With more than 70 percent of physicians now employed by hospitals and corporations, many physicians are left with little say in how the healthcare industry is changing.
Ramin Rafie, MD, a strategic adviser and clinical consultant based in West Bloomfield Township, Michigan, joined Becker's ASC Review to discuss how loss of physician autonomy is affecting the industry.
Editor's note: This interview was edited lightly for clarity and brevity.
Question: What's the biggest threat to physicians?
Dr. Ramin Rafie: Lack of autonomy, because a lot of the groups that physicians join as employees are owned by venture capital firms or hospitals. Here, we don't have much say in how things work — it's kind of just 'take it or leave it.' With the ever-changing nature of healthcare, it's also very difficult for a physician to open up their own practice. If you want to participate in Medicare, you have to be in a health system. That's why these doctors open up their own cash-based practices doing direct primary care — so they go out of the insurance-based system. But if you're going to be accepting the insurance-based system, you have to be in this health system, where you're basically a robot, and you don't have much say. You don't choose who you work with or who your staff is. It puts a lot of pressure on you, because you could be working with people that are not as devoted or not as responsible, and it does affect the quality of care.
Q: In what ways is physician autonomy affecting quality of care?
Dr. Rafie: You have people that are not necessarily qualified doing these other jobs, because there's a shortage of people even becoming medical assistants or nurses. Since you're not the one choosing who you work with, you might not be getting the best quality of staff working with you. They're not as dedicated as if you were to hire your own staff and keep them accountable. And, at the end of the day, these big institutions are always looking to cut down on costs. They try to benefit from economies of scale, but that doesn't always work out. With the stresses of COVID-19, a lot of the doctors and nurses ended up just retiring altogether because it's just something never-ending.
Q: From a physician standpoint, is there a solution?
Dr. Rafie: I think making groups of a manageable size and having physicians be in charge of meetings and teams. Insurance has way too much power, and part of that is because of Medicare. They pass these laws and don't even think about the physicians' point of view. The doctor's voice gets swept under the rug.
Q: How do you see this trend toward physician employment progressing?
Dr. Rafie: I think it's going to continue because I think the younger generation of physicians, a lot of them, are choosing not to do a residency. They just become consultants. So even though there's people going to medical school, a lot of them may not choose to go through the struggles of doing a residency or becoming board-certified because they're not willing to make the sacrifices, because at the same time, the rewards may not be there.