Non-physi­cian providers will pick up the slack for less-pro­duc­tive em­ployed doc­tors

Modern Healthcare - - Q & A -

Mark Smith joined Irv­ing, Texas-based health­care staffing firm Mer­ritt Hawkins in 1988 and be­came its pres­i­dent in 2008.

The com­pany con­ducted al­most 3,100 physi­cian searches in its last re­cruit­ing year. Since it opened in 1987, it has con­ducted 45,000 searches. Smith has watched the trends for many years and has a bird’s-eye view of re­cruit­ing hot spots and trou­ble zones. He has ex­pe­ri­ence per­suad­ing physi­cians to prac­tice in the na­tion’s smaller and ru­ral com­mu­ni­ties, as well as in its in­ner-city clin­ics. Mer­ritt Hawkins has ex­panded its ser­vices to in­clude staffing for nurses, nurse prac­ti­tion­ers and physi­cian as­sis­tants. It also reg­u­larly con­ducts sur­veys on is­sues such as wait­ing times to see physi­cians in ma­jor met­ro­pol­i­tan mar­kets and re­cruit­ing in­cen­tives used to land top can­di­dates. Mod­ern Health­care re­porter An­dis Robeznieks re­cently talked with Smith about the con­tin­u­ing shift of U.S. physi­cians into em­ploy­ment, which spe­cial­ties are mak­ing the shift more rapidly and why that is hap­pen­ing.

Mod­ern Health­care: What is your es­ti­mate of the per­cent­age of em­ployed physi­cians in the U.S., and how has that fig­ure changed over the past five years?

Mark Smith: The best in­for­ma­tion that we have is from the Amer­i­can Med­i­cal As­so­ci­a­tion, which es­ti­mates that 53% of physi­cians are em­ployed. But in the more com­mon spe­cial­ties, fam­ily prac­tice is 60%, pe­di­atrics is around 63% and in­ter­nal medicine is ap­proach­ing 55%. We see sig­nif­i­cant change hap­pen­ing in those num­bers. Six­ty­four per­cent of Mer­ritt Hawkins searches from 2013 were for hospi­tal-em­ployed doc­tors, while 16% were for med­i­cal groups. When you add in com­mu­nity health cen­ters, that’s an­other 10% and aca­demics an­other 5%. You quickly get to the fact that 95% of our physi­cians in 2013 were em­ployed in one form or an­other.

MH: What spe­cial­ties are leading this trend?

Smith: Pri­mary care is leading the charge. In 2004, we had 11% of em­ploy­ment op­por­tu­ni­ties for hos­pi­tals, and 15% of doc­tors over­all were em­ployed. For that to jump to 95% over a pe­riod of nine years is pretty in­cred­i­ble. Leading that charge were fam­ily prac­tice, pe­di­atrics and in­ter­nal medicine. The big move is pri­mary-care physi­cians be­com­ing part of hos­pi­tals.

MH: There seems to be a big shift in car­di­ol­ogy too.

Smith: There has been. My view is that a lot of that is driven fi­nan­cially. Even be­fore the im­pact of the Medi­care sus­tain­able growth-rate for­mula hang­ing over physi­cians’ heads, car­di­ol­o­gists took a sig­nif­i­cant re­im­burse­ment cut. So you saw them run­ning for cover a bit, and em­ploy­ment be­came much more at­trac­tive.

MH: Two years ago, you tes­ti­fied be­fore a con­gres­sional com­mit­tee on this sub­ject.

Smith: They wanted to know what can be done to get physi­cians back to be­ing small busi­ness­peo­ple, but that ship had left the port. There re­ally wasn’t any­thing that they could do at that time to change that trend, es­pe­cially if you look at why it’s hap­pen­ing. In the 1990s, it was driven by Hil­laryCare. The coun­try was mov­ing to adopt a gate­keeper model. Hos­pi­tals bought up pri­vate prac­tices at high pre­mi­ums. They com­peted with other en­ti­ties such as physi­cian prac­tice man­age­ment groups. Then, as you got to­ward the later ’90s, that trend fell apart. It was just not a suc­cess­ful ex­pe­ri­ence for many rea­sons. This time it’s very dif­fer­ent. We’re see­ing moves oc­cur in the mar­ket be­cause you have a gen­er­a­tional is­sue with mil­len­ni­als who are look­ing for an em­ployed sit­u­a­tion, high qual­ity of life, etc. And then, of course, the Af­ford­able Care Act has been a big driver as well.

