opinion

Autonomy or employment — doctors must not be forced to choose

The AMA House of Delegates has adopted principles to help the growing number of doctors being employed by hospitals and other entities.

Posted Dec. 17, 2012.

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It may seem like something out of a Norman Rockwell painting: A doctor hangs up his shingle, opens a practice and begins filling his waiting room with patients. For years, it was a rite of passage for physicians when they began practicing medicine.

But this image is fading as more doctors enter medicine as employed physicians or practicing physicians make the switch to employee. Recent research paints a picture of how doctors are pursuing employment at hospitals, group practices and other delivery systems, driven by business pressures and the cost of operating a practice.

By the end of 2013, only 36% of the nation's projected 792,594 practicing doctors will have a practice ownership stake. That will be down from 57% in 2000, says consulting firm Accenture, which analyzed data from the American Medical Association and MGMA-ACMPE, the organization representing group practices.

An accompanying survey of 204 doctors gave insight into some of the reasons why independent practice looks less inviting these days. In addition to concerns about the expense of operating a practice, respondents mentioned the prevalence of managed care, requirements for electronic health record systems and issues managing staff.

Physicians are clear on what they are walking away from, but where they're headed could contain some nasty surprises. The AMA has come forward with help that will benefit both physicians and the patients in their care.

In 2011, the AMA House of Delegates adopted policy stating that the Association would work to become the lead association for doctors employed by hospitals, health systems and other entities.

In November, the AMA took a major step toward ensuring that doctors have the right road map to guide them as they enter into employment and contractual agreements. At the AMA Interim Meeting, the house adopted principles for physician employment to prevent potential conflicts in the employee-employer relationship while promoting high-quality and cost-effective care to patients (link).

These principles are needed as the trend of physician employment continues. Doctors need only look at their newspaper or television to see some of the conflicts that might occur. A November article in The New York Times showed how doctors face growing pressures to meet the financial goals of their employers. A “60 Minutes” segment that aired a few days later claimed that the hospital chain Health Management Associates pressured employees to admit patients, an allegation HMA denied.

To avoid such problems and place the patient's welfare at the forefront, the AMA principles address six areas: conflicts of interest; advocacy for patients and the profession; contracting; hospital medical staff relations; peer review and performance evaluations; and payment agreements. They state that a doctor's primary responsibility is his or her patient, that employed physicians should be free to exercise their judgment regarding patient care, and that patients take priority in conflicts over the economic interests of an employer. The principles can't address every scenario that employed doctors may encounter, but they provide a valuable framework so physicians can try to steer clear of trouble.

The guidelines, detailed in an AMA Board of Trustees report, also state that employers should make it clear to doctors when compensation is related to the revenue they generate. The principles say employed doctors should be members of the organized medical staff and should be subject to the same peer review procedures as other physicians, regardless of employment status.

The house directed the AMA to disseminate the principles to graduating residents and fellows and advocate that the guidelines be adopted by organizations representing hospitals and medical groups. That is an important directive, considering that a 2011 survey by physician recruiting firm Merritt Hawkins showed that 32% of final-year residents said hospital employment is their preferred practice setting.

Those new doctors and their more established peers also will benefit from the AMA's Annotated Model Physician-Hospital Employment Agreement. It is available for free to AMA members and for purchase to nonmembers. The model contract gives guidance to help doctors prepare to negotiate a fair employment contract.

With the AMA principles in hand, physicians now are better able to identify and deal with the challenges of being an employed doctor. Like all good career choices, this involves a question of heading somewhere to do the best work possible, not trading one set of problems for another. That's all the more important when the well-being of patients is at stake.

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