Presented To HEALTH REFORM AND
THE DECLINE OF PHYSICIAN PRIVATE PRACTICE
BASED ON A WHITE PAPER CONDUCTED FOR: THE PHYSICIANS FOUNDATION
Signatory Medical Societies:
• Alaska State Medical Association • California Medical Association • Connecticut State Medical Society • Denton County Medical Society (Texas) • El Paso County Medical Society (Colorado) • Florida Medical Association
• Hawaii Medical Association • Louisiana Medical Association • Medical Association of Georgia
•Medical Society of New Jersey •Medical Society of New York •Nebraska Medical Association •New Hampshire Medical Society •North Carolina Medical Society •Northern Virginia Medical Societies •South Carolina Medical Association •Tennessee Medical Association •Texas Medical Association •Vermont Medical Society •Washington State Medical
Association
FIVE COMPONENTS
1. Reform provisions affecting doctors 2. A national survey of physicians
3. Physician practice model case histories 4. Analysis: physician workforce implications 5. Analysis: legal implications for physicians
A FOCUS ON PHYSICIANS. HOW DID WE GO FROM THIS……
AND WHY ARE WE HEADED TO THIS?
FROM 1970-2010 WHAT HAS CHANGED…AND WHAT HAS NOT
A HAMBURGER IS STILL
A meat patty and lettuce on a bun
1970…….25 cents 2010…….$1
HEALTHCARE: NO LONGER “TAKE TWO ASPRIN…”
Close to 200 Board Certified Specialties Over 10,000 prescription drugs
Organ Transplants Face Transplants
Teleradiology/Telemedicine Non-invasive Techniques Gene Therapy
2011 HEALTHCARE: FROM BIG….
1970… 200 million people
1970… 200 million people
TO REALLY BIG2010… 300 million people
2010… 300 million people
MORE PEOPLE… AND OLDER PEOPLE 75 million baby boomers started turning 65 in 2011.
One every 8 seconds
SOMETHING HAS COME BETWEEN US, OUR DOCTORS, AND HEALTHCARE DELIVERY…MONEY
Virtually limitless demand vs. finite resources
$3 TRILLION AND COUNTING
IN TWO DAYS, WE SOLVE THE RIDDLE
RES IPSA LOQUITUR – “The Thing Speaks for Itself”
THE IMPACT ON DOCTORS
What does reform mean to physicians
and to their patients?
WHITE PAPER KEY FINDINGS: Two types of reform:
• Formal………. PPACA
• Informal…………. Market/societal forces
KEY FINDINGS:
• The independent, private
practice model will be largely (though not uniformly)
replaced.
• Physicians will consolidate,
be employed, or align with larger entities
KEY FINDINGS:
REGIONAL VARIANCE/PREVAILING MODELS • ACOs (Medicare & Commercial)
• Larger, non-aligned groups • Larger, aligned groups • Medical homes
• Community Health Centers • Concierge practices
• Smaller, aligned groups • Traditional private practice
OBSTACLES TO FORMING AN ACO
• Physician staffing/alignment...42% • Lack of Capital………..38% • Lack of integrated IT systems………..32% • Lack of evidence-based protocols…..25%
Source: AMN Healthcare 2011 ACO Survey
KEY FINDINGS:
THE MEDICAL PRACTICE ENVIRONMENT: FURTHER EROSION
Through acts of omission and commission, “reform” is, on balance, a net loss for physicians and will further erode the medical practice environment
• No payment fix (SGR)
• Tort reform not addressed
• Onerous compliance regulations
• More patient volume
• Higher patient acuity
• Problematic cost/quality tracking
• Increased office expense
KEY FINDINGS:
REFORM WILL EXACERBATE THE PHYSICIAN SHORTAGE
• Supply provisions inadequate to meet demand
• Access issues for Medicaid, Medicare and other patients • Primary care/specialist disparities to continue
• Many physicians will cut back or opt out
• Physicians will redefine their roles, rethink delivery models
DID ANYBODY ASK WHAT PHYSICIANS THINK?
SURVEY OF PHYSICIANS AND HEALTH REFORM
RESULTS:
WHAT WAS YOUR INITIAL REACTION TO PASSAGE OF HEALTH REFORM?
0% 10% 20% 30% 40% 50% 60% Very Positive Somewhat Positive Neutral Somewhat Negative Very Negative 12% 15% 6% 15% 52%
HOW DO YOU FEEL NOW ABOUT HEALTH REFORM?
