Physician business ideas, Physician Recruiting - The Physician Market

The best book on the market state and status of physicians in America is Guide to Physician Recruiting (154 pages, Physician Support Resources, Inc, Publisher, 2007, $59). It’s pricey, but it’s worth it.


In the interest of full disclosure, I know one of the authors, Phillip Miller, and the publisher, Mike Martin, who has published two of my books. The authors are James Merritt, Joseph Hawkins, and Phillip Miller of the Merritt, Hawkins & Associatesa physician recruiting firm, and a division of AMN Healthcare in Irving, Texas., 800-876-0500, www.merritthawkins.com


The chapter on the physician market opens, “Without doctors, hospitals are just empty hotels with mediocre food.”


The authors note physicians drive the lion’s share of America’s $2.2 trillion health market. Physician services are much in demand, but America is in the midst of a “serious, widespread, and protracted physician shortage,” as outlined in the author’s previous book, Will the Last Physician in America Please Turn Off the Lights? A Look at America’s Looming Doctor Shortage.


The book offers this table from Cooper, R, et, in the Feb, 2002 Health Affairs as evidence of the shortage.


Total Physicians, 2000, 772,000, 2010, 887, 300, 2020, 964,700

Physicians per 100,000, 2000,000, 270, 2010, 283, 2020, 280

Pop. Millions 2000, 286, 2010, 326, 2020, 335

Physician Shortage, 2000, N.S. 2010, 50,000, 201, 200,000


The book brims with numerical nuggets you won’t find elsewhere.

Examples are,


• Return on Investment in Specialty Hospitals

1. Average doctor investment $10,000 to $50,000
2. Annual return 30%
3. Annual take-home $3,000 0 $15,000
4. Efficiency gains, to one more $6,000/month
case per week
5. Annual increase in income $72,000


• Average Base Salaries/Guarantees offers to Physicians

Cardiology $342,000
Orthopedic surgery $370,000
Internal Medicine $162,000
OB/GYN $232,000
Family Practice $145,000
Gastroenterology $315,000
General Surgery $272,000
Urology $320,000


• Percent of Medical Residents Who are Female

OB/GYN 68%
Pediatrics 65%
Dermatology 54%
Psychiatry 49%
Family Medicine 47%
Pathology 47%
Internal Medicine 40%


• Based on Population, In What Size Community Would You Like to Practice?

Over 1 million 7.0%
500,000 – 1 million 18.0%
250,000 to 500,000 26.0%
100,00- 250,000 30.0%
50,000 – 100,000 16.0%
25,000 - 50,000 4.0%
10,000 - 25,000 <1%
10,000 0%


• International Medical Graduates by Specialty

Nephrology 40%
Anesthesiology 32%
Psychiatry 31%
Internal Medicine 30%
Cardiology 30%
Neurology 30%
Pulmonology 27%
Gastroenterolgy 26%


• Percent Increase in Physician Searches, 2006 vs. 2005

Emergency Medicine up 94%
Hospitalist up 81%
Family Practice up 49%
Internal Medicine up 46%
General Surgery up 42%
OB/GYN up 34%
Urology up 37%
Neurology up 23%

There are other tidbits as well, costs of recruiting, size of hospitals recruiting, number and types of locum tenens, problems in retaining physicians. All in all, this is a deep and detailed look at the physician market.

Value-based care - Rerouting of Patients Based on Value-Based Purchasing

A new approach to health care is in the works and in the wind, and you should be aware of it. It’s important in that it may reroute patients away from you before they have the chance to see you. It may make data the criteria for seeing you rather than their relationship to you. It represents a new form of intensive managed care.


It started with Medicare this summer. It’s called PQRI, for Physician Quality Reporting Initiative, and it’s now spilling over into the private sector into health plans and corporate worksite clinics. Under the initiative Medicare will pay doctors a 1.5% bonus incentive for recording and reporting quality measures, and doctors will be required to measure quality of service.


Ultimately, PQRI will probably require doctors to install software so they can comply with “best practices” and electronically record how they measure up in meeting various quality measures, of which there are already more than 500 for more than 200 clinical conditions.


