Trends in Compensation for Primary Care and Specialist Physicians After Implementation of the Affordable Care Act

Increased Organizational Stress in Primary Care: Understanding the Impact of the COVID-19 Pandemic, Medicaid Expansion, and Practice Ownership

BACKGROUND

Primary care is the foundation of health care, resulting in longer lives and improved equity. Primary care was the frontline of the COVID-19 pandemic public response and essential for access to care. Yet primary care faces substantial structural and systemic challenges. As part of a longitudinal analysis to track the capacity and health of primary care, we surveyed every primary care practice in Virginia in 2018 and again in 2022.

METHODS

Surveys were emailed or mailed up to 6 times and nonresponders received a phone call. Questions assessed organizational characteristics, scope of care, capacity, and organizational stress in the prior year. From respondents, 39 clinicians, nurses, staff, administrators, and practice managers were interviewed.

RESULTS

526 out of 2296 primary care practices (23% response rate) completed the survey, with broad representation across geography, ownership, and payer mix. Compared with 2018, in 2022 there were increases in practices owned by health systems (25% vs 43%, P < .0001) and average percent of patients with Medicaid per practice (12% vs 22%, P < .0001). The percent of practices reporting any major stressor increased from 34% to 53% (P < .0001). The main increased stress was losing a clinician, with 13% of practices in 2018 versus 42% in 2022 reporting losing a clinician (P < .0001).

CONCLUSIONS

Primary care practices are resilient and continue to serve their communities, including a broad scope of services and care for underserved people. However, the COVID-19 pandemic caused significant stress. With an increase in clinicians leaving clinical practice, we anticipate worsening access to primary care.

Burnout Among Family Physicians in the United States: A Review of the Literature

BACKGROUND AND OBJECTIVES

Burnout among physicians who work in primary care is an important problem that impacts health care quality, local communities, and the public's health. It can degrade the quality of primary care services in an area and exacerbate workforce shortages. This study conducted a review of the published research on burnout among family physicians working in the United States.

METHODS

We used a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided approach and several article databases to identify, filter, and analyze published research on US family physician burnout that uses data collected from 2015 onward.

RESULTS

Thirty-three empirical studies were identified with findings that included US family physician burnout prevalence and/or associations between burnout and specific personal and contextual drivers. Mean family physician burnout prevalence across studies that measured it was 35%. Almost half of the studies classified one-third or more of their family physician samples as burned out. Physician gender (being female), age (being younger), and job/work-related factors (workload, time pressures) were the most commonly identified correlates of family physician burnout. The vast majority of studies were cross-sectional and used secondary data.

CONCLUSIONS

The extant research literature on family physician burnout in the United States shows that burnout is currently a meaningful problem. Several important correlates of the problem can be identified, some of which managers and health care organizations can proactively address. Other correlates require managers and health care organizations also viewing family physicians in differentiated ways. The collective literature can be improved through a more consistent focus on similar burnout correlates across studies; inclusion of interventions aimed at lessening the effects of key burnout correlates; employment of more robust longitudinal and quasi-experimental research designs; and additional pandemic-era data collection on burnout.

Trends in Cardiac Anesthesiologist Compensation, Work Patterns, and Training From 2010 to 2020: A Longitudinal Analysis of the Society of Cardiovascular Anesthesiologists Salary Survey

Increasing cardiac procedural volume, a shortage of practicing cardiac anesthesiologists, and growth in specialist physician compensation would be expected to increase cardiac anesthesiologist compensation and work load. Additionally, more cardiac anesthesiologists are graduating from accredited fellowships and completing echocardiography certification. The Society of Cardiovascular Anesthesiologists (SCA) biannual salary survey longitudinally measures these data; we analyzed these data from 2010 to 2020 and hypothesized survey respondent inflation-adjusted total compensation, work load, and training would increase. For the primary outcome, we adjusted the median reported annual gross taxable income for inflation using the Consumer Price Index and then used linear regression to assess changes in inflation-adjusted median compensation. For the secondary outcomes, we analyzed the number of cardiac anesthetics managed annually and the most common care delivery staffing ratios. For the tertiary outcomes, we assessed changes in the proportion of respondents reporting transesophageal echocardiography (TEE) certification and completion of a 12-month cardiac anesthesia fellowship. We performed sensitivity analyses adjusting for yearly proportions of academic and private practice respondents. Annual survey response rates ranged from 8% to 17%. From 2010 to 2020, respondents reported a continuously compounded inflation-adjusted compensation decrease of 1.1% (95% confidence interval [CI], -1.6% to -0.6%; P = .003), equivalent to a total inflation-adjusted salary reduction of 10%. In sensitivity analysis, private practice respondents reported a continuously compounded compensation loss of -0.8% (95% CI, -1.4% to -0.2%; P = .022), while academic respondents reported no significant change (continuously compounded change, 0.4%; 95% CI, -0.4% to 1.1%; P = .23). The percentage of respondents managing more than 150 cardiac anesthetics per year increased from 26% in 2010 to 43% in 2020 (adjusted odds ratio [aOR], 1.03 per year; 95% CI, 1.03-1.04; P < .001). The proportion of respondents reporting high-ratio care models increased from 31% to 41% (aOR, 1.01 per year; 95% CI, 1.01-1.02; P < .001). Reported TEE certification increased from 69% to 90% (aOR, 1.10 per year; 95% CI, 1.10-1.11; P < .001); reported fellowship training increased from 63% to 82% (aOR, 1.15 per year; 95% CI, 1.14-1.16; P < .001). After adjusting for the proportion of academic or private practice survey respondents, SCA salary survey respondents reported decreasing inflation-adjusted compensation, rising volumes of cardiac anesthetics, and increasing levels of formal training in the 2010 to 2020 period. Future surveys measuring burnout and job satisfaction are needed to assess the association of increasing work and lower compensation with attrition in cardiac anesthesiologists.

