When Toledo, OH, neurologist, Mark G. Loomus, MD, left private practice three years ago in order to join ProMedica Healthcare, a nonprofit health care organization, he chose to become office-based. His former group of three neurologists had each taken one full week of call out of three, covering the entire group and up to four hospitals some years. His call weeks were long and onerous, and as the years went on, it became harder and harder for him to recover if he was hit with a deluge of consultations on Monday or Tuesday nights.
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“I was tired all the time and my quality of life was suffering,” he said.
Dr. Loomus, who now only takes call for his own patients, serves as the sole employed neurologist for a network that includes 300 physicians and which has recently hired two hospital-based neuro-interventionalists. He is able to see as many patients in the office in four and a half days a week as he had been able to achieve rounding at two to three hospitals, and in a more reasonable time frame. “Back then, there was always anxiety about spending hours at one hospital, going to the second, and getting called back to the first,” he recalled.
Dr. Loomus appreciates the predictability of office practice in which he gets paid on a straight work relative value unit (wRVU) basis, with a baseline set based on past year's billings and a bonus. His employer takes care of overhead, including computer technical support, billing, and purchasing supplies. “For me, things have worked out great,” he said, explaining that he now chooses his own work hours, is allowed five weeks of vacation a year, and for all practical purposes, has nights, weekends, and holidays off. “Not only is my income is higher, but I get to sleep at night,” he said.
EXODUS OF SMALL GROUP PRACTICES
Dr. Loomus is one of many doctors who have chosen to leave small group practice in recent years. Between 2012 and 2013, hospital-employed physicians increased from 20 to 26 percent, according to a Jackson Healthcare staffing company report on 2013 practice trends. Solo practitioners decreased from 21 to 15 percent, and 39 percent of physicians younger than 45 had never worked in private practice. The trend is supported by findings by Merritt Hawkins, another physician staffing company, which last year reported that 63 percent of its search assignments featured hospital employment positions for doctors, up from 56 percent the previous year and only 11 percent eight years ago. Experts forecast that if the trend continues at this rate, over 75 percent of newly hired physicians will be hospital employees by 2014.
But the hospital-buying binge [of physician practices] that has spearheaded the exodus from private practice may soon suffer a setback. Currently, hospitals can bill for the services and procedures performed by their employed physicians at rates typically much higher than outpatient office rates. But, in a June 2013 report to Congress, the Medicare Payment Advisory Commission (MedPAC) advocated to urgently realign payment to become site neutral. If that takes effect, hospitals may choose to lower physician salaries when it's time to renegotiate physician contracts. Because hospitals learned from their mistakes in the employment frenzy of the 1990s when physicians who were issued income guarantees became less industrious, more recent compensation models have been designed with a fixed base salary and productivity incentives.
Indeed, only 7 percent of physician search assignments Merritt Hawkins conducted in 2011-12 featured income guarantees, down from 21 percent in 2006-07 and 41 percent in 2003-04. The majority of search assignments (73 percent) featured a salary with production bonus; 54 percent were based on an RVU formula, and 35 percent offered a quality-based component as well, up from less than 7 percent the previous year. This year, employed neurologists paid on productivity measures will be hit by the 2013 Medicare cuts and revenues further eroded by the 2 percent reduction in Medicare reimbursement, effective in April, as a result of the sequestration.
Many physicians who transitioned to employed practice have already taken pay cuts. Roland Brilla, MD, MPH, clinical assistant professor at the department of neurology at the University of Wisconsin, Madison, is one of them. When he made the shift in 2009 from a large multispecialty group covering southeast Wisconsin he was happy to leave behind the compromises that can trouble small groups — in particular, the division of call and procedures.
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Dr. Brilla, who practices general neurology and has a subspecialty interest in headache, also appreciates the greater variety of cases he sees when working at a teaching institution as well as the direct interaction with other subspecialties available there. He has no regrets about his move, but has had to take a 20-25 percent pay cut, which was slightly more than anticipated.
