Six Biggest Gripes of Physicians Employed by Hospitals

Victoria Rentel, a family physician in Columbus, Ohio, joined a hospital-owned group several years ago. At first, nearly everything went fine. There were a few glitches: she'd occasionally order tests or consults at competing facilities, either for patient convenience or because of health plan coverage. When the hospital's administrators found out, they told her it was a violation of her contract; but that didn't stop her because she knew the hospital never enforced this provision.

Four years after Rentel took the job, the administration praised her financial performance and promised to expand her solo practice by bringing in more physicians and adding more office space.

Then, out of the blue, she was informed that the hospital was going to close her practice within 45 days. She knew this wasn't her fault; the recession had hit the hospital hard, and it was laying off nearly half of the primary care doctors in her group. Still, it was a hard pill to swallow.

Making matters worse, her contract's noncompete clause prohibited her from going to work for any of the other healthcare systems in town. To avoid legal sanctions, she joined the student health service at Ohio State University.

Would she ever work for a hospital again? "I never say 'never' anymore. But if I did, I'd go into it with my eyes wide open and with much more due diligence than I did before."

Many other physicians -- especially those who, like Rentel, were previously in private practice -- complain about their jobs. In some cases, it's because physicians rushed into the arms of a hospital without looking carefully at their contracts or asking the right questions during their job interviews.

Older doctors are as apt to make this mistake as young ones, physician recruiters say. But doctors fresh out of residency expect to work for a hospital or a medical group, so they're less likely to complain about working conditions or compensation, notes Gary Matthews, a healthcare management consultant in Atlanta.

Ultimately, the loss of control over their own professional lives is what irks employed doctors the most if they used to be in private practice. But some doctors also get the sinking feeling that they've become cogs in the corporate machine.

"The reality is that when you work for a hospital system, you're a service line," says Rentel. "And because primary care reimbursement is relatively low, you're a service line that feeds more lucrative service lines."

Following are the 6 biggest gripes of employed physicians, according to consultants, recruiters, and doctors.

1. Lack of Job Security

Some observers don't think job security is a problem for physicians. Matt Robbins, Senior Director of Marketing for Delta Physician Placement in Dallas, points out that doctors are in great demand. He expects hospitals will hire more physicians as healthcare reform expands coverage and increases the emphasis on care coordination. But he admits that some hospitals hire too many doctors, placing those physicians' incomes at risk.

Some hospitals dump physicians when their contracts are up if they're not productive enough or if the hospital is having financial problems, notes Michael LaPenna, a healthcare consultant in Grand Rapids, Michigan. Typical employment contracts last for 3 or 4 years, but they may allow either party to terminate the pact with 6 months' notice, he adds.

Sometimes a merger of hospital systems will lead to physician layoffs. For example, North Shore-LIJ, a big healthcare system in the New York area, recently absorbed Lenox Hill Hospital in Manhattan. LaPenna expects a few radiologists will lose their positions as the 2 systems' radiology groups are merged.

2. Changes in Compensation

Employers may unexpectedly change the requirements for earning payment. Additionally, some physicians who are thinking about leaving a hospital's employment don't believe they get paid enough, notes Jim Fuller, Vice President of Delta Physician Placement.

"There's a perception that income opportunities are lower than in private practice," says Fuller. "That's not necessarily true, but some organizations will be much more conservative on the income guarantee, and compensation will be more skewed to the production end."

Robbins has seen situations in which the hospital bumps up production goals without paying doctors more. "If family physicians have an employment agreement without any kind of production bonus, they're going to increase their patient load by 10 or 15 people a day, and they're still going to be paid the same."

Because of physician shortages and hospitals' eagerness to employ doctors, newly hired doctors may receive higher salaries than those who have been in a hospital group for a while, Robbins adds. That will irritate the doctors who have been there longer and get paid less.

Frequent changes in compensation methods may also anger some employed doctors, notes Tommy Bohannon, Senior Director of Recruiting and Development Training for Merritt Hawkins & Associates. "They may change the basis of payment to RVUs [relative-value units], quality scores, or something else. That wears on people after a while."