What are the clinical implications of PQRI? It will require either an EHR or online software to implement best practices and to measure quality. It may give doctors incentives to treat healthier patients with better outcomes. It may cause many doctors, wary and weary of bureaucracy and paperwork, to no longer accept new Medicare patients. It will be an added practice expense. It may force doctors into larger groups so they can afford the information infrastructure they need. It may improve care and outcomes. And lastly, in the name of equality and cost savings, it may reroute patients to other care settings and other doctors before they have the opportunity to see you.


Now let’s examine how value-based reporting might work outside the Medicare setting. Today a new wave of corporate worksite clinics is opening, driven by employers’ desperation to reduce health insurance premiums by taking care of workers before they need to see outside doctors.


More than 100 of the nation’s 1,000 largest employers now offer on-site primary care or preventive health services — forecast to exceed 250 by the end of 2007. Companies opening or expanding these clinics include Toyota, Sprint Nextel, Florida Power and Light, Credit Suisse and Pepsi Bottling, and a small company in Florida called MycareTLC, which plans to franchise these clinics across multiple corporate settings.


According to MycareTLC, these clinics are projected to save as much as 45% to 50% inhealth care expenses for employers. How? Well, it’s claimed company doctors onsite can conveniently assess the situation, prescribe generic drugs on site, follow best practice guidelines, and refer to pre-selected specialists, judged by data mining to be the best performers, the most quality oriented, and the most economical. Furthermore, employees need not travel to see a doctor for routine care, pay no co-pay, receive generics at cost, and they and their families can be coached on healthy living and preventive care.


The clinics have an EHR integrated with an online editing and publishing service containing best practice information and evidence-based data on 200 clinical conditions, updated daily. In addition, the clinic and its doctors have access to information from a data-mining company which identifies high risk individuals, high performance physicians to whom to refer, and offers clinical advice and strategies to employers, purchasers, and patients.


The concept of a company doctor at worksite clinics isn’t new. Companies have had doctors on site for decades, and Kaiser Permanente turned the concept into the largest medical empire in the land. But the idea franchising medical onsite clinics across multiple corporations is relatively new and may be something for physicians to watch for and know about.





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Teamwork - Know Who Is Packing Your Parachute

This is dedicated to physician spouses, families, medical school classmates and teachers, office staffs, patients, nurses, hospital executives and personnel, the physician sisterhood and brotherhood, and Stephen Barchet, MD, FACOG, CPE, FACPM, Rear Admiral, MC, USN, who was kind enough to share with me this story.


Who Packed Your Parachute?


“Charles Plumb was a US Navy jet pilot in Vietnam.


After 75 combat missions, his plane was destroyed by a surface-to-air missile. Plumb ejected and parachuted into enemy hands. He was captured and spent 6 years in a communist Vietnamese prison.


He survived the ordeal and now lectures on lessons learned from that experience.


One day when Plumb and his wife were sitting in a restaurant, a man at another table came up and said, ”You’re Plumb! You flew jet fighters in Vietnam from the aircraft carrier Kitty Haw. You were shot down!”


“How did you know that?” asked Plumb.


“I packed your parachute,” the man replied.


Plumb gasped in surprise and gratitude.


The man pumped his hand and said, “I guessed it worked!”


Plumb assured him, ”It sure did. If your chute hadn’t opened, I wouldn’t be here today.”


Plumb couldn’t sleep that night, thinking about that man.



Plumb says, “I kept wondering what he had looked like in a Navy uniform: a white hat, a bib in the back; and bell-bottom-trousers.


I wonder how many times I might have seen him and not even said,”Good morning, how are you?” Or anything because, you see, I was a fighter pilot and he was just a sailor.


Plumb though of the many hours the sailor had spent at a long wooden table in the bowels of the ship, carefully weaving the shrouds and folding the silks of each chute, holding in his hands each time the fate of someone he didn’t know.


Now, plumb asks his audience.


“Who’s packing your parachute?’


Everyone has someone who provides what they need to make it through the day.


He points out he need his physical parachute, his mental parachute, his emotional parachute, and his spiritual parachute.


Sometimes in the daily challenges that life gives us, we miss what is really important.


We may fail to say hello, please, or thank you, congratulate someone on something wonderful that has happened to them, give them a compliment, or just do something nice for no reason. As you go through this week, this month, this year, recognize who packs your parachute.”


As I was reading Plumb’s tale, a favorite book The Successful Physician: A Productivity Handbook for Practitioners by Marshall Zaslove, MD, a psychiatrist who gives productivity seminars for fellow doctors, came to mind.



