Doctoring The Doctor Shortage

We need more doctors in private practice.

As the U.S. population ages and needs more medical care, there is growing concern this will exacerbate the projected physician shortage.  The number of Americans age 65 or older is expected to double over the next 40 years. A report from the American Association of Medical Colleges predicts a dearth of 120,000 physicians by 2030. Without adequate physicians, patients may experience long wait times, receive delayed medical attention, and be limited to care from non-physician providers.

I'm a radiation oncologist and grew up in a family of private practice physicians, so I’ve learned about the changes in healthcare over the past 30 years firsthand. I believe that mitigating the physician shortage is possible by empowering physicians to stay independent. By eliminating the crippling handcuffs placed on private practice physicians today, we may be able heal the profession from within.

Here’s why:

A concerning trend is that fewer physicians are self-employed. In 2016, fewer than half of U.S. doctors were in private practice and this movement is expected to continue. Private practice physicians care for more patients than hospital-employed physicians.  Therefore, a good way to improve access to medical care is for doctors to stay in private practice, where they see more patients. There is also evidence that private practice doctors experience lower rates of burnout, and therefore remain in the healthcare workforce for longer instead of quitting medicine. A recent study found that only 13.5% of private practice doctors reported burnout, which is significantly lower than the commonly seen 50% rate of burnout for hospital-employed physicians.

How can we empower physicians to stay in private practice? Let’s address some reasons why doctors are turning away from self-employment.

Physicians today face increasing administrative burdens that require their time, money, and energy. These burdens are a financial drain since they require doctors’ time that could be used seeing more patients and bringing in revenue. Physicians also need to spend money hiring more administrative staff to help deal with insurance companies, and these tasks are a drain on resources.

A great example of this is the startling increase in prior authorizations, a tactic insurance companies use to restrict access to medical care. A prior authorization means that your doctor is required to contact their patient’s insurance company to get permission to do a test or procedure. If the insurance company refuses, the physician must appeal, and re-appeal. This process takes a tremendous amount of time and energy for the physician and their support staff.

For example, here’s a daily situation in my office, where I care for patients with cancer (note: this is an example scenario, not related to a specific patient).

Cathy is a 59 year old woman with breast cancer. She comes to see me for a follow up visit, and she’s complaining of headaches. I am worried her breast cancer has spread to the brain, so I write a prescription for a brain MRI. When my assistant tries to schedule Cathy’s MRI, we find out that her insurance company won’t pay for the MRI without a prior authorization. So, I tell Cathy “I think you need a brain MRI, but your insurance company may not approve it. We will try to fight them.”

Cathy says goodbye and goes home. Now, we get to work. My administrative assistant contacts the insurance company, and faxes over my notes and other patient documents to support the case that the patient needs a brain MRI. The insurance company says “No.” They tell us we can appeal via a process called “peer-to-peer.” We set up a time for the phone call, and the next day I talk to the insurance company doctor (the “peer”), and try to convince him why my patient needs an MRI and why he should allow it. The doctor (who is not an oncologist like myself) decides to deny it. Now we can have appeal again.

See where this is going? My practice has now spent hours of time and money fighting an insurance company for a brain MRI that we don’t get paid for. This is not only immoral and stressful, but it required time that could have been used helping other patients.

The American Medical Association surveyed physicians in 2018, and in response to the question “How would you describe the burden associated with prior authorization in your practice?” 86% of doctors responded “high or extremely high.”

These administrative tasks aren’t simply an annoyance. They can actually make or break the ability of a physician to stay self-employed. And this financial uncertainty is increasingly less desirable to a generation of physicians facing high student debt.

The average debt for medical students in 2018 was $192,000. Despite having completed their medical degrees, physicians-in-training are paid low salaries, which means paying back these enormous loans is difficult. Many residents choose to place their student loans in forbearance during their training, which gives them temporary reprieve but ultimately increases the amount they owe in the future.  When ready to start practicing, these young physicians need a steady income to pay back their loans, and opening one’s own practice is fraught with uncertainty, as evidenced above.

Another pervasive issue is the complexity of running a private practice. The vast majority of medical students receive no formal education regarding the business of medicine. Trainees don’t learn about how to bill insurance companies, how to negotiate rates, how to calculate overhead costs, and how to create a business plan.

These are some of the common reasons doctors are shying away from private practice. With the public’s awareness and help, I hope these crippling trends will end so more physicians can embrace self-employment for the sake of their patients.

Follow me on Twitter.

Dr. Miriam A. Knoll, MD, is a board-certified radiation oncologist at the John Theurer Cancer Center at Hackensack University Medical Center in New Jersey. Dr. "Mimi" Kn...