Monday, September 24, 2012

Physicians Foundation Survey of 630,000 Physicians: Morale, Practice Patterns, Career Plans, Perspectives, and Aggregation by Age, Gender, Primary Care/Specialists, and Practice Ownership/Employment – Interview with Walker Ray, MD, Chair, Research Committee, Physicians Foundation
September 24, 2012-  This interview is important because it addresses a fundamental question: Who shall care for the sick once the forces for reform are spent?

Reece: Good morning, Dr. Ray.
Ray: Good morning. I appreciate the opportunity to speak with you.
Reece: What is the Physicians Foundation, and what is your position within that Foundation?
Ray: The Physicians Foundation is a nonprofit 501/C3 Organization. As a non-lobbying organization, we do not lobby. We do our work through policy statements, research, and surveys to advance the work of practicing physicians to help facilitate the delivery  of health care. Part of our mission is to strengthen the physician-patient relationship and to help physicians sustain their practices in a difficult medical environment. The P.F. is  committed to demonstrating the link between a dedicated robust physician workforce and patient access to the highest quality of medical care.
I serve as Vice-President of the Physicians Foundation and as Chairman of the Research Committee from which this survey originated.
The Survey
Reece: This survey is a 127 page document. It is the most comprehensive examination of physicians’ mindsets ever undertaken. The purpose of this interview is to humanize, summarize, and highlight what is said in the document. Give us a little background how this survey evolved.
Ray: There is a tremendous amount of data in this survey. It will be our job here to bring its contents out in such a way as the public, policy makers, pundits, and politicians can understand. Our Foundation has representatives from 20 states and county medical societies.
We represent blue states, red states, states from New York, New Jersey, Vermont, Connecticut, New Hampshire, Southern states – Georgia, North Carolina, South Carolina,  Tennessee and Florida  and Western states, such as Texas,  Nebraska, Colorado, California, Washington State, Alaska, Hawaii.
We are non-partisan. But we have known for quite a while there is a great deal  of discontent and disaffection among physicians with the medical practice environment. The trend is growing stronger, and it has alarmed us how this has impacted  access to care. We needed data. We did our first survey in collaboration with the Merritt Hawkins organization in 2008. We did another comprehensive survey in 2010. This 2012 survey is our third in collaboration with Merritt Hawkins.
Physicians at Vortex of System
Reece: As you know, physicians are at the vortex of the health system. They diagnose patients, admit them to the hospital, order tests, perform procedures and supervise treatments. Without them, there would be no system. They are there when Americans enter this world, and they are there when Americans depart from it. To me, this is the most extensive documentation of how doctors feel about reform and how they are reacting to it. What are the highlights and general tone of this survey? And what about its accuracy and validity?
Survey Data: Extent, Accuracy, and Validity
Ray: That’s tough to answer. This survey is replete with data. There are over a million data points from 47 questions within the survey. Many of these questions call for multiple responses. There are also 8000 written comments by physicians.
We are very careful to make sure this survey was representative of all physicians. We contacted a PhD statistician at the University of Tennessee business school, Chad Autry, who is an expert on survey validation. We talked to him before we did the survey and discussed  how to bring a high level of confidence to our survey. After the survey we asked him to validate and estimate the reliability of the data. He said the margin of error was .99, indicating a tremendous degree of reliability for a survey as comprehensive as this one. The survey drew 13,575 responses among 630,000 physicians representing 80% of all practicing physicians. The validity and trustworthiness was at the 99% confidence level.
Morale of Physicians
Reece: Could you comment on the general morale of physicians? I detect a sense of powerlessness and helplessness among doctors of where things are going and whether they have any influence over the direction of reform.
Ray: That is entirely correct. From this survey, we know physicians are suffering from low morale and disaffection with the practice of medicine. Reluctantly, they are making plans individually and independently to make changes in their practice arrangements that may likely lead to limited access to care.
For instance, we asked physicians what the morale is among other physicians whom they know. Eighty percent said it was low or very low. 20% said it was good. We asked physicians about their own morale, and 62% said their own morale was low. We found this in other surveys; physicians are more candid about their colleagues than themselves. We found 77% of physicians were pessimistic about the future of the medical profession. Only 3.1% answered that question as being”very positive.” We found 84% agreed with  the statement;“The medical profession is in decline.”
