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A Challenging Road Ahead for America’s Physicians

By  Louis J. Goodman and Timothy B. Norbeck 

This year promises to be a watershed year for healthcare in general, and for patients and physicians, in particular.  No matter how the U.S. Supreme Court determines the constitutionality of the Patient Protection and Affordable Care Act (PPACA), 2012 will be a crucial turning point in the delivery of healthcare.

Louis J. Goodman, Ph.D.

During the Congressional passage of the PPACA, White House advisors acknowledged that the economic forces in the legislation would accelerate physician employment by hospitals and larger physician groups.  As mentioned in the “Roadmap for Physicians to Health Care Reform,” the “private” part of private practice for physicians is disappearing.  Currently, more than 80 percent of visits to physician offices have been to practices with five or fewer physicians.  That will change drastically as more physicians feel pressure to move into larger groups or become employed by hospital systems.  Through October of 2011, there have been 71 hospital mergers. All of this will change the face of the delivery aspect of health care, but a question remains: will it be for the better or worse?

Expert opinion is almost universal that there is a present shortage of physicians, especially those in primary care and those practicing in rural areas.  This is a workforce problem that must be addressed now, but it seems to be lost in the debate over the PPACA.  The Physicians Foundation recognizes the shortage problem and recently awarded a large grant to The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill to develop a dynamic web-based projection model that can be continually updated to track ongoing physician workforce needs across the country.  Information gleaned from the UNC research will further enhance efforts to identify where physicians are most needed to support patients in a growing healthcare system.  Thirty-six percent of practicing physicians are over age 55 and may retire by 2020.  According to Physician Foundation surveys conducted by Merritt Hawkins in 2008 and 2010, fewer physicians are seeing Medicare patients or taking on new Medicare patients.  With 10,000 baby boomers becoming eligible for Medicare every single day, the survey results do not bode well for access to care for Medicare patients.

Timothy B. Norbeck

Why do we have fewer physicians seeing Medicare patients at the very time that we need more of them?  First of all, the Sustainable Growth Rate (SGR) used to pay physicians under Medicare, singles out physicians for financial punishment in the form of payment reductions when volume of service increases.  With an aging population and increasing numbers of chronically ill elderly people, of course the volume of services continues to rise.  However, unless Congress steps in and acts promptly, Medicare physician payments are scheduled for an average reduction of 27.4 percent effective January 1, 2012.  The Physicians Foundation joins all other medical associations and the AARP in warning of the dire consequences on patients’ access to care should this massive and unwarranted reduction go through.  The fatally flawed SGR must be fixed and the aforementioned 27.4 percent scheduled reduction must be stopped.

Much has been said about the PPACA, some good and some bad.  We would like to address the legislation from a physician’s point of view.  Physicians are extremely happy to have the American public insured and are delighted to have an end to the discrimination against their patients with pre-existing conditions. They also applaud the new focus on preventive care which should help lead to a healthier public.  As for the downside to the legislation, there was no SGR fix and no tort reform.  The PPACA also assumes a planned 30 percent reduction in physician fees scheduled under the SGR over the next three years.  Furthermore, and this is something that is largely overlooked when discussing the legislation, any physician’s office which mistakenly and by mere accident improperly bills too much for a Medicare visit, is subject to potential liability under federal fraud and abuse statutes. Before the PPACA, intent to commit fraud was necessary for a charge of fraud to be made, but now even an innocent error can result in prosecution.  Finally, and also overlooked by many, is the “translation” fee which must be paid by the treating physician.  If a physician treats a patient who doesn’t speak English and requires a translator, the physician is responsible for the translation fee.  In other words, the translator’s bill would probably exceed the physician’s reimbursement for the office visit!

These issues and other pressures on physicians help explain some of the survey results from the 2010 Physicians Foundation Health Reform Research Study, and the numbers only become bleaker when comparing the results from our 2008 survey.  Only one-quarter of physicians surveyed said they plan to continue practicing as they are; while half reported that they would adopt a style of practice different from the traditional full-time independent private practice model.  Hence, the “private” in private practice is going, going, gone!

