The practice environment for current and future surgeons is changing dramatically. Among the most prominent changes is a shift from independent private practices to large, integrated health care organizations, in which surgeons practice as employees. Whereas some surgeons see new opportunities in this integrated model, others fear it will lead to a loss of autonomy and a weakening of the physician-patient relationship.
The topic, “What Is the Future of Surgery: Autonomous Professionals or Stuck as Employees?” was debated at the 2011 Clinical Congress of the American College of Surgeons’ Resident and Associate Society (RAS-ACS) Symposium in San Francisco, CA. With both sides represented, the audience was presented with important facts and strong opinions in support of physicians practicing as either independent providers or as hospital employees. Following is a summary of the opinions offered during the debate, as well as a further exploration of the topic.
2011 RAS debate
Philip R. Corvo, MD, FACS, assistant professor of surgery at Columbia University, New York, NY, and surgeon at Stamford (CT) Hospital, moderated the debate on the topic of autonomy or employment, which involved four invited discussants.
Demetrius Litwin, MD, the Harry M. Haidak Distinguished Professor and chairman of the department of surgery at the University of Massachusetts, Worcester, concluded that “employment works,” based on his personal experience. He emphasized that surgeons can have a significant influence in health care organizations and actively shape the future of health care provision in general if they are willing to accept leadership roles.
Supporting Dr. Litwin’s position was the RAS essay competition winner, Kerianne H. Quanstrum Holman, MD, from the University of Michigan, Ann Arbor. Dr. Quanstrum challenged the audience to actively participate in shaping the future of health care. “Whether we like it or not, we are likely to be employees of integrated health care systems in the future. But whether we are ‘stuck’ in this position, or operating as respected and collaborative members of the same, is up to us,” she concluded.
Robert C. Moesinger, MD, FACS, adjunct assistant professor in the department of surgery at the University of Utah, Salt Lake City, spoke in favor of surgeons as autonomous professionals. He reported his experience as an independent provider within an integrated health care system in Utah, and asserted that continuity of care and a closer physician-patient relationship are major benefits of the private practice model.
RAS essay competition winner Ronald D. Collier, MD, from the University of Toledo, OH, supported Dr. Moesinger’s position on the basis of his extensive personal experience in health care policy. He emphasized that “physicians must be more active in the health care system.” They need to “advocate for patients,” to “actively participate in the creation of health care law and policy,” and to “demonstrate the long-term benefits of improved treatment beyond the short-term costs.”
The lively debate was followed by questions from the audience, many from senior residents and Fellows facing the difficult decision of whether to join a large health care organization as an employee, or to commence a career as a private practitioner. These practical questions underscored the importance and timeliness of the topic.
Throughout the discussion, it became apparent that despite their differing opinions about practice and reimbursement systems, all participants shared a common goal: to ensure that our nation’s health care system will continue to provide high-quality care to all patients. All speakers agreed on the magnitude and significance of the current changes in the health care system, and emphasized that physicians have to be more active and vocal in the health care reform debate. This includes the willingness to actively shape the future of health care provision through leadership.
A time of change
Health care is undergoing a “quiet revolution.”1 Large health care networks with physicians as employees increasingly replace small group or solo practices managed by independent providers. This trend has been fostered by current developments in health care policy, medical innovation, and changing attitudes toward resident training and physician lifestyle. Whereas medical specialties seem to be the most affected, this trend has not spared the surgical community, and surgeons—whose identity as autonomous entrepreneurs is anchored deeply in history—are divided as to whether to struggle against the feared loss of independence or to embrace the opportunities that employment at large institutions may afford.2-4
The majority of today’s graduates start their careers burdened by overwhelming debt from ever-rising medical school tuition. Nearly 80 percent of all general surgery residents pursue fellowships after their five-to-seven-year residency, thus spending even more time in training.5 After training has been completed, the prospect of starting or joining a modern private practice, which requires a substantial investment of time and money, can seem daunting and quickly become a life-long commitment with limited profitability. Conversely, a salaried position may offer relative financial security, require less commitment, and provide more flexibility with regard to changes in career or location, thus making it an attractive financial option for surgeons early in their career.
Additional concerns, particularly among newly trained surgeons, include the increasing quantity and complexity of administrative and legislative challenges physicians are facing today. Practicing as an independent provider not only requires accounting and entrepreneurial skills, but also means more direct exposure to the consequences of legal and political decision making.
