Here are five trends on physician perspective of the United States healthcare system, addressing healthcare reform, industry consolidation, compensation, accountable care organizations and physician opinions on the future. The data is based on the Deloitte's Physician Perspectives Survey. 1. Industry consolidation reaches specialists. The healthcare industry has seen a massive trend toward consolidation and although most physicians reported not having considered consolidating in the past, two-thirds foresee physicians and hospitals becoming more integrated within the next one to three years. Around 73 percent of surgical specialists reported consolidation between physicians and hospitals as "likely" or "very likely" in the near future.
"We see a huge amount of physician consolidation with large health systems," says Bob Williams, MD, a leader in Deloitte's U.S. health practice. "Some are consolidating with health plans, multispecialty groups or other models. The systems that are out front doing this are beginning to bring physicians in so they are engaged in the health system and their success. It creates a successful functioning group practice and engages physicians in leadership roles to make the overall health system better."
Among physicians who did report consolidating over the past one or two years, 29 percent did so to retain income security and 21 percent did so to leverage negotiating power with payors, according to the report. The general attitude among surgeons about consolidation and hospital employment also varies between the generations.
"Physicians who are later in their career and used to working independently are finding it more challenging to make the adjustments for being part of a larger organization," says Mitch Morris, MD, a leader in Deloitte's U.S. health practice. "Physicians who own their practice are the CEO of their own company and becoming part of something larger is a significant cultural change. Younger physicians more often prefer to be employed and like the idea. They find being in an independent practice would be challenging and they like the security of the employed model."2. Compensation remains in the decline. Surgeons are seeing reimbursement declines from Medicare and private payors alike, and employed surgeons rely on a variety of compensation models to sustain them in the future. Trending today, more hospitals and organizations are asking surgeons to become part of service line leadership or participate in shared savings programs that could boost lower base compensation going forward.
"There are still a variety of ways that compensation models for physicians, but most organizations are trying to move into a uniform contract," says Dr. Morris. "The expectation of the employment relationships is not only about productivity and revenue generation, but the surgeons are also participating in initiatives to drive the hospital toward demonstrated outcomes that show more efficient care, fewer complications and higher patient satisfaction."
One of the big trends for the future would be a low base compensation for employed surgeons with the potential to receive more based on quality of care.
"In our experience, physicians are willing to engage and participate in improvement processes, and come to an agreement with the hospital about how to best share compensation," says Dr. Williams. "There is an overall anxiety, as there normally would be any time there is a big change for work and life, especially when it comes to new reimbursement methods because most specialists don't believe their income will be increased. However, some are participating in pilot programs for new payment methods because they feel it's better to be on the bus than miss it entirely. I think the general encouragement for physicians has been to avoid being dismissive and take a careful look at new programs because they are not going away."
Among government payors, 90 percent of physicians believe that Medicaid reimbursements will not increase to match Medicare rates for primary care services in the next three years, and 25 percent of physicians would place new or additional limits on accepting Medicare patients if the program was changed to lower payments or switch to a voucher system.
3. Accountable care organization and bundled payment awareness. In 2012, fewer surgical specialists reported familiarity with accountable care organizations. However, around 57 percent of physicians believe that capitation will replace fee-for-service payments within the next three years and physicians already engaged in ACOs report some success in improving quality.
"Most ACOs are really engaging initially with primary care physicians and then will bring in subspecialty physicians as they mature because a lot of initiatives are with improving outcomes through prevention and other means," says Dr. Williams. "Surgical specialists are more involved in bundled payments. They are beginning to participate with the increased assumption of risk based on value."
Around 51 percent of physicians believe their income will fall dramatically over the next one to three years, with the number jumping to 68 percent among solo practice physicians. Around 90 percent of physicians report their greatest concern about financial viability under bundled payment structures as receiving inadequate payment and being penalized for factors outside of their control, according to the report. However, 80 percent of physicians believe trends in the next decade will involve interdisciplinary teams and coordinated care.
"Despite skepticism about new payment models, there is a general agreement among physicians who took the survey that we have significant flaws in our health system now and they want to address them," says Dr. Williams. "Some of the programs have the potential to address these flaws, and that's why physicians want to participate."
4. Attitude toward the future. Around 70 percent of all physicians are satisfied with practicing medicine, and the percentage is higher among surgical specialists than primary care physicians. Specialists cited the most satisfying aspect about practicing medicine is the patient relationships (41 percent), followed by protecting and promoting the health of individuals (38 percent).
"Specialists differed with other physicians on this question, with a higher percentage reporting 'patient relationships' as the most satisfying part of their practice than primary care physicians," says Dr. Morris. "There is a concern that in the future patients will not have as much choice in their specialists because of the new environment and that has the potential to disrupt those relationships."
Notably, 0 percent of surgical specialists reported running a business or administering a complex healthcare organization as the biggest factor in job satisfaction.
"Physicians preferred to spend their time with patients instead of practicing business," says Dr. Williams. "Whether they can be successful on the business side with someone else working for them is a challenge. They have to figure out how to become valued as part of a team that helps create the future of the organization."
Among non-surgical specialists who are not satisfied with practicing medicine, 21 percent said the biggest factor was having less time to spend with each patient. Surgical specialists reported the long hours and work week as the biggest factor in their dissatisfaction. Around 57 percent of physicians feel the practice of medicine is in jeopardy and 81 percent of surgical specialists think the "best and brightest" may not consider medicine in the future.
5. Acceptance of healthcare reform. According to the survey, 44 percent of physicians say the Patient Protection and Affordable Care Act is a good start, while the number of physicians who said it was a step in the wrong direction fell from 44 percent in 2011 to 38 percent in 2012.
"The survey supports that physicians are accepting and feeling increasingly positive about some components of the ACA," says Dr. Williams. "Physicians are still concerned about access to care and have patients with access issues. They are comfortable targeting waste and are engaged with doing their best for patients. That combination is part of the optimism about what's ahead."
However, surgical specialists are much more likely to think the ACA is a step in the wrong direction, with 48 percent reporting as such in 2012. This is still down from 60 percent in 2011, but 16 percentage points higher than primary care physicians when asked the same question.
"There is a lot of concern about the ability of patients to choose where they receive specialty care," says Dr. Morris. "Surgical specialists are also facing a decrease in reimbursement and impact on individual income that is clearly part of their attitude towards ACA."
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