Physicians are gloomy about health reform

Recently, The Doctors Company (TDC), the country’s largest insurer of physician and surgeon medical liability, decided to survey doctors to determine what they are thinking and feeling about health reform.  The results are pretty gloomy.

To put this in context, it is important to understand a bit about how TDC conducted the survey.  First of all, the universe of doctors they reached out to were doctors insured by The Doctors Company.  That means large self-insured medical groups, such as those affiliated with Kaiser Permanente, were not included.  Nor were doctors whose insurance was provided by their employers or doctors using other insurance carriers.  This matters because if the TDC insured physicians are not representative of doctors as a whole, the results of this survey would not necessarily reflect the attitudes of all doctors.

TDC provides insurance to 71,000 of the country’s ~700,000 physicians, or about 10%.  According to Dave Troxel, MD, TDC’s Chief Medical Officer, the survey was initially sent to ~36,000  practices that had 15 doctors or less – so doctors choosing to practice in larger groups were not included.  A second mailing went out to the initial group plus ~14,000 additional larger practices (>15 doctors in the group).

More than 5,000 of these doctors filled out and returned the survey.  80% of the respondents of the respondents were male.  This is somewhat higher than the percent of males found in a 2008 study of physicians conducted by the AAMC (72% male vs. 28% female).  And, it is substantially different from the characteristics of the youngest doctors (residents and fellows) who are 55% male and 45% female.  77% of the TDC respondents were 51 or older.  The AAMC survey found 37% of doctors were 55 or older.  So keeping in mind that the TDC respondents are little grayer and more male than the population of US physicians in general, let’s take a look at what the survey showed.

The times they are a changin’

As health reform begins to roll out, you would think change would be the name of the game.  There are new practice models and payment mechanisms being proposed, such as accountable care organizations and bundled payments, that will be different from the traditional fee-for-service, volume-driven practice of medicine.  However, only 14% of the surveyed doctors reported they were planning to shift their practice model.  Fifty-six percent said they do not plan to change models in the next 5 years.

For all those folks (like me) out there hoping to help practices transform to accountable care in the next few years the implications are obvious.  In fact, only 14% of survey respondents had plans to participate in an ACO.  Comments in this section were interesting, one North Carolina PCP said “ACOs will destroy private practices and raise the cost of health care without improving health.” A surgeon in Michigan opined that “ACOs are nothing but a marketing gimmick” and another in Virginia said “Binding care to hospital in ‘ACO’ is the most expensive way to give care.”  It was a relief, to me anyway, to see that 57% of doctors are either undecided or need more information regarding ACO participation.  One docs summed it up by saying, “What IS an ACO?” Have you ever seen one?” [Does that mean there is hope for ACOs yet?]

Planned participation in patient-centered medical homes was also low.  Only 10% said they planned to embrace this model and 51% were either undecided or needed more information.   39% said they do not plan to participate.  One California PCP stated bluntly that “medical home will not lower the cost of health care” and a Montana-based specialist offered, “Insurance companies must spend a higher percentage of revenue on medical care.  Rather than pay doctors more, they are building patient centered medical homes.”

Physicians do think there will be a shift from smaller groups (solos or two- to three person practices) to larger groups.  This should not be a surprise as, according to Dr. Troxel, small group practices have been disappearing at a rate of about 3% per year for a number of years.  The biggest change reported in the TDC survey was from solo to a larger type of practice (56%) with 30% being from solo to small group and 10% being from solo to hospital practice.

Other interesting findings in this survey are as follows:

  • 44% either have an EHR or are planning to implement on in the next three years (thank you Meaningful Use).
  • 17% have no plans to use an EHR – per Dr. Troxel, one-half of these doctors plan to retire in the next five years.
  • Doctors are still focused on defensive medicine; 65% of those who responded to the survey said that they do not think health care reform will reduce defensive medicine. [This part of the survey contained an interesting comment from a nonsurgical specialist in New Mexico:  “We all practice very expensive defensive medicine.  I realize I order between 5-15 unnecessary MRIs, maybe 2-3 specialist consults, maybe some unnecessary lab test weekly to prevent lawsuits.”]
  • Fully 60% of respondents believe that health care reform will negatively affect patient care.  Comments included “too much interference with patient care”, “without private practice, quality of patient care or choices for patients goes away,” and “physicians have no input/control in providing care.”
  • 22% of respondents, however, were optimistic about health care reform.  Their comments were much more egalitarian, including “far better, more patients can have health care,” “patients are no longer being denied insurance for pre-existing condition” and “better availability and awareness of preventive care measures.”  One doc noted that it “allowed my children to continue to have insurance as college students.”
  • More than half of doctors surveyed believe that increased bureaucracy is reducing the personal interaction with patient essential for building a close relationship and understanding the nature of patient health.
  • But the question that really got these doctors on the same page was this:  How will health care reform impact your earnings over the next five years?  Almost 80% said ‘negatively’ or ‘strongly negatively.’  A PCP from Ohio commented “dropping reimbursements and increasing ‘mandates’ will drive physicians out-of-practice…and quality of care will drop.  There will be no one I trust to take care of me.”
  • So what to do?  Well 43% of respondents said they would retire over the next five years.  Of course, the docs most likely to retire were the older ones who may have retired within 5 years anyway, however, it is of note that 63% of those in the 51-60 age range indicated they were looking to retire in that time frame as well.
  • And most damning of all was the answer to the final question:  Would you recommend health care as a profession?  Nine out of ten responding physicians said no.  One commenting, “I am a third generation physician and have actively discouraged my son from pursuing a career in medicine…” another putting forth that he “would not recommend becoming an MD to anyone.”

As health care undergoes what feels to me like the most rapid change at any time in the last 20-30 years, it should not be a surprise that some physicians – those who entered medicine with the dream of being their own boss of a small independent business – may not want to practice in the brave new world of accountable care organizations, integrated delivery systems, and hospital-owned practices.  It has to be particularly hard if you are just trying to hang in there until you can sell your practice and retire.  This type of change has happened in other professions as well, leaving people bitter and disillusioned at how things played out for them.  Unfortunately, timing is everything.

On the bright side of life

We will get through this period of transition and, I believe, emerge with new practice models that are better for patients, better for society, and, in the end, better for the physicians who choose to enter this brave new world of medicine.  So I will close this post by sharing the comments from a handful of the only eleven percent of doctors who responded to the survey by saying that they were likely to recommend the medical profession to their children or other family members in spite of health are reform:

“It is a blessing and privilege to be a doctor.  I am a third generation MD (Surgeon, Pennsylvania)

“It will be a different business model from what we are used to, but I still want to be a physician.” (Surgeon, Tennessee).

And my favorite, from a surgeon in California:

“Despite all the bumps in health care, [I] still believe the practice of medicine is a great and rewarding life work!!””

To that, I can only add …”me too.”

Patricia Salber is an internal medicine and emergency physician who blogs at The Doctor Weighs In

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