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Friday, February 14, 2014

Physician Experience vs. Expectation

During the past decade we have witnessed the corporatization of medicine.  Solo private practice physicians in the U.S. are dwindling rapidly in the United States, except perhaps for a few selective specialists and in underserved areas. Some physicians are experimenting with the new "Direct Payment" model or "Concierge Medicine"

Although private solo or small group practices offer autonomy and control, there are disadvantages. Those who join an integrated health system, or become employed by a hospital gain administrative support and the ability to negotiate insurance contracts with more bargaining power than a small provider. However there are serious trade-offs. Physicians who sell their practice to a hospital find that hospitals receive failing grades in their prowess to run medical practices.

This is a relatively new phenomenon and hospital management may improve in the next several years. Kaiser seems to have met the challenge by forming a separate entity for a medical group which then interfaces with the hospital.  The governance structure is distinctly separated.   This allows the providers negotiating power and the abiity to make more decisions for themselves.

There are other issues in making this transition to a group practice.  Cultural clash  and generational difference can also affect the new relationship.

 Modern Health Care presents this case

"Dr. Janet Chipman worked for more than a decade in a busy surgery practice she owned with three other physicians, treating patients and sharing the responsibility of running a multimillion-dollar business. She says she valued the autonomy of private practice, which was a common career path among her peers and one she sought when she finished her training.

"But nearly three years ago, Chipman and her colleagues signed an employment contract with Baptist Health, a Kentucky hospital operator that has doubled its number of employed doctors to 485 in the past three years. They felt that joining a sizable health system would boost their negotiating leverage with health insurers and make it easier to recruit surgeons into the practice. They'd also have more bargaining clout with vendors. And it would be more viable to participate in one of the new alternative payment and delivery models, such as an accountable care organization

Even so, Chipman had plenty of doubts before signing the deal. “The decision was incredibly hard for me personally,” she said. “I came from the culture of having your own practice and your independence.”  

Not so for Dr. Nicole Lee. The first-year fellow in maternal and fetal health at the University of Mississippi will enter the workforce in two years. She expects to go directly into hospital employment. That's because working for a large health system likely will mean less on-call duty, allowing her to balance work and personal life. “If I have a family, they will definitely be my priority,” Lee said. “Being on call every other week is not feasible to me.”

Other factors enter decisiono making processes
Regular work hours, enhanced family life
Guaranteed on call coverage
Working for a large health system likely will mean less on-call duty

Younger physicians work ethic has changed, largely bevause of new workoplace rule setting strict liits for work hours, and call schedules, caliing for controls much like the airline industry for pilots to reduce risks of error due to fatigue. When thes physicians enter the workforce they carry over this new ethic in private prctice.

Doctors moving from independent practice to employment may be more autonomous, business-savvy and likely to prioritize work over other obligations. But they also may chafe under bosses and rules. “They're used to setting the rules,” said Dr. T. Clifford Deveny, Catholic Health Initiatives' senior vice president for physician services and clinical integration. “One of the things you give up is that complete independence.” 

Younger doctors may have no experience with or desire to take on demanding call schedules or leadership roles. “They're looking for lifestyle,” said Danise Cooper, manager of physician recruiting specialists for Cejka Search

Thrown together, once-independent physicians and younger doctors may clash over how to share the

workload and rotation duties. In addition, physicians may differ in how they respond to their employer's invitation to participate in quality improvement or strategic efforts. And since physicians may treat one another's patients, some doctors may worry about how their colleagues' work ethic and attitudes and accessibility to patients may reflect on them and influence their patients' satisfaction. 

Cultural discord among doctors can lead to costly turnover. Culture conflict ranked in the top five reasons for turnover among doctors in the most recent retention survey by the American Medical Group Association and Cejka Search. Hospitals lose revenue when doctors depart.

The shift is taking place relatively quickly, and may accelerate even more with the mandates of the Affordable Care Act, as more physicians are saddled with non-medical responsibilities.

Twenty percent of U.S. doctors worked for a hospital in 2012, according to the American Medical Association. That figure rises to 26% if you include doctors in a medical practice partly owned by a hospital. Six years earlier, 16% of doctors were hospital employees..

The growth in direct hospital employment of physicians has accelerated for a variety of reasons, including new payment models offered by public and private insurers that bundle payments for hospitals and doctors for entire episodes of care or establish financial incentives for providers to coordinate care and achieve better outcomes and lower costs. These new models require closer collaboration between hospitals, physicians and other providers, and may be easier to achieve when physician practices are more closely integrated with health systems.

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