A community of 30,000 US Transcriptionist serving Medical Transcription Industry

Critical physician shortage already. Plus 30 mil more patients under Obamacare.


Posted: Dec 13, 2012

From the AMA's amednews.com: (Where will your doctor be next year?)

Will a “silent exodus” from medicine worsen doctor shortage?

Many physicians, nervous about the impact of health system reform and dispirited by trends in medicine, are exploring career options that involve treating fewer patients.

By KEVIN B. O'REILLY, amednews staff. Posted Oct. 8, 2012. 

Frustrated by mounting regulation, declining pay, loss of autonomy and uncertainty about the effect of health system reform, doctors are cutting back the number of hours they work and how many patients they see.

Between 2008 and 2012, the average number of hours physicians worked fell by 5.9%, from 57 hours a week to 53, and doctors saw 16.6% fewer patients, according to a survey of nearly 14,000 doctors released in September. If the trend continues through 2016, it would equate to the loss of 44,250 full-time physicians, said the report, conducted by the doctor-recruiting firm Merritt Hawkins & Associates for the Physicians Foundation. The foundation was started in 2003 with more than $30 million from class-action settlements that 22 state and county medical societies made with health plans.

“This is a silent exodus,” said Mark Smith, president of Merritt Hawkins. “Physicians are feeling extremely overtaxed, overrun and overburdened.”

Only half of doctors will continue their current practice during the next three years, the survey said. Many plan to cut back on hours, retire, see fewer patients, seek hospital employment, work part time, transition to a concierge model or seek a nonclinical job in health care. Sixty percent would retire today if they could, compared with 45% in 2008.

A quarter of doctors cited long hours and lack of personal time as among the least satisfying elements of their careers. Nine in 10 physicians agreed that most doctors “are unsure where the health system will be or how they will fit into it” during the next five years.

“There’s a great degree of uncertainty and angst related to problematic reimbursement, the high-regulation environment and many other things,” said Walker Ray, MD, a retired pediatrician and vice president and research committee chair for the Physicians Foundation. “Now, what this all is about is more than professional grumbling. All professions at times have unhappiness surfacing. What we’re looking at are trends where physicians are in their own individual minds and their own individual practices, making decisions that may affect the supply of physicians going forward.”

Impact on access to care

The less-intensive doctor work schedule could hamper access to care for the 30 million Americans the Congressional Budget Office estimates will obtain health insurance coverage under the Affordable Care Act during the next decade. The U.S. Census Bureau also projects a 36% rise in Americans eligible for Medicare during that period.

In 2010, the Assn. of American Medical Colleges projected a shortage of 130,600 physicians by 2025, with half of the shortfall occurring in primary care specialties. That estimate accounts for the work patterns of older physicians and female doctors, who are more likely to work part-time schedules, said Clese Erikson, director of the AAMC’s Center for Workforce Studies. But the projection does not factor in growing hospital employment of physicians, a trend noted in the foundation’s report.

Hospitals directly employ about 20% of practicing physicians, according to the American Hospital Assn. Many other physicians are employed in group practices owned by health systems. The proportion of doctors in independent practice is now a minority, says the MGMA-ACMPE, the entity formed by the merger of the Medical Group Management Assn. and the American College of Medical Practice Executives. That matters because hospital-employed physicians work fewer hours and see fewer patients than do independent doctors, the foundation’s survey showed.

20% of practicing physicians were directly employed by hospitals in 2011.

Employed physicians averaged 53.1 hours a week, compared with 54.1 for doctors in private practice. Employed physicians saw 17% fewer patients — 18.1 a day­ — compared with 21.9 a day seen by practice-owning doctors. Slightly more than 20% of employed doctors worked fewer than 40 hours a week, compared with 18.4% of physicians with an ownership stake in their practice. More than 60% of physicians younger than 40 are employed by a hospital, physician group or other entity.

“We know that an employed physician is less productive than a practice owner,” said Smith of Merritt Hawkins. “Physicians are looking for a safe harbor [in hospital employment], for someone to say, ‘I think I see what’s coming, and I can mitigate this risk for you.’ ”

The foundation survey was sent to more than 630,000 U.S. physicians. Despite the low response rate, an academic consultant cited in the report said the survey’s margin of error is less than 1%. Smith said a sample of nonresponding physicians was later contacted to answer a few of the survey’s dozens of questions, and their responses were highly consistent with those of doctors who completed the full survey. Respondents were likelier than the general population of physicians to be white, male, older and in solo or independent practice. Yet the lighter workload seen was not limited to the older physicians surveyed. Doctors younger than 40 averaged 19 patients a day, compared with 19.8 for physicians 40 and older.

Leaders at physician organizations said the low morale reflected in the survey is unsurprising.