Expensive medical liability insurance coverage and the cost of practicing defensive medicine, exacerbated by the government’s failure to address tort reform, illustrate the legal risks and costs that individual surgeons bear. Surgeons in solo or small group practices are often at a disadvantage because of their focus on clinical practice rather than political advocacy and lobbying. Insurance companies, device manufacturers, and pharmaceutical companies, on the other hand, are well-versed in the means necessary to pursue their political agendas.6 Physicians in large health care organizations may be offered some degree of protection from liability costs and political representation. It remains to be seen, however, if the increased influence of large health care institutions and accountable care organizations will be of benefit to the individual physician.7
The increased power of health care organizations or larger physician groups may also influence negotiations about payment and reimbursement. The movement toward bundled payments, which would provide a predetermined sum to providers based on a given diagnosis, is being driven by the desire to increase value—for example, improving care and lowering costs.8 Large health care organizations may be more effective than individual surgeons or small group practices when it comes to negotiating these types of payment systems with Medicare and other insurers.
This increase in market power, however, might come at the price of higher fees and inhibition of competition. Reports from several parts of the country raise concerns that large, powerful health care organizations may not convey cost savings to patients and payors.9 Furthermore, questions regarding whether measures such as care coordination, integration, and capitation translate into significant cost reductions have been ongoing.10 As an example, the recent results of the Centers for Medicare & Medicaid Services’ (CMS) Physician Group Practice Demonstration project have been interpreted very positively by the CMS, but more critically by others.11
Improved value and patient outcomes are also the rationale for several of the more recent developments in the health care sector, including best practice guidelines, the maintenance of outcomes databases, and initiatives to coordinate and bundle patient care, among others. These measures have received significant attention from insurance companies and the government. In fact, the 2010 Medicare Improvement for Patients and Providers Act sets a mandatory time frame for physicians to comply with certain electronic medical record requirements or face penalties.12
Indeed, participation in quality initiatives like the ACS National Surgical Quality Improvement Program (ACS NSQIP®) can improve patient outcomes and has the potential to lower costs over time.13,14 Implementing many of these quality initiatives, however, is a costly endeavor and may be difficult or impossible for a solo or small group practice. Subsequently, these concepts are more likely to be implemented in large group practices and health care organizations than in small private practices.15
For patients, the transition from a fee-for-service model to a system that provides physicians with a guaranteed income might ease concerns that they are receiving unnecessary services for the physician’s financial gain, or that they are receiving inadequate treatment if they are under- or uninsured. Moreover, despite the recent changes in our health care system, lack of adequate insurance or any insurance at all may remain a significant problem for both patients and providers and will affect autonomous providers more than employed physicians in large health care organizations.16
Teaching and research
Economic and administrative obligations influence the role of teaching and research among autonomous and employed physicians. The education of medical students and residents and the advancement of medical science through research are crucial to maintaining the high standard of medical care in this country. Both, however, require enormous investments of money and time. A physician-entrepreneur may therefore encounter substantial difficulty attempting to balance academic interests with personal productivity, while a physician-employee may negotiate contractual reimbursements or incentives for participation in these activities.
