While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Although new numbers from the Bureau of Labor Statistics (BLS) report a 24 percent growth in jobs for physicians and surgeons by 2018, with doctors benefiting from an increase of 312,500 new jobs in the health care sector over the past year, fewer physicians are choosing primary care or to starting private practices. A June 2011 study by Accenture reports that by 2013, less than one third of physicians will be in private practice.
Many experts suggest that financial pressures are the primary driving force behind the shift, but younger doctors with new attitudes about work and lifestyle are also changing the way clinicians practice. Newly minted physicians (48 percent of new graduates are women) maintain their commitment to patients, but many are juggling work and family responsibilities. But of course, money still plays a role. More than half of them finish their training with at least $100,000 in student loan debt, while veteran private practice physicians face increasing costs on several fronts. The combination of these pressures and policy changes are shifting how physicians choose their specialty and the environments in which they practice medicine.
Weighing in here on the newest practice trends are Mark Linzer, MD, director of the division of General Internal Medicine at Hennepin County Medical Center in Minneapolis and a professor of medicine at the University of Minnesota and Glen Stream, MD, the president of the American Academy of Family Physicians and a family physician in Spokane, Wash.
Linzer has worked on several Robert Wood Johnson Foundation (RWJF) grants. The Physician Work Life Study (1996-98), was a national survey of physicians. An additional study funded by RWJF in 2007 focused on instruments to measure a healthy clinical workplace that minimizes stress and burnout for health care providers.
RWJF: Dr. Linzer, your research, published in the April 2011 issue of the Archives of Internal Medicine, “Changes in Medical Students’ Views of Internal Medicine Careers from 1990 to 2007,” indicates that fewer doctors are specializing in primary care medicine than they did 20 years ago. What’s driving that shift?
Dr. Linzer: Physicians choose a career that fits their interests, but they also have other factors to consider. Many are part of dual career couples now, so they are looking for time for family. Our data show there’s a very strong commitment to society: they’re committed to making the world a better place, but they also have very practical concerns about debt and family.
RWJF: What’s the current outlook for private practice? Is it harder or easier to make a go of it on your own?
Dr. Linzer: You can be in private practice if you share practice with a group of other physicians. But, practitioners have to find innovative ways to practice this specialty, if it’s going to compete with other types of medical practice that offer more favorable work schedules. The idea of being on call at most times is not favorable. It will take strategies that allow teams to rotate on-call duty and allow physicians to share electronic records. Physicians report that they like the relationships and the long term challenge of managing the health of a group of patients. The work itself is favorable, but the work life can be challenging.
Dr. Stream: It’s clear that over time, fewer and fewer new family practice physicians are starting their careers in an individual or small practice. With the shortage of available family physicians, many hospitals or larger integrated health care delivery systems offer a guaranteed salary, moving expenses, and educational debt forgiveness.
It’s also a challenge to run a small practice. The business aspect of it—such as the interaction with health plans, government regulations and managing staff— that’s not what physicians typically learn in their residency training.
In addition, large practices have some advantages in the current health care market. A small practice might receive a take-it-or-leave-it contract from insurance providers. But a large multi-specialty group, that’s also a dominant health care provider in a community, can negotiate better payment rates. Those larger practices also have staff to navigate that environment, such as a practice administrator or CEO.
RWJF: How will the Affordable Care Act (ACA) affect the physician workforce?
Dr. Linzer: I think it’s helped to raise the profile of primary care. But, electronic medical records present both an opportunity and challenge. They provide a means for physician teams to share information, but they also present an additional portal of patient access that could add to physician stress, making them feel as if they’re constantly on call.
Dr. Stream: The debate over the ACA has brought uncertainty to physician practice and that will continue, even if it goes forward as written. Many smaller practices will adapt by merging into larger groups to function in this environment. Some practices may adapt toward a micro practice model, with a single physician and another employee who handles receptionist duties, taking blood, and administration. This strategy could drive down overhead costs enough to serve as a viable model. A micro practice or group practice might also be able to contract with a local employer directly for basic medical care, cutting out the expense of working with an insurance provider.
Blended payment models, such as those being tested by the Center for Medicare and Medicaid Innovation, may also help primary care. Insurance models that compensate primary care physicians with a care management fee, such as a monthly payment that covers following up with patients over time and reminding them of overdue wellness care, could help make the health care system more cost effective. My hope is that those features will evolve out of the ACA and transform primary care.
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