In this episode, we are joined by Phil Miller, Vice President of Communications at Merritt Hawkins, to discuss their nationwide survey of physicians that reveals the impact of several factors driving physicians to reassess their careers.
Highlights of this episode include:
- The responses of over 9,000 physicians surveyed and what they had to say about the future of their profession
- What factors are contributing to increased physician burnout
- What is the best direction for the healthcare system to take?
- What is driving the movement towards quality-based payment for doctors?
- And more…
Mike Passanante: Hi, this is Mike Passanante. And welcome back to the Hospital Finance Podcast.
Every other year, the Physicians Foundation, with the assistance of Merritt Hawkins, conducts a nationwide survey that gather physician perspectives on a range of topics regarding their practice patterns and how they see healthcare evolving.
To talk with me about the results of this study, I’m joined by Phil Miller who is Vice President of Communications at Merritt Hawkins. Phil, welcome to the show!
Phil Miller: Thanks! Good to be here.
Mike: So Phil, you’re a repeat visitor to the show. Welcome back. Just to refresh everyone’s memory, could you just tell us a little bit about what Merritt Hawkins does, and then just describe what the 2018 Survey of America’s Physicians is all about.
Phil: Sure! Merritt Hawkins is the nation’s largest physician search and consulting firm. We’ve been in business for over 30 years. And we are a company of A&M Healthcare which is the largest healthcare staffing firm in the country.
Over the years, we’ve conducted a good deal of research on an in-house basis looking at the types of incentives physicians are offered, financial packages, practice plans and so on. We do that internally, but we’re also contracted by third parties. We conduct research on those types of topics as well.
One of those third parties is the Physicians Foundation. It’s a not for profit group composed of physician leaders and state medical society leaders that are trying to improve healthcare for patients and the overall practice environment for physicians.
So now every other year since 2012, they asked to do a national survey of doctors. We call it the Survey of America’s Physicians, looking at how they feel, what their practice metrics are, how many hours they spend doing clinical work, non-clinical work, and practice plans, and generally, how they feel about the medical profession.
Our latest version of that survey was just released a few days ago. It’s based on about 9000 physician responses. And it’s one of the more comprehensive physician surveys that is conducted in the United States.
Mike: Yeah, it is very comprehensive. And for time’s sake, I’d like to focus on just a few areas with you here today.
So first, let’s talk about physician themselves. They’ve obviously gone through many changes regarding things like practice ownership, working hours, practice patterns. What can you tell us?
Phil: Well, physicians, like everybody else involved in healthcare, are undergoing a transitional period. And change is always challenging. And I think they have been challenged by some of those changes.
Overall, we’re going from what has traditionally been sort of a transactional system based on one-on-one encounters that is driven by volume, the volume of things that hospitals, physicians and others do. It’s basically the basis on which they are rewarded. Now, as you know, we’re trying to move towards a more experiential process where we’re trying to look at making whole populations better through sort of team-based care. That’s paid on value rather than volume.
So, it’s a complete philosophical turnaround. And it’s something that everyone is sort of struggling with—how do we get from classic fee-for-service to fee-for-value. Essentially, how do we take better care of people at less cost? And that’s obviously something that’s difficult to do.
In the old fee-for-service model, it was basically based—in the physician world—on small private practices dealing with basis on kind of an autonomous basis. A doctor would hang up a shingle, maybe practice with a partner or two, and that was sort of the style.
Now, to accomplish this transition, it takes much more sophisticated electronic medical record keeping, it takes economies of scale, it takes integration with hospitals, therapists, labs. Everyone is supposed to be working together.
And to do that, it really almost requires the employed physician model rather than practicing in the small setting autonomously. The doctor is employed by some larger entity off in a hospital.
So, when we first did this in 2012, close to 50% of the doctors had identified themselves as private practice owners. In 2018, that was down to 31%—so less than a third now—indicate that they are and autonomous private practice. Everybody else is in some sort of employed type of setting. And that really changes the dynamic of how physicians practice.
When you own your own business, whether it’s an ice cream shop or whatever it is, your emotional stake, your financial stake tends to be greater. And it’s more difficult to relocate, essentially turn over. So now we have this workforce of physicians that is largely employed. They’re getting a paycheck from somebody. It’s more easy for them to leave that setting when they get offers from people like us, of which they get many.
So, it really changes the whole working dynamic of what these physicians are doing. When you’re employed, somewhat counter-intuitively, you’re still seeing a lot of paperwork in your practice. These doctors have seen quite fewer patients, 12% fewer patients, among employed physicians versus private practice.
And that in turn sort of leads to a patient access issue for you and me when we’re trying to go see a doctor. We already have a shortage of physicians. And it tends to be compounded by this transition that we’re making from the private practice setting to the employed setting.
So, for all these reasons, doctors, like most people in healthcare, are facing quite a few challenges.
Mike: Yeah. And based on the results of the survey, it looks like it’s infecting their morale quite a bit. And I find that pretty concerning as a patient myself (as we all are at one time or another).
What can you tell us about that, Phil?
Phil: So there’s a dichotomy in medicine. These doctors are very bright as we know. They’re sort of the best and brightest. They did very well in high school. They got into good colleges where they completed four years of collegiate training, four years of medical school, three to seven years or more of residency training.
But then when they get out and actually practice medicine, they find that they don’t have the control over the patient’s experience that they trained for and what really gives them their satisfaction.
So, on a lot of occasions, they feel that they are spending more time documenting the patient encounter and processing the reimbursement, et cetera, than they are actually seeing the patient. In our survey, we found that doctors spend about 23% of their time doing non-clinical paperwork.
