Physician Retention in the Era of COVID-19

Reducing physician burnout and physician turnover rates was an ongoing challenge for many medical groups, even prior to the spread of COVID-19.

In the 2018 Survey of America’s Physicians(1) conducted by Merritt Hawkins on behalf of The Physicians Foundation, 40% of physicians said they often experienced feelings of professional burnout. In the 2020 version of this survey, conducted well after the pandemic had become widespread,, that number had increased to 58%.

Physician turnover rates are likely to increase in the era of COVID-19.

Burnout is one reason medical groups, hospitals, and other facilities experience a physician relocation and turnover rate annually of approximately 12% among primary care physicians and up to approximately 20% among some specialists.(2) Unfortunately, physician turnover rates are likely to increase in the era of COVID-19. In the 2020 Survey of America’s Physicians, (1) published when the pandemic was well underway, 20% of physicians said they plan to seek a new practice, opt out of patient care, or work locum tenens as a result of the coronavirus. Thirty-seven percent said they would like to retire in the next year.

Medical groups can take a variety of steps to reduce physician burnout and turnover in response to the pandemic. Several of these are discussed in the following sections.

Have a Vision

The way healthcare is delivered in the United States is rapidly changing. Larger, integrated delivery models employing team-based care within value-based payment structures are proliferating. COVID-19, which imposed particular financial hardship on smaller medical groups and hospitals, is likely to accelerate healthcare system consolidation. There is also an industry-wide movement toward outpatient care, offering patients convenience and quick access to services.

To remain engaged, physicians need a vision of where the practice is going in these transformative times. Will there be growth through mergers, consolidation, or affiliations? To what extent will team-based care, telemedicine, and emerging IT systems be embraced? How will the practice respond to COVID-19? What will the balance be between physician autonomy and the achievement of group or system goals?

Not all physicians may buy into the vison, but assurance about the direction of the practice is preferable to the indecision, confusion, and uncertainty that often breeds turnover.

Create a Positive Workplace

Like snowflakes, no two medical practices are alike. Some practices are more appealing than others, not necessarily because they are located by a beach or near the mountains, but because they feature a practice style and a work environment tailored to what physicians today prefer. Medical groups cannot control the fact that they are not close to the ocean or to mountains, but they can, to some extent, control the quality of the medical practice environment they offer.

The “primacy of the workplace” may be the most important factor to consider when seeking to enhance physician retention. First and foremost, physicians want a safe, efficient place to treat their patients, one in which they can focus on what they were trained to do. To the extent they can provide this type of positive environment, medical groups are likely to build physician loyalty and rapport. For medical groups that cannot create positive working conditions for physicians, physician disengagement and turnover are inevitable.

Following are some ways to maintain a premier physician “workshop”:

• Offer clear, competitive, fair compensation (as discussed later in this article);

• Implement a physician-friendly EHR that communicates with the hospital and with specialists;

• Employ scribes to reduce the need for the physician to perform data entry;

• Employ specialists to handle preauthorizations;

• Develop and promote physician group practice leaders;

• Offer flexibility in terms of schedules, vacations, duties, and specialty focus;

• Offer short sabbaticals for physician recharge;

• Provide on-site labs, imaging, and other ancillaries;

• Maintain a qualified, efficient support staff;

• Improve physician access to patient data;

• Improve test turnaround times;

• Use locum doctors during peak usage periods to avoid physician burnout;

• Provide convenient parking and access for physicians;

• Maintain appropriate equipment;

• Add specialty support as needed; and

• Seek physician input.

The primary goal is to reduce or eliminate those regulatory, reimbursement, and related paperwork tasks that detract from physician efficiency and take physicians away from patient care.

Respond to COVID-19

Today, a positive workplace for physicians is one that has adjusted to COVID-19. Many practices have had to transform quickly to meet challenges presented by the coronavirus. This includes the essential step of adopting safety protocols and personal protective equipment use for workers and patients.

The willingness to be flexible was a key to physician retention before COVID-19 and has become even more important as a result of the coronavirus.