A new generation of physicians
Financial and administrative implications of various practice models aside, the expectations of today’s physicians are generally quite different from those of previous generations. Although still dedicated to patient care and willing to spend long hours in the hospital, many younger physicians also demand a lifestyle that allows time for family, friends, and hobbies.17 Running a private practice often means being on call 24/7, and a recent analysis of a 2008 surgeons’ survey demonstrated burnout and depression to be more significant problems among private practice surgeons than among surgeons in academic and large group settings.18 Furthermore, particularly among the growing number of women in surgery, salaried and part-time employment is popular, as it provides an opportunity to reconcile professional and private life.19
When comparing employment models, concerns pertaining to the loss of productivity and quality in salaried positions must be addressed. When reimbursement is guaranteed, the average employee may receive the same amount of money as one who goes the extra mile. Therefore, some employers provide additional compensation based on performance in addition to a base salary, thus offering incentives for quality, productivity, and/or cost control. The most important guarantor of excellence in patient care, however, is a strong, positive employer-employee relationship. Large health care organizations and hospitals need to grant their employed physicians a high degree of autonomy and emphasize each individual physician’s importance to the hospital’s success. In a favorable environment, productivity in hospital-owned versus independent practice need not suffer.19
Salary-based employment models in large health care organizations may allow surgeons to focus on patient care, reconcile professional and private life, and provide flexibility for education and research. However, concerns about loss of autonomy, weakening of the physician-patient relationship, and decreased productivity are valid and real. Inefficient use of resources, excessive spending, and defensive medicine significantly contribute to the ever rising costs of the U.S. health care system, which is already among the most expensive in the world.20 Substantial changes are inevitable, and surgeons must assume a leadership role to ensure that excellence in patient care remains the center of our health care model. As Haile T. Debas, MD, FACS, 2002 president of the American Surgical Association, so aptly stated, if we fail to accept this role, “History will record that the medical profession was sidelined and watched haplessly as MBAs and business executives defined the fate of healthcare.”21
- Harris G. More doctors giving up private practices. New York Times. March 25, 2010. Available at: http://www.nytimes.com/2010/03/26/health/policy/26docs.html?pagewanted=all. Accessed February 9, 2012.
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- Chamberland C. Honor, brotherhood, and the corporate ethos of London’s Barber-Surgeons’ Company, 1570-1640. J Hist Med Allied Sci. 2009;64(3):300-332.
- Bagwell CE. “Respectful image”: Revenge of the barber surgeon. Ann Surg. 2005;241(6):872-878; discussion 8.
- Sheldon GF. Access to care and the surgeon shortage: American Surgical Association forum. Ann Surg. 2010;252(4):582-590.
- Steinbrook R. Lobbying, campaign contributions, and health care reform. N Engl J Med. 2009;361:e52(4).
- Kocher R, Sahni NR. Physicians versus hospitals as leaders of accountable care organizations. N Engl J Med. 2010;363(27):2579-2582.
- Struijs JN, Baan CA. Integrating care through bundled payments—Lessons from The Netherlands. N Engl J Med. 2011;364(11):990-991.
- Kocher R, Sahni NR. Hospitals’ race to employ physicians—The logic behind a money-losing proposition. N Engl J Med. 2011;364(19):1790-1793.
- Bazzoli GJ, Dynan L, Burns LR, Lindrooth R. Is provider capitation working? Effects on physician-hospital integration and costs of care. Med Care. 2000;38(3):311-324.
- Wilensky GR. Lessons from the Physician Group Practice Demonstration—a sobering reflection. N Engl J Med. 2011;365(18):1659-1661.
- Lawrence D. Steps forward on e-prescribing. As e-prescribing becomes more widespread, even hospital organizations without full EMR implementation are seeing gains in clinician workflow and patient safety. Healthc Inform. 2010;27(5):24-26.
- Khuri SF, Daley J, Henderson WG. The comparative assessment and improvement of quality of surgical care in the Department of Veterans Affairs. Arch Surg. 2002;137(1):20-27.
- Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: An evaluation of all participating hospitals. Ann Surg. 2009;250(3):363-376.
- Boukus E, Cassil A, O’Malley A. A Snapshot of U.S. Physicians: Key Findings From the 2008 Health Tracking Physician Survey. Washington: Center for Studying Health System Change; 2009. Available at: http://www.rwjf.org/qualityequality/product.jsp?id=47988. Accessed March 29, 2012.
- Evans M. The new underinsured. While health reform is expected to add 31 million to the ranks of the insured, low-income families—and providers—may still face significant financial risk. Mod Healthc. 2010;40(32):28-30.
- Harris G. More physicians say no to endless workdays. The New York Times. April 1, 2011. Available at: http://www.nytimes.com/2011/04/02/health/02resident.html?pagewanted=all. Accessed February 9, 2012.
- Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg. 2011;254(4):558-568.
- The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. Washington, D.C.: U.S. Department of Health and Human Services; 2008. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. Accessed March 29, 2012.
- Organisation for Economic Co-operation and Development. Health Data 2011. Available at: http://www.oecd.org/document/16/0,3746,en_2649_37407_2085200_1_1_1_37407,00.html. Accessed February 13, 2012.
- Debas HT. Surgery: A noble profession in a changing world. Ann Surg. 2002;236(3):263-269.