0% 10% 20% 30% 40% 50% 60% I am more positive than I was initially My feelings have not changed I am more negative than I was initially 10% 51% 39% RESULTS:
DO YOU BELIEVE THE VIEWPOINT OF PHYSICIANS WAS ADEQUATELY RESPRESENTED TO POLICY MAKERS AND THE PUBLIC DURING THE RUN-UP
TO PASSAGE OF HEALTH REFORM?
86% No 14% Yes No Yes RESULTS: RESULTS:
WHICH BEST DESCRIBES YOUR ATTITUDE TOWARD
MEDICAL PRACTICE BEFORE REFORM WAS
ENACTED? 0% 5% 10% 15% 20% 25% 30% 35% 40%
Very Somewhat Somewhat Very
14%
37% 36%
RESULTS:
WHICH BEST DESCRIBES YOUR MEDICAL PRACTICE NOW THAT REFORM HAS BEEN ENACTED?
0% 5% 10% 15% 20% 25% 30% 35% Very Positive Somewhat Positive Somewhat Negative Very Negative 6% 29% 33% 32% RESULTS:
DO YOU BELIEVE REFORM WILL COMPEL YOU TO CLOSE OR SIGNIFICANTLY RESTRICT YOUR PRACTICE TO ANY CATEGORY OF PATIENT?
40%
No
60%
Yes No
RESULTS:
IF YES, PLEASE INDICATE ALL THAT APPLY:
CLOSE SIGNIFICANTLY RESTRICT
Medicaid………. 51% ………..42%
Medicare………. 30% ………. 57%
Indigent……… 43% ………. 38%
Patients covered through exchange… 24% ………. 44%
Some HMO/managed care patients… 17% ………. 42%
All New patients………..… 5% …….………. 37%
Self Pay………..………..… 10% …….………. 24%
Privately Insured………..… 3% ……..………. 18%
Other………..… 6% ………..………. 9%
CONSIDER YOUR PRACTICE PLANS OVER THE NEXT THREE YEARS AS REFORM IS PHASING IN. DO YOU
PLAN TO: 0% 5% 10% 15% 20% 25% 30% 26% 19% 16% 16% 14% 14% 12% 12% 12% 11% 8% 6% 4% RESULTS:
IF YOU COULD MAKE A STATEMENT TO POLICY MAKERS AND THE PUBLIC ABOUT HEALTH CARE
REFORM AND THE STATE OF THE MEDICAL PROFESSION TODAY, WHAT WOULD YOU SAY?
1,200 written responses
“The bill is too long and comprehensive to
“The bill is too long and comprehensive to
“The bill is too long and comprehensive to
“The bill is too long and comprehensive to
know what is coming
know what is coming
know what is coming
know what is coming. I fear the unknown
. I fear the unknown
. I fear the unknown
. I fear the unknown
. I fear the unknown
. I fear the unknown
. I fear the unknown
. I fear the unknown.”
.”
.”
.”
SURVEY CONCLUSION
Physicians are being systemically disengaged from the practice of medicine
REFORM AND THE PHYSICIAN WORK FORCE
WHO WILL SEE THE 32 MILLION NEWLY INSURED?
THE 75 MILLION BABY BOOMERS ACCESSING MEDICARE?
THE 50 MILLION NEW ADDITIONS, 2000 – 2020?
HOW MANY MORE PCs? 32 million newly insured patients
X
2 additional patients visits per year
=
64 million patient visits
divided by 4,000
=
16,000 additional primary care doctors
REFORM: CONSPICUOUS FOR WHAT IT DOES NOT DO
Does not remove the cap on GME funding
Just 889 “new” residency slots through redistribution
RESIDENCY CHOKE POINT
Medical School Enrollment: 18,000+ and growing
Residency: 25,000 and stagnant
THE PHYSICIAN SHORTAGE: RESULT
Health Reform throws one bucket of water on the fire and two buckets of gasoline
MEDICAL STUDENTS ARE TAKING THE ROAD TO SUCCESS
Radiology Ophthalmology Anesthesiology Dermatology
THE PROBLEM: MEDICAL STUDENTS ARE GOOD AT MATH Average income, Primary Care, with Medicare increases, vs.
