More doctors flock to hospitals as insurer system daunts small practices
The number of Hawaii doctors employed by hospitals has grown by more than 30 percent in the past three years as health-care providers try to find ways to improve quality — the primary measure for calculating payments.
Thirty percent of Hawaii physicians were employed by hospitals in July 2015, up from 22 percent in July 2012, according to a recent study released by the Physicians Advocacy Institute Inc., a Washington, D.C.-based nonprofit that promotes fair and transparent payment policies.
Even with the increase, Hawaii doctors lag physicians nationwide, where nearly 4 in 10 are employed by a hospital, the study showed.
In Hawaii, 15.6 percent of physician group practices were owned by hospitals in 2015, up from 8.5 percent in 2012. Nationally, about 25 percent of physician group practices are owned by hospitals.
The growing trend, which is reducing the number of independent doctors in private practice, is alarming to the head of the Hawaii Medical Association, the trade group representing 1,900 physicians.
“You cannot serve two masters. The independence of physicians is an important aspect of care, and it is being eroded in today’s environment,” said HMA president Dr. Scott McCaffrey. “Large groups and insurers would like to get doctors contracted so they have an additional level of control over a doctor’s behavior, and can apply pressure and influence over doctors’ decision-making for cost-control purposes. A good physician workforce is one of the best things for a community from a medical standpoint because independent doctors are in a position of truly advocating for a patient.”
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Private health insurers, including Hawaii Medical Service Association, Hawaii’s largest, and government insurers, including Medicare, have fundamentally changed the way hospitals and doctors are paid for medical services in recent years.
The payment system has shifted away from paying for the quantity of services performed and now bases reimbursements on quality measures. A major goal of the payment model is to decrease readmission and infection rates, as well as ensure a viable health-care system by rewarding hospitals and physicians for coordinating care to produce positive health outcomes while controlling costs.
“The small physician practice is going to struggle to be financially viable under the new value-based payment methodologies being adopted,” said Kelly Kenney, executive vice president of the Physicians Advocacy Institute. “A value-based system for Medicare is all heavily reliant on reporting quality measures. It’s pretty data-intensive and expensive. … For a small-practice physician, it looks pretty daunting.”
In addition, hospitals are looking at physician practices as a way to secure a patient base, she said.
“These big systems are competing for patients. It’s one way that hospitals can kind of lock in a patient base and ensure a stream of patients into their system,” Kenney said. “Hospital systems are all competing for those dollars.”
For doctors, it’s difficult to keep up with the changing requirements and rules tagged to compensation, McCaffrey said.
“They’re trying to phase out fee for service and individual doctors and small practices simply do not have the staff resources to keep up with onerous new requirements of today’s new payment models,” he said. “Individual and small group practices are at a distinct disadvantage. This is the reason young new doctors are not going into private practice and the reason older doctors are looking to retire early.”
In the past two years, the Queen’s Medical Center has employed about 25 additional physicians.
Dr. Whitney Limm, Queen’s chief physician officer, said there is still a large role for private practice doctors to play in the health-care system. Of the more than 1,200 physicians on Queen’s medical staff, only 165 are employed by the hospital.
“It’s the uniqueness of the Hawaii environment that we have a lot more private practice doctors than employed physicians,” he said. “That has definitely increased in the last 10 years. The benefits to the community is helping to provide access to care.”
9 responses to “More doctors flock to hospitals as insurer system daunts small practices”
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Are these doctors hired by the hospitals like the nurses and other staff members including the administrative staffed? Or are the independent contractors with agreements to use the hospital facilities to treat their patient? like the 165 doctors who work for Queens the ore 1,200 other doctors contract to use Queens facilities for medical necessities? We prefer Kaiser’s HMO system as all encompassing .
What is the ratio of onsite doctors who care for the patients that are hospitalized? Have heard that one doctor must care for literally hundreds during a given shift, want to verify if that is true.
In the end, it doesn’t matter if a doc works for themselves or for a hospital as long as they put the patient first and give quality care. My doctor is affiliated with Straub and I’m glad. That means she has access to resources and expertise that she maybe wouldn’t have as an independent doc.
VIRTUAL QUALITY OR REAL QUALITY?
For years, Hawaii has had some of the lowest heath costs in the country along with high percentage of our doctors in private practice. As Dr.Stephen Kemble has repeatedly pointed out in these pages in recent years, intrusive and misguided efforts to track arbitrary clinical data and call it “quality’ is mainly serving to drive doctors out of private practice or into early retirement.
To make matters worse, we are in the midst of a physician shortage and patients have trouble accessing care. Those doctors who remain have even more patients to care for but must spend roughly half their precious time on paperwork, phone calls and data entry just to satisfy these regulations. They have no option but to cut the time spent with patients and their own families. They are getting burned-out in record numbers, and fleeing to non-clinical jobs as managers, consultants and administrators. Significant portions of medical conferences, meetings and physician education is spent on learning about ever-changing insurance rules and regulations rather than the art and science of actual patient care.
