Top three challenges facing today’s independent medical practices
The number of independent medical practices has decreased significantly in the past several years. Only 14% of U.S. physician practices were hospital-owned in 2012; that number had increased to 29% in 2016.1 According to a 2018 survey, 54% of physicians worked in independent medical practices in that year, while in 2020, that number had decreased to just 49%.2 The Affordable Care Act provides financial incentives for physicians to join hospital-affiliated accountable care organizations,3 and hospitals and multi-hospital systems have been acquiring more and more independent practices in a process known as vertical integration.1,3,4
The goal of vertical integration is to decrease healthcare spending while improving quality of care. So far, though, research has not shown an association between vertical integration and either financial savings or improved care. In fact, several studies show that vertical integration is associated with increased spending.1
On the other hand, independent practices deliver cost effective, quality care to patients. Despite their dwindling numbers, they are responsible for the majority of the healthcare delivered in the U.S. today.5 Studies show that smaller, physician-owned practices provide a higher degree of personalization and responsiveness to patients’ needs; lower average cost per patient; fewer preventable hospital admissions; and lower readmission rates than larger or hospital-owned practices.5-7
Independent practices are a valuable part of the medical system—but they face numerous challenges in today’s changing healthcare environment. In this article, we look at three of the top challenges currently faced by independent medical practices and explore some ways Practice Fusion can support today’s independent medical practices.
Challenge #1: Decreased time with patients
Electronic health records (EHRs) and other administrative work have consistently demanded more time from physicians in recent years, both in independent and hospital-owned practices. These tasks decrease the amount of time providers have available to spend with patients.5,8,9
One facet of this challenge is that the nature and workflow of patient visits are changing. In the past decade, nearly all providers started using EHRs to document their patient encounters. Adding healthcare IT into clinical encounters has made it necessary for providers to change their patient visit and documentation workflows—a process further complicated by the arrival of COVID-19.10
A physician survey found that clinicians are working longer hours but spending less time with patients, due to the growing amount of paperwork required, including time spent in EHRs.12 Providers are spending more time than ever before on documentation and administrative tasks, leading to dissatisfaction and burnout.10 A 2016 study found that providers spend nearly two hours on EHR and desk work for every hour of direct clinical face time with patients, and a 2018 physician survey found that providers spend almost half their time on data entry and other administrative tasks.13,14
Time is an essential resource for physicians. Time is what allows a physician to get to know their patients and any relevant psychosocial circumstances; to make a thorough diagnosis; and to develop an effective treatment plan. More time with patients can lead to:10,11,15
- Enhanced job satisfaction for providers
- More positive patient outcomes
- More satisfied patients
- Decreased rates of malpractice claims
More time with patients can help to decrease the risk of inappropriate prescribing practices, as there is an association between shorter visits and increased rates of medication prescriptions.15
Giving providers the time they need to effectively care for patients is essential for both patients and providers.
Challenge #2: Increased regulatory requirements for data reporting
Another pressure facing independent practices is the increased data reporting required by regulatory measures such as the Quality Payment Program (QPP). As payment models shift from volume-based to value-based, there are more and more reporting requirements for the QPP and similar programs.16 Staying on top of the latest programs and their reporting requirements is an ongoing challenge for today’s providers. This is particularly true for providers in independent practices, who are less likely to have administrative support from IT personnel, office managers, practice managers, or other support staff.
For instance, the Merit-Based Incentive Payment System (MIPS) is one of two programs used by the Centers for Medicare and Medicaid Services (CMS) to reward high-quality providers with payment increases while simultaneously decreasing payments to providers who fail to meet performance standards.17 MIPS is used to determine Medicare Part B payment adjustments under the QPP based on eligible providers’ participation and performance levels.17,18
MIPS participation requires eligible providers to track and submit data for three of four performance categories for the 2021 MIPS performance year:19
- Improvement activities
- Promoting interoperability
Performance in these categories is used to help determine providers’ MIPS Final Score which, in turn, is used to help determine if a provider receives a positive payment adjustment, negative payment adjustment, or neutral payment adjustment.19
This increased need for data collection and reporting also affects physicians’ time with patients.5,8
Challenge #3: Increased physician burnout
The first two challenges contribute to the third top challenge facing physicians in today’s independent practices: burnout.
