Almost cut my hair,
Happened just the other day.
It was gettin’ kinda long,
Could’ve said it was in my way.
But I didn’t and I wonder why,
I feel like letting my freak flag fly,
And I feel like I owe it to someone…
I’m suffering from whiplash — perhaps I should call one of those attorneys whose ads I see at bus stops and on the back of grocery carts…
In a recent post, I waxed euphoric about a big transition in my professional life, wherein I would move from being a solo practitioner to a hospital group employee, working predominantly in an inpatient capacity, with a much reduced load of office paperwork and business responsibilities, with the expectation of significantly more free time. I was truly excited about these possibilities, and felt great relief at the promise of unloading the crushing burden of paperwork, compliance with endless government regulatory demands, intrusive and abusive audits, and a host of other ugly and unpleasant parasites which suck all the life out of the profession of medicine.
More pay, less work — what’s not to like?
That was yesterday. And this is today: I have decided not to pursue this course — or perhaps, more accurately, this is not the course chosen for me to pursue.
The decision is, in a way, rather shocking, a wrenching change of direction for which I was wholly unprepared, and which is still deeply unsettling. I feel in some ways like the shipwreck sailor, watching a passing ship — recently his only hope of salvation — sail slowly into the distance, as he floats, unseen and unsaved. At yet there is a certainty that this sudden change of course is the correct one — though I’m quite in the dark about what comes next.
So what changed?
Nothing whatsoever about my current situation: private solo practice, as it is now configured, has become an enormous burden in so many ways. It’s ugly — and getting uglier in a hurry.
Much of the non-medical world seems dimly aware, if at all, of the tectonic changes occurring in health care. Patients are beginning to notice that their doctor’s practice name has changed to something like “Big Hospital Medical Associates”, but otherwise see little change: they can still see their doctor, the staff is, by and large, the same familiar faces, no worries, carry on.
Behind the scenes, however, the changes are enormous. As of 2009, 65 percent of established doctors were in hospital-owned practices. That percentage is growing rapidly, as physicians and other providers, such as nurse practitioners, flock to the perceived safety and security of large groups and hospital-owned practice affiliations.
The attraction is undeniable: offloading the burden of burgeoning administrative and regulatory requirements; attractive first year salaries and sign-on bonuses, combined with the promise of more free time and predictable schedules; and the lure of better reimbursement for services due to a large organization’s greater heft in negotiating contracts with insurance companies. It’s easy to overlook the potential downsides when the eye candy is so attractive.
After much happy talk and eagerness from the hospital recruiters and medical administrators, the process of merging my practice with the hospital group moved like continental drift. Months passed with no action; emails and phone calls were answered slowly, if at all. My frustration was enormous, but the delay proved a blessing in disguise.
The bad news trickled in slowly, as I waited, impatiently. A large local hospital group announced layoffs of nearly 400 people, for starters — no administrators or middle managers, of course: only the clerical and support staff that keeps a practice running. A busy surgical practice with an incompetent scheduler could not fire her (her race guaranteed a discrimination lawsuit), so they simply eliminated her position — and now they have no permanent scheduler for a year. Other schedulers were moved offsite, far removed from the physicians and practices whose lives they controlled. A former associate, a true workaholic who routinely saw 50-60 patients a day, had his salary cut because he wasn’t productive enough(!!). Highly-trained support staff were told they could not perform certain procedures because the hospital legal department decided their license did not permit them to perform them — although the procedures themselves were not restricted under their state licensing privileges, and they were far more highly skilled and experienced at these procedures than those “credentialed” to do them.
Big picture insights also came into play:
Hospitals lose $150,000 to $250,000 per year over the first 3 years of employing a physician — owing in part to a slow ramp-up period as physicians establish themselves or transition their practices and adapt to management changes. The losses decrease by approximately 50% after 3 years but do persist thereafter. New primary care physicians (PCPs) contribute nearly $150,000 less to hospitals than their more-established counterparts; among specialists, the difference is $200,000. For hospitals to break even, newly hired PCPs must generate at least 30% more visits, and new specialists 25% more referrals, than they do at the outset.