Clearly, increasing administrative burdens attributable to the PPACA requirements plus insurance, red tape and costly regulatory measures are having a likely negative effect on patient care.  Sixty-three percent of physicians surveyed claimed that non-clinical paperwork has caused them to spend less time with their patients and 94 percent said that the time they devote to non-clinical paperwork has increased over the past three years.  Ask any physician what he or she enjoys the most about practicing medicine and the response will be: “seeing, helping and interacting with my patients.” The increasing amount of regulations and paperwork are becoming a more formidable barrier to the joy of practicing medicine.  Add to that the declining reimbursements and difficulty in sustaining one’s practice, the constant threat of liability, decreased time with patients and low or no bargaining power with insurers, it is not surprising to note that general physician morale is low and getting lower.

A recent Robert Wood Johnson Foundation survey of physicians indicated that four out of five physicians agreed that unmet social needs are connected to declining health for many Americans. By the same ratio, they also agreed that addressing patients’ social needs are just as important as addressing their medical conditions.  An innovative Boston, Massachusetts organization called Health Leads interviewed local physicians about their needs in providing patient care.  Many expressed frustration that they could not help their poor patients beyond simply providing medical care – with housing, nutrition (food) or other resources that could improve their health.  Not only have these important issues been excluded from the health reform debate, they are largely ignored by policymakers.

With a substantial grant from The Physicians Foundation, Health Leads has been able to expand their efforts to train college student volunteers in five cities to “assist” physicians to “prescribe” food, housing and fuel assistance, or other resources for their patients – just as they do medication.  Patients then take those “prescriptions” to the Health Leads Family Help Desks located in clinic waiting rooms, where the volunteers “fill” them by connecting patients with those resources.  Most of the student volunteers (64 percent of who are pre-med students) end up choosing to go into primary care – another plus!

Generally exacerbating the overall workforce problem is the plight of medical students now coming into practice.  Graduates, on average, carry a debt of $156,000 and payments of up to $2,000 a month!  According to the American Association of Medical Colleges (AAMC), each member of the graduating medical school class of 2033 will face a $700,000 debt!

So what can be done to help physicians sustain their practices and have more time with their patients?  An obvious place to start would be to fix the unfair SGR – and promptly!  This Congressional and government inability to solve this problem reminds us of the late economist Milton Friedman’s observation on the inefficacy of government: If you put the government in charge of the Sahara Desert, he said, in five years there will be a shortage of sand.  And so it is with the growing shortage of physicians.  Congress should relieve physicians of onerous and time-consuming regulations and insurance red tape – which do not help patient care and only add to the cost of that care.  It should create more incentives for physicians to go into rural areas and find additional ways for medical students to pay off their medical school loans.  Build more medical schools and increase the number of the 25,000 residents and fellows completing their training every year.

Of course, the big question is: Where do you find the money to do all this?  Throughout America’s history, that question has been asked many times.  The obvious answer: If you have the will you can find the wallet.  America always has, if the issue is considered important enough.  It won’t be easy but healthcare delivery and its workforce are being challenged in a major way today, and it will only worsen tomorrow without Congress stepping up and addressing it.  As noted in Shakespeare’s Henry VI: “Delays have dangerous ends.”


Louis J. Goodman, PhD, is President and Timothy B. Norbeck is CEO of The Physicians Foundation, which is a nonprofit 501(c)(3) organization that seeks to advance the work of practicing physicians and to improve the quality of healthcare for all Americans. It pursues its mission through a variety of activities including grantmaking, research and policy impact studies. Since 2005, The Foundation has awarded numerous multi-year grants totaling more than $28 million. 

In addition, The Foundation focuses on the following core areas: health system reform, health information technology, physician leadership, workforce needs and pilot projects.  As the health system in America continues to evolve, The Physicians Foundation is steadfast in its determination to foster the physician / patient relationship and assist physicians in sustaining their medical practices during this evolution. For more information, visit www.physiciansfoundation.org.



