Who is Minding the Store? The Depletion of the US Physician Workforce
A newly published study on physician burnout (n=1373), funded by the Massachusetts General Physicians Organization (and performed by doctors who are members), reported that doctor burnout is on the rise.
They report that physician burnout rates have increased over 3 time points, 2017, 2019, and 2021. Burnout was assessed using the Maslach Burnout Inventory, as determined by high scores in 2 of the 3 subscales of “Exhaustion, Cynicism, and Reduced Personal Efficacy”. Those at higher risk were female and primary care doctors as well as those with less than ten (10) years of experience.
But the rising rates of doctor burnout, alone, do not fully account for the exodus of physicians from direct patient care (post the Covid’s pandemic). But when coupled with what is termed “moral injury” and loss of autonomy the road signs point to the exit door.
Moral injury is a term first used for psychologically traumatized, first line soldiers. Moral injury depicts a state of acting against one’s core values - and recognizing it. It has become a fitting term for when doctors cannot hold to an oath that when “…healing the sick, I will take care that they suffer no hurt or damage”; and that they have a duty to diagnose, treat, and inform the patient.
Moral injury is bred when doctors adhere to medical and billing practices they know to be errant from caring for the patient. Instead, they have acceded to the mandates lorded over them by for-profit, corporate healthcare payers and the managed care organizations that execute on their mission that profits come before patients.
Physicians make medical treatment decisions for their patients. Except when their autonomy, their control, over medical treatment decisions and the fees (charged to patients and the federal and state governments that fund Medicare and Medicaid) has been hijacked by the corporatization of US medical care.
“Upcoding” is the practice of inflating medical procedure codes. A recent analysis of Medicare Advantage Plans (Managed Care under Medicare) by the Physicians For A National Health Program reveals how these plans are fleecing the federal government of $88 billion /year (perhaps as much as $140 billion). These estimates do not include “dual eligible” patients with Dental, Hearing, and Vision coverage, which would add tens of billions more. To insure upcoding, in some settings, data is collected to measure the performance by doctors of using higher cost, doctor procedure codes, and then used to bully the provision of “better” (more pricey) billing codes.
The American Economic Review provides further evidence of the chicanery of Medicare Advantage Plans. They reported that Plans game risk adjustment (key to payment rates) by switching from selecting the least costly of patients to identifying and sub-selecting those same low-cost patients who have conditions that allow for higher risk scores that can increase payment adjustments.
Fleeing a Toxic Workplace
No one should have to ‘get used to’ a workplace with a toxic milieu. Could you? Where “Exhaustion, Cynicism, and Reduced Personal Efficacy”, moral injury, and obeisance to the medical and billing decisions are the result of the corporatization of healthcare in America.
Who’s Minding the Store?`
What surprises me the most is that US, for-profit health, healthcare organizations are not seeing a dead end ahead. They live and die by the revenues they generate. Their principal asset in generating revenue is physicians.
To compensate for a waning workforce, knowingly or not, for-profit medical practices are not only upcoding and otherwise tinkering with payments, they also are increasing the volume of services provided by their doctors. To do so, they accelerate the conveyor belt for doctors seeing patients. Its speed is determined by corporate balance sheets.
If you wonder why doctor (now nurse) visits are ten minutes or less, and how much doctor time is spend filling in fields in an Electronic Medical Record (EMR), designed for revenue, not clinical precision and communication, you now need not wonder any longer.
But here’s the rub, the irony if you will.
There is only so much blood to be drawn from a stone. Not that doctors are stones but that may be a fitting adage.
First, doctors hate their jobs, as this blog highlighted earlier.
With the acceleration of doctor visits and diminished time spent with patients, next goes quality, the bedrock of (positive) clinical outcomes. That is already happening as attested to by the US having the most expensive healthcare system on earth, which has drifted to the very bottom on measures of quality, efficiency, access to care, equity, and having long and productive lives - when compared to Canada, Germany, Australia and New Zealand, the Netherlands, and the United Kingdom.
Then usually comes low satisfaction ratings, but let’s not dwell on that since about everyone already hates healthcare insurance and managed care organizations.
Then the doc on the conveyor belt exsanguinates. That’s why this blog asks, Who’s Minding the Store? I thought a good business that wants to last makes sure its production line will continue to deliver. For-profit healthcare insurers and national, for-profit hospital chains are businesses.
They are headed to business disruptions: operating hospital beds and admissions will decrease because there is no one to care for the patient; inpatient wards will close, including high revenue specialty services including interventional cardiology, orthopedic surgery, gastroenterology, family medicine, and OB-GYN , with no end in sight; appointments with doctors will be set many months ahead (some already are); and, to the extent geographically and financially feasible, people in need of medical care will go north to Canada, south to Mexico and Costa Rica, and across the Atlantic. Much like rich people moving their money abroad to avoid US taxes, the flow of US medical revenues will recede, especially by those who are self-pay (where profit margins often are better).
Isn’t anybody minding the store in these for-profit healthcare companies?
Isn’t anybody home in the corporate C-Suites of companies headed to falling stock prices and an inability to pay their equity investors?
If there is, taking a liberty with what Cuba Gooding exclaimed in Jerry Maguire, “Show me the money – that’s ahead”.
Lloyd I Sederer, MD