MH: How is health­care re­form af­fect­ing physi­cian em­ploy­ment?

Smith: If you look at the im­pact of ACA, it’s as much about per­cep­tion as re­al­ity. Fear of the un­known has driven physi­cians to move for cover. There are 1,500 new Medi­care au­di­tors in the field who can dis­burse some very puni­tive fines against physi­cians even if some­thing is done by ac­ci­dent. The Physi­cian

Qual­ity Reporting Sys­tem that kicks in next year will have a neg­a­tive im­pact on re­im­burse­ment. Elec­tronic med­i­cal records, mean­ing­ful use, all those fac­tors have sig­nif­i­cantly pushed physi­cians in droves to­ward hospi­tal em­ploy­ment. This time it’s hap­pen­ing with­out that very heavy price tag that hos­pi­tals had to pay last time, and so it’s moved much quicker.

MH: Are there any lessons to be learned about physi­cian sup­ply from Mas­sachusetts, which ex­panded in­sur­ance cov­er­age years be­fore the ACA came long?

Smith: We just com­pleted our most re­cent physi­cian wait­ing-time sur­vey. Bos­ton, which has the most physi­cians per capita and has had the op­por­tu­nity to set­tle in with uni­ver­sal health­care, continues to have the long­est wait times to see a physi­cian across the ma­jor mar­kets we’ve looked at na­tion­wide.

MH: What can you tell us about em­ploy­ment trends for physi­cian as­sis­tants and nurse prac­ti­tion­ers?

Smith: That is some­thing that we see pick­ing up pace in gen­eral. That trend should fol­low the physi­cian side since they’re as­so­ci­ated in most cases with a physi­cian and they would be­come part of that same prac­tice. My best guess would be that the num­bers would be very sim­i­lar in terms of the change. But from the start, most NPs and PAs are em­ployed by an­other party.

MH: Any pre­dic­tions about these ad­vanced prac­ti­tion­ers?

Smith: At Staff Care, our locum te­nens com­pany, ad­vanced prac­ti­tion­ers are the No. 1 grow­ing piece of the busi­ness. Sta­tis­tics alone show you that growth has to oc­cur for many rea­sons, in­clud­ing the gray­ing of Amer­ica. Also, as you look at hospi­tal-em­ployed physi­cians, a hospi­tal-em­ployed fam­ily prac­ti­tioner in an out­pa­tient set­ting sees 25% fewer pa­tients than the same physi­cian who owns his or her prac­tice. In in­ter­nal medicine, it’s the same sit­u­a­tion: The physi­cian-owned prac­tice sees 36% more pa­tients than the hospi­tal-em­ployed in­ter­nal medicine physi­cian. With the na­tional physi­cian short­age we have, you com­pound that with physi­cians mov­ing to hospi­tal em­ploy­ment. We can’t train doc­tors fast enough. The only re­lief valve is go­ing to be those ad­vanced prac­ti­tion­ers.

MH: What would you say are your most dif­fi­cult physi­cian-re­cruit­ing as­sign­ments?

Smith: Pri­mary care re­mains very chal­leng­ing. You have so many of those searches, and if the po­si­tions are not in the most at­trac­tive ge­og­ra­phy or are not com­pet­i­tive fi­nan­cially, those can be very chal­leng­ing. The top of the list are some of those sub­spe­cial­ties such as urol­ogy, with very few can­di­dates and very high de­mand. Der­ma­tol­ogy re­mains in very high de­mand. De­mand for ortho­pe­dics and oto­laryn­gol­ogy is still fairly strong. But they can re­main in­de­pen­dent be­cause they are higher-in­come spe­cial­ties, not be­cause of re­im­burse­ment, but be­cause they can ben­e­fit from the rev­enue from an­cil­lar­ies and am­bu­la­tory surgery cen­ters.

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