The U.S. health care delivery system is undergoing a massive restructuring. There are many forces, seen and unseen, contributing to this transformation.
First, since the 1990s, hospitals have been consolidating to form health systems that exert monopolistic leverage in many health care markets. Second, after the passage of the Affordable Care act in 2010, these systems – along with large insurers and other corporate entities – began aggressively acquiring physician practices. Third, with new physicians leaving training with mountains of debt, they are unwilling or unable to operate a private practice with the risk and administrative burden this would entail.
The result has been a sea change in the structure of physician practice structures. In 2012, only 5.6% of U.S. physicians were directly employed by a hospital. By Jan 2022, the proportion of hospital-employed physicians had risen to 52% with another 22% of physicians being employed by other corporate entities. That 74% of physicians are employed by hospital or insurance corporations yields a huge culture shock for a profession that has jealously guarded its independence and autonomy.
So, how is that working out for doctors? Physicians previous employed by the Oregon Medical Group or Corvallis Clinic, whose clinics were purchased by Optum, would give low scores. In the last 2 years, 32 doctors have left the Oregon Medical Group. Working under corporate vice presidents and hired medical directors who could not thrive in private practice, being treated as a widget, with little opportunity to modify practice expectations or policies can’t be a pleasant experience. In a recent poll, doctors were asked if they would advise their son or daughter to go to medical school. Only 38% replied with yes.
Not coincidentally, another workforce related change has begun to rise: the formation of physician unions. Between 2014 and 2019, the proportion of physician who were unionized grew by 26% (albeit from a low level), and this trend has accelerated over the past few years.
Unionization is neither a rash decision nor a political movement. It is a natural consequence of these changes along with the impersonal nature of employment where physicians find that management seems to view their service as a financial drain. With U.S. physicians becoming employees, they have been exposed to a world in which the terms and conditions of their employment are enshrined in legal contracts. These contracts, which govern their employment, are subject to negotiation. Individual physicians have little expertise and less bargaining leverage to navigate these seas. Collective bargaining by means of unions offers a potential remedy to this power imbalance.
Finally, there is the issue of physician shortage. By the end of this year, the United States is expected to have a shortage of up to 64,000 physicians. Current projections indicate the physician deficits could grow up to 86,000 by 2036.
One reason for the expected shortage is that some 20 percent of clinical physicians are aged 65 and older. At the same time, the percent of the US population aged 65 and up – an inherently higher-need patient group – is expected to rise from 17 percent to 23 percent of the population by 2050. In a recent survey by McKinsey and Company, over a third of physician respondents say they are likely to leave their jobs in the next 5 years, and that’s not restricted to those nearing retirement.
What’s the point?
Evergreen finds itself like a sparrow in a hurricane seeking refuge from these shifting winds. The danger with health systems that oversimplify complex clinical workflows, while conveying little sense of trust or value in doctors, is that they turn healthcare settings into places no one, including patients seem to enjoy being in, which for a helping industry is sad.
Primary care is hard work. I have learned not every individual is capable of the rigors inherent in this profession, even when their medical credentials are acceptable. But a difficult job becomes impossible without a supportive culture.
My own observations suggest that most providers are driven primarily by intrinsic desires, i.e., things such as the personal meaning in their work, strong interpersonal relationships with coworkers and patients, and the emotional rewards they get from helping people. This is precisely the environment Evergreen must cultivate.
The interest of administration in a healthy group is to manage performance results, not individual decisions. Providers need a firewall and an infrastructure to protect from outside distraction and fatigue. A health care information system is most costly when it slows you down or providers can’t trust the data. Administration’s role is to facilitate these conditions.
Every system is perfectly designed to get the results it is getting. I like what I see and hear about each of you. I wouldn’t trade what we have at Evergreen for any of the situations I described. Unionization is just another form of control. Evergreen is the group I would have liked to join when I arrived in Roseburg in 1980. Not perfect, but I prefer this model to any of the alternatives above.
The point is that it’s a good feeling to have some control over your professional experience. And that each of you are part of our solution. We will not solve the national health care mess. But we can design a primary care system for Douglas County. We’re doing that. I’m grateful. That’s important. If we are to keep what we have worked so hard to build, it begins with appreciating what we have.
Thank you for working with us.
Tim Powell MD
November 2024
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