Good morning to this session on the new normal, the physician as employee. I'm Arnold Sito, the Sky Treasurer. I'm at the Long Beach VA Health System. I'm pleased to be joined by Jeff Marshall from Northside. And we have an illustrious panel here that helps share some of our stories of employed physicians, including Dr. Michael Lee from Griffin Hospital, formerly of UCLA, Dr. Mithul Patel from Intermountain Healthcare, formerly at UCSD, David Tarani from Stanford Healthcare, Islam Abidaya from VA Loma Linda, and Olga Toleva at the Georgia Heart Institute. So I wanted to kick this off. We think that some of this is going to be some of the most interesting discussion points. And we've allowed plenty of time for discussion. But I wanted to lead off by saying, how did we get here to this point where the vast majority of physicians are employees? And where are we now? So these are my titles. I'm part-time private practice in a private practice nearby. And that gives me some leg in both realms. These are my disclosures, which are not relevant. So it's no surprise to any of us that doctors have been underpaid now for the last 20 years. This graph illustrates that in the last 20 years, the physician fee schedule has been updated to only increase by 7% over 20 years, far below the medical inflation rate, the green line, but also far behind the inpatient and outpatient hospital reimbursement, which has gone up a comparative 60% over 20 years. So doctors have been targeted by Congress and Medicare to essentially keep our fees flat and our incomes flat, because the image of the wealthy doctor didn't play well in Congress. So we need to advocate for ourselves better in that regard. Specific to cardiology, many of you recall in 2005, 2006, Medicare looked at the growth in office-based imaging. Remember, this is also the time when cardiac CT was going to be the next big thing. So they saw the growth of physician-based office imaging, provider-based office imaging. And they said, well, this is growing our volumes and the costs. And they comparatively saw hospital-based imaging was relatively flat. So naturally, they decided to cut physician-based office payments by up to a half, and then ultimately a third, such that now hospital-based office imaging actually generates. It costs them 2 and 1 half times more than a comparative nuclear in the office. So if you do a nuclear in the office, you get paid on average 1 third to 1 half of what the hospital outpatient practice gets. What's the result? Well, that means you drive more people to become hospital-based employees. You drive up the hospital outpatient imaging. And you drive down the provider-based imaging, such that the total remains flat. So this is one of many reasons why Medicare expenses have been held flat for the last 15 years. But it's been on our backs, not on the hospital's. So this has been a problem. So this illustrates some of the charges and the differences in charges and the effects of the volume. So for stress echo, you get 2 and 1 half times. The hospital gets 2 and 1 half times what we get paid in the office. For resting echo, you get 2 times more. For a stress nuclear, 2.5 times. And what does that do? It drives up the volume in the hospital outpatient practice, because all of us then follow the money. And we have to go and sustain our incomes by becoming hospital employees. And this is the most recent survey from MedAxiom, showing that 89% of their respondents are now hospital-employed or integrated, with only 11% truly being private practice in this day and age. This is also illustrated in this slide. And it turns out that you end up working harder in private practice, with an average per RVU dollar reimbursement of $46, compared with an employed practice where you get $65 per RVU. So you're actually working harder and making less. And so that's driving people to become employed. And that's all well and good if employment was a great thing. But physician employment doesn't actually cost Medicare more money. So for certain cardiology procedures, it actually costs Medicare more money, 27% higher cost for Medicare. And actually, because hospital outpatient charges more, it actually costs the patients more. So they pay a bigger component of that. Physicians employed by hospitals perform a higher volume of services in the hospital outpatient setting than in physician offices. That just makes economic sense. And then, as we mentioned, the health care services provided in the hospital outpatient centers are reimbursed at higher rates. As a result, the physician employment grew by 49% over just three years, between 2012 and 2015. What are the consequences for us as doctors? Well, what is the impact? Burnout and conflicts. And this is one interesting slide which showed that those who are employed actually have a more negative way of talking about work. 69% of corporate doctors, employed doctors, were negative about work, compared to 51% of independent physicians. 72% of corporate doctors reported lower empathy for patients as a result of burnout, versus 57% of independent physicians. And then, burnout rates were higher, 48% versus 36%. Burnout's a problem for everyone, but especially for the employed physician, there are more issues involved. Among some of these issues are lack of respect from other staff. My nurses boss me around all the time and tell me what to do. There's lack of control, autonomy, insufficient compensation. And then, there's this concept of moral injury, where you think, as a provider, we know what's best for our patient. We know what we want to do, and yet we're not able to provide that due to the economic pressures or the direct managerial pressures from our organization, who is often trying to make more money. So this is a scary thing. I want to close by saying, Simone's maxim was that, first of all, institutions don't love you back. The relationship between a trainee, faculty member, and any employee or the institution is impersonal and contractual, and many of us have experienced that. Among those things are restrictive covenants. You know, you can't work for somebody else. You can't work for someone else even afterwards. In other words, we own you as the employer. Non-compete clauses. Oh, you know, if things don't work out, move away. We don't need you, so you're the one that moves away. We're going to still be here. And then finally, if we really don't like you, there's sham peer review. Don't speak up about quality or other things, because we will bury you. And we're going to share some of those stories, and I hope that we can be open and discuss some of these issues. And we've, again, allotted a lot of time for that. Thank you.

physician employment

burnout

autonomy

moral injury

physician compensation