  1. Just shut my practice down to join a hospital. I was in solo practice, patients were happy, we were barely making ends meet with my wife at the front desk. Medicare collapses codes yearly – loss of the consultation code cost 20% revenue, combining X-ray guidance with procedure codes shaves another 15%. This does not include the 50% reduction in reimbursement which was phased in from 2005 to 2010. Regulations are increasing monthly both state and federal requiring full time employees just to keep up with compliance.

    Medicine as we knew it is dead… in another 10 years you will be lucky if you can even see a physician. I am thankful I have 20 years behind me, rather than in front of me. At least my loans are paid off.

    And with all of this, the lawyers fight against tort reform so the goose that lays the golden eggs for them is not killed. In the end, it will not be worth the pittance the government pays to assume the risk of providing care for patients.

    This is a sad situation, but it is what America wants… however, free medical care will be worth what you pay for it.

  2. Increase the pay for primary care physicians and reduce the passing score for step one. I believe some classes I medical school can be taught online with satalite centers for testing. This will reduce some of the students cost. Many medical students go into specialties to. Pay the high cost. So why isn’t there some type of insinative for working in rural areas.

  3. Susan Van de Water, MD

    This is an excellent discussion of what happened to my practice, why I and many other doctors are forced by Obamacare to leave the work we love. Health reform had such potential to make health insurance more widely available to Americans without the frightening exclusions of pre-existing conditions, but Obama’s incarnation of health care reform has only worsened the situation for health care providers. If everyone has health insurance but the doctors are bankrupt and no longer available, then we have gained nothing and lost what had been previously available.

  4. Private medical practices are dying everywhere. The stench is overwhelming.

    To make the new medical practice model profitable, doctors flit from one exam room to the next, one patient to the next; they toil under oppressing financial pressures which dictate that they see X number of patients per hour. Need I tell your readers?

    Gone, forevermore, is the care and respect that patients expected and received from their PCP (known, in days of yore, as the GP). Gone is the doctor who truly listens and who helps patients navigate the medical system to obtain the care they need. Gone is the joy and excitement of practicing medicine; hours of energy-sapping paperwork and drudgery have taken it’s place. Gone is the security of making a nice living; gone is the assurance that paying off those steep medical school loans in just a couple of years.

    How did we ever get into such a predicament? Where were the protests and strikes–as organized by doctors in other countries? Why were the regional and national medical societies so silent and acquiescent? Who truly represents the interests of the medical practitioner?

    I fear the jig is up. Computer models that can project the need for physicians across the country will be made obsolete, since, I believe, that as the emphasis on cutting costs increases, doctors will be replaced by lower level practitioners like PA’s and nurse practitioners; doctors will practice medicine remotely, via telephone and teleconferencing. It won’t matter if a doctor is working out of Cleveland, San Francisco, or Memphis.

    The entire medical paradigm is shifting and I’m afraid of what the medical community will look like when the dust settles. And, I admit that I’m personally afraid of how things will play out if/when I, or a family member, become a patient in the “new system.” God help us.

  5. Good Read about a Big problem – Rural America is in serious trouble. The solution to the problem is not necessarily more Medical Schools and More Physicians – Although that is needed and would help – the solution is less debt/fewer restrictions from the Government and Insurance companies. Physicians are running scared these days and for good reason – they are now seen as financial targets from just about all segments of the population

  6. Tort Reform is a legal weapon used in Texas to kill Texans without accountability ever since Governor Rick Perry signed the 2003 Tort Reform Act.

    I do not want to bore you with rhetoric. I think sometimes a visual is the best way to communicate a message.

    I will add however, even though Tort Reform in Texas makes it impossible to get accountability because it killed our 7th Amendment, there are always ways to get justice if one is persistent.

    The video is a chronological account of a patient’s 17 1/2 hour stay in a Galveston, Texas emergency room and how the basic standard of care was not given. He was a 7 day post op abdominal hernia repair with his medical records in their computer data system.

    The rest of the video is explanatory.


    Thank you for your time,

    Cilla Mitchell

    A Texas nurse and vet

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