Decisions, Decisions...

The statistics should give us pause. Today’s physicians spend 10.58 hours per week on nonclinical paperwork or 20 percent of our time. Fully 2.6 hours per week are spent dealing with external quality measures, equivalent to about five percent of our time or 2.25 weeks of the year.

These are among the main findings of the 2014 Survey of America’s Physicians: Practice Patterns and Perspectives, conducted by Merritt Hawkins on behalf of the Physicians Foundation.¹

The survey helps put concrete numbers on the strain that third-party payers and other practice intrusions have put on physicians. As a result of this strain, 56 percent of respondents described their feelings about the medical profession as “negative,” and 51 percent were pessimistic about the future. Half would not recommend medicine as a career to their children.¹

What Comes Next?

When asked what they plan to do during the next one to three years, 43.6 percent of respondents said they would make changes that would either remove them from patient care altogether or limit patients’ access to their practices. What’s more, 38.7 percent of physicians are thinking about early retirement. Given the projected doctor shortage, this is very bad news.¹ By 2025, demand for physicians will exceed supply by a range of 46,000 to 90,000, according to the latest report from the Association of American Medical Colleges.²

Dermatologists—established, just starting out, or medical students contemplating this specialty—have some decisions to make today to help plan for the future. Some options include:

Getting a Job. We are not talking about leaving the specialty, but instead searching for an employed position at a hospital, university, or group practice. Employment allows you to focus on patients, not paperwork. This just may be the wave of the future: 53 percent of physicians responding to the 2014 Merrit Hawkins survey were hospital or medical group employees, up from 44 percent in 2012; only 35 percent were practice owners or partners, down from 48.5 percent. Employment offers a safe harbor from administrative burdens.¹ Kaiser Permanente and Mayo Clinic follow this model, and they are flourishing. The downsides? Employed physicians see fewer patients—a concern give projected doctor shortages. There is also less autonomy when you are not your own boss.

Creating a Network Without Walls. Another option is to partner with like-minded physicians—fellow dermatologists or other specialists—to share an administrator. This helps control overhead costs and curtails some administrative headaches, a nice compromise if you don’t want to work for someone else.

Practicing Teledermatology. Dermatologists are clearly trailblazers in the telemedicine realm, given the visual nature of the specialty. As we move from volume to value, teledermatology may well represent a way to deliver care in a quick and efficient manner. The American Academy of Dermatology Association (AADA) is currently working to promote policies that expand teledermatology services.

Teaching the Next Generation. A professorial position may provide some shelter from the storm. The downside is that you may give up all or some of your clinical practice. Other dermatologists may take up medical writing and focus on textbooks or textbook chapters as a means of furthering the specialty. Like teaching, this can be an additional revenue stream for those who choose to work fewer hours or scale back their practice.

Making Some Noise

The jury is not in yet when it comes to how the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will be structured and what quality metrics will matter most. Speak up. It’s either Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs) for dermatologists under MACRA. MIPS streamlines the different penalty/payment systems into one. APMs such as accountable care organizations, patient-centered medical homes, and bundled payment models attempt to better tie volume of care to quality of care. The AADA is working toward developing and piloting APMs for dermatologic services. With MACRA, the devil is in the details, and details have yet to be finalized. We can submit comments to the Centers for Medicare & Medicaid Services (CMS) electronically via www.regulations.gov until June 27, 2016. And there’s always early retirement, but hopefully it won’t come down to that for most of us. n

Mark D. Kaufmann, MD is an associate Clinical Professor of Dermatology Dept of Dermatology at the Icahn School of Medicine at Mount Sinai in
New York City.

1. http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf

2. https://www.aamc.org/download/458082/data/2016_complexities_of_supply_and_demand_projections.pdf