RICHARD REECE, MD
I would like to bring to your attention a remarkable document. It is a 110 page white paper Health Reform and the Decline of Physician Private Practice.
It is a grassroots report conducted on behalf of The Physicians Foundation by Merritt Hawkins, the nation’s largest physician recruiting firm. The Foundation is a nonpartisan, grant-making organization representing independent practicing physicians in state medical societies.
Why do I say the document is remarkable? Because it puts health reform in perspective. Amidst all the sound and fury about the health reform law, it tells what’s happening to physicians on the ground and where they are on that ground.
Where Doctors Practice
The document notes, for example, where doctors actually practice. To hear health reform critics talk, you would think most doctors do their work in large integrated groups or medical centers. Not so. Most of them hang out in solo or small to medium-sized groups.
- Solo, two physician practices, 32%
- Group practice, 3-5 doctors, 15%
- Group practices, 6-10 doctors, 19%
- Hospital-based, 13%
- Medical schools/university, 7%
- Group practice, 51+ doctors , 6%
- Group/Staff HMO, 4%
- Community health centers, 3%
What’s Happening at the Grassroots
The document observes that “informal reform,” socioeconomic trends and pressures on the ground, are just as important, perhaps even more so, than policies being dictated from Washington as embodied in the new health care law.
These trends and pressures include:
- The replacement of traditional independent practice by consolidated entities – hospital-doctor alliances, larger groups, and emerging models, such as accountable care organizations, medical homes, concierge practices, and community health centers.
- Legal and government pressures fostering and forcing an environment to “comply” with outside authorities and statutes and “improvement” and “compliance” measures.
- Increased demand for physician services in the face of growing physician shortages, especially of primary care doctors and general surgeons, with no relief in sight because of time required to mint new physicians.
- The “imperative to care for more patients, to provide higher perceived quality, at less costs, with increased reporting and tracking demands, in an environment of high potential liability and problematic reimbursement,” Many physicians regard these imperatives as “mission improbable,” or to use a word that runs through the report, as “problematic.”
- The reluctance of Congress to include a “fix” for reasonable doctor Medicare pay, as embodied in the SGR formula, which indicates to physicians that Congress is not on the side of doctors, that health care is too important in the minds of politicians to be left to doctors, and that the viewpoint of doctors in likely to be ignored, further disengaging doctors from the profession and making access to them more difficult.
- Changes induced by reform, both “informal” and “formal” are inevitable and sometimes necessary, but do not bode well for increased coverage, quality, access, and private independent practice survival, which now and in the future, will be required for a high quality accessible health system.
Doctors, conveniently available on the ground and using individual clinical judgment rather than just marching to government mandates, are important, especially when you are sick and need their help.
1) Are you in an independent, physician-owned practice or are you employed by a hospital, health system, or other entity?
Physician-owned practice 59%
Employed by hospital or other entity 41%
2) What was your initial reaction to passage of the 21010 Patient Protection and Affordable Care?
Very positive 12%
Somewhat positive 15%
Somewhat negative 15%
Very negative 52%
3) How do you now feel about health reform?
I am more positive than I was initially 10%
My feelings have not changed 51%
I am more negative than I was initially 39%
4) Do you believe the viewpoint of physicians was adequately represented in policy matters and the public during the run-up to passage of health reform?
5) How do you think reform will affect patient volume at your practice?
Patient volume will increase 54%
Patient volume will remain the same 35%
Patient volume will decrease 11%
6) Do you now have the time and resources to see additional patients in your practice while still maintaining quality of care?
7) How do you believe reform will affect the quality of care you are able to provide to your patients?
No effect 19%
8) How do you believe health reform will affect the amount of time you are able to spend per patients?
I will be able to spend more time per patients 5%
There will be change in the amount of time I can spend per patient 24%
I will have less time per patients 59%
9) What effect do you believe reform will have on the financial viability of your practice?
No effect 9%
10) Health reform provides pilot projects to rest “bundled (capitates) payments” for patients for episodic care. What is your view of bundled payments?
A generally good idea 11%
A generally bad idea 68%
11) Which is likely to have the greatest impact on your practice – health reform or a “fix” of Medicare’s Sustainable Growth Rare (SGR) formula?
Health reform 34%
12) Do you believe reform will compel you to close or significantly restrict your practice to any category of patient?
13) What categories?
Close Significantly Restrict
Medicaid 51% 42%
Medicare 30% 57%
Indigent 43% 38%
Patients covered through exchanges 24% 44%
HMO 17% 42%
All new patients 5% 37%
Self-pay 10% 24%
Privately insured 5% 18%
Other 6% 9%
14) Consider your practice plans over the next three years as reform is phasing in. What do you plan to do)
Continue as I have 26%
Cut back on hours 19%
Switch to cash or concierge practice 16%
Relocate to another computer 14%
Work locum tenens 14%
Cut back on patents seen 12%
Seek a non-clinical lob in health care 12%
Seek a job/business unrelated to health care 12%
Seek employment within a hospital 11%
Work 20 hours or less 8%
Close my practice to new patients 6%
15) How do you believe reform will affect the independent private practice?
Will enhance the viability of private practice 34%
Will have little or one affect on pirate practiced 36%
Will erode private practice 30%
16) Which best describe your view of independent, private practice?
It is a dinosaur soon to go extinct 28%
Is on shaky ground 58%
Is relatively robust and viable? 14%
- Four of five physicians surveyed (2,400 in all) believe that one of the consequences of health reform will be the erosion of traditional independent private practice.
- 24% will continue to practice as is, but 76% will seek other forms of practice or employment or will retire.
- 65% of doctors have a somewhat negative or very negative attitude towards reform.
- The majority of physicians responded unfavorably to passage of health reform.
- The majority of physicians believe health reform will increase their patient loads while decre3asing the financial viability of their practices.
- The majority of physicians plan to alter their practice patterns in ways that will reduce patient access to care, by retiring, working part-time or taking other steps.
- Physician practice styles will be increasing less homogeneous. The full-time, independent practitioners accepting third party payment will largely be supplanted by employed, part-time, locum tenens, and concierge practitioners.
For additional information about this survey, contact Phillip Miller of Merritt Hawkins and AMN Healthcare.
Richard L. Reece, MD, is a retired pathologist and author who believes in the abilities of practicing doctors and their patients to control and improve their health destinies through innovation. His latest book is Obama, Doctors and Health Reform (2009).