Other Alarming Metrics
There are other metrics that were worrisome. Almost 60% would not recommend medicine as a career to young people or their children; 34% would not choose to go into medicine again, up from 27% who answered that question in 2008. Physicians are working 6% fewer hours, which means if this  pattern  continues for another 4 years, 44,250 FTEs will be lost from the physician workplace.  Sixteen percent of physicians are seeing fewer patients than in 2008, which would portend 100 million fewer patient visits than in 2008. Physicians spend 22% of their time on non-clinical paperwork – a huge distraction of time from direct patient care. Because of this and other factors, 60% of physicians would retire today if given the opportunity. That’s up from 45% in 2008. What’s worrisome here is that 47% of physicians under 40 years of age say they would retire, if given the opportunity.
Changes in Practice Patterns
Reece: What changes do physicians plan to make in their practices in the next 3 years?
Ray: Half of the physicians said they would continue to practice as they are. The other 50% plan to make these changes: 22% plan to work part time; 13% plan to retire; 10% plan to work fewer hours; 6% to 8% plan to do locum tenens; 6% to 8% plan to do concierge medicine; 5% plan to close their practices to new patients; and almost 10% plan to seek a job within healthcare not related to clinical practice. The thing that is disturbing is that all of these different choices indicate a decline of the medical workforce at a time when physicians are already in short supply. This will result in less access of patients to physicians.
Reece: A prominent concern among physicians is usefulness, expense, and privacy of electronic health records. Did you address EHRs in your survey?
Ray: We did. We asked physicians if they were using EHRs, and, surprisingly, 70% of physicians are. We asked if they had any concerns about privacy. Forty seven percent said they had concerns about privacy. Of the 70% now using EHRs, we asked: How are you doing with these electronic records? Are EHRs lowering costs and improving quality? At this point, physicians said they did not know enough on costs, but on quality, their impressions were split.  About half said they thought EHRs had improved quality, and about half said no, EHRs weren’t worth the effort, or they were too difficult and cumbersome to use.
Impending Crisis
Reece: I foresee a political crisis evolving by 2015. If 30 million new Medicaid recipients become insured in 2014 as envisioned by the health law, and as aging baby boomers enter the Medicare rolls at the rate of 10,000 a day, a process which began in 2011, the factors you mentioned will exacerbate the physician shortage. What’s going to happen when all of these patients go out there and can’t find a doctor?
Closing Practices to Medicaid and Medicare Patients
Ray: You are correct. These are very disturbing issues. I can give you more data to back up what you’re saying. Physicians are closing their practices to Medicaid and Medicare recipients more so than in the past. In 2012, 35% of doctors have closed their practice to either Medicare or Medicaid patients. This is up from 24% in 2008. Physicians are doing this not because they want to discriminate against any type of patient but because low reimbursement threatens the very financial viability of their practices.
That’s not the only issue. There is also a demand for physicians to deliver higher perceived quality at less cost with increased reporting and tracking requirements. This is occurring in an environment with higher potential legal liability and declining  reimbursement. The result is that physicians are opting out of medicine and especially out of private practice.
Organizational Transformation – ACOs and Medical Homes
Reece: Part of the health law are initiatives to create an organizational transformation of doctors into accountable care organizations and into medical homes. What is the physicians’ reaction to these federal initiatives?
Ray: As you are aware, the Affordable Care Act puts a large premium on doctors joining Accountable Care organizations (ACOs). ACOs will force physicians to rethink their practices. ACOs  require them to join larger groups more closely aligned with hospitals, to take on financial risks and  to improve quality. This is quite an upheaval.
Medical homes will also require fundamental practice restructuring. They oblige physicians to aggressively pursue health information technology, may engender higher staffing costs, and involve difficult to implement treatment protocols. Many of the standards  physicians will be evaluated and compensated for  will be subjective and beyond physicians’ control.
We asked physicians if they thought ACOs would increase quality and decrease costs. Only 9% said yes, 62% said no and 28% said they really were not  sure of the purpose and the structure. We asked similar questions about Medical Homes. Only 24% of physicians said yes, 34% to 37% said it would not, and 37% to 38% said they weren’t sure about the purpose and structure of Medical Homes.
These two entities are the thrust of health care reform to change the delivery system to decrease costs and increase quality. The pessimistic physician response makes one wonder if these two new organizations can deliver on what they promise.
