Salaried doctors are less engaged in the health reform debate

The Disease Management Care Blog would like to introduce you to two alternate realities.

In the first reality, physicians own the bricks and the equipment that make up their clinics. They hire and fire their office staff members. They don’t mind fee-for-service payment systems, because the harder they work, the greater the reward.

“Pay-for-performance” generally results in greater practice income because they’re already doing a good job unless it’s Medicare. They like their patients and their patients like them. They like being in control of their own destiny.

They’re anxious about health reform. They’re paying attention.

In a JAMA commentary about an alternate reality written by the former New England Journal Editor-in-Chief Arnold Relman, physicians refer to themselves as “providers.” They’ve been told about the strategies underlying their employer’s capital allocations thanks to emails and evening staff meetings. Their input on human resource issues is generally not expected or necessary. They’re paid a market-based salary and are expected to generate market-based patent care revenue. The details of pay-for-performance have been negotiated for them by their administrators with the insurer’s administrators, unless it’s Medicare. Patients populate their appointment slots. They don’t mind not being in control of their destiny, just so long as they can get home by 5:30.

They’re clueless about health reform. They’re not paying attention.

In its travels, the DMCB has found that docs who are in physician-owned settings, thanks to their sweat equity, are far more likely to be engaged in health reform. That passion is one reason why the American Medical Association remains such a potent political force. The assumptions by Dr. Relman that salaried/employed doctors will make hospitals virtuous, attain consumer loyalty, exude professionalism, control costs, increase quality, manage global contracting and bypass partisan gridlock is silly for a single reason: with some notable exceptions, docs who go into salaried positions are, on average, less interested in the issues driving health reform and the business of medicine. Not having to worry about it is why they’ve agreed to be salaried and employed in the first place.

That’s the real reality.

Jaan Sidorov is an internal medicine physician who blogs at the Disease Management Care Blog.

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  • soloFP

    Once the salaried doc has made the base salary, which usually is around the national average salary, there usually is low incentive to make more than that. The overhead to the doctor is higher in a salaried practice, as hospitals-owned practices come in with practice managers, general administrators, and increased staffing requirements. Where the money is gained is that the primary care docs in a multispecialty group order excessive studies and procedures through the specialists and hospital that backs them. To avoid Stark difficulties in my area, the employed docs maintain privileges only at the hospital that pays the salary. As a side note and as a private doc, I make around twice what my primary care colleagues make as employed docs with a much lower overhead and the ability to pick and choose which patients I wish to see.

  • Winslow Murdoch

    I am on the board of our local county medical society.
    There are twelve of us altogether. Only one is an employed physician, and it seems primarily because the current president and his wife, also a doctor in independent practice, are close friends.

    At grand rounds at our local hospitals, I haven’t seen any employed outpatient primary care doctors in almost a decade.

    In our five hospital primary care working group, we meet one evening every other month. Our collective goal is to improve hospital system to community primary care doctor and patient
    needs, there are generally only 12 regulars out of hundreds invited to every meeting. All, but one is an independant physician. He happens to be (of the two primary care residencies in the system, IM & FP) a Family Practice residency director who has an office at the facility where we meet.
    Decades of stress, wear and tear and failing to achieve any meaningful change has forced many local doctors to give up essentially, and enter into employment models. I would estimate that 60- 70% of primary care doctors locally are either employed by the hospital or a very large physician group that uses an employment model. Almost none of any new doctor hires come in the non employed sector, and the average age in our primary care department is mid 50s. (that’s me!)
    Some of us are still actively tilting at the healthcare windmills, but we are getting old and very tired.

  • Winslow Murdoch

    A subset of all patients are very needy, dependent, anxious, hypochondriacal, black hole of misery and narcissistic worry.
    They call day and night and often with the same complaints and ask if it is ok to take their “as needed” pain medicine or anti anxiety pill.
    They refuse to get counseling, often citing financial reasons, or take maintenance medications like an SSRI for fear of side
    effects. When they come in there are usually at least a half dozen problems that they are quite anxious about. They often don’t follow up with specialists and ask you to do what you can.
    They frequently call and ask to be squeezed in urgently due to their somatic anxiety when there isn’t enough time to really do much more than reassure them which generally isn’t a very easily billable encounter.
    Is this the patient you would chose not to see?

    That is likely one reason among the many cited that enables you to make double the salary of an employed doctor who
    Pretty much has little control of the scheduling and who rotates the privilege of providing care with others in the group.
    These same patients are often heavy utilizers of the ER and admitted often due to uncertainty and fear of litigation.

    Yes, there are many many tough patients out there even for the most emotionally tuned in and skilled doctors.

    Question to all,
    Any ideas on how to handle these better other than soldiering through and doing office bases regular counseling by doctor
    or dismissing Them to another facility or practice that may better connect or be more assertive and successful?

  • Pamela Wible MD

    When I speak at events I am always surprised at how clueless employed docs are to basic details such as local malpractice premiums which for family docs can vary from 4K to 30K around the United States.

    I guess as long as they’re home by 5:00 or 5:30 it does’t matter to them. But it should. . .

    For any meaningful health-care reform we all need to be engaged. That would include all physicians.

