Being a physician is complicated: The rewards associated with helping patients are great, but the demands tied to running a practice can prove taxing. Still, 71 percent of respondents to a recent survey said that given the choice, they'd go into medicine all over again -- a figure that beats the previous mark of less than 67 percent.
Overall, the 2014 Survey of America's Physicians(www.physiciansfoundation.org) revealed that physicians find the profession rewarding but are concerned about how the business side of health care and new health care policy will affect their practices.
Published by The Physicians Foundation, the biennial survey was conducted by the physician search and consulting firm Merritt Hawkins and asked physicians about topics ranging from how many hours they work each week to how they perceive the Patient Protection and Affordable Care Act (ACA). Nearly 15 percent of survey respondents were family physicians.
Morale on the Rise Despite Busy Schedules
Compared with the previous survey, physicians were more likely to describe their morale and their feelings about the current state of the profession as being "very positive" or "somewhat positive" -- more than 44 percent in 2014 compared with less than 32 percent in 2012. In general, physicians who were younger, female or employed, as well as those practicing primary care, were more positive about the current practice environment.
- According to a recent survey, four out of five physicians say they are working at or above capacity in their practices.
- A small percentage of physicians say they are planning to cut ties with insurers and move to a direct payment model.
- Although physicians overwhelmingly ranked patient relationships at the top of the list when it comes to satisfaction with their career choice, four in 10 still plan to leave the profession or otherwise cut back on the number of patients they see.
"Family medicine rates above the national norm in terms of feeling more positive overall about our profession," said AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn. "To maintain this positivity, I hope our legislators keep talking about how to move away from fee-for-service toward a system that pays for value. The increased emphasis on and discussion about primary care is welcome, but we need to see actions that support this newfound value."
As for what survey respondents found most satisfying about medical practice -- building and nurturing relationships with patients was overwhelmingly ranked the highest.
Although physicians who responded to the 2014 survey reported being busier than before, with slightly more than 81 percent saying they were overextended or working at capacity compared with about 76 percent in 2012, they actually worked slightly fewer hours per week than in years past. According to the 2014 survey, the average was less than 53 hours, virtually identical to what they reported working in 2012, but down from nearly 57 hours in 2008.
Of that total, respondents reported they spent between 10 and 11 hours on nonclinical tasks such as paperwork. But according to Blackwelder, that's to be expected in the current practice environment.
"The reality of medicine in all specialties is there's a shift from developing relationships with patients to spending more time on electronic health records, on the phone or handling administrative burdens that don't improve patient care or that are done solely to support billing," he said.
Health Reform Rollout Draws Mixed Reviews
Many physicians professed to skepticism about the ACA's prospects for bringing about system change, with nearly 46 percent of respondents giving the law a grade of "D" or "F." It's important to remember, however, that at the time of its passage, the ACA had as a priority expanding access to care and making some substantive changes to support primary care, said Blackwelder. He pointed out that the law created a number of provisions family physicians have long sought that increased the value of primary care, such as payment parity between Medicaid and Medicare and a primary care bonus.
"It is common for people to form a global opinion about big changes," Blackwelder observed, "especially when they are associated with an acronym like the ACA. But the reality is that any such process always has positive components as well as issues that need attention," he added.
A linchpin of the ACA is the development of new care delivery and payment models such as accountable care organizations (ACOs). Some survey respondents, however, expressed uncertainty about the ability of ACOs to enhance quality and reduce costs, with about 36 percent of respondents saying they thought ACOs were unlikely to achieve those goals. Still, that figure represents an improvement compared with 2012, when nearly 41 percent of respondents said they doubted ACOs were up to the task.
The way Blackwelder sees it, differences in physicians' perceptions of ACOs aren't all that hard to explain. "If you are part of an ACO that is run by physicians, you are likely to be feel positive, but if you are practicing in an area with a delayed commitment to an ACO, or are a member of an ACO that a hospital has taken over, then you're pessimistic," he said.
For physicians who want to work outside an insurance network, alternative payment models also are emerging as an option. Although almost 80 percent of physicians said they had no plans to move to what the survey termed a concierge or direct pay model, the percentage considering such a move is not insignificant.
Currently, a little more than 7 percent of physicians said they currently practice some form of direct pay or concierge medicine, and some 13 percent indicated they are planning to transition in whole or in part to this type of practice. Of physicians 45 or younger, 17 percent indicated they plan to make the transition, and almost 7 percent are already there.
Blackwelder noted that the upside of such alternative payment models is that they allow for more direct relationships with patients and avoid the burdens imposed by most payers.
"Direct primary care is one delivery and payment model that supports physicians doing what they most want to do, which is care for patients," he said. "Early data from some of these practices suggest the model can improve patient outcomes and increase both patient and physician satisfaction at lower cost (the quadruple aim), while cutting out the administrative headaches of insurance. It's a viable model for members."
It's worth noting, however, that the two terms used in the survey are not synonymous, Blackwelder cautioned. "Direct primary care is different from concierge medicine in both how it provides access for patients and payment structure."
Insurance Network Limits Are Cause for Concern
The survey also demonstrated that narrow insurance networks are a growing concern for physicians. Twenty-seven percent of respondents said the health insurance exchange in their state includes a narrow network. Of that total, more than 28 percent said they were excluded from participating in an insurance plan.
Insurers' growing influence also appears to be cutting into physicians' authority over patient care, with 54 percent of survey respondents reporting they have encountered limitations when treating patients and that their decisions about what is best for patients are sometimes compromised.
Taken together, Blackwelder said, the demands that regulations and insurance-related paperwork place on a physician no doubt contribute to the daily grind of many current practices. The survey appears to bear this out, with nearly 44 percent of physicians saying they plan to make a practice or lifestyle change that will cut back on the number of patients they see and, thus, patients' overall access to physician services.
Still, Blackwelder believes ongoing reforms offer hope for the future. "There is good reason to be cautiously optimistic because we are on the cusp of changes that are beginning to address issues that family physicians have wrestled with," he said.