So, that’s really not what they got into this for. They didn’t necessarily get into it for the money or for any of those things. They really got into it to exercise their judgment, to have an impact, a positive impact, on people’s lives. And they feel, on many cases, that that’s not happening.
So, we found that 78% of doctors sometimes will often have feelings of burnout; about 50% wouldn’t recommend medicine to their children; 62% are pessimistic about the future of medicine; and the same percentage, 62%, feel like they have little input into how the health system is run. So that’s also a source of frustration.
Consequently, many of them, close to half, are planning to make some sort of career change in the next one to three years. About 17% plan to retire. Others plan to cut back on their hours or work locum tenens on a temporary basis, or seek a job that’s not even related to healthcare.
So that, from a patient perspective, is concerning because all of those choices tend to limit patient access to doctors. If they retire, they’re completely out of the workforce. If they cut back, they’re seeing fewer patients. If they work locum tenens, they’re seeing fewer patients.
So, all those things tend to compound the challenge that you and I have when we want to go see a doctor. We may have a hard time doing it.
In addition to physicians, having some dissatisfaction with the medical practice environment, it’s more than just doctors getting something off their chest. It has an impact on access to care which, in turn, affects quality of care.
Mike: It certainly is a transformation time, no question about it. Maybe something that dovetails with that is their perception and their practice patterns related to Medicare and Medicaid, and also their preference for single payer versus market-driven system. A lot of debate there. I’m curious what you can tell us about that.
Phil: We did find that most physicians still indicate they see Medicare patients. So 78% said that they see all Medicare patients, or a smaller percentage, 68% say that they see Medicaid patients. Those are the majority. But nevertheless, again, it’s an access issue. A lot of demand for Medicare patients and Medicaid, both of those groups. The numbers of people covered there are increasing.
They have over a third of people or doctors not seeing Medicaid and about a quarter not seeing Medicare. So that does create access issue again especially now that we already have a physicians shortage. So that tends to compound the problem for people who are covered by government payers such as Medicare and Medicaid.
We did ask physicians what they thought was the best direction for the healthcare system to take. Over 60% said they favored single payer or single payer with a private option. And that is a change that we’ve seen over the years. Historically, most physicians have not favored single payer. And now it seems that many of them do favor some form. It all depends on your definition of what you mean by single payer.
But they seem to be trending in that direction. I would say it’s not necessarily a wholehearted embrace of that concept. It’s just a preference to what we have now.
I think doctors want to move towards clarity. They want to move towards simplicity. We kind of see the way things are going. And I think that’s what we’re looking out for.
Mike: A few minutes ago, you mentioned payment reimbursement based on things like value and quality, that disconnect there. And as you dig down into the study, you see that physicians don’t necessarily believe there’s maybe a correlation or at least a benefit at this point. Is that the way to interpret that?
Phil: Yes. We do see a movement towards quality-based payment for doctors. So the number who said that they have similar compensation types of value increased to 47% in 2018 up from about 42% in 2016. But nevertheless, that’s still only less than half of doctors who indicate that some of their compensation is tied to the value.
So, that shows that the old value-based concept is still aspirational. We haven’t gotten there yet. We still have over half of doctors who basically are getting paid on pure fee-for-service of some kind or another whether it’s based on relative value units or net collections or whatever it is. It’s a volume-based determinant.
Of those who are paid on quality, about 14% of their total compensation is tied to quality which is significant. I mean that will tend to help drive physician behaviors once that percent of their compensation is tied to quality.
So, we do see it picking up. nevertheless, we’re not there yet. The negative is that most doctors, about 60%, don’t think that those type of payments will improve quality or decrease cost which is what they’re supposed to do. And I think the reason is because quality in healthcare is very difficult to determine. It’s kind of like beauty. It’s in the eye of the beholder. And often, it’s beyond the doctor’s control.
So, if you’re a physician, and you have, say, poor patients who don’t really have the option necessarily of getting better nutrition, they may not even have transportation to go see the doctor, or if you have non-compliant patients, you put them on a treatment plan, but they simply don’t follow it, it’s harder to achieve quality or what we now measure as quality. And so you’re actually going to penalize the same doctor for seeing patients who have social challenges or simply don’t follow your directions. You can be penalized for that.
And philosophically, what actually determines quality in healthcare, no one can seem to figure out what that formula is or how you measure it. It’s all somewhat subjective. And doctors are essentially scientists who look at hard date, and they have reservations about this whole business of measuring quality.
So, what we also found in the survey is that a very alarming percentage of doctors, 88%, said that some, many or all of their patients face some sort of social situation such as poverty or unemployment or drug addiction that poses a serious impediment to their health. I emphasize the word “serious” because these types of things are common, but do they really directly and seriously affect health, and these doctors are saying yes.
So, we have a big societal problem. We have a lot of people who are experiencing ill health in part because they experience ill wealth. They don’t have the money to take care of themselves, to get good nutrition, to follow up with the doctor, et cetera.
So, this is a larger societal problem. We’re seeing it with things like reduced life expectancy in the United States. It is a little shocking to see that that has actually decreased. And it’s kind of hard to put that big societal problem on the shoulder of doctors and say, “You take care of these people, and we’ll pay you on how well we perceive that you’re doing that.”
So I think that’s another reasons why doctors are feeling stressed and that they are not able to do what they want to do, what they’ve trained to do.
Mike: As I mentioned, the survey is very comprehensive. And it goes into a lot more detail than we’ve covered here today.
Phil, if someone would like to get a copy of the full survey results, where they can go?
Mike: Phil Miller, thanks again for joining us today on the Hospital Finance Podcast. It’s a pleasure as always.
Phil: My pleasure!