William C. Davison, MD, who had practiced in the Park Ridge, IL, area since 1977, was also willing to accept a significant pay cut when he accepted a job with a medical school in the Chicago area last fall. The trade-off was clear: after worrying about the business of practice for 35 years, he was happy to leave the insurance hassles to someone else. He now practices two and a half days a week at a multispecialty clinic ten miles away from his prior office location.
“I have no more call or long days but still get to see my patients, many of whom followed me to my new facility,” he said. He was also pleased to get his own nurse and handy access to an on-site laboratory and MRI machine.
WHERE YOU ARE IN YOUR CAREER
Career phase may also play a role in how neurologists adapt to becoming new employees. Dr. Davison, who just turned 68, sees this change as a “soft landing” — that is, he is no longer as concerned about autonomy as he might have been at age 40.
For many in earlier stages of their careers trying to raise a family, the appeal is a more regular schedule. When Clark W. Pinyan, MD, MPH, was in private practice in High Point, NC, with five neurologists and had to cover five hospitals, call was very demanding and required a great deal of travel, so much so that on weekends his group had to hire locums tenens neurologists to help with coverage. When the practice was finally sold to a local hospital in 2010, Dr. Pinyan became an employee. The practice did not change for the most part, but it had also lost two neurologists by then and was having trouble finding new employees. “Each day we covered both in-patients and out-patients, making the day very unpredictable,” said Dr. Pinyan. He found it increasingly challenging to help his wife, a private practice dentist, raise their now 7-year old daughter.
When Dr. Pinyan got an offer from Wake Forest in 2012, he was ready to make a change. He likes having access to a large network of renowned experts and a greater pool of knowledge at his fingertips, which allows him to stay much more current.
“There are so many opportunities today for clinically-focused positions like mine that were not present 15 years ago,” he observed. His schedule is predictable now with eight half-days of clinic a week and two half-days of teaching. Although his salary was cut about 30-40 percent, some of the loss has been mitigated by better benefits. The biggest adjustment has been dealing with the bureaucratic aspects of academia, he said. “If I had needed a new machine in my own practice it may have taken two weeks, but now it may take longer, since there are so many more people involved in the decision-making.”
A better family life also drew Gavin F. Brown, MD, back to academic medicine. When his first child was born during his first year of private practice, he realized that he wanted a career that would allow him to spend more time with family. In April 2012, he left his small practice of three neurologists and came back to Emory where he had trained. He advises those who are interested in making the switch to learn a bit about the institutional politics of the department or hospital system they are joining, and to spend some time with a physician in the clinic before deciding. “Even a brief look might reveal a lot that you wouldn't learn in an interview,” he concluded.
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Dr. Brown found his transition seamless, but admits that Emory was a familiar environment for him. Yet some doctors find the transition to employed practice to be rocky. According to a recent Medscape story, “4 Top Complaints of Employed Doctors,” the biggest challenges included being “bossed around by less-educated admins;” not being able to make decisions about staff and personnel; having less authority over billing and charge coding; and being forced to use new equipment and technology.
One neurologist who requested anonymity, found the changes intolerable when his practice was bought by a large New York City medical center several years ago. “We had to stay in-house to be available for stroke call, basically sleeping in the office waiting for the beeper to go off for one week out of three,” he said. “The conditions were so bad, doctors just quit.” There was also pressure to see people in the clinic at a rapid pace — about thirty patients in three hours — with a push to add more from “college grads breathing down our necks,” the neurologist recalled. He has since returned to private practice. “As for employed practice, I would never consider it again,” he said.
Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is an associate editor of Neurology Today and chair of the AAN Medical Economics and Management Committee.
COMING IN NEUROLOGY TODAY: PRESIDENT BILL CLINTON TO HEADLINE PUBLIC POLICY FORUM AT ANA ANNUAL MEETING
President Bill Clinton, Founder of the Clinton Foundation and 42nd President of the United States, will be the keynote speaker at the American Neurological Association (ANA) 2013 Annual Meeting, Oct. 13-15, in New Orleans. President Clinton will address the ANA Public Policy Symposium on Oct. 15, which will be held from 9:15 am-noon, followed by a panel discussion that includes NIH representatives, health care experts, and university officials.
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For registration and hotel reservations for this year's ANA Annual Meeting, visit http://bit.ly/14ieaAP.
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