I predict the “next few years” less frequently and with less certainly than I did 15 or 20 or 25 years ago. There was a certain linear nature to the trajectory of healthcare created by TEFRA “77 and various logical next steps. I say logical not in the sense of good policy, but logical simply as following the paved road of defined processes.
Those who know health policy history, know the Tax Equity and Fiscal Responsibility Act of 1977 (TEFRA-77) laid the groundwork for the prospective pricing system and precipitated most of the changes that occurred up to and until the PPACA, aka Obamacare.
Now, the arc has changed – actually in some ways it has looped back on itself, but the momentum is different and the political/social environment has changed significantly.
My primary focus in both analysis and practice is the plight of physicians and medical practice. Certainly, hospitals/health systems, insurers, pharma, biotech, HIT and others are involved in the Medical Industrial Complex processes, but this is an article, not a book.
Medical practice is changing both in evolutionary improvements but also in somewhat revolutionary threats. Likewise, physicians are changing – a bit more evolutionary, but nevertheless changing at a marked and observable pace. Those are the two points of focus of this article, Physicians and Medical Practice.
First Medical Practice. It’s no longer an independent physician driven activity. More physicians are employed today than are independent practitioners. However, physician employment is an odd arrangement. Most physicians are employed by contract, not simply “at will” employees. Physician contracts are usually quite restrictive. Moonlighting is discouraged or simply prohibited, work places, staff and other underpinnings of a “practice” may be changed at the discretion of the employer, and physicians must often agree to various sometimes intrusive processes to insure the employer is paid for the physician’s labors.
There are other interesting elements as well, what I would call the “a wink and a nod” agreements. Physician contracts almost universally state the employer will not interfere with the “medical judgments and medical decision-making of the physician.” But where certain employer contracts exist for referral networks, formularies, etc… employers usually state physicians are only encouraged to consider these relationships they are not bound by them.
Woe be the physician whose medical judgment, pharmaceutical prescribing or referrals regularly conflict with the written or unwritten rules of the employer.
But other practice issues seem equally inequitable. What about the need to pay tail coverage if you wish to terminate your employment or the simple fact that by complying with employer wishes, and perhaps not following your own judgment precisely, you – you carry the ultimate burden of liability. Sure, a litigious patient will certainly sue both the hospital/system and the physician, but the hospital won’t be risking licensure sanctions and the possibility of not being able to deliver healthcare. Only physicians carry the liability of carrying out their employer’s wishes. And, add to that, they aren’t even “your” patients. No, physicians no longer have patients, hospitals have patients, and payor systems have patients, but not the employed physician.
Further, contracts aside, physicians are regularly terminated or discriminated against based on disability, gender, and race/national origin. Yes, I spoke with an ER physician with MS who needed to have some “rest” time occasionally – periodically, not regularly, not having demonstrated an inability to keep pace, just alerting her group members she may need to sit for a few minutes on occasion. She was terminated not because she sat, not because she didn’t keep pace, but because they “feared she might slow down.” Another physician told me the story of a coworker, a fellow physician, who was told by the health system CEO that he’d hit the glass ceiling because of his country of origin. He couldn’t advance further administratively in the health system because he wasn’t born in the U.S.
These are just a couple of the many, many situations physicians share with me. But, what I find even more unfortunate is that physicians are afraid to seek any legal action against their employers for fear of retaliation in future employment. Consider this fact, if you're terminated by your hospital employer and your medical staff privileges are revoked, this is a reportable incident for the rest of your career. The reason for termination is immaterial.
Now on to how physicians are changing. In 1981 when I recruited a new physician to the staff, the first question was, “Do you believe I can get extra call?” After all, no physicians in our area were employed. Each new physician had to build a practice, and additional call coverage for the ER was a sure way to grow a practice. By the mid-1990s the first question new physicians asked had changed. Now I was asked, “Do I have to take ER call?” Physicians had changed and they continue to change.
Physicians now seek out opportunities to job-share, to work only outpatient or only inpatient. With patient panels owned by employers, the need to build a practice is mostly gone. These “rule changes” that frustrate 55-year old physicians are considered a typical day for 35-year old docs. Dealing with corporate mandates is just part of the job, perhaps irritating at times, but not the teeth gnashing exercise it was 25 years ago. Today, young physicians expect to be employed. They expect to have more than one practice in their lifetimes and some consider Locums a great way to “see the world.” And while “lifestyle” issues are gaining in importance, physician suicide is, unfortunately, gaining even faster. Statistics vary, but about one physician every day takes his or her own life – a sad fact and commentary on the profession.
But, where do these various issues lead? I’m regularly asked by physicians if I can sum up the problems, the major frustrations, of physicians in one word… and I can. It is “control.” Physicians feel increasingly out of control. They are out of control of their practices, of their patients, and of their medical decision-making. Many are also out of control of their personal lives and out of touch with their family’s.
Many years ago, I developed a physician presentation called “Take Back Your Practice.” At that time, most practices were owned and run by physicians. And my message was about regaining control of staff and patient relationships and building your practice around the way or the ways individual physicians worked best. It’s a somewhat outdated thought today. However, the idea of physicians taking back “the” practice of medicine, is something you should consider. As I’m always reminded, by physicians, there are no advocates for physicians, and lobbyists for major medical organization rarely address the real issues and concerns of regular practicing physicians and surgeons.
