The Future for Physicians: The Realities and Challenges

Last week, the nominee to run the Centers for Medicare and Medicaid Services, Seema Verma testified before the Senate Finance Committee. She conveyed a message akin to that of her new boss, Health and Human Services Secretary Tom Price, a physician and House of Representatives veteran: the federal government has made life miserable for providers adding unnecessary complexity and cost.

She challenged the value of electronic health records especially in small practices and rural settings and likened interoperability to a bridge too far. And she observed that Medicare and Medicaid, that cover 128 million Americans accounting for $1 trillion in federal spending, should play a leading role in fixing the problems it has created.

In their confirmation testimony, both Verma and Price were particularly deferential to the plight of physicians, explicitly associating the profession’s challenges with laws and regulations that frustrate clinicians and compromise patient care. It’s clear the role physicians will play in the post Affordable Care Act era will be a prominent theme under their leadership. The realities are these:

1.   Physicians are respected: Gallup polls have consistently placed physicians ahead of all other professions and just behind nurses and pharmacists. By contrast, Congress and car salespersons are at the bottom. Since 2001, Gallup’s surveys have shown the public’s level of respect for physicians has been relatively unchanged, while other professions have seen erosion.

2.           Medicine is a high profile profession: Daytime and prime time TV would be void of content were it not for medical drama: from Gunsmoke’s Doc Adams to Marcus Welby, Doogie Howser and House, pop culture includes a unique depiction of the heroics and humanity of this profession. And, as a result of the Physician Sunshine Act and 5000 websites where physician profiles can be obtained, the profession’s visibility is unparalleled. At least 80% of adults have searched online for insight about a physician they have seen on sites like HealthGrades.com, Vitals.com, Yelp.com, YP.com, RevolutionHealth.com, RateMD.com, Angieslist.com, Checkbook.org, Kudzu.com, and ZocDoc.com

3.           The running a medical practice is a tough business: coordinating care with multiple payers and capturing mandated quality measures costs $40,069 per physician (Caslino et al Health Affairs 3/16). More than 250,000 have elected to work under employment agreements with hospitals to mitigate the hassle. Federal regulations mandating the implementation of electronic medical records, quality reporting and participation in value-based purchasing programs have led the majority of physicians to suspect the profession’s future is not bright.

4.           U.S. physicians are paid well: median compensation for physicians varies widely by specialty, with the lowest paid (hospitalists, psychiatrists, intensivists, internists, pediatricians, and family physicians) earning 5 times the average U.S. household and the highest specialties (orthopedics, invasive cardiology, plastic surgery, gastroenterology, and radiation oncology) earning 11 times the average. And for many specialties, additional income is earned from in-office procedures, ownership of diagnostic and surgical facilities, and practice related investments. (Modern Healthcare 2016 Physician Compensation Survey). Nonetheless, 28% of physicians saw their income shrink last year as a result of increasing administrative costs in their practices (Nerdwallet).

5.           Most physicians aren’t happy: the average physician waited 9 years after undergraduate school to begin practice (AMA) and three in four left with debt averaging $166,750 (Nerdwallet). Per the Physicians Foundation Survey, the majority are dispirited and burnout is an issue for growing numbers. While the majority would choose medicine as a career again and incoming MCAT scores remain high, the intangibles of the profession seem to be fading among many medical students.

6.           Demand for physician services is increasing faster than the supply: Last year, only 83% of adults and 92% of children saw a physician or advanced practice nurse (CDC) accounting for almost 1 trillion visits. Per the AAMC, the shortage of physicians is acute: between 46,000 and 90,000 including 13-31 PCPs with the most acute needs in rural areas (Institute of Medicine). The fact is no one knows for sure what the shortage is, since the 51 states and territorial licensing boards monitor clinician practice activity differently. Four of five physicians say they’re over-extended and three in four think additional physicians are needed. Given the doubling of the senior population in the next two decades and increased role of mid-level practitioners, it’s difficult to know for sure how the profession should address its demand. But it’s clear how patient care is delivered is likely to change as technologies and incentives change.

But for the profession to maintain its central role in reforming healthcare, it must be more effective in addressing four issues for which it will likely be held accountable:

1-Health costs and affordability: National health expenditures last year were $3.35 trillion, or $10,435 per capita. The recommendations of physicians to patients drive 80% of these costs, though physicians are unaware of and not trained to consider costs in their recommendations. (AMA Code of Ethics). The scoring for the Merit-based Incentive Payment System (MIPS) reflects growing regulator assignment of cost-management as a core competence of medical professionals: in 2019, only 10% of physician performance will be weighed against effective cost controls, increasing to 15% in 2020 and 30% in 2021 (against 30% for quality, 15% for clinical practice improvement and 25% for use of information technologies). (CMS). As part of the MACRA reimbursement program, physician compensation by Medicare under MIPS will be adjusted plus/minus 4% based on their performance in these four categories. As a result, physicians will be forced to pay closer attention to costs, whether comfortable or not.

2-Patient adherence: patients rely on their physicians for treatment recommendations, and 80% augment these with their own online searches. But patient adherence to treatment recommendations is problematic: most prescriptions are either not filled or not followed as directed (Lexis/Nexis Risk Solutions 2016). The majority of newly diagnosed patients do not receive follow-up communication from their practitioner unless the diagnosis is grave. And adherence to treatment recommendations, which ranges from 50-63% depending on the condition, is enhanced by follow-up interaction with an individual’s physician (CapGemini). Non adherence costs $300 billion yearly for avoidable hospitalizations and mortality. It’s an opportunity and challenge for the profession!

3-Weeding out bad actors: for $9.95, anyone can obtain a report on disciplinary actions taken by the Federation of State Medical Boards against a clinician. But physician misconduct and impairment, conflicts of interest that might influence a treatment recommendation, and non-adherence to evidence-based practices far exceed these official reports. The majority of physicians practice ethically and with integrity putting their patients’ interests first. But like every profession, there are bad actors, and medicine’s aggressiveness in weeding them out has been lacking.

4-Integrating technologies that improve care coordination and outcomes: two in three U.S. adults believes telehealth and online interaction with their physician would improve care and they expect to pay for this service (American Well Telehealth Survey 2015). The majority want access to their own medical record and think clinicians who are accessible online are more current in their training and expertise. They recognize that electronic medical records are useful in improving care coordination, diagnostic accuracy and error avoidance. But most practitioners have resist their use fearing exposure to liability and additional costs as their rationale. E-health and data-driven healthcare is here to stay: how the profession embraces both is its challenge.

No doubt, Dr. Price and CMS Director Verma will seek to restore the professions’ sense of purpose by tackling the administrative costs and complexity of practicing medicine. It’s music to the ears of physicians who are understandably anxious about the future for their profession.

But addressing these four challenges is equally important and they’re keys to the system’s future as well.

Transforming healthcare is not about hospitals, insurers and the profession of medicine. They play key roles, but it’s ultimately about patients—the role they’ll play and the choices they make.

Paul