health care

Doctors Don't Have To Quit To Become Less Accessible

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Doctor

I wrote a week ago about a survey revealing declining morale among physicians and a desire by a majority of them to scale back their practices or even leave medicine entirely. I received some very thoughtful, well-considered responses, which essentially boiled down to: "Those rich bastards should suck it up and treat our boo-boos for whatever we choose to pay 'em. They can't afford to quit, anyway!" This is, of course, a compelling argument. It's also unlikely that a large percentage of physicians, no matter how demoralized, will abandon medicine en masse, both because of economic concerns, and because it's hard to abandon a career in which you've invested many years of life. But even if none of those unhappy physicians abandon ship, it's undeniable that the healthcare industry is moving in a direction that will leave patients scrambling for access to doctors.

Most people agree that demand for physicians already outstrips supply in many areas, and that the problem is likely to get worse. The Association of American Medical Colleges says there was a national doctor shortage of 13,700 in 2010, predicted to grow to 130,600 (PDF) by 2025. Even allowing that the AAMC has an interest in recruiting eager new students to its pricey campuses, there seems to be  too few doctors to go around, with demand likely to grow for that limited supply. But even if the numbers of doctors don't fall as short as predicted, the number of patients they see very likely will. That's because doctors are pulling down their shingles and taking salaried jobs with hospitals and other employers, and as they do so, they see fewer patients in any given day.

Independent doctors

According to American Medical News:

Hospitals directly employ about 20% of practicing physicians, according to the American Hospital Assn. Many other physicians are employed in group practices owned by health systems. The proportion of doctors in independent practice is now a minority, says the MGMA-ACMPE, the entity formed by the merger of the Medical Group Management Assn. and the American College of Medical Practice Executives. That matters because hospital-employed physicians work fewer hours and see fewer patients than do independent doctors, the foundation's survey showed.

Employed physicians averaged 53.1 hours a week, compared with 54.1 for doctors in private practice. Employed physicians saw 17% fewer patients — 18.1 a day­ — compared with 21.9 a day seen by practice-owning doctors. Slightly more than 20% of employed doctors worked fewer than 40 hours a week, compared with 18.4% of physicians with an ownership stake in their practice. More than 60% of physicians younger than 40 are employed by a hospital, physician group or other entity.

"We know that an employed physician is less productive than a practice owner," said Smith of Merritt Hawkins. "Physicians are looking for a safe harbor [in hospital employment], for someone to say, 'I think I see what's coming, and I can mitigate this risk for you.' "

That makes sense. Few people work as hard for other people as they do for themselves. And that temptation to slack off, just a little bit, represents patients unseen. The migration of physicians from independent, private practices to employed positions has been continuous as the challenges of dealing with red tape and both public and private insurance have risen. There are no signs of those difficulties easing in the near future, so the trend of employee-doctors will likely continue.

And, yes, that means it will be harder to get in to see your doctor.

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  1. If I were a doctor, I think I’d consider operating a cash-only business. No government crap, no insurance. Fuck it.

    1. More and more are going to that.

    2. Any time I go to the doctor now and tell them I’m paying cash, their poor assistants have no idea what to do.

      1. That’s because they were confused as to whether that was a money roll, or you were just glad to see them.

        1. Well they are about the same size.

          1. Oh, you poor, poor man.

    3. Clinic docs running cash-only businesses tend to get extra visits by the DEA.

    4. I found it hard to find an independent doctor that simply wasn’t affiliated with a major co-operative. Cash only? I’d love to see that.

      But I’d love to see them post prices too. THEN we’d be talkin’ about a game changer.

      1. Wal-mart is.

        That is one of their guarantees at their clinics — prices will be clearly posted.

        1. “CAN I GET A PRICE CHECK ON ANAL WARTS? PRICE CHECK ON ANAL WARTS, PLEASE.”

          1. PLU-456-756

            That is per each discrete verruca.

            1. Will you then commence Verruca Assault?

              1. As soon as the check clears.

          2. They’ll have to be HIPAA compliant, so I suspect no PA systems tied to the clinic.

          3. But will they get you out of ‘nam?

            Take it from here, shrike!

    5. This is how my doc operates. $50 office visit. No insurance. Cash, credit or check. A price list for procedures is posted in the lobby. They will point you to the low cost labs and imaging when needed. Supported Ron Paul. Good people.

      1. Fuck. You’re not in Colorado, are you?

  2. Fortunately, the shortage of doctors is mitigated by the limitations on physician education and certification through the Med School and AMA cabals.

    Oh, wait….