It also may include the adoption or expansion of telemedicine, which involves a technological component but also a management component, in which episodes of care are defined. Physicians should set the group standard for what is an in-person service, what is always virtual, and what may vary based on patient preferences or regulatory or reimbursement considerations.

The willingness to be flexible was a key to physician retention before COVID-19 and has become even more important as a result of the coronavirus. COVID-19 saw physicians practicing outside of their subspecialty, upskilling to work in higher-acuity settings, and practicing across different sites. They will want to maintain this type of practice flexibility.

Maintaining patient loyalty (and, therefore, the patient base physicians require to meet financial goals) requires paths to patient convenience, which may include afterhours care, the use of remote patient monitoring devices, video visits, and phone-based visits, all of which have been made more important due to COVID-19.

Team-based care in which advanced practice professionals have more autonomy and handle basic care needs allows physicians to practice to the top of their training. This can be important, because COVID-19 has increased patient acuity, both among patients who have contracted the virus and among those who have postponed care for fear of contracting the virus. Team-based care also can improve physicians’ quality of life by eliminating or lessening call duties and by removing the entire responsibility for the patient panel from their shoulders.

Medical groups also may wish to introduce or expand services such as imaging, laboratory testing, and minor procedures. Patients in the COVID-19 era may be more open to receiving treatment in an ambulatory setting rather than exposing themselves to the pathogens found inside a hospital. CMS and private payers will continue to push payments from inpatient to outpatient, so medical groups that offer these services will have the opportunity to gain market share and increase revenue.

Offer Clear, Competitive, Fair Compensation

There are a variety of sources that track physician compensation, including the Medical Group Management Association and the American Medical Group Association. Merritt Hawkins, in its annual Review of Physician and Advanced Practitioner Recruiting Incentives, (3) tracks physician starting salaries, signing bonuses, relocation allowances, and other recruiting incentives.

Physicians are aware of these data and usually have a fairly accurate idea of what is competitive in their specialty. Medical groups seeking to enhance physician retention should offer physicians income in the range of what is competitive to ensure the physicians feel valued and do not seek opportunities elsewhere.

However, the way physician compensation is structured may be as important as the amount that is offered. Out of the 3251search assignments Merritt Hawkins conducted in the last year, 72% featured a salary with a production bonus. The production bonus is the physician’s path to maximizing his or her financial potential. A family physician, for example, might be paid a base salary of $240,000 with a potential production bonus of $50,000.(3)

In most physician contracts, the production bonus is achieved through the number of relative value units the physician generates, number of patients seen, or amount of revenue collected. These are all volume-based metrics typical of the fee-for-service model.

Increasingly, however, physicians are being compensated on outcomes, adherence to quality measures, use of healthcare information technology, cost effectiveness, and patient satisfaction. These measures are more subjective, less easily understood, and usually less well received by physicians than are standard volume-based measures, which are comparatively easy to understand. It is important, therefore, for medical groups to follow evolving physician payment models and to ensure physician performance and pay metrics are as clear as possible.

This entails keeping the number of metrics as low as possible and having evaluation measures be physician directed. It also entails tracking outcomes data, such as which physicians achieve low rates of diabetes or high blood pressure among their patients; which have low readmission rates; positive patient satisfaction scores; and other benchmarking metrics. Buy-in is more likely when physicians are presented with physician-instituted quality standards and meaningful outcomes data.

Alter Compensation to Reflect COVID-19

All of this is particularly true in the era of COVID-19. By depressing utilization, the coronavirus further eroded the viability of the production- or volume-based compensation model for individual physicians. Private practices that had capitated reimbursement contracts in place in 2020 generally experienced less financial loss and emotional stress than those without such contracts. In light of COVID-19, some groups are moving toward models that pay physicians for group rather than individual performance. These models incorporate group patient volume, telemedicine, total cost of care, and the patient experience. Due to COVID-19, it will be particularly important to adjust payment formulas to reflect the expanded use of telemedicine.

