Will a silent exodus from medicine worsen doctor shortage?

Frustrated by mounting regulation, declining pay, loss of autonomy and uncertainty about the effect of health system reform, doctors are cutting back the number of hours they work and how many patients they see.

Between 2008 and 2012, the average number of hours physicians worked fell by 5.9%, from 57 hours a week to 53, and doctors saw 16.6% fewer patients, according to a survey of nearly 14,000 doctors released in September. If the trend continues through 2016, it would equate to the loss of 44,250 full-time physicians, said the report, conducted by the doctor-recruiting firm Merritt Hawkins & Associates for the Physicians Foundation. The foundation was started in 2003 with more than $30 million from class-action settlements that 22 state and county medical societies made with health plans.

“This is a silent exodus,” said Mark Smith, president of Merritt Hawkins. “Physicians are feeling extremely overtaxed, overrun and overburdened.”

Only half of doctors will continue their current practice during the next three years, the survey said. Many plan to cut back on hours, retire, see fewer patients, seek hospital employment, work part time, transition to a concierge model or seek a nonclinical job in health care. Sixty percent would retire today if they could, compared with 45% in 2008.

A quarter of doctors cited long hours and lack of personal time as among the least satisfying elements of their careers. Nine in 10 physicians agreed that most doctors “are unsure where the health system will be or how they will fit into it” during the next five years.

“There’s a great degree of uncertainty and angst related to problematic reimbursement, the high-regulation environment and many other things,” said Walker Ray, MD, a retired pediatrician and vice president and research committee chair for the Physicians Foundation. “Now, what this all is about is more than professional grumbling. All professions at times have unhappiness surfacing. What we’re looking at are trends where physicians are in their own individual minds and their own individual practices, making decisions that may affect the supply of physicians going forward.”

Impact on access to care

The less-intensive doctor work schedule could hamper access to care for the 30 million Americans the Congressional Budget Office estimates will obtain health insurance coverage under the Affordable Care Act during the next decade. The U.S. Census Bureau also projects a 36% rise in Americans eligible for Medicare during that period.

In 2010, the Assn. of American Medical Colleges projected a shortage of 130,600 physicians by 2025, with half of the shortfall occurring in primary care specialties. That estimate accounts for the work patterns of older physicians and female doctors, who are more likely to work part-time schedules, said Clese Erikson, director of the AAMC’s Center for Workforce Studies. But the projection does not factor in growing hospital employment of physicians, a trend noted in the foundation’s report.

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.’ ”

The foundation survey was sent to more than 630,000 U.S. physicians. Despite the low response rate, an academic consultant cited in the report said the survey’s margin of error is less than 1%. Smith said a sample of nonresponding physicians was later contacted to answer a few of the survey’s dozens of questions, and their responses were highly consistent with those of doctors who completed the full survey. Respondents were likelier than the general population of physicians to be white, male, older and in solo or independent practice. Yet the lighter workload seen was not limited to the older physicians surveyed. Doctors younger than 40 averaged 19 patients a day, compared with 19.8 for physicians 40 and older.

Leaders at physician organizations said the low morale reflected in the survey is unsurprising.

“Many doctors have been beaten down pretty significantly by the current system and have developed an unfortunate cynicism about the potential for change,” said David Bronson, MD, president of the American College of Physicians.

Long-term trends have hit smaller, independent practices especially hard, said Glen Stream, MD, president of the American Academy of Family Physicians.

“People in small and solo practices are struggling, with all the administrative and regulatory burden of insurance and payment challenges,” said Dr. Stream, an employee at a hospital-owned clinic in Spokane, Wash. “In a small group, you don’t have any negotiating power with insurance companies. If you’re in small or solo practice, life is hard.”

Physician leaders said the survey results highlight the need to expand federal funding for residency slots, which have been capped since the Balanced Budget Act of 1997. The AAMC, American Assn. of Colleges of Osteopathic Medicine, the American Medical Association and many other physician organizations support expanding residency slots.

On Sept. 25, Rep. Joseph Crowley (D, N.Y.) introduced a bill to boost Medicare-funded residencies by 15%, or about 15,000, during the next five years. Rep. Aaron Schock (R., Ill.) introduced a similar bill in August, and Sen. Bill Nelson (D, Fla.) proposed comparable legislation in September 2011. The AMA has publicly supported Nelson’s bill, which has not received a hearing or been put to a vote.

Shortage sparks debate over NPs’ role

The looming physician shortage is drawing more attention to the use of nurse practitioners, physician assistants and other midlevel health professionals to help maintain access to care. But the shift toward more team-based care in patient-centered medical homes should occur in a physician-led environment, the AAFP said in a Sept. 18 report. The American Academy of Nurse Practitioners objected to the report, arguing that NPs could help fill the physician gap by independently treating patients.

Dr. Stream, of the AAFP, said a two-tier system of primary care — physicians for some, nurse practitioners for others — is untenable.

“To the people who propose that to fill this gap that we should somehow alter our expectations of the kind of care people should get — that is not what we want in this country,” he said. “It’s not a viable, ethical or reasonable solution.”

Primary care doctors complete 21,700 hours of education and training over 11 years, said the AAFP report. That compares with 5,350 hours of training and education NPs get during five to seven years. The AMA backed the academy’s report, noting a recent survey showing that 86% of patients believe they benefit from a physician-led primary care team.

“Physicians and other health professionals have long worked together to meet patient needs for a reason — the physician-led team approach to care works,” said AMA President Jeremy A. Lazarus, MD. “Patients win when each member of their health care team plays the role they are educated and trained to play.”