“Many doctors have been beaten down pretty significantly by the current system and have developed an unfortunate cynicism about the potential for change,” said David Bronson, MD, president of the American College of Physicians.

More than 60% of doctors younger than 40 are employed by a hospital, physician group or other entity.

Long-term trends have hit smaller, independent practices especially hard, said Glen Stream, MD, president of the American Academy of Family Physicians.

“People in small and solo practices are struggling, with all the administrative and regulatory burden of insurance and payment challenges,” said Dr. Stream, an employee at a hospital-owned clinic in Spokane, Wash. “In a small group, you don’t have any negotiating power with insurance companies. If you’re in small or solo practice, life is hard.

Physician leaders said the survey results highlight the need to expand federal funding for residency slots, which have been capped since the Balanced Budget Act of 1997. The AAMC, American Assn. of Colleges of Osteopathic Medicine, the American Medical Association and many other physician organizations support expanding residency slots.

On Sept. 25, Rep. Joseph Crowley (D, N.Y.) introduced a bill to boost Medicare-funded residencies by 15%, or about 15,000, during the next five years. Rep. Aaron Schock (R., Ill.) introduced a similar bill in August, and Sen. Bill Nelson (D, Fla.) proposed comparable legislation in September 2011. The AMA has publicly supported Nelson’s bill, which has not received a hearing or been put to a vote.

Shortage sparks debate over NPs’ role

The looming physician shortage is drawing more attention to the use of nurse practitioners, physician assistants and other midlevel health professionals to help maintain access to care. But the shift toward more team-based care in patient-centered medical homes should occur in a physician-led environment, the AAFP said in a Sept. 18 report. The American Academy of Nurse Practitioners objected to the report, arguing that NPs could help fill the physician gap by independently treating patients.

Dr. Stream, of the AAFP, said a two-tier system of primary care — physicians for some, nurse practitioners for others — is untenable.

“To the people who propose that to fill this gap that we should somehow alter our expectations of the kind of care people should get — that is not what we want in this country,” he said. “It’s not a viable, ethical or reasonable solution.”

Primary care doctors complete 21,700 hours of education and training over 11 years, said the AAFP report. That compares with 5,350 hours of training and education NPs get during five to seven years. The AMA backed the academy’s report, noting a recent survey showing that 86% of patients believe they benefit from a physician-led primary care team.

“Physicians and other health professionals have long worked together to meet patient needs for a reason — the physician-led team approach to care works,” said AMA President Jeremy A. Lazarus, MD. “Patients win when each member of their health care team plays the role they are educated and trained to play.”

BACK TO TOP


 

 ADDITIONAL INFORMATION: 

The practice changes physicians are planning

In 2012, only half of surveyed physicians said they will continue their current medical practice over the next one to three years. The other half are pondering other options — respondents could choose any that applied to them. Many plans involve treating fewer patients, and that shift could impede access to care amid projected doctor shortages and expanded health insurance coverage.

Practice planPhysicians agree
Continue as I am 49.8%
Cut back on hours 22.0%
Retire 13.4%
Relocate to another practice or community 10.9%
Seek nonclinical job in health care 9.9%
Cut back on patients seen 9.6%
Switch to cash/concierge practice 6.8%
Work part time 6.5%
Work locum tenens 6.4%
Seek job outside health care 6.4%
Seek hospital employment 5.6%
Close practice to new patients 4.0%
Other 5.5%

Source: “A Survey of America’s Physicians: Practice Patterns and Perspectives,” Physicians Foundation, Sept. 21 (physiciansfoundation.org/uploads/default/
Physicians_Foundation_2012_Biennial_Survey.pdf
)

BACK TO TOP


What feeds physician frustration

Three-quarters of physicians have a pessimistic outlook about the future of the medical profession, says a recent survey. More than 80% say the profession is in decline. Doctors said the following factors — respondents could choose any they felt applied — played a “very important” role in the profession’s decline.

79.2%: Too much regulation/paperwork

64.5%: Loss of clinical autonomy

58.6%: Physicians not compensated for quality

54.4%: Erosion of physician-patient relationship

45.9%: Money trumps patient care

43.7%: Scope of practice encroachment

6.9%: Too many part-time doctors

“A Survey of America’s Physicians: Practice Patterns and Perspectives,” Physicians Foundation, Sept. 21 (physiciansfoundation.org/uploads/default/
Physicians_Foundation_2012_Biennial_Survey.pdf
)

 

 

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Physician incomes, Obamacare encouraging - higher pay for PCPs. sm

[ In Reply To ..]
A little remuneration perspective from Forbes.com. Note that the AMA "silent exodus" article doesn't mention money as a cause of physician dissatisfaction.

"Compensation of primary care physicians â now at more than $200,000 â grew at a faster rate than specialists over the last five years, a sign that those who hire health professionals are putting a greater emphasis on lower cost outpatient care, a new study shows.