  3. “We know that an employed physician is less productive than a practice owner,” said Smith of Merritt Hawkins. “Physicians are looking for a safe harbor [in hospital employment], for someone to say, ‘I think I see what’s coming, and I can mitigate this risk for you.’ “

    I find this interesting and a bit surprising, but I’ll accept the numbers.

    Having worked 1.5 careers in Healthcare, both in Hospitals and Clinics, it always seemed like the practice owner/docs worked three, maybe four days a week, taking Wednesdays for golf, leaving early on Fridays and not really feeling Mondays either. Closed weekends.

    True, I’m exaggerating, but in our Hospital owned practices, they crack the whip: Clinic docs will see this many patients a day, Clinic docs will do this many RVUs a month, Clinic docs will…will… will.

    Which is why we occasionally have a clinic doc jump ship, open up his own independent clinic so he can pull back to three days a week.

  4. Welcome to single payer headaches!

    I know the US is not there yet, but its still a mess. As a Canadian I cannot doctor shop. I have a ‘family’ doctor and I am lucky to like him. If I don’t like him I can’t go to another doctor, they are all filled up. Worse for my wife, she wants a female doctor. She can’t sign up where my doctor works, not taking new patients.

    Centralized control=shortages

    1. I can’t believe that morons like Tony and Shrike still haven’t been able to figure this out.

      1. Why, is it hard to believe that Christian fundies can’t figure out evolution? It’s not that Tony can’t understand market forces, it’s that he doesn’t want to believe in market forces because they’re against his religion.

  5. I’m not sure why people seem to think that the consolidation and corporatization we’ve seen in pretty much every industry must be the result of government and not normal market forces when it happens in healthcare. Which is not to say there aren’t problems created by government, but this isn’t one of them.

    1. This is basically just the doctor version of “OMG, WALMART IS DESTROYING MOM AND POP STORES WE MUST STOP THEM”, yet for some reason Libertarians are taking the protectionist side this time.

      1. Not really. The point of the article is not a plea to save the private practice, rather an observation that statistically speaking private practice doctors see fewer patients a day than ones who are simply employees of some company and in an environment where there are already shortages of doctors which are guaranteed to get far worse as 30 million previously uninsured enter the system even a small decrease in “productivity” from the doctors can have a major impact on a patients ability to find a doctor.

        No one is crying to save the private practice, they are warning that perhaps we should not be herding doctors out of them and into corporate controled employee situations quite so fast.

      2. Libertarians are taking the protectionist side

        Apparently you don’t know what protectionist means.

        If Libertarians were advocating for protectionism, then they’d be asking for the government to take steps to tax consumers of the “wrong” product, making it more expensive, and thus encouraging them to consume the “right” product.

        No, there is no advocating for protectionism here.

      3. I disagree. Market forces are not at work here, because without gov’t over-regulation of the health care industry, private practice docs would not have to deal with half of the paperwork that they have to deal with now. More paperwork=more people to put on payroll to sort it all out, and more people on payroll=more costs to run a private practice.

        Doctors understand that there is some paperwork involved, but every doc I’ve talked to has said that medicine is not the same as it used to be and has turned into one huge bureaucratic headache.

        In turn, doctors are more attracted to hospitals, where the pay is often higher, and they do not have to worry about the business-side to the degree that private practice docs do.

      4. For my field, Medicare pays 30% more for the same procedures in hospital-owned practices compared with standalone clinics. This is for a field that is majority older patients. You’d better believe that’s a big incentive to centralize.

    2. Because in this case it really is government action causing it. Maybe the market would have headed that way one way or the other however government interference into the market is effectively mandating it meaning that it is highly likely that it is being done in a sub optimal manner because it is not being driven by market forces and consumer preferences.

    3. Applying the term “normal market forces” to the American healthcare sector is a clear signal that you have no idea what you’re talking about.

    4. Which is not to say there aren’t problems created by government, but this isn’t one of them.

      Explain. Because I see this as the government and Big Healthcare conspiring to create regulations so onerous that an independent doctor doesn’t have the time nor the staff to deal with all of the paperwork and red-tape (not to mention the threat of malpractice, which a large hospital can absorb, but would utterly bankrupt a private doctor).

      1. You missed out on DEA raids because they perscribed one too many bottles of Oxycontin in the last 3 months.

      2. Even if the government was uninvolved in healthcare, there would still be tons of paperwork and red tape. And it’s economically inefficient to have your medical specialists doing more of it than necessary. Instead of having five individual practices where doctors spend 20% of their time on paperwork, it’s more profitable for them to join into a group practice an hire someone else to do it, freeing them up to see more patients, a much better use of their time. The economies of scale make larger and larger practices more and more profitable.

