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Surgeons as Hospital Employees: Comment on “The Employed Surgeon”

Surgeons as Hospital Employees: Comment on “The Employed Surgeon” Over the past decade, there has been an explosive growth in hospital medicine with regard to hospital-based employment of hospitalists, and now surgeons are following in the footsteps of the hospitalists.1 Overall, data from the American Hospital Association indicate that hospitals currently employ about 25% of all active physicians.2 This increase mirrors the increase in the use of hospitalists from 2003 (30%) to 2010 (60%). The significant increase in the number of hospital-employed surgeons is paralleling this increase in the number of hospital-employed medical physicians. Throughout the United States, hospitals are increasingly implementing programs in which a core group of employed surgeons provide dedicated on-site services. Charles and colleagues3 from the American College of Surgeons Health Policy Research Institute, in this issue of the journal, provide compelling national data documenting a 32% increase in the number of surgeons in full-time hospital employment. However, there are some limitations to this workforce analysis that should be noted: Approximately 30% of surgeons provided insufficient information to be categorized. Only 2 categories were used: (1) self-employed and (2) surgeon employee, which was defined as being employed by a hospital or in a large group practice. A number of specialties were included as general surgery (general, abdominal, hand, oral/maxillofacial, pediatric, trauma, transplant, cardiovascular, vascular, surgical critical care, and surgical oncology), many of which are surgeon specialties. Because of these issues, it is challenging to determine the exact number of hospital-employed surgeons in the United States. At present, there is no specific information source that provides these exact data. The American College of Surgeons Survey of Fellows in 2010 reported 12% of surgeons as full-time hospital employees (Figure). Other specialty surgeon surveys, such as the one for orthopedic surgery, confirm a 3-fold increase in surgeons as hospital employees over the last decade.4 View LargeDownload Figure. American College of Surgeons 2010 Fellow Survey of 1014 surgeons. So what are the forces moving surgeons in this direction? Some hope to gain a reprieve from the headaches of operating a business, particularly at a time when many general surgery practices face economic challenges, including on-call issues and uncompensated emergency care. Employment by hospitals may be attractive to young surgeon graduates with financial debt from their training, with offers of sign-on bonuses, high salaries, a balanced lifestyle, ensured vacation, and a sense of security in this time of uncertainty. Hospital employment also guarantees an immediate patient base, which can be difficult to build up in a private practice. Hospital-based physician employment, for the hospital, provides a vehicle for recruitment and retention of surgeons. Employment is a strategy that some hospitals need to consider to strengthen or protect a service line. Hospital employment of an entire general and/or specialty surgical group may be desirable. In the current era of health care reform and the promotion of accountable care organizations, a hospital-physician integrated system is better positioned to reap benefits than the private practice independent physician. In the future, accountable care organizations will receive a single “bundled” payment, which will be distributed to those involved in caring for the patient. Finally, the significant expenses of health care information technology systems (ie, billing and collection systems), the increasing costs of staff and ancillary services, and the administrative burden have driven 75% of all physicians to look for other employment opportunities. The American College of Surgeons Board of Governors Committee on Socioeconomic Issues has developed a white paper addressing the roles and the future of surgeons as employees that will be useful for those seeking hospital employment.5 Similarly, the American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons have published a primer to help educate members on issues related to hospital employment of orthopedic surgeons.6 One thing is for certain: employment does not ensure physician and hospital alignment. There is a need to deliberately and actively engage hospital-employed surgeons in their governance model. Surgeon leadership is essential. Although all surgeons will make their own decisions regarding hospital employment or not, physician-hospital alliances will always be necessary. We must not lose sight of the fact that our priority is surgical patient care, no matter the employment paradigm we choose. Quality of patient care must still be the prime focus of our surgical practices, and surgeon champions should lead the quality-of-care efforts, even as hospital-employed surgeons. Back to top Article Information Correspondence: Dr Napolitano, Department of Surgery, University of Michigan, Room 1C421, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0033 (lenan@umich.edu). Published Online: December 17, 2012. doi:10.1001/jamasurg.2013.1021 Conflict of Interest Disclosures: None reported. References 1. Kocher R, Sahni NR. Hospitals' race to employ physicians—the logic behind a money-losing proposition. N Engl J Med. 2011;364(19):1790-179321449774PubMedGoogle ScholarCrossref 2. American Hospital Association (AHA) data. AHA Annual Survey of Hospitals 1998-2010. AHA website. http://www.ahadataviewer.com/?gclid=CPHfiv3anLMCFcxAMgodIBAAUA. Accessed October 25, 2012 3. Charles AG, Ortiz-Pujols S, Ricketts T, et al. The employed surgeon: a changing professional paradigm [published online December 17, 2012]. JAMA Surg. 2013;148(4):323-328Google Scholar 4. Bozic KJ, Roche M, Agnew SG. Hospital-based employment of oerthopaedic surgeons—passing trend or new paradigm? AOA critical issues. J Bone Joint Surg Am. 2012;94(9):e5922552681PubMedGoogle Scholar 5. Vickers SM. Surgeons as employees. Bulletin of the American College of Surgeons. October 9, 2012. http://wordpress.facs.org/wordpress/2012/10/socioeconomic-issues/ 6. American Academy of Orthopaedic Surgeons; American Association of Orthopaedic Surgeons. Hospital employment of orthopaedic surgeons: a primer for orthopaedic surgeons. http://www.pwrnewmedia.com/2011/aaos/advocacy_now/special_edition/aug30/downloads/Hospital_Physician_primer.pdf.Published March 2010. Accessed October 25, 2012 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Surgeons as Hospital Employees: Comment on “The Employed Surgeon”