The Agency for Healthcare Research and Quality defines burnout as a long-term stress reaction that is characterized by emotional exhaustion, depersonalization, and a loss of feelings of personal accomplishment.20-22 The National Academy of Medicine reports that more than 50% of U.S. physicians report symptoms of burnout.22 A survey from the Physicians Foundation reveals:12
- 80% of physicians in all specialties report feeling they are working at full capacity or are overextended
- 78% report feelings of burnout
- 65% feel more overworked now than at the start of their careers
COVID-19 has only exacerbated the issue.23
Initial studies of physician burnout focused on hospital settings and large primary care practices.24 However, when researchers looked at small, independent practices (fewer than five physicians, nurse practitioners, or physician assistants) they found a burnout rate of just 13.5% of providers.9,25 A closer look revealed that there is not a direct connection between practice organization and burnout rates, though; instead, burnout seems to be connected to a number of organizational risk factors, such as:26
- Excessive workload
- Lack of workplace control
- Misalignment of physician and organizational values
Studies suggest that smaller independent practices are associated with several protective factors against burnout:24,25
- Greater autonomy
- Opportunities to form deeper relationships with patients
- Fewer work hours
- Increased learning opportunities
Burnout also affects clinicians’ happiness, personal relationships, and career satisfaction.27 The consequences of burnout range from high rates of provider turnover to reduced job performance, threatening patient safety and quality of care.20-22,27 A study in the American Journal of Critical Care shows a link between burnout and an increase in medical errors. Burnout is also associated with decreased patient satisfaction and malpractice claims become more likely when physicians are suffering from burnout.23,28
Researchers believe the leading cause of provider burnout is the administrative burden physicians face.27-29 The 2017 Medscape Lifestyle Report names bureaucratic tasks as the primary cause of physician burnout.30 The 2017 Medscape Physician Compensation Report revealed that more than half (57%) of physicians spent at least ten hours per week on paperwork and administrative tasks.30 By 2018, that number had increased to nearly three-quarters (70%) of physicians; 32% of providers were spending 20 hours or more a week.27,29,31 By 2021, physicians were spending an average of 15.6 hours per week on paperwork and administration.32 They also found that EHR usability was unacceptable to most U.S. clinicians.33
Burnout is a major challenge for independent practices, but by tackling EHR usability, practices can address one of burnout’s major causes.
Combating challenges for independent medical practices
Physicians in today’s independent medical practices face steadily increasing pressures. The three challenges highlighted here—decreased time with patients, increased regulatory reporting requirements, and increased provider burnout—are connected, each magnifying the others. At Practice Fusion, our goal is to help providers combat and minimize each of these pressures.
Since EHRs can directly affect all three of these challenges, we believe it’s critical to work closely with providers to identify their specific workflow needs. This enables us to improve our EHR in ways that will:
- Make EHRs faster and more intuitive to use, so they free more time to spend with patients and don’t contribute to provider burnout.
- Improve EHR usability, which is associated with improved patient care, more positive patient outcomes, and improved work-life integration for providers.
- Implement features that will help combat other pressures, such as helping track and report data for the QPP.
We utilize a user-centered design process in order to develop a product more closely aligned with providers’ requirements.35 Our goal is to develop an EHR with high usability—that is, one that is intuitive to use and allows users to perform required tasks quickly and efficiently. By prioritizing usability, we believe Practice Fusion can help improve both patient care and physician well-being, helping independent medical practices to thrive in 2022 and beyond.34
- Ho V, Metcalfe L, Vu L, Short M, Morrow R. Annual Spending per Patient and Quality in Hospital-Owned Versus Physician-Owned Organizations: an Observational Study. J Gen Intern Med. March 2020;35:649-655. doi: https://doi.org/10.1007/s11606-019-05312-z.
- AMA analysis shows most physicians work outside of private practice. American Medical Association; May 5, 2021. https://www.ama-assn.org/press-center/press-releases/ama-analysis-shows-most-physicians-work-outside-private-practice.
- Robinson JC, Miller K. Total expenditures per patient in hospital-owned and physician-owned physician organizations in California. JAMA. October 22, 2014;312(16):1663-1669. doi:10.1001/jama.2014.14072.
- Burns LR, Goldsmith JC, Sen A. Horizontal and vertical integration of physicians: a tale of two tails. Adv Health Care Manag. 2013;15:39-117. doi:10.1108/s1474-8231(2013)0000015009.
- Kareo. State of the Independent Practice Industry Report 2019.1-34. 2019. https://www.kareo.com/dl/wp_10301.
- Applied Consumer Analytics program at University of Georgia, Knebel C. State of the Independent Practice Industry Report.1-36. 2021. Accessed December 3, 2021. https://www.kareo.com/dl/gu_24326.
- Casalino LP, Pesko MF, Ryan AM, et al. Small Primary Care Physician Practices Have Low Rates of Preventable Hospital Admissions. Health Affairs. September 2014;33(9):1680-1688. doi:https://doi.org/10.1377/hlthaff.2014.0434.
- Tower Physician Solutions. Top Challenges Facing Medical Practices.1-3. Accessed December 3, 2021. https://towerps.com/pdf/Tower-Nephrology-Medical-Practice-Challenges-Facing-Medical-Practices.pdf.
- Finnegan J. Burnout, time spent on EHRs top challenges for independent practice leaders. Fierce Healthcare. Updated May 23, 2019. Accessed December 3, 2021, https://www.fiercehealthcare.com/practices/4-challenges-for-independent-medical-practices.
- Franklin R. Are doctors spending less time with patients? Mobius MD. Updated October 9, 2021. Accessed December 9, 2021, https://mobius.md/2021/10/09/how-much-time-do-physicians-spend-with-patients/.
- Solomon J. How Strategies for Managing Patient Visit Time Affect Physician Job Satisfaction: A Qualitative Analysis. Journal of General Internal Medicine. March 26, 2008;23:775-780.
