Published in the May 2010 issue of Today’s Hospitalist
Just over two years ago, I wrote a blog entitled “Welcome to New Jersey!” More than a little tongue in cheek, it was a recruiting plea with this simple message: “Misery loves company.”
Has the misery changed in New Jersey in the ensuing years? We did have an investigation into the sale of black-market kidneys and fake Gucci handbags last summer that led to the arrest of more than 40 people, including three mayors, two state lawmakers and several rabbis. An FBI official involved in the case claimed corruption was “a cancer that is destroying the core values of this state.” But other than that, not much.
I began thinking of the state of my state when Physician Practice magazine offered a 2009 guide for deciding where physicians should hang out their shingle.
Not surprisingly, New Jersey did not fare too well. Actually, that might be an overly kind assessment. We scored poorly in terms of malpractice environment (“in crisis”) and in state and property taxes (“the highest”), and we placed in the overall bottom five in the category “Climate for Physicians is the Worst,” along with four other Northeastern States and Guam. (Guam? Who knew!)
To add insult to injury, the American Tort Reform Association put one of New Jersey’s largest counties on its top five lists for most “unfair” civil court jurisdictions in which to be sued. (This can be found at the Web site, which is aptly entitled www.judicialhellhole.com.)
We didn’t even make Physician Practice’s “The Medical Board is Physician Friendly” top five. To earn this honor, your state board had to discipline its physicians at a rate of less than 2.1 per 1,000 physicians. Not coincidentally, New Jersey fares much better with this metric when viewed from the perspective of Public Citizen, a nonprofit consumer advocacy organization. Their report last year examined the reporting of doctors to the National Physician Data Bank (NPDB). New Jersey ranked “first in the proportion of hospitals sending at least one report to the NPDB.” Yay! We’re finally No. 1 at something!
So, how do I stay happy working in such a crappy state for physicians? Simple: I work for someone else in that state. And that someone else, a large nonprofit health care organization, is a pretty darn good boss. Further, I will submit, and this will likely shock no one nor am I the first to say it, that the trend toward direct hospital employment in states that aren’t so hospitable to physicians (if not all states) will only intensify.
What evidence do I have to support my hypothesis? First, fee for service is dead. Well not dead yet, but FFS must feel only slightly less secure than someone on death row facing his last appeal.
While health care reform has finally passed, it is far from clear what this might mean. But one possible result may be the bundling of payments. This may not matter so much if you are procedurally-based like an orthopedic surgeon, but it will matter a lot to the cognitive specialties, especially if the hospital controls the bundle.
Second, fee for service might as well already be dead for most primary care physicians in a state like mine. Recently, I interviewed a traditional internist from New Jersey who was looking to jump ship to the hospitalist-employed model. Her schedule was nothing short of brutal, with 14-hour days, six days a week, call every fourth night and only two weeks of vacation a year.
For that kind of work, you’d expect to make half a million bucks a year. Hardly. Despite seeing an otherworldly number of patients each day, her compensation was on par with what our employed hospitalists make in a year.
Finally, for hospitalists at least, working directly for hospitals just plain makes good sense. Again, nothing groundbreaking here, but our specialty and the hospital’s interests are almost always going to be in natural alignment. This is not to say that subcontracted groups have no place. However, I suspect that the better private hospitalist groups will contract with hospitals in such a way as to make it almost indistinguishable to individual hospitalists who are actually employing them.
Admittedly, working for someone else does not guarantee happiness. Poor hospital leadership will always create physician relationships that are destined to implode. Yet as hospitalists become more and more indispensable in a reformed health care environment, poorly-run hospital programs will increasingly become the outliers.
So “Welcome to New Jersey.” I’ve survived two more years, and I hope to survive many more.