JAMA Surgery , Volume 148 (4) – Apr 1, 2013

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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2013.1021
Publisher site
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Abstract

Over the past decade, there has been an explosive growth in hospital medicine with regard to hospital-based employment of hospitalists, and now surgeons are following in the footsteps of the hospitalists.1 Overall, data from the American Hospital Association indicate that hospitals currently employ about 25% of all active physicians.2 This increase mirrors the increase in the use of hospitalists from 2003 (30%) to 2010 (60%). The significant increase in the number of hospital-employed surgeons is paralleling this increase in the number of hospital-employed medical physicians. Throughout the United States, hospitals are increasingly implementing programs in which a core group of employed surgeons provide dedicated on-site services. Charles and colleagues3 from the American College of Surgeons Health Policy Research Institute, in this issue of the journal, provide compelling national data documenting a 32% increase in the number of surgeons in full-time hospital employment. However, there are some limitations to this workforce analysis that should be noted: Approximately 30% of surgeons provided insufficient information to be categorized. Only 2 categories were used: (1) self-employed and (2) surgeon employee, which was defined as being employed by a hospital or in a large group practice. A number of specialties were included as general surgery (general, abdominal, hand, oral/maxillofacial, pediatric, trauma, transplant, cardiovascular, vascular, surgical critical care, and surgical oncology), many of which are surgeon specialties. Because of these issues, it is challenging to determine the exact number of hospital-employed surgeons in the United States. At present, there is no specific information source that provides these exact data. The American College of Surgeons Survey of Fellows in 2010 reported 12% of surgeons as full-time hospital employees (Figure). Other specialty surgeon surveys, such as the one for orthopedic surgery, confirm a 3-fold increase in surgeons as hospital employees over the last decade.4 View LargeDownload Figure. American College of Surgeons 2010 Fellow Survey of 1014 surgeons. So what are the forces moving surgeons in this direction? Some hope to gain a reprieve from the headaches of operating a business, particularly at a time when many general surgery practices face economic challenges, including on-call issues and uncompensated emergency care. Employment by hospitals may be attractive to young surgeon graduates with financial debt from their training, with offers of sign-on bonuses, high salaries, a balanced lifestyle, ensured vacation, and a sense of security in this time of uncertainty. Hospital employment also guarantees an immediate patient base, which can be difficult to build up in a private practice. Hospital-based physician employment, for the hospital, provides a vehicle for recruitment and retention of surgeons. Employment is a strategy that some hospitals need to consider to strengthen or protect a service line. Hospital employment of an entire general and/or specialty surgical group may be desirable. In the current era of health care reform and the promotion of accountable care organizations, a hospital-physician integrated system is better positioned to reap benefits than the private practice independent physician. In the future, accountable care organizations will receive a single “bundled” payment, which will be distributed to those involved in caring for the patient. Finally, the significant expenses of health care information technology systems (ie, billing and collection systems), the increasing costs of staff and ancillary services, and the administrative burden have driven 75% of all physicians to look for other employment opportunities. The American College of Surgeons Board of Governors Committee on Socioeconomic Issues has developed a white paper addressing the roles and the future of surgeons as employees that will be useful for those seeking hospital employment.5 Similarly, the American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons have published a primer to help educate members on issues related to hospital employment of orthopedic surgeons.6 One thing is for certain: employment does not ensure physician and hospital alignment. There is a need to deliberately and actively engage hospital-employed surgeons in their governance model. Surgeon leadership is essential. Although all surgeons will make their own decisions regarding hospital employment or not, physician-hospital alliances will always be necessary. We must not lose sight of the fact that our priority is surgical patient care, no matter the employment paradigm we choose. Quality of patient care must still be the prime focus of our surgical practices, and surgeon champions should lead the quality-of-care efforts, even as hospital-employed surgeons. Back to top Article Information Correspondence: Dr Napolitano, Department of Surgery, University of Michigan, Room 1C421, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0033 (lenan@umich.edu). Published Online: December 17, 2012. doi:10.1001/jamasurg.2013.1021 Conflict of Interest Disclosures: None reported. References 1. Kocher R, Sahni NR. Hospitals' race to employ physicians—the logic behind a money-losing proposition. N Engl J Med. 2011;364(19):1790-179321449774PubMedGoogle ScholarCrossref 2. American Hospital Association (AHA) data. AHA Annual Survey of Hospitals 1998-2010. AHA website. http://www.ahadataviewer.com/?gclid=CPHfiv3anLMCFcxAMgodIBAAUA. Accessed October 25, 2012 3. Charles AG, Ortiz-Pujols S, Ricketts T, et al. The employed surgeon: a changing professional paradigm [published online December 17, 2012]. JAMA Surg. 2013;148(4):323-328Google Scholar 4. Bozic KJ, Roche M, Agnew SG. Hospital-based employment of oerthopaedic surgeons—passing trend or new paradigm? AOA critical issues. J Bone Joint Surg Am. 2012;94(9):e5922552681PubMedGoogle Scholar 5. Vickers SM. Surgeons as employees. Bulletin of the American College of Surgeons. October 9, 2012. http://wordpress.facs.org/wordpress/2012/10/socioeconomic-issues/ 6. American Academy of Orthopaedic Surgeons; American Association of Orthopaedic Surgeons. Hospital employment of orthopaedic surgeons: a primer for orthopaedic surgeons. http://www.pwrnewmedia.com/2011/aaos/advocacy_now/special_edition/aug30/downloads/Hospital_Physician_primer.pdf.Published March 2010. Accessed October 25, 2012

Journal

JAMA SurgeryAmerican Medical Association

Published: Apr 1, 2013

Keywords: surgeons

References