In one chapter, Zaslove says an important key to productivity is to turn to your nurse or other member of your staff and ask, “Tell me, how I could do this better?” Or, “What would you do in this situation?” Or, “How could we run the office better?” “What would you like to be called?”


Let your staff know you need their help, you’re curious what they think, you
know what they contribute, and you’re aware who is packing your parachute.

Medicare, Coding - Medicare Code Phobia: Physician Innovation Obstacle

Medicare’s code controls and phobias block many physician innovations. As Joseph Antos, an American Enterprise Institute economist and an inside-the-Beltway health care expert, asserts, “Medicare is the Sheriff of the System. You better heed the Man with the Badge.” Health plans are Medicare’s deputies, who usually meekly following payment codes set by the Sheriff.



Third parties – Medicare and health plans – set codes for 7 of 8 health care dollars. This third party intervention stops cold many physician innovations. Physicians can’t innovate on the basis of price, can’t bill individually for their services without codes, can’t bundle or set fees for episodes of care, can’t collaborate with hospitals, and often can’t introduce new procedures or types of service due to lack of payment. This set of circumstances would be unthinkable in private industry. It relies on innovation to survive and thrive.



There are other obstacles as well. As Regina Herzlinger has observed, “Medical treatment has made astonishing advances over the years. But the delivery of that treatment are often inefficient, ineffective, and consumer unfriendly.” Often one can’t be paid for innovations that save the system money; and unreasonable regulations to prevent fraud may cripple the private sector. As a result, effective technologies often remain still borne, and threatened competitors whose oxen may be gored by an innovation have the political clout to block new approaches.



Take the case of telemedicine. In a book on medical innovation, I have a chapter on benefits of audiovisual devices at homebound patients’ besides. The chapter includes a case study by Randall Moore, MD, CEO of American Telecare and Erin Denholm of Centura of Health. These two CEOs explain how bedside devices, under patients’ control, dramatically reduce hospital and ER admissions, educate patients, and subdue many complications. Yet American Telecare has a difficult time marketing their proven product beyond demonstration projects due to lack of any set means of payment.



What’s the problem? The problem is Medicare code phobia – fear telemedicine will open a coding can or worms Medicare can’t control. This is true even though a series of Medicare projects, for which Medicare has spent $60 million, using devices and computers in patients homes, have demonstrated improved outcomes and money savings for patients with diabetes, congestive heart failure, and chronic obstructive lung disease.


Medicare fears physicians and other providers will bury the system with fee-for-service charges . Medicare is biding time until it comes up codes that will pay doctors a set fee for total care management. Meanwhile Medicare is conducting its projects and restricting telemedicine codes for which it will pay. Medicare further rslows telemedicine progress by paying only for patients in demonstration projects, insisting a health professional be present when communication is established, frightening doctors with threats of anti-kickback laws, and demanding providers present evidence telemedicine is just as effective as “hands-on” treatment when no one has enough experience with telemedicine to compile that evidence.



Dr. Richard Bakalar, MD, CMO of IBM's health care and life science division and immediate past president of the American Telemedicine Association, maintains. ”One advantage of telehealth is that is allows physicians to stay closer – to retain control and retain relationships with their patients.” But the Sheriff and his deputies remain skeptical they can control physicians, so doctors remain prisoners to Medicare coding fears and whims.



Telemedicine is a technological tiger. How does Medicare bell the tiger, i.e., pay vendors and care overseers inside or outside its coding system without breaking the bank? One suggestion is a set code for the patient’s medical home – be it a hospital, home health agency, or personal physician.



1. Innovation-Driven Care: 34 Key Concepts for Innovation (Jones and Bartlett, 2007).



2. Regina Herzlinger, “Why Innovation is So Hard, Harvard Business Review, May, 2006.



3. David Glenndinning, “Medicare and Telehealth, Slow Connection, American Medical News, September 3, 2007

U.S.health care system - The More Things Change, The More They Remain the Same

In 1988 Eli Ginzberg, leading medical economist of his time, wrote The Medical Triangle: Physician, Politicians, and the Public (Harvard University Press). As I read it now, I realize how much has changed but how most things remain the same.


Here is what Ginzberg said “about beliefs that run counter to reality.”