Specialists
Family Practice: $178,000 + 2.5% increase……….….. $182,450 Internal Medicine: $205,000 + 5% - 10% increase….. $215,250 - $225,500 Pediatrics: $183,000 + 0% increase……….. $183,000 Anesthesiology……….…………. $335,000 Radiology………...…….….… $402,000 Cardiology (inv.)……….………. $532,000 Dermatology………...…… $331,000 Orthopedic Surgery………..….……… $521,000 Urology……….. $453,000
Source: Merritt Hawkins 2011 Revenue of Physician Recruiting Incentives
PROGRESS IS BEING MADE, BUT…..
Primary physicians
make 55% of what
PHYSICIAN MALDISTRIBUTION TO CONTINUE
6,200 Health Professional Shortages Areas (HPSAs) 67% in rural areas
65 million Americans
$1.5 billion over 5 years (2011 – 2015) to National Health Service Corps for Loan Forgiveness
38% of MERRITT HAWKINS SEARCH ASSIGNMENTS FEATURE LOAN FORGIVENESS
ED CROWDING WILL PERSIST
ER visits grew 7% in Massachusetts from 2005 to 2007
PATIENTS ARE SEEKING CONVENIENT CARE RATHER THAN EMERGENCY CARE
AGING WILL DRIVE UTILIZATION
By 2030, the entire country will be as old, on average, as
Florida is now.
Source: U.S. Census Bureau
AND THE ELDERLY WILL DRIVE POLITICS • 40 million people in AARP
• Largest organization in the U.S., after the Catholic church
• 18% of U.S. population will be baby boomers by 2029
WE HAVE SEEN THIS MOVIE BEFORE
RESULT:
REFORMED MASSACHUSETTS
40% of family physicians in Massachusetts no longer accept new patients, up from 30% in 2007.
Almost 60% of general internists have stopped taking new patients, up from 49% in 2007
Yet Massachusetts has 130 primary care
physicians per 100,000 population, first highest in the country (the national rate is 90 per
100,000 pop.)
Source: Massachusetts Medical Society
ACCESS TO CARE WILL BE LIMITED
Average Patient Appointment Wait Times
Boston 50 days Philadelphia 27 days Los Angeles 24 days Houston 23 days Washington, D.C. 23 days San Diego 20 days Minneapolis 20 days
MEDICAID / MEDICARE PATIENTS WILL DEPEND ON SAFETY NET PROVIDERS
16+ million new Medicaid enrollees
Temporary bump in physician fees
WILL YOU CLOSE OR SIGNIFICANTLY RESTRICT PATIENT ACCESS TO ANY CATEGORY OF PATIENT?
Medicaid…….93% Medicare…….87%
Source: Physician Foundation 2010 Survey of Physicians and Health Reform
WHO WILL SEE PATIENTS?
Medicare reimbursement may fall below Medicaid
levels by 2019. Medicare/Medicaid now covers 110 million
DOCTORS WILL VOTE WITH THEIR FEET
No changes to practice……….….. 26% Retire, cut-back, work part-time, close
practice, seek non-clinical role, seek non medical job, work locum tenens, concierge,
etc……….……. 74%
WILL DOCTORS REALLY CHOOSE TO LIMIT ACCESS?
They already have…
Hours worked per week:
1977 – 1997……….. 55 1996 – 2008..……… 51
Equals 36,000 fewer FTEs
A MESSAGE FROM AMA PRESIDENT, CECIL B. WILSON, M.D.
AMA anticipates a deficiency of 125,000 physicians by 2025.
2014 will be the year of shrinking access
WHAT’S EMERGING? A NEW WORKFORCE PARADIGM
THE “CONE OF COMPLEXITY”
Medical specialists Primary care physicians Pharmacists (Pharm D) Advanced practice Nurses/PAs Nurse specialists
Therapists LPNs Nurses aides
4 GENERATIONS OF DOCTORS Gen Y 1982 - Present Gen X 1965 - 1981 Baby Boomers 1946 - 1964 Traditionalist 1945 and before
TOMORROW’S DOCTOR WILL REDEFINE THEIR ROLES
• Concede the less complex patients to PAs and NPs
• Let pharmacists help directly manage patients with
chronic conditions
THEY WILL EXPAND THEIR HOURS
Practices that can arrange for patients to see a doctor or nurse after hours
Netherlands 95% New Zealand 90% United Kingdom 87% Australia 81% Germany 78% Canada 47% United States 40%
Source: 2006 Commonwealth Fund International Policy Survey of Primary Care Physicians
OR, THEY WILL WORK PART-TIME
21% of all doctors
now work part-time
Hospitals and Groups must accommodate the rise of
THEY WILL EMBRACE TELEMEDICINE
• April, 2010, Park Nicollet
rolls out online diagnosis/12 month pilot program
• Online diagnosis of minor
problems (cold, flu, acne, bladder infections/allergies)
• $25 per visit
• PAs provide diagnosis
• 17 clinics for walk-in care
THEY WILL BE PAID FOR “EXTRACURRICULARS” • Telemedicine
• E-mails
• Telephone calls
Doctors will be compensated outside of the traditional billable appointment.