Differences Between Physician Types
Reece: What is the difference in mindsets between younger physicians, women physicians, and employed physicians and the traditional older independent predominately male physicians?
Ray: Younger physicians answer the survey in slightly different ways than older physicians, but the direction in which they are thinking is the same. Younger physicians are slightly more optimistic by 2% to 3% about the effectiveness of ACOs. Whether physicians are younger or older, male or female, independent or employed, they generally have the same point of view.
Hospital Employment
Reece: Merritt Hawkins has estimated that within the next decade, hospitals will employ 75% of doctors, up from 50% now. What are the implications of this trend?
Ray: This employment data comes from multiple sources, one of which is Accenture,  which tracks employment of physicians. A decade ago 60% of physicians were independent; By 2013, only 33% will be in independent practice. So there is a huge migration towards employed physicians. In our survey, we asked physicians: Is hospital employment a positive trend that will increase quality and decrease costs? Seventy five percent of physicians disagree this was a positive trend while 25% agreed. Younger physicians and female physicians were slightly more positive; about 68%  disagreed.
About 3/4s of all physicians, regardless of age, gender, or employment, agreed hospital employment is not a positive trend. Only 11% of private practice owners thought this was  a positive development; 88.9% thought it was negative. What about employed physicians? Some  62%  felt it was not a positive thing. Physicians who are becoming employed seek economic security and relief from regulatory, business, and malpractice pressures. We also asked if hospital employment would erode the physician patient relationship, and 72% said yes, while  22% said no.
Reece: Other concerns are that hospital employment will increase physician fees, create potential monopolies, and lead to anti-trust suits.
Ray: That’s true. Even if hospital employment doesn’t become an anti-trust issue, it becomes a market force because hospitals  can negotiate higher rates if they employ large numbers of physicians. When physicians become an employee, they may feel obligated to please their employer or risk jeopardizing their  position. Most physicians want to do the right thing for patients regardless of payer or employer Doing the right thing at the right time may be compromised.
Doctor Ray’s View of the Future
Reece: In your career you’ve been a pediatrician in a group, you’ve been a solo pediatrician, and you’ve been active in the medical association in Georgia and at the national level. Where do you think the health system is headed? Are you optimistic?
Ray: I share the opinion of the physicians in this survey. One , when asked if the profession was in decline, 84% agreed.  Only 16% disagreed.  All demographic groups in this survey agree – young, old, male, female, hospital employees, independents. Two, there has been an erosion of physician autonomy. Three, there has been a marked decline in reimbursement. Four, there has been a spike in regulatory responsibilities and liability. All of these things have escalated after passage of the health reform law.
I also agree with physicians who say they are unsure where  we will be or how we will fit in three years.  Ninety-two percent  of physicians in this survey agreed with that statement. Only 2.7% strongly disagreed. There is tremendous uncertainty, and uncertainty always invites anxiety and lack of confidence.
The Physicians Foundation desires a vibrant,  dedicated, confident, energetic and  enthusiastic workforce. There is a connection between this type of workforce, quality  and satisfaction with access to care. Negative trends are now clearly documented and predictable. We know this from this and previous surveys. We are headed towards a significant problem with access to care. We want patients to receive the right care at the right time from the right professional. This ideal situation is in jeopardy.
Reece: People who read this interview can have access to the entire 127 page survey by going to the website. The survey is open to the public, policy makers, pundits, and, of course, physicians.
Ray: This survey is about more than physicians grumbling. This is about the future of health care and access to care. Physicians are patients too . We are concerned about the care for our families, which we fear may be deteriorating.
Reece: Thank you, Dr. Ray, for this conversation and your insights.

Tweet:   A survey of 630,000 physicians indiates   physicians suffer from low morale secondary to health reform, and 6 of 10 would quit practice if given the opportunity.


Doctor Richard L. Reece is a retired pathologist and frequent health care commentator. He is the author of 11 books on health reform. The latest three are Innovation-Driven Health Care (2007), Obama, Doctors, and Health Reform (2009), and The Health Reform Maze (2011). Doctor Reece blogs at Medinnovation blog, where he has composed 2475 blogs over the last six years. He welcomes comments on his blogs.

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