The “right” physician compensation formula is hard to come by, particularly when consolidation is taking place and physicians from various groups are joining a central system where compensation must be standardized. The “Goldilocks zone,” in which physicians are rewarded sufficiently for volume to stay productive, yet also are rewarded enough on value to embrace new delivery models, is still aspirational for many medical groups. This will continue to be a challenge, but medical groups that can keep their compensation formulas transparent and equitable will go a long way toward enhancing their physician retention rates.

In addition, signing bonuses that encourage retention, such as a $100,000 bonus paid over five years, can be an effective physician engagement tool.

Recruit to Retain

Many of the seeds leading to physician turnover are planted during the recruiting process. Retention problems often are created or compounded due to an insufficiently detailed or accurate practice opportunity presentation. If expectations regarding required work hours, patients seen per day, group governance, quality metrics, COVID-19 protocols, compensation, and related issues are not clearly communicated to candidates on the front end of the recruiting process, misunderstandings that lead to physician disengagement or turnover can result on the back end.

It is important to delineate in writing exactly what is expected of the physician and to accurately project the financial potential of the practice so that expectations are realistic and achievable. The majority of these details should be communicated during the candidate screening process, before the physician interviews. In the COVID-19 era, physician interviews are most likely to be virtual, not in-person.

Once the physician is hired, he or she should be properly onboarded. Medical groups should create an onboarding checklist, which may review such items as benefits, licensing and credentialing processes, materials management, and EHR training and setup. In addition, the medical group should ensure that the physician’s family is transitioned into the community by preparing a packet with information about the community, its educational venues, cultural and entertainment amenities, and religious forums.

Provide Support

In the 2020 Survey of America’s Physicians, (3) 24% of physicians said they had sought medical treatment for a physical problem caused by COVID-19, and 13% said they had sought medical treatment for an emotional problem caused by COVID-19. Medical groups should be sensitive to the emotional needs of physicians and direct them to resources that can enhance their well-being. These include Federation of State Physician Health Programs (FSPHP).

A FSPHP is a confidential resource for physicians, other licensed healthcare professionals, or those in training suffering from addictive, psychiatric, medical, behavioral, or other potentially impairing conditions. FSPHPs coordinate effective detection, evaluation, treatment, and continuing care monitoring of physicians with these conditions. This coordination and documentation of a participant’s progress allows FSPHPs to provide documentation verifying a participant’s compliance with treatment or continuing care recommendations.

Continually Communicate

Several years ago, Merritt Hawkins recruited a neurologist to a growing group practice. When he was contacted some months later to see how he was fitting in with the group, we were informed that he was leaving because the group had not yet put his name on the door or on other signage, and he therefore assumed he was not wanted. A simple lapse in communication almost caused this group to lose a good doctor. This anecdote illustrates the importance of continual communication with the medical staff, and the hazards of assuming physicians have received a message when it has not been explicitly stated (Kurt Mosley, Merritt Hawkins, personal communication).

Physician communication should be both:

• Formal, through regular medical staff surveys and/or “stay interviews.” Stay interviews do not feature performance evaluations. They are periodic discussions to determine how physicians are adjusting to their colleagues and the practice’s culture.

• Informal, through regular contact with group physicians during lunch, throughout the workday, and during off-hours social engagements.

COVID-19 has exacted a toll on many physicians, who were negatively affected by the pandemic financially, physically, and emotionally. Many physicians will be evaluating how their medical groups responded to the coronavirus and may seek opportunities elsewhere if they feel the response was lacking. It will be more important than ever, therefore, for medical groups to create the conditions and follow the practices most likely to lead to enhanced physician retention.

References

1. 2018 Survey of America’s Physicians. The Physicians Foundation/Merritt Hawkins. September 18, 2018. https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf .

2. Healthcare Professional Move Rates. IQVIA/SK&A. Fall 2018. www.onekeydata.com/reports/provider-move-rates

3. 2020 Review of Physician and Advanced Practitioner Recruiting Incentives and the Impact of COVID-19. Merritt Hawkins. June, 2020. www.merritthawkins.com/news-and-insights/blog/healthcare-news-and-trends/Merritt-Hawkins-2020-Incentive-Review-How-COVID-19-Changed-the-Market-for-Physicians/ .