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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  • http://twitter.com/MLMillenson Michael Millenson

    When Americans approve or disapprove of a president or even a brand of automobiles, journalists look at the record with other presidents to get a sense of perspective. Alas, doctors somehow assume their forebears were delightfully happy. Or, perhaps, remember that they themselves were happier when 20 years younger, a completely different problem. Physicians in the early 1980s declared that DRGs were the end of medicine, as they did in the 1970s with the onset of HMOs as they did — yes — in the 1960s even before the passage of Medicare! If you cared to, you could look it up. Not that even editors of medical journals care to; they’d rather print the kvetching and pretend it’s gospel rather than grumpiness.

    But as I documented in my book, “Demanding Medical Excellence: Doctors and Accountability in the Information Age,” physicians in those eras, as a whole, were much less attuned to issues of cost and quality and listening to patients than they are today. Yes, Doctor, as terrible as it may be to consider this, you and your colleagues may be better technically, better personally and more ethical as a whole than any group of physicians in this country has ever been. Doesn’t mean all the terrible things you hate aren’t terrible; it’s just that if (gasp!), you actually put them in context (hint: the 1950s were not really Ozzie and Harriet), you’d find that you and your colleagues have a lot to be proud of. And your kids will do even better.

    I apologize for being the bearer of good news.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Interesting survey.
    I would like to point out that the superiority of the model of an employed physician, providing medical services in an “accountable care” corporation, is nothing more than a hypothesis at this point. I do not doubt the good intentions of those supporting this hypothesis, and similarly I find it extremely difficult to writhe off the objections of those who have been providing patient care for many years and are therefore at the top of their profession. The assumption that dashed dreams of “being their own boss of a small independent business” is the root cause for these objections, is unwarranted at best.
    Either way, the scientific method would dictate that no matter how plausible a hypothesis looks to its proponents, it must be objectively tested in real life (not a handful of self-reporting outlier institutions). Considering the risks, it is a mystery to me why we are expected to proceed based on faith alone and without a shred of solid evidence.

    On a side note, I don’t think that those who oppose the transition of medicine to a corporate model are insensitive to the needs of vulnerable populations and an egalitarian delivery system. It may very well be just the other way around.

    • Anonymous

      Bingo.  The innovations are experiments, and most experiments fail. 

  • Anonymous

    I am a graying male primary care physician who agrees with many of the complaints voiced by docs in the survey. There is a lot to worry about, but let me list just a few things.  First is loss of control to people who are powerful but not knowledgable or who have agendas that benefit technocrats at the expense of doctors and patients.  Such things are EHRs, ACOs and the PCMH are innovations that, in my view, are not likely to improve care or save money and which distract us from attacking the main problem in primary care, which is that America does not have enough warm medical or nursing bodies to do the work that needs to be done.  Indeed, these innovations might make things worse by taking us further from patient care and by further demoralizing an already struggling group. Enthusiasts tell us to just give it 2 or 5 or 10 years and practice will get better with the new ways, but in fact no one knows what the outcome will be. 
    Of course the salary discrepancy compared with proceduralists, a direct result of their  regulatory capture of the RUC, is both a cause and a consequence of the primary care shortage and the immiseration of the primary care field. 
    Third, I see non-physicans or no-longer-practicing physicians trying to redefine my job.  I signed up for prevention, diagnosis and treatment.  I never wanted to be a public health official, managing the health of a group of people that I might not ever see.  I never wanted to be a mid-level bureaucrat, responsible to non-physicians for meeting clinically arbitrary and silly targets. I will resist taking on these roles to the end. 
    Maybe the young primary care docs know what they’re getting into and are OK with it. Maybe it’s better at large medical groups.  Maybe the physician of tomorrow needs to be more tractable in disposition, less independent. Maybe people like me should no longer go into medicine.  If so, great.  I’ll have a doc when I need one.

    • Anonymous

      If the clinical targets are arbitrary, then participate in setting meaningful ones. And don’t dis the doctors who DO participate at the management level.

      Guys like you just kill me. You object to non-medical technocrats, you object to doctors who aren’t in the clinical setting anymore making any rules, but you don’t object to getting paid. Whe third parties are hired as go-betweens to pay the high cost of care, using OPM (other people’s money), there have to be rules.

      As far as I can tell, doctors are willing to prescribe unlimited testing and procedures as long as somebody pays. Well, we can’t afford that anymore. What’s your solution?

  • Anonymous

    Thanks Michael Millenson for bearing good news and to buzzkillersmith and Margalit Gur-Arie for pointing out the uncertainty associated with the proposed changes (e.g., ACOs, PCMH). There are some early studies suggesting that these new practice models may indeed achieve the goal of lowering costs while maintaining and/or improving quality, but it is early.  We must see if the results hold up and, more importantly, if these models can scale.  I do think that the impetus for change is due to dissatisfaction of many stakeholders with the status quo (insurers, patients, policy makers, and some physicians).  If it isn’t broken, why would so many people be trying to fix it?

    • Anonymous

      “Why would so many people be trying to fix it?”

      Increased profits.

  • Killroy71

    Apparently doctors don’t actually KNOW what percentage of premium goes to pay for patient care. Which is sad, since they drive most of it themselves with their prescribing practices. This is public information from the National Association of Insurance Commissioners (NAIC.org) – they can get five reports for free. They will find that the larger nonprofits and for-profits spend around 85% of each premium dollar on claims. The Kaiser-type models spend more than 90%.

    So, just where do these doctors think the biggest opportunity for savings lies? Cost of care? Cost of medical devices and supplies? Hospital charges?

    If they aren’t willing to be part of the solution bor coordinating care, maybe they should just go into concierge practice and see how that works for them.

  • Anonymous

    The idea that anyone can say they will never need health care is a joke. It would be abnormal for someone to not be born in a hospital or not die in a hospital. If you are breathing, a doctor probably delivered you at birth. So, by default, you entered the health care market at birth. Now, the question before the U.S. Supreme Court is, who should pay if someone refuses to pay for themselves. Someone paid when you were born. Someone will pay when you die. Who will that someone be if it’s not you?

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