Assess importance of personal, professional goals when considering employment
Click Here to Manage Email Alerts
The landscape of orthopedic surgery practice has significantly changed during the past decade, with a marked shift toward varied employment models over traditional private practices.
The most recent American Academy of Orthopaedic Surgeons Census reported 30,141 orthopedists on record with the AAOS, with 36% of respondents in private practice –orthopedic group setting; 17% in hospital/medical centers and 14% in academic practice with the salary from an institution. The Physicians Advocacy Institute and Avalere Health reported 108,700 physicians left independent practice for employment as employees of hospitals or other corporate entities from 2019 to 2021, with 76% of the increase after the start of the COVID-19 pandemic.
Role of ancillary services
The preference and market influence toward larger, single-specialty groups or health care organizations will continue to reduce the prospect of joining and becoming an owner of a private practice, including its ancillary services. Health care and orthopedic care has moved from small business principles where six to 10 physician partners can flourish to that of large corporate principles where the complexity and cost of providing care requires management service expertise or corporate infrastructure to sustain and grow the business.
Without the support of ancillary services, orthopedic private practices will not survive in the future due to declining reimbursements from government and private insurers and increased operating costs. Ancillary services, such as ASCs, radiological services and rehabilitation, have maintained a reasonable margin for the business.
The Affordable Care Act and other value-based initiatives and payment models further pressure the margins, especially for surgical specialties. The impact of the pandemic has led to a significant increase in wages for ancillary personnel, including nurses, advanced practice providers, surgical technicians and medical assistants, increasing personnel costs while reimbursement declines. Employment may offer the opportunity to focus on the practice of orthopedics without the stress of managing the business.
Employment
Employment offers several advantages to orthopedic surgeons. In most practices, guaranteed salaries and benefits provide a stable income. Hospital employment frequently starts with higher salaries than private practice group employment, which is based on fair market value calculations. Also, the benefits of employment often include excellent health insurance, time off for continuing education and other educational opportunities, and possible loan forgiveness programs. These benefits are desirable for early practice physicians, especially those with high student loan debt.
Other benefits include malpractice insurance, advanced technology for patient management and collaboration with non-orthopedic physicians. With larger groups, the on-call and emergency care responsibilities are split among more physicians, which allow for more predictable work schedules and a healthier work-life balance. Employment also can offer opportunities for community engagement, diversity, physician leadership and support for research endeavors.
Employment may not be the right environment for every orthopedic surgeon to flourish. Some level of autonomy will be lost. In a recent survey of 1,000 employed U.S. physicians commissioned by Physicians Advocacy Institute and conducted through NORC, a research group at the University of Chicago, almost 60% of physicians reported reduced autonomy as one of the top negative impacts of ownership changes on patient care quality. The employed surgeons also reported less autonomy in patient scheduling, treatment options for patients and availability of surgical equipment and techniques. Overall, 80% of the respondents cited decreased time and communication as one of top negative impacts of ownership changes on the physician-patient relationship.
Other considerations
Other factors can influence the decision to be an employed orthopedic surgeon. Employment may offer higher initial salaries, however, long-term growth tends to be limited compared with private practice. After 5 to 7 years of developing a private practice, compensation would be expected to be 30% to 50% higher for private practice orthopedic surgeons who have well-developed ancillary services compared with those in an employment model.
For many orthopedic surgeons, there has been a culture of innovation and entrepreneurship fostered during their training. The drive for innovation may be stifled in an employment model. With corporate ownership, the bureaucracy of implementing new ideas, policy workarounds and a focus on cost reduction to improve margins may create significant resistance to change, regardless of any potential enhancements to clinical outcomes from surgeons’ and patients’ viewpoints.
Most employment contracts also come with restrictive covenants that limit the surgeons’ ability to transition their practice and innovations to more supportive environments, further tethering the entrepreneurial spirit and professional growth.
Job security is also not guaranteed. The current business climate of health care has seen an increase in the termination of physicians as part of a corporate business practice to balance books, prioritize financial goals and create valuations attractive to potential buyers. In the absence of significant equity, effective physician leadership and transparent financial practices, employed orthopedic surgeons may find themselves as “cogs” in the machinery of corporate health care economics.
Personal goals
Ultimately, orthopedic surgeons need to assess what is most important to their patient care and personal goals. A successful career with less burnout is more likely to occur when one pursues the practice environment that best aligns with personal goals and nurtures purpose as an orthopedic surgeon.
As the government, insurance companies and health care centers move forward with expensive technology, declining reimbursements and technological solutions, such as pre-authorization and increased denials to care to control costs, the ability to develop a successful private practice in orthopedic surgery may not be possible without the support of a large orthopedic super group. Employment in the right environment allows orthopedic surgeons to focus on quality patient care and healthy work-life balance while fulfilling professional and personal purposes.
- References:
- AAOS Department of Clinical Quality and Value. Orthopaedic practice in the U.S. 2018. Available at: https://www.aaos.org/globalassets/quality-and-practice-resources/census/2018-census.pdf. Published: January 2019. Accessed: April 3, 2024.
- https://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI-Research/NORC-Employed-Physicians-Survey-Press-Release-FINAL-for-PAI.pdf?ver=FnkmJ6_1eO4YyNIPksOGog%3d%3d. Published Dec. 4, 2023. Accessed April 3, 2024.
- https://www.physiciansadvocacyinstitute.org/PAI-Research/Employed-Physician-Survey.
- Physicians Advocacy Institute. Physicians Advocacy Institute-Avalere health report on trends in physician employment and acquisitions of medical practices: 2019-2021. Available at: https://www.physiciansadvocacyinstitute.org/PAI-Research/Physician-Employment-and-Practice-Acquisitions-Trends-2019-21. Accessed April 3, 2024.
- NORC at the University of Chicago. The impact of practice acquisitions and employment on physician experience and care delivery. Physicians Advocacy Institute; November 2023. Available at: https://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI-Research/NORC-Employed-Physician-Survey-Report-Final.pdf?ver=yInykkKFPb3EZ6JmfQCelA%3d%3d. Published November 2023. Accessed April 3, 2024.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Healio | Orthopedics Today. He can be reached at Healio, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.
Collapse
Read more about
Click Here to Manage Email Alerts