"Sadness." In a word, that's how Todd Rothenhaus, M.D., chief medical officer of health IT cloud vendor athenahealth Inc., describes what the numbers reveal in the company's fourth annual Physician Sentiment Index Report.
Two main causes of the situation? The complicated IT initiatives surrounding meaningful use implementation, and commercial and public payers demanding more data and offering reimbursement cuts in return. As a result, independent physicians now comprise less than 50% of U.S. doctors, and those who remain their own employers are struggling to hold on to what they have. In fact, the survey indicated almost 80% of docs overall (health-system employed and independent) are not optimistic about the long-term survival of independent physician practices and small groups.
We've got almost a complete disgust and breakdown among independent physicians in the United States.
Todd Rothenhaus, M.D.,
chief medical officer, athenahealth
"We've got almost a complete disgust and breakdown among independent physicians in the United States," Rothenhaus said. "They are representing a minority now. It seems ... they feel healthcare reform has not reached them, and if it has it's not going to improve care, it's not going to reduce costs. The EHRs have not helped them solve business processes."
Compared to employed physicians, the independents were down on new public and commercial payer reimbursement models, such as accountable care organizations (ACOs) that reward providers for keeping patients healthier: They were 16% less likely to think they will improve care, 61% more likely to believe ACOs and their cousins will make it harder to get paid, and 43% more likely to believe they will negatively impact practice profitability.
Independent physicians also were down on EHR systems, more than their employed peers. Fewer than half felt neither the financial nor patient care benefits outweighed the costs of EHRs, while more than half of employed physicians felt they eventually will.
"[Independent physicians fear,] most of all, going it alone," Rothenhaus said. "They're concerned they won't choose employment out of choice, but out of necessity."
Who responded to the survey
This year's survey included 1,200 physicians from the Epocrates user base, a popular smartphone medical reference application athenahealth acquired earlier this year. Of the respondents, 75% identified themselves as being either solo physicians or in groups of 21 or fewer docs.
To make its research more accurately reflect actual U.S. physician sentiment instead of athenahealth customer sentiment, the company partnered with outside organizations to find respondents from past surveys. Rothenhaus believes the 40,000-plus users of athena's EHR and practice-management systems would skew "happier" than the physician population as a whole. Epocrates is used by 350,000 U.S. docs, many of them office-based primary care physicians. Furthermore, he pointed out that respondents were not paid to participate.
While the quality-based payment programs such as ACOs are a big part of what's driving poor physician outlooks, the lack of faith in IT investments driving better economic times is also a major concern, Rothenhaus said. It's hard to separate the two, because next-generation data systems are the tools used to compile quality metrics en route to getting paid in these new models.
The good news: It's not over for indies
Despite the overall doom and gloom the survey revealed, Rothenhaus found a few pockets of optimism: He sees some practices "doubling and tripling down" on solving the IT and reimbursement complexities evolving in healthcare. Instead of capitulating to the challenge, they're embracing it and applying their entrepreneurial acumen to solving it.
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Rothenhaus also sees strength in medium-sized physician groups banding together for themselves, unaffiliated with larger health systems. It takes a certain annual revenue, which he estimates takes about 20 physicians to generate, to support the IT investments and make a go at profiting from emerging payment models.
Those organizations might be equipped for survival in the long haul, he believes. If present federal price-transparency efforts can show patients the costs of care from locally competing healthcare providers, it could boost the prospects of these leaner medical groups. They aren't responsible for a share of a behemoth health system's overhead and consequently don't pass those costs on to the patient.
"It's become an opportunity, if only we could unleash some shopping in America," Rothenhaus said, citing an example: "Orthopedic groups that are not tied to a giant academic medical center are the cheapest, and just as good as anybody else -- and they represent the way forward."
This was first published in August 2013