satellite clinics and limiting physician autonomy (GAO, 2022). This shift reshapes workforce distribution and reduces availability of care in rural or lower-income areas.
Declining Reimbursement: Medicare physician payments are 33% lower today (adjusted for inflation) than in 2001 (AMA, 2023). With successive annual cuts, many independent specialists struggle to sustain rural practice. Consolidated systems often centralize care in urban hubs to maintain margins, leaving underserved communities behind.
Restrictive Non-Compete Clauses: Many physicians are contractually barred from practicing in nearby regions after leaving a group. These clauses limit flexibility and discourage moonlighting or relocation to underserved areas. Some states have moved to void non-competes in rural health settings, recognizing their harm to access (FTC, 2024).
Lack of Infrastructure for Mobility: Few systems exist to support regional or mobile practice. Licensing, credentialing, equipment access, and referral logistics create steep barriers. Itinerant models have existed in ad-hoc formats, but no widespread infrastructure currently enables consistent, scalable specialist rotations (Burkhalter et al., 2019).
Consequences for Providers and Patients
Providers face limited flexibility, mounting administrative demands, and burnout. Many younger specialists feel forced into rigid jobs that underutilize their skills or constrain their values. Dr. Elizabeth Jones notes, “teledermatology can reduce burnout by offering flexibility” (Health Affairs, 2023).
Patients, especially in rural areas, suffer most. Elderly or chronically ill individuals often must drive over an hour for short appointments—or go without care altogether. Long travel times and delays worsen outcomes and exacerbate inequity (Health Affairs, 2023).
Opportunity: Tech-Enabled Regional Models
Fractional Staffing for Specialists: A growing solution to regional access gaps is fractional staffing, which DIN defines as a staffing model that enables specialists to serve multiple locations on a part-time or rotating basis. Unlike locum tenens, which is often short-term and transactional, fractional staffing emphasizes continuity, returning providers, and community integration. This structure benefits both providers seeking autonomy and flexibility as well as underserved systems seeking stable, recurring access to high-quality care.
Telehealth Integration: Secure image sharing, virtual triage, and remote consultations allow for expanded reach. Tele-ophthalmology and teledermatology have shown success in diabetic screening and dermatologic triage, improving access and reducing unnecessary travel (Eagle, 2023; Health Affairs, 2023).
Regional Collaboration: Multi-site, hub-and-spoke models can allow ENT, dermatology, and urology specialists to rotate across rural hospitals with centralized coordination. Legal reform to ease licensure and non-competes would bolster these networks (FTC, 2024).
Improved Efficiency and Access: These models reduce fragmentation and geographic mismatch. Providers practice at the top of their license. Systems operate more efficiently, matching provider time with true demand. Patient outcomes and satisfaction improve.
Conclusion
Building flexible practice models for microsurgical specialists is both necessary and feasible. Technology, regulatory reform, and regional coordination can expand access while preserving professional satisfaction. Fractional staffing models, when paired with modern infrastructure, offer a scalable path forward. Policymakers and healthcare systems should invest in these approaches to enable specialists to deliver care across wider geographies—no longer confined to traditional models that leave too many patients behind.
Works Cited
AMA. (2023). Medicare pay cuts: How they endanger physician practices. https://www.ama-assn.org/delivering-care/payment-delivery-models/medicare-pay-cuts-how-they-endanger-physician-practices
Burkhalter, H., Pathman, D.E., & Ricketts, T.C. (2019). Itinerant surgical and medical specialist care in Kansas: Report of a survey of rural hospital administrators. PubMed. https://pubmed.ncbi.nlm.nih.gov/31116137/
Commonwealth Fund. (2023). Rural health care challenges go beyond a lack of doctors. https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/rural-health-care-challenges-go-beyond-lack-doctors
Eagle. (2023). Tele-Ophthalmology is Transforming Eye Care. https://www.eaglemds.com/tele-ophthalmology
FTC. (2024). Non-Compete Clause Rulemaking and Rural Access to Care. https://www.ftc.gov/legal-library/browse/federal-register-notices/non-compete-clause-rulemaking
GAO. (2022). Private Equity and Physician Practice Consolidation. https://www.gao.gov/products/gao-23-105876
Health Affairs. (2023). Teledermatology Benefits Underserved Populations, Reduces Physician Burnout. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.00125
Khullar, D., Bond, A.M., & Casalino, L.P. (2023). Private equity in ophthalmology and optometry: A time series analysis from 2012 to 2021. JAMA Health Forum, 4(3), e230030. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2802302
Ophthalmology Advisor. (2023). Rural Areas Face Growing Shortages of Ophthalmic Specialists. https://www.ophthalmologyadvisor.com/home/topics/general-ophthalmology/rural-us-may-face-rising-ophthalmic-subspecialists-shortages/