The analysis of physician pay by the Medical Group Management Association indicates a greater shift to lower-cost primary care as employers, insurance companies and government health programs try to provide financial incentives to health professionals who work in outpatient care settings.

Median compensation for primary care physicians grew five percent last year to $212,840, capping a five-year increase of 16.7 percent from 2007 to 2011. Though specialized physicians still make almost double the compensation their primary care counterparts at $384,467, their median compensation grew more slowly at 15.6 percent from 2007 to 2011.

Primary care professionals are expected to take on a greater role as health benefits are expanded in the next two years under the Affordable Care Act. Most health insurers like Aetna Inc. (AET), UnitedHealth Group (UNH), Humana (HUM) and Blue Cross plans are moving toward payment models that want doctors to better coordinate care for larger groups or âpopulationsâ of patients through so-called Accountable Care Organizations (ACOs). Under the Affordable Care Act, larger doctor groups and hospitals are forming ACOs to contract with the Medicare program."

I recently saw an advertisement - only yesterday

[ In Reply To ..]
for a physician, primary care at that, with a starting salary of $415,000. Awww, the poor babies cannot meet their financial obligations on that! poor things! I had also heard on a conversation that was being recorded when the physician forgot to turn off the recorder that the physician was upset because the clinic where he worked was capping their salaries at $47,000 per month!!! per MONTH! Do I feel sorry for these doctors?? not in the least! They give minimal care as it is, greedily seeing upwards of 60 patients per day (now how good really is the care being provided at that rate?) and it seems the doctor's prescription for every ailment that came through his offices was to give a steroid injection of some sort. Talk about band-aids! Nope! I do not feel sorry for these god-like egos in the least! If it means fewer physicians, seeing fewer patients, etc it may just mean better healthcare for the patients in the long run! Paying physicians in the same context as perhaps a sports figure is ridiculous for the service they provide, which is minimal, at best and laughable second.

who controls how many docs graduate? - it is a racket, nm

[ In Reply To ..]
Here in Georgia they've increased med student slots - a lot, but the bottleneck is in residencies.
[ In Reply To ..]
That seems to be a big problem nationally too. And, yes, although we're trying to produce more doctors now, for many decades the AMA and others tried to keep the supply of docs low so prices could be high.

Right on. Count me in on the - cry-me-a-river chorus.

[ In Reply To ..]
At 64, the most excellent physician I've ever encountered is the PCP I have now, who by PERSONAL CHOICE practices in a county system where the most stringent income controls and regulations apply. During my visit with her just this week, we talked about the pros and cons of her remaining in a setting where she sees a minimum of 30 scheduled patients per day plus whatever walk-in emergencies are thrown her way. The top reason she cited for choosing a county care over an ivory tower "glass office" setting was that she gets to see a "broadly multicultural" population which spans the entire spectrum of newborn infant to the most advanced-age Medicare patients....an environment she says she THRIVES on and one she believes helps make her a better physician.

She said she has conversations all the time with her husband about "advancing" to a more lucrative practice where she could slow down to a more leisurely pace and bring in more money. Trouble with that for her is she much prefers to go WHERE SHE CAN DO THE MOST GOOD, and believes such as change would make her life as a physician "miserable."

The part of the article about female physicians being more likely to be part-timers made me laugh out loud. My PCP has 3 school-age children between ages 9 and 16, yet she still manages to teach medicine at Baylor College of Medicine, where she holds a position as a tenured professor.

The thing I love most about her is that, unlike the former ivory-tower MDs I've seen in the past, she takes all the time I NEED on an appointment-by-appointment basis to explain my options and discusss the wheres- and why-fors of specific medical treatments, medications, symptomatologies, disease processes, etc., using MEDICAL TERMINOLOGY as per my request, thus demonstrating a respect for who I am as an individual. In the past, I've had more than one doctor refuse to give me that same respect by acknowledging that, after more than 30 years of transcription, I just might be able to handle discussions that rise above the level of basic lay terminology. On the flip side of that coin, I've seen her converse in Spanish, Hindi and Mandarin Chinese with her patients as well as using the most basic of lay explanations with those who may require patient and repetitive presentations of information so that they can fully UNDERSTAND their medical conditions and treatment options.

I want my physician to be dedicated to medical science and to the delivery of the best medical care as is humanly possible, NOT one who prioritizes greed and money over excellence in care. My experience with her has taught me this is not too much to expect. Oh, BTW, she has taken the advent of Obamacare in her stride, and believes it will ENHANCE medical care in the long run by weeding out those MDs with less loftier goals.
We'd all love to have your PCP. Unfortunately, too - many find themselves corporate controlled.
[ In Reply To ..]
I found the part of the article about single practitioners getting jerked about by the insurance companies extremely interesting. If they lack power to deal with the insurers, their patients suffer, something those who give up and go to work for companies that then also jerk them around have to have lots of painful experience of.