        Again, you can see this in almost any industry, they end up being controlled by several large corporations rather than tons of tiny independent shops. And yest, managing a Home Depot is a lot less prestigious than owning your own hardware store. That doesn’t mean the fact Home Depot and Lowe’s have grown to take up most of the market is the result of government having it out for independent hardware stores.

        Single practices just aren’t as competetive.

        1. This isnt about single practices. Group practices are still independent doctors, if its a partnership and they arent just employees.

        2. Even if the government was uninvolved in healthcare, there would still be tons of paperwork and red tape.

          You’re begging the question.

          You’re assuming that there’d be tons of red tape and paperwork… because you say there’ll be tons of red tape and paperwork. Imposed by whom or what?

          1. You’re assuming that there’d be tons of red tape and paperwork… because you say there’ll be tons of red tape and paperwork. Imposed by whom or what?

            1) State Boards of Health.

            2) State Legislatures.

            3) Insurance Providers.

            4) CMS (both/either Medicare/Caid)

            5) Joint Commission (formerly known as JCAHO)

            1. Look at that. 4 out of 5 of those are governmental in nature!

              1. Yep, and if you think states are going to to give up THEIR Game of Medical Thrones here, your are bonkers.

                Also, it is getting much more difficult to open even a group practice, as ObamneyCare specifically makes it very difficult to do so. The current trend is for group physician owned practices to sell their practices to corporate medicine and regional hospital networks.

                Even specialists, concierge medical clinics and boutiques, and free standing sugicentres can’t really escape this paradigm forever.

              2. You think Insurance providers aren’t governmental in nature? They were quasi-government entities even before Obamacare.

            2. My response was to:

              Even if the government was uninvolved in healthcare

              You kindly listed 4 government agencies, and one highly regulated by government agencies with coverage mandates, rate restrictions, etc.

              And JCAHO can kiss my ass. They’re all up in my shit lately.

              1. That’s my point Paul, government (and these are all state level agencies, or administered at the state level) will NEVER get out of the way. And yes, I hate JCAHO with a passion as well. Even all the CPT/ICD coding you do is implemented utilized by some medical, accrediting, or billing entity.

                1. My point about your point was that your point was irrelevant to the OPs fantasy scenario. I understand your point, and your point is well taken and on point in the really reall discussion about political reality.

                  But my point is that sans government being the agency in the way of all points of care, my point still stands.

          2. Productivity is driven largely by specialization. You can specialize more completely in a large organization than in a small one. Large organizations need more documentation to function than small ones.

            1. Large organizations need more documentation to function than small ones.

              Often, laws are passed that apply the “needed documentation” to both large and small organizations. Large ones will have a better time managing the fiscal load of regulations than small ones will.

    5. Because its happening in an era of increased government interference in health care. Correlation isnt causation, but its the way to bet.

      pretty much every industry

      I call bullshit.

      Okay, that is just one industry, but I claim that it clearly marks the shift from the industrial era to the information era, which comes with decreased consolidation and corporatization.

      1. Yeah, and all those little craft breweries together produce less than 6% of annual beer production:

        http://www.brewersassociation……tics/facts

        By comparison, Anheuser-Busch InBev alone produces 25% of the world’s beer.

        1. There’s always going to be independent mechanics. That doesn’t change the fact most people get service through a national chain like Jiffy Lube or their dealer.

          There’s always going to be independent restaurants. That doesn’t change the fact most people eat at places like Olive Garden.

          And there will always be independent doctors, but most people are eventually going to be going to the medical version of Walmart/Jiffy Lube/Olive Garden/etc.

          1. And people are eating at independent restuarants more than they did in the 80s.

            And they are buying artisanal mayo more than they did in the 80s.

            And they are buying artisanal cheese more than they did in the 80s.

            The 20th century was all about consolidation. But that is changing. The majority may remain in control of the big boys, but there are going to be a lot more little guys in lots of fields than there used to be. And the amount they control will be much larger.

            1. Heck, 17 years ago (I chose ’95 on purpose) there were basically two operating systems for home computers–Windows and MacOS.

              If we count all the flavors of linux as different, how many are there now? Microsoft and Apple still control the majority of the market (although if we count phones, google is doing good too), but their are options that didnt used to exist.

        2. Craft breweries sell the vast majority of their product domestically.
          Comparing that Bud which exports all over the world (in Ireland they drink more Bud than Guinness because it’s an import) is a false equivalency.