More and more, physicians are opting out of all public and private health plans and taking cash only. More and more, health plan members are forced to go to see nurses or to face long waits to see a distracted doctor. They are unhappy about the decline in quality time and often blame the doctors.
Meanwhile, salaries and benefits for hospital, insurance and pharmaceutical executives (those making these onerous practice rules) are at an all time high. Many of these folks are lawyers, MBAs, bureaucrats and professional administrators with little or no clinical experience. Despite their control over the health-care system, and the damage they have inflicted on it, these “leaders” have escaped accountability by designing a system that instead puts the burden of “accountable care” on the backs of the doctors, whose fees only account for 10-15% of total health costs.
Now these “leaders” want all doctors to begin following a model called “Collaborative Care’, in which the physician acts more like a team manager, and the doctor-patient relationship is avoided in favor of nurses and even para-professionals with few qualifications. These teams will be monitored and overseen by added layers of clerks, computer programmers, consultants and administrators, none of whom provide any direct care. Taxpayers and plan members will pay more and more for the privilege of this bloated, bureaucratic model of care. Many are disheartened and at a loss to know what else we could do.
There is one part of the system in which the “leaders’ of this “quality care revolution’ can be held accountable, and this is for the adequacy of their health plan networks. There are laws that require all plan members be able to access medically necessary care in a timely manner. For many plans in many areas, this is not the case. These network adeqacy violations have been getting worse with the passage of the Affordable Care Act and the regulatory burdens Kristen has reported on. Shockingly, there had been little to no monitoring or enforcement here in Hawaii.
In what other the industry would a Hawaii company be allowed to promise goods or services to customers, to collect payments for this, to promise government officials and accreditation bodies that they had adequate capacity as condition to operate, but then blatantly violate these all of promises and tequirements?
Would we do nothing if Hawaiian Airlines sold tickets for seats on planes that couldn’t fly because it lacked enough pilots, then it squeezed more passengers on existing planes by making people sit on each other’s laps and made pilots fly longer and longer hours?
What if scheduled flights were delayed for months, many passengers at rural airports were unable to fly at all, while the airline kept all the payments?
What if this happened month after month, and when people demanded action, the airline executives responded by blaming the overworked pilots and forcing them to fill out hours of extra paperwork each day, and by raising tocket prices?
When such actions backfired, what if the a
executives at Hawaiian Air then crafted a plan to put pilots on the ground fielding calls from unqualified low-cost workers in the cockpit, to still hold the pilots responsible for any crashes, to select irrelevant data measures and to label this “quality”?
What if people got sick and died because of the airline’s broken promises, its defrauding of customers and its reckless scheme to cover up its lack of pilots?
What if these executives received lavish salaries and bonuses, but refused to pay pilots who resisted this scheme by insisting on being in the cockpit and not filling out senseless paperwork each day?
Would we ever allow any airline or other business to operate this way?
Of course not, yet this is essentially what has been taking place in the health insurance industry for over a decade. It’s getting worse, yet our state officials have done nothing but turn a blind eye to health plans’ legal obligation to maintain adequate provider networks, in fact not just on paper.
In essence, the health-care system our “leaders” have created is a virtual one in which the living, breathing, suffering patient and the actual care they receive is now less important than the electronic patient and care data entered into the computer. The result is virtual quality, not real quality. Sick patients know this, practicing doctors know this, and concerned families know this. It is a costly, demoralizing and maladaptive response to rising health costs.
By the way, this same obsession with arbitrary metrics is not limited to health-care. It reflects a voyeristic, suspicious desire to measure and control from above what can not be controlled, only destroyed – helping relationships based on compassion, honest communication, trust and respect. These relationships take many different forms (teacher-student, doctor-patient, comtractor-client, salesman-customer, etc…), and are the source of most of life’s meaning and most of our careers. No matter the occupation, we are paid to help others or we do so voluntarily.
Computers, databases, communication technologies and other fruits of the information age are powerful tools. But because of this power, they carry the risk that we will confuse the virtual with the real, and that that over reliance on the former will degrade the latter. Perhaps nowhere is this confusion and degradation seen more clearly than in the doctor-patient relationship.
It is time for us to grow up, to put these toys and tools in their proper place, and to transcend the information age to the relationship age. We must learn to keep in mind that data is only able to capture simplistic and static measures, and sometimes even this lacks accuracy, while most of reality is complex and dynamic.
The power of computers and data can be applied to relatively simple, static situations, like the ultra-contolled setting of a robotic manufacturing facility where identical versions of an item can be precisely made by a carefully designed mechanical process.
