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quality and safety of care, and clinical innovation.
PRACTICE TREND: MOVEMENT OF PHYSICIANS TO EMPLOYMENT
A rapidly increasing percentage of American physicians practice in employed that the majority of their physician searches are for employed positions.3
This movement of physicians from independent practice to health system- owned employment has a number of prominent effects on the professional life of physicians. First, physicians become employees rather than owners. The psychological impact of that change varies with the personal values and expectations of each physician. In these new employed respective roles of physicians relative
to other employees is likely to be more formal. Clinical decision making is often care. Finally, physician referral practices may become subject to the employer’s expectations, which are increasingly driven by the rise of value-based payment metrics. This movement to employed status is likely to reduce the perceived
and actual control physicians have over their professional lives. The effect of this change in practice structure on patients has some favorable results. Increases in accountability, better systems of care, the managed patterns of referral care all promise great quality improvements and convenience for patients. These effects are summarized in Table 1.
There are some important caveats, however.
if actualized
by the formulation and implementation of good systems and helpful policies. Patients
TABLE LEGEND
could experience quite negative effects of the change to physician employment and its concomitant loss of physician autonomy. For example, if employer policies
constrain a physician’s ability to refer
to specialists of her choice that can best meet the needs of an individual patient,
the patient will suffer. Similarly, if health systems implement incentives that value business above patient care, the physician’s loss of autonomy as a counterweight to organizational interests can become highly problematic for her patient. While these negative effects are only possibilities, there is nothing inherent in the structure of physician employment to prevent them.
We theorize that the movement to employed status can also result in improvements in the professional lives of physicians. The loss of physician
autonomy for physicians is not all
operational burdens of business ownership, the installation of effective systems of
the salutary effects of clinical decision support due to standardized protocols
all can make a physician’s life easier and more productive. Whether the net effects of employment are positive or negative for physicians will depend on a health system’s culture and the particulars of management and implementation. The loss of physician autonomy exposes physicians and their
an employer’s organizational culture and management.
Patient advocacy, clinical expertise, the assurance of quality and safety, and the ability to apply new innovations in
TABLE 2: Movement to Value-Based Revenue
Effect on Physician Autonomy, Patients and Physicians
CONSEQUENCES OF TREND
EFFECT ON PHYSICIAN AUTONOMY
EFFECT ON PATIENTS
EFFECT ON PHYSICIANS
Primary revenue driver for professional component is no longer based on individual effort alone but rather on clinical performance.
Reduced:
If individual physician performance is measured as part of group performance.
Favorable: If well designed, value-based incentives support improved care.
Favorable: If new payment models free physicians from “piecework” limitations of FFS practice.
Unfavorable: If excellence
in individual effort and competence is not recognized.
Effects on Patient Benefits Associated with Physician Autonomy
EFFECT ON ADVOCACY
EFFECT ON EXPERTISE
EFFECT ON QUALITY AND SAFETY
EFFECT ON INNOVATION
Enhanced: By freedom from ‘production line’ economics.
Reduced: If physician feels less personally responsible for patient’s care or is conflicted by organizational incentives.
Enhanced: If expertise that leads to real value is supported by physician financial incentives.
Enhanced: If practices that result in safety and quality are supported by physician financial incentives.
Enhanced:
If clinicians freed from production incentives are supported
in clinical innovation.
Reduced/Unfavorable
Enhanced/Favorable
Mixed
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Del Med J | January 2018 | Vol. 90 | No. 1