- Flores L. America’s Physicians: Overworked and Burning Out. The Hospital Leader. Updated December 17, 2018. Accessed December 10, 2021, https://thehospitalleader.org/americas-physicians-overworked-and-burning-out/.
- Sinsky C, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Annals of Internal Medicine. December 6, 2016;165(11):753-760. doi:https://doi.org/10.7326/M16-0961.
- Amount of time U.S. primary care physicians spent with each patient as of 2018. Statista. Updated April 2018. Accessed December 7, 2021, https://www.statista.com/statistics/250219/us-physicians-opinion-about-their-compensation/.
- Dugdale DC, Epstein R, Pantilat SZ. Time and the Patient-Physician Relationship. J Gen Intern Med. Jan 1999;14(Suppl 1):S34-S40. doi:10.1046/j.1525-1497.1999.00263.x.
- Participation Options Overview. Centers for Medicaid and Medicare Services (CMS). Accessed December 7, 2021, https://qpp.cms.gov/mips/overview.
- CMS. Quality Payment Program Overview. CMS. Accessed April 10, 2021, https://qpp.cms.gov/about/qpp-overview.
- CMS. Reporting Options Overview. CMS. Accessed April 10, 2021, https://qpp.cms.gov/mips/reporting-options-overview.
- Merit-based Incentive Payment System (MIPS) 2021 MIPS Quick Start Guide (CMS) (2021).
- Physician Burnout. Agency for Healthcare Research and Quality. Updated July 2017. Accessed December 8, 2021, https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html.
- Cheney C. Physician Burnout: A Shrinking Problem? Ramaon Healthcare. Updated March 3, 2019. Accessed December 8, 2021, https://ramaonhealthcare.com/physician-burnout-a-shrinking-problem/.
- National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience. National Academy of Medicine. Accessed December 8, 2021, https://nam.edu/initiatives/clinician-resilience-and-well-being/.
- Butte N, MD, Sharp J. Provider Perspective: Finding Solutions that Address Physician Needs; Advocate Perspective: Finding Solutions Using Passion and Data. Healthcare Information and Management Systems Society (HIMSS) website. Updated January 22, 2021. Accessed January 27, 2021, 2021. https://www.himss.org/resources/physician-burnout-providers-and-advocates-perspective.
- Finnegan J. Which kind of doctors experience dramatically lower levels of burnout? Study offers new perspective. Fierce Healthcare. Updated July 10, 2018. Accessed December 8, 2021, https://www.fiercehealthcare.com/practices/doctors-small-independent-practices-experience-less-burnout.
- Henry TA. Small practice, less doctor burnout? 4 reasons that may be. American Medical Association (AMA). Updated October 29, 2018. Accessed December 8, 2021, https://www.ama-assn.org/practice-management/physician-health/small-practice-less-doctor-burnout-4-reasons-may-be.
- Creager J, Coutinho AJ, Peterson LE. Associations Between Burnout and Practice Organization in Family Physicians. The Annals of Family Medicine. November 2019;17(6):502-509. doi:https://doi.org/10.1370/afm.2448.
- Kane L. Medscape National Physician Burnout & Suicide Report 2020: The Generational Divide. 2020. January 15, 2020. Accessed January 26, 2021. https://www.medscape.com/slideshow/2020-lifestyle-burnout-6012460.
- 5 causes of physician burnout and how to address them. PatientPop website. Updated April 30, 2019. Accessed January 26, 2021, https://www.patientpop.com/blog/running-a-practice/physician-burnout-causes/.
- 40+ medical doctor statistics for National Doctors Day. PatientPop website. Updated March 17, 2020. Accessed January 26, 2021, https://www.patientpop.com/blog/infographics/medical-doctor-statistics/.
- Grisham S. Medscape Physician Compensation Report 2017. April 5, 2017. Accessed December 9, 2021. https://www.medscape.com/slideshow/compensation-2017-overview-6008547#33.
- Kane L. Medscape Physician Compensation Report 2018. April 11, 2018. https://www.medscape.com/slideshow/2018-compensation-overview-6009667#32.
- Kane L. Medscape Physician Compensation Report 2021: The Recovery Begins. April 16, 2021. Accessed December 9, 2021. https://www.medscape.com/slideshow/2021-compensation-overview-6013761#21.
- Melnick ER, Sinsky CA, Dyrbye LN, et al. Association of Perceived Electronic Health Record Usability With Patient Interactions and Work-Life Integration Among US Physicians. JAMA Network Open. June 22, 2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374.
- Jason C. EHR Usability Leads to Better Patient Care, Work-Life Balance. EHR Intelligence website. Updated June 23, 2020. Accessed January 26, 2021, https://ehrintelligence.com/news/ehr-usability-leads-to-better-patient-care-work-life-balance.
- Jason C. How to Boost EHR Usability Using a User-Centered Design Process. EHR Intelligence website. Updated November 25, 2020. Accessed January 26, 2021, https://ehrintelligence.com/news/how-to-boost-ehr-usability-using-a-user-centered-design-process.
- Glossary-Usability. usability.gov website. Accessed January 28, 2021, https://www.usability.gov/what-and-why/glossary/u/index.html.