Should physicians team up to treat chronic diseases?

This paper studies referral strategy and effort provision of a primary care physician and a specialist who are responsible for the treatment of chronically ill patients who can be in a mild or severe condition. Two organizational settings are compared, a team in which physicians cooperate and solo practices in which they do not. Team care is strictly superior to solo practice care if the difference in expected treatment costs between disease severities is relatively larger for the primary care physician. Otherwise, solo practice care is weakly superior to team care under reasonable assumptions.

Fewer medical students are open to body donation after dissecting human cadavers

INTRODUCTION

Cadaver dissection has long been hailed as a vital component of medical education. Although most physicians acknowledge positive impacts of cadaver dissection on their learning, they are less likely to will their bodies for anatomical dissection than the general public. This study aims to determine whether the proportion of medical students open to willed body donation changes after completing cadaver dissection.

METHODS

We conducted a longitudinal study surveying 323 medical students across three cohorts before and after anatomical dissection of human cadavers. Through the survey, students indicated whether they would will their body for anatomical dissection. Additionally, students responded to items regarding the rationale underlying their decision, demographics and perceived effects of anatomical dissection on medical education.

RESULTS

The proportion of students who expressed openness to willed body donation decreased by 25% after cadaver dissection. Of the 171 students who initially stated they would will their body, 61 (35%) changed their response after completing cadaver dissection. Those who cited religion as a motivating factor were less likely to show openness to body donation, whereas those who cited ethical factors were more likely.

CONCLUSIONS

This study documents a substantial decrease in the proportion of students open to willed body donation after completion of cadaver dissection. Despite this, students almost universally report educational benefits of cadaver dissection. This raises interesting questions regarding the emotional impact of cadaver dissection and the ethical implications of willed body donation.

The Underuse of Medicare's Prevention and Coordination Codes in Primary Care : A Cross-Sectional and Modeling Study

BACKGROUND

Efforts to better support primary care include the addition of primary care-focused billing codes to the Medicare Physician Fee Schedule (MPFS).

OBJECTIVE

To examine potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS.

DESIGN

Cross-sectional and modeling study.

SETTING

Nationally representative claims and survey data.

PARTICIPANTS

Medicare patients.

MEASUREMENTS

Frequency of use and estimated Medicare revenue involving 34 billing codes representing prevention and coordination services for which PCPs could but do not necessarily bill.

RESULTS

Eligibility among Medicare patients for each service ranged from 8.8% to 100%. Among eligible patients, the median use of billing codes was 2.3%, even though PCPs provided code-appropriate services to more patients, for example, to 5.0% to 60.6% of patients eligible for prevention services. If a PCP provided and billed all prevention and coordination services to half of all eligible patients, the PCP could add to the practice's annual revenue $124 435 (interquartile range [IQR], $30 654 to $226 813) for prevention services and $86 082 (IQR, $18 011 to $154 152) for coordination services.

LIMITATION

Service provision based on survey questions may not reflect all billing requirements; revenues do not incorporate the compliance, billing, and opportunity costs that may be incurred when using these codes.

CONCLUSION

Primary care physicians forego considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients. Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care.

PRIMARY FUNDING SOURCE

National Institute on Aging.

US Primary Care vs Specialty Care Trainee Positions and Physician Incomes: Trends From 2001 to 2019

BACKGROUND

Much of the Affordable Care Act (ACA) and subsequent US health care policies were designed to address deficiencies in health care access and enhance primary care services. How residency positions and physician incomes have changed in the post-ACA era is not well characterized.

OBJECTIVE

We evaluated the growth of US trainee positions and physician income, in the pre- vs post-ACA environment by specialty and among primary care vs specialty care.

METHODS

Total resident complement by specialty and year was extracted from the National Graduate Medical Education (GME) Census and stratified into primary care vs specialty care. Median incomes were extracted from Medical Group Management Association surveys. Piecewise linear regression with interaction terms (pre-ACA, 2001-2010, vs post-ACA, 2011-2019) assessed growth rate by specialty and growth rate differences between primary care and specialty care. Sensitivity analyses were performed by focusing on family medicine and excluding additional GME positions contributed by the introduction of the 2015 single GME accreditation system.

RESULTS

Resident complements increased for primary care (+0.16%/year pre-ACA to +2.06%/year post-ACA, P < .001) and specialty care (+1.49%/year to +2.07%/year, P = .005). Specialty care growth outpaced primary care pre-ACA (P < .001) but not post-ACA (P = .10). Family medicine had the largest increase in the pre- vs post-ACA era (-0.77%/year vs +2.09%/year, P < .001). Excluding positions contributed by the single GME accreditation system transition did not result in any statistically significant changes to the findings. Income growth increased for primary care (+0.84%/year to +1.37%/year, P = .044), but decreased for specialty care (+1.44%/year to +0.49%/year, P = .011). Specialty care income growth outpaced primary care pre-ACA (P < .001), but not post-ACA (P = .22).

CONCLUSIONS

We found significant growth differences in resident complement and income among primary care versus specialty care in the pre-/post-ACA eras.