          1. He’s saying that the beer industry isn’t consolidated. When there’s a handful of companies that account for 90% of the market, it doesn’t matter how many tiny companies make up that remaining slice, the fact is the industry is pretty damn consolidated.

            1. Before the 1970s when homebrewing and craft brewing were finally made legal, that handful of companies accounted for 100% of the market.

              Since then they’ve lost ten percent, and there are more craft breweries popping up daily.

              1. Not quite true, the beer wars killed lots of small guys off. They werent craft, but they existed.

                By the late 80s, that was true. A small group of breweries brewed virtually everything. Since then, with imports and craft, that has been pushed way back.

        3. Of course.

          But in the 80s, they were selling approximately zero percent.

          The trend of is currently against consolidation.

        4. 8,13,12,6,7,12,13.

          That is the percent growth in craft sales the last 7 years. That was to break 5% finally.

          Double digit growth looks to be the projection for this year too (12% the first 6 months of the year).

          What does 5.68% grow to with a few more years of double digit growth?

          And the small guys that make up most of the 2000 are growing much faster than that. Sam Adams and Sierra Nevada make up the bulk of the volume of growth and they are “only” growing 6-9 percent per year.

    6. government and not normal market forces when it happens in healthcare

      Describe these “normal market forces”?

      A hospital that isn’t allowed to upgrade the number of beds or it loses a government subsidy isn’t “normal market forces”.

      1. As I said, I’m not suggesting that there aren’t issues with government involvement in helathcare. I’m just saying that consolidation and the shift to doctors as employees of corporations isn’t one of them. And that has nothing to do with how many beds a hospital is allowed to have.

        1. That explains why we only have three networks on the television.

          Good observation.

          1. When cable first appeared, there were hundreds of independent channels. Overtime they started merging until now, despite having the same number of channels, they’re pretty much all owned by a few large corporations like Viacom.

            1. And how many independent youtube broadcasts are there?

              They still arent large, but there are a couple I watch regularly (Wil Wheaton’s Tabletop for one).

                1. Didnt see anything there suggesting consolidation, they are growing but that doesnt mean they bought out other online companies.

                  Also, there has been some consolidation in the craft beer market, yet despite that, the total number is going up.

                  There will always be some consolidation.

        2. I’m just saying that consolidation and the shift to doctors as employees of corporations isn’t one of them

          Yeah it is. When government regulations make doing business extremely onerous, hostile and expensive, you consolidate and allow a larger agency handle things like licensing, compliance, insurance etc.

    7. Health care has had many of the characteristics of a cartel for generations now. The AMA works with Congress and the FDA and etc. to restrict competition. It’s about as much a free market as banking.

    8. Stormy, I disagree.

      The overhead imposed on doctors by truly staggering masses of regulation is very significant. We get a lot of doctors who are just sick of dealing with it, and join a group solely so that they have a “real” billing office/administration to handle it for them.

      1. Oh, and far and away the major source of regulation, headaches, and the rest is CMS and Medicare, with even its bastard stepchild Medicaid running a distant second.

  6. even if very few physicians retire or quit, it won’t take many to cause access problems. IIRC, primary care physician practices had annual median caseloads of 260 Medicare patients.

  7. All doctors are alcoholic drug addicts who only want to talk about their expensive vacations. They’re bad people and we must destroy them. Especially Groovus.

    1. Don’t forget their immaculately trimmed beards.

    2. Shut up, Maggot. You’re STILL pissed I would’nt fix your allegedly creepy ambiguous genitally. Alleged genitally, that is.

      1. I didn’t want you to fix, you idiot. I wanted you to augment. And instead, you took one look and ran away crying to your stupid yacht, like doctors always do. Fuck, I hate doctors.

        1. Ha! The joke’s on you! I don’t have a yacht, numbskull. And need I remind you that you owe your excellent vision to a…GASP…doctor?! Not to mention your wretched (and unusual) conception. Augmentation of that…well, I’m not quite sure what it is. I guess we can call it a Baby Sarlacc, and certainly can’t be augmented. You, as usual, are projecting your ire at the wrong target. -)

          1. That’s a great idea. Move your practice to a ship that operates in international waters. While you’re at it, run a pharmacy from there, too.

            Later, when you’re insanely rich, start a satellite office in space.

  8. There’s a lot of talk about cumbersome government protectionism in the health care market, but don’t physicians already receive a good helping of protection from the FDA/DEA/etc. in the form of their prescription pad?

    1. As far as the DEA goes, that “protection” is generally the sort you used to have to go to a fat guy in wifebeater for.

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