Wednesday, March 18th was annual Match Day, the day graduating fourth year medical students learn if they “matched” in their chosen post graduate specialty. As I watched my Twitter feed, there was excitement from those who “matched” and disappointment from those who did not. I responded with words of encouragement for those that did not and congratulations for those that did.
One tweet really got my attention as it was a post for the number to the national suicide hotline under the hash tag #Match2022. As I read the feed, I could not help but feel sad and disappointed that a failure to match could be so devastating and lead to such a tragic contemplation. I began to think about my match day 30 years ago and how medicine has changed in those thirty years.
Of course, there was no social media or cellphones, and the internet was a shell of what we know today. It would be easy to say that such feelings of doom for those who did not match, did not exist, but they did, we were just not aware of them.
No different than this year’s class of 2022, our class of 1992 eyes and ears were hypersensitive to any new visual or verbal morsel of information. Our brains were thirsty for knowledge and our hearts were wide open yearning to have influence in the vast world of medicine and healthcare. We could not wait for day one of our residency, to begin our journey, and show the world what we could do.
But one day the absorptive, educational odyssey ended and the reality of finding a real job, practicing independently, managing people, and responding to healthcare’s unrelenting regulation, insurance, policy changes, new advances in technology, treatment, and care delivery set in.
Please do not get me wrong or take this editorial out of context. This is not a pessimistic diatribe from a disgruntled doctor. In fact, I am happier today in my career than I have ever been. This is an attempt to offer our newest class of doctors and those currently in practice a high-level look at the reality of where we stand today. Also, this is not meant to be a comprehensive dissertation on the state of healthcare. It is meant to slightly pull back the veil on what awaits the next generation of doctors and provide a sobering perspective for those in the business now who may not be experiencing the satisfaction they anticipated prior to embarking on this journey.
Oh, did I just use the word satisfaction, or more appropriately, dissatisfaction. Yes, I did. Let us examine that issue first.
According to LUDI Inc, a national physician compensation and payment solutions consulting firm, in 2021, 68% of physicians were pessimistic or indifferent about the profession and 68% experienced burnout.1
Surveys of this type tend to place too much emphasis on physician dissatisfaction and its assumed cause, administrative and electronic medical record (EMR) overburden. However, they fail to go deeper. For example, in the LUDI survey, “55% reported spending 1 to 3 hours per day on admin work unrelated to patient care or EHRs”, and “83% of physicians agreed better technology to automate administrative work would help improve productivity.”
Although these types of surveys usually stop here, it is not the end of the story. Just improve the ease of use and efficiency of technology and the world would be a much better place for providers. Really? Is that it? I think not. Who does that really serve? Let me be clear, this approach only serves the interest of companies like LUDI who sell the technology solutions and the hospitals and healthcare systems who use it to save money. I am a capitalist and from a business perspective, I have absolutely no problem with this. However, as a physician, I simply ask is this really the concern and solution for the most valuable resource in healthcare, the physician, and does it really make sense for patients, the real reason we exist?
Let us dig a little deeper. Did you notice the word “productivity”? I did. Why does that matter? And why is the doctors main concern productivity? Shouldn’t doctors’ biggest concern be the outcome of the care they deliver?
Of course, it should, but sadly, that is not how physicians are compensated and therefore, the incentive is out of line with the ideal objective, which is the best possible outcome for the patient, or value-based care.
Lead by government policy changes beginning in the early nineties and continuing into this millennium, public and private payors have sought to increase the value of care delivery by implementing value-based alternative payment systems and reimbursement to hospitals.
In this context, value equals quality and service divided by cost delivered to highest number of those in need, access. Put simply, the best possible outcome at the highest level of satisfaction for the patient, delivered at the lowest cost to the greatest number of those in need. (V=Q+S/C x A).
Unfortunately, this ideal system has not trickled down to physician compensation and incentives and thus we have the disconnect between the stated objective of high value care delivery and a highly engaged and satisfied physicians working to achieve the high value objective
Why is this the case? According to a recent study published in the JAMA Health Forum, by Reid et al, over 80% of primary care providers (PCPs) and 90% of specialists are compensated on volume or productivity. Stated differently physicians get paid for what they “do” and not the “value” of what they do.2 Sure, there are quality and cost incentives in these plans, but those represent less than 10% of compensation packages. . So, one can understand why providers place so much emphasis on increasing productivity. It is the number one mechanism to increase compensation.
Another major driver of the issues we have discussed thus far is physician employment. According to multiple sources including the Physician Advocacy Institute and Avalere Health, 70% of physicians are now employed within health systems or corporate entities including private equity firms.3
Several states have corporate practice of medicine regulations prohibiting direct ownership of physician practices but not the management of administrative functions, supply change, real estate, and human resources. Theoretically, private equity investors can maximize efficiency in these non-clinical areas, reduce cost and improve revenue, while allowing physicians the ability to make independent clinical decisions unencumbered by business operations. Yes, this sounds good on paper, but we know this does not make practical sense. The bottom line is none of these strategies have improved the working condition for providers. The productivity model is still the driver of revenue and thus physician incentives.
Furthermore, the employed model coupled with productivity-based compensation has created unique challenges and potential conflicts within practice environments. Imagine collaborating with the professionals that you are in direct competition with for patients which equates to volume, productivity, and compensation.
This can lead to unfair practices in evaluation, management and yes, even compensation. Often, junior “partners” have the worst call schedules, operative blocks, and most difficult, time-consuming, non-productive patient care responsibilities. This can affect performance evaluations, peer review and other policies and procedures that may have the affect of an unfair labor practice within these employed scenarios.
Once the excitement and delusions of what you think the practice of medicine should be, pause, and begin to work on your own vision, value, and worth. Understand first, who you are, what you want, and where you are going. Be careful not to assume the brand equity and identity of an institution is your brand. Create your own! Start today.
In the morass of chaos described here, there are two valuable diamonds in the rough, you and the patients you serve, embrace both, nurture both, deflect the noise a enjoy the journey.
“Go confidently in the direction of your dreams! Live the life you have imagined. As you simplify your life, the laws of the universe will be simpler.” -Henry David Thoreau
William A. Cooper, MD MBA is a board-certified cardiothoracic surgeon. He is a solo, independent contract practitioner. He is the Founder and Chairman of PRIMO Health Partners.
Social Media: @drcoopmd