Maybe reading the AMA article would help, OnlyYesterday. Average patients per - day is 18 for employee docs and 22 for private

[ In Reply To ..]
practice physicians. Now, that does include specialists and part-time, so no doubt some are seeing significantly more, my own PCP among them, but if you google this you'll find 20-30 is actually more of a normal range, far fewer for specialists. Upwards of 60 per day would be extremely atypical.

And let's be fair too. If you scan down to the list of complaints ranked by percentages, you won't find pay on it. They are frustrated by paperwork, loss of clinical autonomy (interference with medical decisions), not being paid for quality work, erosion of patient relationships... Most are now employees, being pushed by corporate employers to produce higher profits. I have real sympathy for all those who feel they are not being allowed to do a good job, and of course concern for all of us.
I did read the AMA article - but also going by my own
[ In Reply To ..]
personal experiences and doing dictations for some of these corporate employer-owned physicians, the ones I have transcribed for see upwards of 60 patients per day, at least 4 days per week, with surgery schedules also thrown in. The AMA article mentioned "average patients per day," but where did they get THEIR info from? Did they actually do a nation-wide survey to get these numbers. The dictations I am currently doing for an elderly primary care physician is 35 patients per day, a pain mgt physician is 50 patients per day, and another pain mgt physician with a PA to help with the work load is 60 patients per day, traveling between 3 different clinics per week. To me, and my personal experiences doing their dictations, that IS the average. Not all of these articles are accurate either, and only surveying a small portion of the "real world" of medicine being practiced.
Last time I visited my PCP there were a dozen - people in the waiting room. SM
[ In Reply To ..]
Don't know what's normal, though, since it was only my second visit and the first was mostly empty.

I googled on reading your 60+/day, though, and that is not normal, although I'm sure some corporations are pushing harder and harder for it. No doubt various types of care visits require more or less time, too.
My docs see 12-15 on average - RC
[ In Reply To ..]
But I live in a doctor-saturated area, with 80% of the population here being very old and very rich. You can't throw a rock without hitting a million clinics here.

Adding--80% is my own personal exaggeration. I have no idea what the real percentage is, but this is a retirement/destination area.
going by my own - my physicians are...
[ In Reply To ..]
pretty much at opposite ends of the nation. One (large) pain mgt clinic is in CA, the other pain mgt clinic that travels between three clinics throughout the week is on the east coast, had been affected by the superstorm sandy, and was up and running again within two days, and the smaller internal med physician, elderly, is in the middle in LA with only about 30 patients per day. I can also go by the patient schedules that I receive on a daily basis. I am not sure if the locations have anything to do with it, but this is the average for the dictations that I do for these physicians on a daily basis. Maybe pain mgt is a specialized practice and sees more patients....hard to tell.
OMG. Your 4-physician "survey" trumps the entire AMA database? - Mighty, mighty impressive stuff.
[ In Reply To ..]
Can you also see through your earphones into their clinical settings and tell us how many PAs, RNs, LPNs and MAs the surgeon, elder PCP, and pain management physicians employ? Do you have stats on how much of the load they may or may not carry for the MDs, who get all the credit for signing off on the charts and delegating the raking-in-the-dough phase to the rest of their administrative staff?

my heart bleeds - sm

[ In Reply To ..]
Angst? Uncertainty? May they pound sand.

LOL. Love the imagery. - nm

[ In Reply To ..]
nm

Ah, to hear from you guys - in a few years

[ In Reply To ..]
It is interesting to hear the negative comments about the docs out there now, and will be interesting to how much more negative they are in a few years. Keep in mind the ole saying, "You get what you pay for..."

Once again, the overwhelming jealousy of participants on this board wins again.

ah, to get a break from meaningless sound bites - sm

[ In Reply To ..]
Your point would have held water with me had you not devolved to invoking "jealousy". I am not jealous of our American physicians. I have become weary of their entitlement philosophy.

Being a physician is the only job in America where newbies are paid the same as their more senior counterparts, without regard for experience or expertise. Nor can I think of any other working cohort that expects their quality of living to surpass that of the year before.

So give me a break. This is not about jealousy. It's about steering away from exaggerated claims and scare tactics. If someone feels it's not worth it for them to be a doctor, I say: Perfect. Stay out. Thanks.
As clueless as the jealousy card is, - hopefully they will
[ In Reply To ..]
continue to play it over and over again. Judging by how much failed 2008 buzz-word rhetoric they dragged out again for a curtain call in 2012, they will. In the end analysis, all it really succeeds in doing is to make assembly of highly motivated opposing voter coalitions that much easier.

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