THEY WILL EMBRACE “SAME DAY” OR “OPEN ACCESS” SCHEDULING
15 minute rather
than 10 minute
appointments.
Higher patient
satisfaction scores
THEY WILL OFFER SHARED MEDICAL APPOINTMENTS (SMAs)/”GROUP APPOINTMENTS”
• 6 to 15 patients • 90 minutes • Physicals
• Well-child check-ups • Pre-natal care
• Chronic illness management
“There is sufficient data to support the effectiveness of group
visits in improving patient and physician satisfaction, quality of care, quality of life and in decreasing emergency department
THEY WILL ALIGN WITH HOSPITALS
65
Alignment for CEO’s: Doctors who keep readmissions low, don’t order too many tests
THEY WILL ALIGN WITH HOSPITALS
Alignment for Doctors: Hospitals that let them practice medicine as they know how
THEY WILL ACCEPT VALUE BASED COMPENSATION
Most physicians surveyed by Price Waterhouse said half their compensation should be a fixed salary. The other half should be quality, cost
and production based.
Source: PWC “From Courtship to Marriage: A Two-Part Series on Physician-hospital alignment”
THE PHYSICIAN ORGANIZATION OF TOMORROW….
Could well be… you!
Only 15% of doctors belong to the AMA
PHYSICIANS: A PRACTICE PARADIGM SHIFT:
• Hospital employment…
• 56% of Merritt Hawkins
searches feature employment
• Not just Primary Care, All
specialties
• Only 25% of doctors could
correctly identify the term “cash flow”
Total Physician vs. Truly Independent Projected Change, 2000 – 2013 (000s) 620 640 660 680 700 720 740 760 780 800 2000 2005 2009 2013 57% 49% 43% 33%
PHYSICIANS: A PRACTICE PARADIGM SHIFT: • Larger groups…economies of scale, strength in
numbers
• Concierge….no more third party payors
• Part-time…lifestyle rules
• Locum tenens….Have Stethoscope, Will Travel
• Cherry picking….no Medicaid, Medicare or other low payors
STANDARDIZATION
“Eminence Based Medicine”
Making the same mistakes with increasing confidence over an impressive number of years
“Evidence Based Medicine”
Rapidly integrating individual clinical expertise with the best available external clinical evidence
from systematic research.
A TECNHOLOGY SHIFT • Mobile app triage
• Virtual visits
• Mobile electronics health records
• In-home implantable devices
AND BY THE WAY….
THE DOCTOR OF TOMORROW WILL….
•
RETIRE!
“I’m mad as hell and I’m not going to take it any more”
HHS estimates 1/3 of today’s practicing physicians (268,000 out of 815,000) will retire
within the next 10 years.
STAFFING PLANS MUST INCORPORATE ALL TYPES OF PHYSICIANS
• Employed………….(over 50% of all doctors) • Independent • Full-time • Part-time • Concierge • On-site • Remote (telemedicine) • Locum tenens • Male
WHERE IS MEDICAL PRACTICE HEADING?
FIVE CASE HISTORIES SHOW vs. TELL
5 CASES HISTORIES
• A Medical Home • 2 “ACOs”
• Concierge Practice – or “flat fee” • Community Health Centers
THE BURDEN OF COMPLIANCE
THE BURDEN OF COMPLIANCE • $350 million to enforce fraud
• Medicare payments suspended during investigations
of “credible allegations of fraud”
• HHS to define “credible allegations” • More latitude to whistleblowers
• Overpayment must be repaid in 60 days • “Intent” no longer a factor
• Specialty hospitals limited
• Encourages states to write their own Stark laws
“EVERYBODY HAS A PLAN, UNTIL THEY ARE PUNCHED IN THE FACE”
-Mike Tyson
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Presented To HEALTH REFORM AND
THE DECLINE OF PHYSICIAN PRIVATE PRACTICE