Cost Containment: “All the talk and action notwithstanding, data provide unequivocal evidence cost containment has been largely sound and fury signifying nothing.” When Ginzberg wrote, health costs were $497 billion, of 11.2% of GNP: today these figures are $2.2 trillion or 16.0% of GNP. What we’re seeing today is more sound and fury.


Waste and Ineffective Care: “Investigators and critics have failed to design a practical program for identifying practical and eliminating suspect and harmful interventions. Today we’re at it again, with P4P and assorted metrics, which have yet to prove “practical.”



Physician Supply: “By the year 2010, there will likely a
shortage after 2010, when the baby boomers will reach
retirement age.” Ditto. Shortages are now predicted to be
50,000 by 2010 and 200,000 by 2020. More nurse
practitioners, physician assistants, and retail clinics will
not solve this problem.


Health Maintenance Organizations: “Not enough
attention has been given to the fact that new HMOs were
for-profit organizations that did not conform to the classic
staffmodel.” Well, attention has now been given, and
physicians and the public don’t like what they see.



The Pro-Competition Solution: “Alain Enthoven, author of
the “pro-competition” approach proposed that the
purchasers of insurance be encouraged to shop around on
the basis of price.” Enthoven was talking about competing
HMOs. Now we’re talking about competing consumers
and doctors. It’s early, but competition is has yet to
to dent costs

Private Insurance: “Corporations opted for self-insurance
rather than to continue to be part of a larger pool likely to
contain high-risk individuals.” This is one reason
why private insurance can no longer afford to cover most
of the population.


Long-Term Care: “Medicare is grievously deficient in
meeting the health needs due to marginal contributions to
nursing home, home, and congregate living care. Ditto.


Rationing Expensive Care: “Proponents of this view have
advanced no evidence that such a harsh approach would be
acceptable to the American public.” Or to American
physicians and American lawyers.

Prevention: “Many believers advocate monetary
incentives for those who pursue a healthy life style: it is
important to remembers some obvious facts: those who jog
develop orthopedic problems; many who are overweight
suffer from glandular, not overeating disturbances; many
chronic medical conditions are inherited ; and even the
most health-conscious, exercise-oriented , cautious
individual is not immune to cancer and other devastating
diseases. My sentiments exactly.

The Canadian Health Care System: “Several reservations
must be noted. The population of Canada is about the size
of California. Emergency departments have ad to be shut
down because of lack of beds; many filled with patients awaiting transfers to longer-term facilities that do not exist. Hospitals have been unable to purchase new equipment True, universal overage has been ensured, but the long-term outlook is not sanguine.” And long waiting times led to Canadian Supreme Court decision allowing private clinics, which are opening at the rate of one per week.

Physician Documentary, Michael Moore - The Potential Power of a Physician Documentary

Say what you will, documentaries have power. They’re a persuasive visual tool for conveying personal experiences and points of view. In the case of Al Gore and Michael Moore, in An Inconvenient Truth and Sicko!, documentaries serve as impassioned polemics to provoke the public and advance a cause.



Documentaries can also be works of calm reportage and historical narrative, as Ken Burns’ “World War II” will surely be. It will appear on public television this fall. This is the type of documentary I’ve had in mind in previous posts when I’ve called for a documentary on the experiences and views of practicing physicians in America.



The American public isn’t fully aware of pressures on physicians brought about by a mix of constant malpractice threats, high education debts, heavy workloads and long hours, administrative hassles, fatigue and exhaustion, and pervasive feelings of loss of control. A documentary featuring interviews of snapshots of physician’s personal journeys could help remedy this lack of awareness.



I’m happy to report two such documentaries are in the works – one by John Tassel, an ABC reporter who is host of 20/20, and one by Ryan Fletcher, MD, a 34 year old emergency room physician in Boston. Ryan called me the other day to tell me of his documentary quest. He has spent the last two years and his own money to compose his documentary, which is “about 85% finished.” It lacks final editing and scripting , a musical score, a few more interviews and vignettes. As we spoke, for example, Dr. Fletcher was about to fly to Seattle to interview a third year medical student, who was already $100,000 in debt and having serious doubts about a medical career.


Dr.Fletcher thinks of himself not only as an ER doctor, but as a film maker. His brother is a documentary film maker in Hollywood, and Ryan has spent time assisting his brother and learning the art of the documentary. Ryan wants the public to walk in the moccasins of practicing physicians, to share their lifes first hand, to show many are economically struggling, and to shoot down stereotypes of doctors.