Perhaps it time for physicians – the rank and file, to do it themselves. But how might that happen. I’m not a labor law expert nor an attorney, but it appears little stands in the way of employed physicians unionizing. Yes, I said unionizing. A quick Google® search brings up some interesting articles from the AAFP to KevinMD, the Union of American Physicians and Dentists and others.
Interestingly, most union activities are ultimately economically driven – think UAW. Workers may say they want more control over their work-product, but the usual end result is that companies would rather add a few cents or dollars to an hourly wage than cede control of any work function. And, it is arguable whether the real outcome is not the real objective of the union to begin with.
Physicians are different. Salary and benefits are not usually contentious topics. However, work load, work control, call schedules, staff support and various work-product and work-function issues are the list toppers. Again, the key word is control.
That’s not to say economics are not important. If productivity is one’s only avenue to financial success and no value is placed on indirect corporate contribution (M&M conferences, peer review, etc…) nor is longevity rewarded, then the opportunity for some economic equalization will likely be proposed by both those physicians who make significant administrative contributions and for those more senior.
The challenge in medicine is that, unlike the law, you can’t be billing for multiple services at once and your fees are capped by outside parties – the payors. As long as we operate under a CPT-RVU based system, physicians’ incomes will be capped by the number of patients they see. Any physician being paid more is on a short road to unemployment. You may receive a bonus to start work and even an inflated income in year one, but somewhere quickly in your tenure you will be reduced to a percentage of the monies collected for your services. And that percentage will, even must, be calculated to include the reasonable and appropriate overhead deductions of your practice.
However, law firms seem to find a way to reward founding partners and emeritus members, why can’t medical groups do the same? Young physicians would certainly benefit from an older physician’s mentoring towards patient management, effective charting and certainly their fund of medical knowledge, not to mention some insights about navigating the administrative labyrinth. That leads us to some of today’s proposals geared towards paying a group (ACO) of physicians for their collective management of a patient base. But, in the short to near-term at least, don’t expect that to break very far from today’s compensation levels? If you do, I have some great swamp land in Florida for sale.
But, moving on, I expect the real focus of a Physicians’ Union would be control. I remember the early 1980’s when physicians were last in far greater control of both medicine and healthcare. Healthcare was seven to nine percent (7-9%) of GDP, most hospitals were nonprofit and the insurance companies were struggling to reconcile physician bills with usual and customary rates and payments. The physicians effectively kept most of the payors guessing and the hospitals were paid on a cost-plus basis. “Profits,” in the non-profit world became funded depreciation set aside to buy new equipment and posted margins were a couple of percent. Health Service Administrative review boards and State CON rules kept competing MRI’s from popping up on every street corner like Starbucks and patient costs were kept low by matching supply to demand. But that was then, and now is now. The economics of healthcare are actually quite simple. You can’t have an outpatient diagnostic center utilized at 50% that can charge less than one used at 90%. The higher the utilization rates, the lower costs can be.
You can’t turn back the clock, but you can learn from your mistakes.
While physicians have always been mostly solo and in small groups, their leverage derived from the overall economics of healthcare. Hospitals and the businesses that surround and support them individually represented a significant cottage industry in each community they served. And, an individual physician with 50 to 100 yearly admissions or 250 surgeries could swing considerable influence. Couple that with the power of doctors/surgeons lounge politics and it’s easy to see the sway physicians used to wield
However, by removing the leverage of patient control, today’s health systems and payors have declawed the physicians to reduce them as much as possible to production units only. Consider how some system owned group practices even try to have patients see different physicians in order to reduce the physician patient bond.
A certain upheaval is in the works, but how it is defined is mostly a function of which generation a physician belongs to. Those 50 and above mostly want out. They see Obamacare as evil incarnate, a blight on them personally and professionally. Those in the 40-50 bracket are frustrated, but not usually to the level of their older peers. They came into the system expecting a certain level of flexibility to be necessary in order to change and adapt to evolving trends. They don’t necessarily like it, but change is a way of life for them. Those under 40? Well, this is all they’ve known. They may have heard about the good old days – or the Gold Old Days, as I just mistakenly typed ( a Freudian slip?), but those are just stories, more reminiscences than expectations, plus none of them want to return to the 90 hour work weeks and never-ending call. So, today is just fine for most.
What will happen – I predict, is this. As physicians’ professional standing continues to erode, as their liability increases disproportionately to their control and as the boundaries of corporate medicine continue to blur under the guise of best practices and formula-matic patient management systems, as mid-level providers replace physicians at every level, and as shareholder returns challenge infrastructure reinvestment for funding, physicians will begin to chafe under the weight of the simple disconnect between responsibility and authority. Add monetary reward to that mix and you have a text book case for unionization.
What happens next..? My crystal ball begins to blur based on various legal and structural changes that could occur relative to current Stark and Medicare rules that were originally written to impact independent physicians, new or refined interpretations of Taft-Hartley Act, the evolution of the PPACA and other factors – some perhaps not in existence today.
The bottom line, however, is that in the coming decade or two, physicians are going to have various chances to regain control of medicine and possibly of healthcare. How they go about it and how successful they are, regardless of individual political beliefs and affiliations, will require a unified voice that today does not exist. Healthcare and medical practice are becoming more consolidated while physicians remain as fragmented as ever. But remember all healthcare is local – remedies need not be grand schemes, but rather, related to the current and ongoing cottage nature of the healthcare industry.