But computers are ill-suited to the task of improving the health of something as complex and dynamic as a human being (genes, proteins, hormones, cells, tissues, organs, brains, personality, gender, age, emotions, memory, intelligence, beliefs, behaviors) embedded in an even more complex and dynamic environment (family, education, occupation, community, language, culture, laws, religion, economics, stressors, supports, resources).
The Information Age (also calked the Digital Age) has about run its course. If we are to thrive in Hawaii and on island Earth, we must enter the Relationship Age (maybe it could be called the Psychological Age).
We should start with health-care because people’s lives and dignity and so much depend on this perspective. The doctor-patient relationship has always been considered sacred, and it remains so because no matter what technology we develop or models of care we design, all us human beings will still get injured, will grow old, will get sick, will be on our death bed and will die. And through that process we want the most competent, compassionate, experienced professional to be with us and our families. Someone who is willing and able to care for us and who has professed that they will put our care above the interests of others, even their own.
These are the kinds of physicians we need, and if we don’t have enough then let’s get to work recruiting and training more of them. This is the proper solution our health system needs.
We could easily pay for more doctors by firing the armies of mindless bureaucrats and unaccountable administrators who never lay helping hands on those who are sick, provide no care whatsoever, who are, in fact, a wasteful intrusion, distraction and a disruption to clinical care. Most wouldn’t know what to do if an injured, sick or dying person were literally staring them in the face. The only thing they could do is call for a doctor, if there were one.
All these useless non-clinical jobs account for over 20% of health costs, probably much more when you look at it broadly. We could double our physician workforce with that.
Even more resources would be available for enough real doctors if we put an end to the greed of drug company executives who have been taking more and more out of the health system for products that are no better than what we had before (or even identical) or that overstate benefits and hide risks, or are just flat-out over-priced.
The same goes for hiring more teachers, university professors and other professions that are being strangled by bloated, legalistic bureaucracy and intrusive digital monitoring and data demands.
Sorry for the length of this comment. If anyone has gotten to the end of this post, what do you think about virtual quality vs real quality?
Remember that old line “follow the money”?
This is payment fir spending less and less and less on us patients
That means, no matter how they try to dress it up as “quality”, Less Care, lower quality ( nothing negative here about our great Hawaii nurses here….but which obviously is higher quality informed care? Seeing a nurse or your physician??) and
It’s by paying our physicians directly to give us less care
That’s it. Insurance companies charge us more, pay physicians to give us less care, insurance companies make even more
Problem w this approach is the insurance company profit model
Well stated Danno Boy.
“quality performance metrics” and “institutionalized employed physicians” are driven by hospitals and insurance companies to make profits, and have resulted in a shift-worker-9-to-5 mentality of healthcare delivery; its human nature. Our current system is still treating our docs with the “The beatings will continue until the morale improves” mentality.
The patient-physician relationship is not a priority, and will only be available to the people with resources to pay for it.
The rest of us will get ‘whoever happens to be working’ at the time of our visit, rather than the physician we trust.
For those who prefer to “thrive” with Kaiser: its cheap and ok if you are young and healthy (yes, kaiser makes big $$$ from healthy members because they collect lots of premiums and they don’t have to pay for anything) but wait until you need to see a specialist & see how the kaiser system will get you ‘throttled instead of thriving’
Unfortunately with employed docs all the hospitals are become more and more like kaiser…
Here’s my personal Kaiser story.
After getting married my wife and I had our first child, a boy. It was a difficult delivery, she had a strange OB we had never met before, and complications were not handled well (vacuum extraction, tears and uterine infection requiring readmission after being initially misdiagnosed by a Kaiser nurse on the phone).
Then we began going to the local Kaiser clinic for routine care. It used a team-based, collaborative care approach. My son’s pediatrician was Dr. Hamilton, but we barely knew him and he didn’t know us at all. He would pop his head in during visits, briefly examine our son and say “How is she?” This happened during every single visit during that first year, until I was able to switch to HMSA.
Then one day, while watching TV, we saw a Kaiser commercial. It talked about the high quality of care and “satisfied” patients. It showed a smiling family with a child being examined by a familiar looking doctor, then the actor says “We’re so glad to have Dr. Hamilton as our doctor, he really cares,” and the scene cuts from the exam room to Dr. Hamilton walking with the family outside, in a park-like setting, holding the hand of the child, with the softened sunlight and a soothing slack-key soundtrack.
Our jaws dropped at the dishonesty of this portrayal of Kaiser. Not only didn’t the photogenic Dr. Hamilton seem to “really care”, after repeated visits, he didn’t even know the most basic fact about his tiny patient – his gender.
We were forced to watched that shibai Kaiser propaganda over and over for months.
Needless to say, we found a good pediatrician in our town, in solo private practice, who just retired. He helped raise both our children, as he had generations of other families in our community, and we never once doubted that he knew them and cared about them.
Simple. You do get What You pay for. Add it up
Read recent article on Vancouver island healthcare and waiting for tests