    Pamela Wible MD

    • buzzkillersmith

      “For any meaningful health-care reform we all need to be engaged. That would include all physicians.”

      Not gonna happen. The old-timers are too tired to fight and are leaning for the tape, and the new docs are sheep.

  • Marc Gorayeb, MD

    Some may disagree, but many will concede that Obamacare has been structured to hasten the decline and extinction of solo or small group practices in this country. Yet you claim that physician-owned practices are a reason for the AMA’s continued political potency. But the AMA supports Obamacare. Can someone explain this contradiction?

    • pcp

      I would disagree with that point in the original post. I don’t think the AMA is at all friendly towards small practices.

    • IVF-MD

      I was once part of a large multi-doctor practice and a former AMA member. After becoming a solo practitioner, I am no longer a member and thus no longer “take advantage” of the lobbying powers of the AMA. I don’t the goals of the AMA mesh with what’s best for my patients and me, but I still support their right to politically achieve their ends even if I don’t agree with them.

      As for being clueless about the realities of healthcare politics, try discussing it with medical students. The irony is that this will affect them all for decades to come and yet, the ones I lecture to seemed relatively disinterested, preferring to focus more on what’s going to be on the shelf exam at the end of the rotation. Oh well.

    • Family Doctor

      I agree that Obamacare is clearly set up to discourage at best or eliminate at worst the solo physician. ACO’s will force us solo docs to band together out of sheer financial necessity. Or force us out altogether & put us into paid positions.

      But despite my above statement, I am probably in favor of Obamacare. We will be more efficient as larger groups.

    • doctor1991

      The AMA gets most of its money from royalties on CPT coding, and these royalites are guaranteed in the Obamacare legislation. That is why they support it.

  • buzzkillersmith

    Many salaried docs are lifestyle docs, who focus on time off and salary and will meekly accept orders from their business school masters. That’s the way corporations and the government want it as it gives them profit and control. Health care is just too big a whale for them not to try to control it. While we’re busy managing pts, they’re busy managing us. Med schools and practices are looking for tractable “team players,” a euphemism for those who will take orders.
    If you want to be your own master, you probably should not go into medicine. If you don’t mind a corporate environment, you might do OK in it.

  • Joe

    Honestly and respectfully Dr Wible, I have worked as both an employed doc and on my own. Though I agree that employed docs are less aware of costs and reimbursements, do you think snarky comments about getting home at 17:00 adds anything to the discussion? I have found very few docs in either situation are underworked. Essentially all of us puts in hours well over a typical 40-45 hour work week.

  • Juliet K. Mavromatis, MD

    Having been salaried for 12 years, and now owning my own solo practice, there is some truth in what you say. Although what I would say is that salaried doctors care differently about health reform and on average may be less engaged than business owners, as you point out. Certainly I know a lot more about the business of medicine than I once did, and am better able to advocate for the profession on that basis. But as a salaried doctor I was very engaged in improving care delivery for my patients– I was interested in making our health care organization work better and improve the quality of services. However, I was a bit more resentful about working long hours (my hours were longer then than they currently are). When I was salaried I was substantially less invested in each individual patient than I currently am, but now I practice retainer fee medicine. Back then my practice was overflowing.

  • soloFP

    To reply to the above questions: most of my patients are not on chronic narcotics. I have a no new patients on chronic BZD or narcotics rule in my practice. My current group of patients has fewer than 10 on chronic pain meds, as I refer pain patients to the local pain clinics.
    I do have about 4-5% of my patients who call with lots of questions. The younger patients email me with their frequent questions. One reason that my practice is successful is I spend time with each patient and do not take weekdays off. I work six days a week in the outpatient world and seven days a week in the hospital. I offer same day appointments to established patients with urgent questions and discourage my patients from going to the ER, unless they have a life threatening condtion, such as an MI/Stroke/Appendicitis etc. By working six days a week, I also keep my patients from wating hours in an urgent care and save them money by only have to pay the office copay instead of the higher urgent care and ER copays. I have very little turnover in my practice, except during the summer months, when patients move out of state.

    • Family Doctor

      Wow. I gotta respect your work ethic. It’s impressive.

      I gotta ask: is your income greater than 250 K?

  • Margalit Gur-Arie

    ” We will be more efficient as larger groups.”

    How so? From all of the above, it seems the opposite is more likely.

  • Alice

    Our doctors at Cleveland Clinic are salaried and highly engaged and able to discuss their opinions in the privacy of their exam rooms, and the voting booth. One was from Eastern Europe and was very vocal about their desire for socialized medicine, another feels every person is entitled and we debated human rights, while another who represents a very important aspect the Clinic promotes is against it… the Clinic is. They are focused on giving care without the mandates, but firmly believe in accountability or responsibility for your own health and prevention of problems. The doctors and employees are expected to be living examples of this. I share this to show that salaried doctors understand the repercussions of legislation, the benefits of good lifestyle choices….but it seems they are limited in what will they share publicly under their real name because their contracts allow little breathing room.

    But many believe the current legislation will make private practice a dinosaur. Which will mean less freedom to share your opinions in a personal manner.

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