Here, Steven C. Anagnost, MD, discusses the future of independent practice and solo physicians in the rapidly evolving healthcare arena.
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Certain idioms seem to always hold true — We live. We die. We pay taxes. It seems we may need to add to this list: We will all get sick at some point and have to take part in our confusing world of healthcare and insurance reform.
While we hear on the news the frustration and the cost of dealing with recent healthcare changes in the last eight years, what we hear less of is how these changes have drastically altered the landscape of how physicians are allowed to care for their patients. With legislative changes, physicians have been pigeonholed into new regulations from the federal government. Private insurance industry has piggybacked onto these new regulations to force doctors to play by rules which many times seem to advocate for the insurer, rather than the patient. These regulations and bureaucratic red tape have produced huge financial burdens on physician practices. Much like Walmart and Home Depot, the small, mom-and-pop stores are shoved out, along with any semblance of personal service and caring. Thus, medicine has become much more of a bottom-line business, rather than an art and practice of individualized caring from doctors, and ethical and moral safe haven for patients.
One example of this is the EMR. Healthcare reform began some of its earliest changes by demanding and requiring physicians to adopt an EMR. This was done under the threat of fines and levies to doctors who did not comply. As we know, implementing an EMR is an enormous expense to a practice. Solo practice and independent physicians undergo a much larger financial burden to implement these expensive changes required by the federal government. Larger hospital-employed multispecialty groups were able to adopt these expensive requirements more easily. Hospitals, who often work hand-in-hand with the government via large and powerful lobbying groups in Washington D.C., were much more easily able to absorb and implement these expensive mandates of purchasing and implementing the electronic record. Recent mandated healthcare reform, also required doctors to adopt these EMR practices, with no standardized format for the kind of EMR systems. In fact, each year, the government would change these requirements, sometimes making the new EMR system a doctor just purchased obsolete. These EMR systems can be in the $50,000 to $100,000 range.
While healthcare reform is forcing these changes on to doctors, it is concurrently lowering the reimbursements to doctors across the board. There is no other industry that lowers the reimbursement rates each year for the same services in such a drastic way as medicine. The formula is less money for doctors and a huge increase in expenses. It is a recipe for disaster with both doctors and patients suffering the consequences.
The independent physician is the cornerstone of American healthcare. Americans demand a physician who is empathic and spends time with each patient. Independent doctors have stood up to the large insurers, and hospital lobby, to do what is best for their patients, and not simply what is best for the bottom line of the corporate health ledger. With reimbursements going down each and every year, and expenses skyrocketing, the independent physician must see more and more patients, in order to meet these demands and expenses.
Physicians are trained to treat patients, not to necessarily be the best business managers. The independent physician is the most susceptible to these financial burdens. Thus in recent years, there has been a mass exodus of independent physicians from solo practice and into hospital employment. This trend from independent physicians to hospital employment is mostly based on the financial burden weighing upon independent doctors. This has resulted in a loss of autonomy of the practitioner, and a decreased ability to do what is right for the patient.
This has led to the some of the current anger patients are feeling in dealing with doctors and healthcare. Doctors are forced to spend less time with patients, because each year, the independent doctor get less and less reimbursement for his or her work. Thus, the only way to keep up, is to see more patients in the same amount of time, to make up the difference and stay afloat. Quality of care suffers and patients suffer.
Insurance premiums are skyrocketing and deductibles are increasing. Employers are no longer able to keep up with the medical insurance premium increases. Patients are getting less care, for more money. This is because fewer and fewer independent doctors are out there, fighting for their patients. Doctors are opting to forego the hassles of regulations and joining bigger hospital systems or insurance companies who will cover the increasing practice expenses and regulation for doctors.
In order to fiscally survive, doctors must become part of a larger hospital system. Unfortunately, doctors are realizing that even though they are giving up control, they are still held to be ultimately responsible for patients legally. Less control and more liability can and will likely lead to disaster for many doctors in the future.
In our colleges, medical schools and residency programs throughout the United States, teachers and doctors alike strive to recruit top young minds to enter into the morally rewarding field of medicine. With modern healthcare's increased regulations and decreased reimbursements, all while demanding more hours worked, many of the nation’s top students are not pursuing medicine as a profession. Soon, medicine will no longer have students from the top of the class, because these top students are increasingly choosing profession other than medicine. I mentor young students and residents in my office and OR. I am all too frequently asked, "why would anyone want to work this hard, with so many hassles in medicine, with all that debt and time in school, when we can just go into business?" Honestly, it is becoming harder and harder to remain optimistic and positive about the beauty of medicine, which is increasingly overshadowed by the negatives of increased regulation and liability, with decreased reward.
National trends show fewer and fewer students at the top of their graduating class choosing medicine. Does anyone want their neurosurgeon to be from the bottom of his class? Of course not! But this is what is happening, much of this is due to the insanity of recent healthcare reform. Healthcare reform has frightened many of the brightest minds away from the field of medicine. This occurs at a time when the baby boomer population is exploding. The population of U.S. citizens over the age of 65 is set to quadruple in the next two years. These senior citizens of America have already paid their hard-earned dollars to Medicare, only to need it now, and then find out that the money has already been spent.
In a system of exponential increase in regulation of doctors, combined with yearly decreased reimbursement for services and procedures, the future of both the independent physician as well as the hospital-owned physician, are both fated between a modern day Scylla and Charybdis; with danger on both sides of this Catch 22 dilemma of current day healthcare.