3. Call Schedule is too Burdensome

Some physicians are unhappy with hospital call duty, Robbins says, especially if they're primary care doctors who are used to handing off their patients to hospitalists. But a high percentage of hospitals now have hospitalist programs, even in rural areas, notes Matthews.

Newly hired doctors may also resent having to take call more often than senior colleagues do, Robbins observes. This may happen if a hospital or physician group has bylaws stating that after a doctor reaches a certain age or length of tenure with the group, their call duty will lessen.

A Delta survey of primary care doctors indicates the gap between their call duty preferences and what their jobs actually entail. A total of 57% preferred no call with a hospitalist program; 40% preferred call that was separately compensated; and 3% had no problem with uncompensated call. But in their current work environment, 28% had no call with a hospitalist program; just under 20% had compensated call, and 52% had to take call without pay.

Robbins says he always makes sure that job candidates know what their call duty will be before setting up an interview. "That's as important as knowing what they would potentially earn," he says. Generally, he adds, hospitals know exactly what call is going to be, "and they're upfront about that with candidates."

4. Lack of Business Control

A doctor coming out of private practice is used to running his or her own office. It's a big shock to some physicians when they discover that the hospital has taken control of all their business functions. In many hospital-owned practices, Matthews says, the hospital controls everything from "how the phones are answered to the signs on the doors to compensation. Maybe your x-ray tech is now under the direction of the chief radiology technician of the hospital, instead of the physician."

Because many hospitals are not expert at physician billing and collection, Matthews continues, physicians may resent the loss of control over that function, especially if a production bonus is a big component of their pay. "Physicians are anticipating that they'll be able to collect at their normal collection rate, and they end up collecting less," he points out.

Another area where doctors may lose income, he adds, is in ancillary revenues, which typically form a third of primary care doctors' volume. "When a hospital acquires a practice, those ancillaries are swept up into the hospital, and they're not figured as part of the practice revenues."

5. Lack of Clinical Autonomy

As hospitals and medical groups alike put more emphasis on quality improvement and measurement, many employed physicians feel like they're losing their clinical autonomy. And the problem is compounded if quality scores determine a significant part of their compensation, Matthews says.

"That's part of the loss of autonomy that bothers doctors even more than the business side. Most of them hate it. They say, 'I do a good job, I take good care of my patients.' Now they've got to meet certain metrics. And often, those metrics are part of their compensation plan."

LaPenna isn't sympathetic to these complaints. "Electronic health records and evidence-based medicine are coming to everyone. I think the doctors who don't realize that are dinosaurs who've stepped on their last eggs. They've walked the earth, and they're sort of in charge, but they don't realize their species is extinct."

Nevertheless, say physician recruiters, major changes in how doctors work, such as how they document visits or how they coordinate care, can make them unhappy and increase their inclination to change jobs. For example, researchers studied a "patient-centered access" program at Group Health Cooperative, a Seattle-based group-model HMO. They found that while patients liked open-access scheduling and the additional work that their doctors did to keep in touch with them between visits, the primary care physicians were getting burnt out.

Said one primary care doctor, "The professional model for physicians always involved giving extra, and I don't begrudge that. It's just I can't do it every day all the time. It has been a couple of years since I've had lunch. I eat at my computer while I'm doing my charting or looking through my results or other in-basket functions, and that's pretty much the way it goes."

6. The Tyranny of Non-compete Clauses

Employed doctors intensely dislike noncompete clauses, which they view as an unfair constraint on their potential mobility.

In Texas, Robbins is seeing an increasing emphasis on noncompetes in employment contracts. "The majority of contracts that have those clauses are reasonable. They might say you can't set up practice within a 10-mile radius or 30-mile radius of the facility. The problem I see sometimes is that you may have a corporate affiliate with 8 hospitals in 7 counties, and you can't compete close to any of them. That's unfair. But there are laws and regulations against that."

Noncompetes can sometimes discourage doctors from changing jobs. For example, if you have a noncompete with a 30-mile radius in Dallas, Robbins says, "you probably can't work in that market if you leave your hospital. So that might prevent a doctor from leaving."

Source: Kenneth J. Terry, MA,  MedScape Business of Medicine