Chained to the oar, the galley master pounding out the cadence…
After 3 years, hospitals expect to begin making money on employed physicians when they account for the value of all care, tests, and referrals. … Outpatient office practices of employed physicians seldom turn a profit for hospitals.
Interesting — most private outpatient office practices are profitable, although less and less so.
Hospitals are willing to take a loss employing PCPs in order to influence the flow of referrals to specialists who use their facilities. In the 1990s, hospitals usually guaranteed physicians nearly 100% of their previous year’s salary during their transition to hospital employment. This arrangement invariably led to losses, since drops in productivity were coupled with higher overhead expenses and less-effective revenue-cycle management. Today, aggressive hiring of PCPs is returning, in part because hospitals fear physicians’ becoming competitors by aggregating into larger integrated groups that direct referrals and utilization to their own advantage. Hospital-employed PCPs generally direct patients to their own hospitals and specialists affiliated with them. In addition, by employing physicians, hospitals retain maximum flexibility in the market, should health plans change their reimbursement structures to require providers to bear risk and manage population health…
Though hospital employment may offer physicians some protection from system reforms, it comes with more performance management than it once did, and the option of reverting to independent practice later may be far less attractive in the future. Employment choices that physicians make today may not be able to be undone.
The hospitals hope to make up for their physician employment losses by improvements in productivity and “performance management” [read: controlling physicians' decision-making based not on quality, but on cost]. That these economic “efficiencies” are largely illusory — and will harm patient care — will become evident in time. This scenario played itself out in the early 90’s, when hospitals bought up practices in anticipation of Clinton Care. They proved financially untenable and ultimately imploded, after massive cuts in support staff and physician salaries made continued hospital group affiliation untenable. The enormous economic pressures soon forthcoming through ObamaCare and ACOs (more on these anon) will invariably result in similar scenarios — with far fewer escape hatches for increasingly unhappy physicians. They will be locked down by highly restrictive regulation and “care standards”; locked in by non-compete clauses and the insurmountable hurdles to starting or returning to practice; and locked out completely of the decision-making processes which control their lives and their profession. Expect a tsunami of early retirements and career changes when this is fully implemented.
And in the unlikely event the hospitals succeed economically at this venture, through the will to power, you may be assured that the vultures will soon descend to strip the pink flesh off their bones:
The consolidation wave [hospitals acquiring practices] is raising red flags among some regulators, researchers and health insurers, who warn that bigger health systems can use their leverage to push for higher rates. “We’ve always been concerned about combinations that are being done to increase prices,” said Karen Ignagni, chief executive of America’s Health Insurance Plans.
These factors made for a long and poignant pause in my rush to employment. But the final straw proved to be the realization that my reconstructive infertility specialization, built laboriously over 30 years with much hands-on care and effort, would die on the vine under hospital management. I would lose control over pricing; lose control over my superb supportive employees who are masters at communicating with patients an the many issues involved in these cases; and lose the freedom to provide discounted and charity care when the Spirit leads.
So my “Dear John” letter went out, two weeks ago. My employees were ecstatic at the news, my wife enormously supportive of the decision (she had previously been a major force prompting me to seek the security of hospital employment, and has now done a complete 180), and I have an enormous peace with the decision in my own soul. Perhaps, like Odysseus, I have been tied to the mast, lest the Sirens lure me onto the rocks of disaster.
Of course, the problems of sustaining and surviving in the hostile environment we now inhabit in health care remains; thus it becomes now a journey of faith.
Ah, faith: not the blind confidence in the unbelievable, but trust in the eminently Trustworthy, without the clarity of vision one might wish, but with the vision of hope based on experience. He has never let me down; He will not do so now.
It should be a most exciting journey.