A Snapshot of U.S. Physicians: Key Findings from the 2008 Health Tracking Physician Survey

Data Bulletin No. 35
September 2009
Ellyn R. Boukus, Alwyn Cassil, Ann S. O'Malley

Physicians serve as the central figures in the American health care system, as their clinical judgments influence how as much as 90 percent of every health care dollar is allocated. With health care expenditures continuing their steep upward trajectory, the ranks of uninsured Americans expanding, and the quality of care remaining inconsistent, there is a pressing need to extract greater value from the nation's $2.4 trillion in annual health care spending.

For policy makers seeking to steer the health care system toward improved value, access to timely and reliable data about physicians and how they deliver care is essential. The nationally representative Center for Studying Health System Change (HSC) 2008 Health Tracking Physician Survey encompasses a broad spectrum of physician and practice dimensions, spanning basic demographic profiles, practice structure, and career satisfaction to insurance acceptance policies, compensation models, and the provision of charity care.

Regrettably, due to modifications in survey administration methods, the results from the 2008 Health Tracking Physician Survey cannot be directly compared with findings from previous HSC Community Tracking Study Physician Surveys. Nevertheless, as the country engages in the most substantive conversation about comprehensive health care reform in 15 years, the 2008 physician survey creates a fresh baseline that will enable ongoing monitoring of how physicians organize their practices and deliver medical care.

A Snapshot of U.S. Physicians

In 2008, close to one-third of physicians were employed in solo or two-physician practices, 15 percent practiced in groups comprising three to five physicians, and 19 percent worked in practices with six to 50 physicians (see Figure 1). Thirteen percent were based in hospital settings, with 44 percent of those hospital-based physicians working in office practices or clinics and the rest divided equally between emergency departments and hospital staff roles. Community health centers (CHCs) employed 3 percent of physicians, while 4 percent worked in group or staff-model health maintenance organizations (HMOs).

Nearly three-quarters of U.S. physicians were male in 2008 (see Table 1). However, among physicians younger than 40, slightly over 41 percent were female, offering a preview of how the physician workforce's gender composition is likely to evolve in the years ahead (findings not shown).

Three out of four physicians described themselves as white, non-Hispanic, while 3.8 percent were Black, non-Hispanic, 5.3 percent identified as Hispanic, and 17.2 percent were Asian or of other racial backgrounds. Among physicians under age 40, roughly two-thirds were white and 33 percent belonged to minority groups — Black (4%), Hispanic (5.4%), and Asian or other race (24%) (findings not shown).

Over 80 percent of the physicians surveyed worked on a full-time basis, more than half (53%) fell between ages 40 and 55, and nearly four in 10 had been practicing medicine for over 20 years. Nine out of 10 physicians held board certification, and 22 percent had completed their medical training outside the United States or Canada. Approximately 40 percent were primary care physicians, 35.1 percent were medical specialists (including psychiatrists), and 25.7 percent were surgeons (including obstetrician/gynecologists).

A slim majority of physicians (56%) held either full or partial ownership stakes in their practices, while 44 percent served as employees or independent contractors.

When examining the geographic distribution of physicians relative to the general U.S. population, physicians were disproportionately concentrated in the Northeast and in large metropolitan areas — likely reflecting, in part, patients traveling to urban centers for specialized care — and were underrepresented in the South (see Figures 2a and 2b).

Physician Compensation Arrangements

In 2008, 44 percent of physicians indicated they received some type of performance-adjusted salary — for instance, adjustments tied to their individual productivity (see Table 2a). Approximately one-quarter reported being paid a fixed salary, and 20 percent received a portion of their practice's revenue.

Productivity metrics and the overall financial performance of the practice were the most prevalent financial incentives shaping physician compensation (see Table 2b). Roughly 61 percent of physicians said these factors were moderately or very important in setting their pay. By contrast, fewer than one in 10 physicians reported that practice profiling results — measuring how a physician's resource utilization compares to peers — were moderately or very important to their compensation. Similarly, about one in eight physicians (13%) cited quality-of-care measures, and roughly one in seven (15%) identified patient satisfaction surveys as moderately or very important determinants of their compensation.

The factors deemed important for compensation varied across physician and practice characteristics. Productivity and practice financial performance grew in significance as physician income increased, while quality measures, patient satisfaction ratings, and profiling became less influential. Among specialties, the compensation of surgical specialists was more heavily driven by productivity and financial performance and less influenced by the other measures when compared with general internists. For physicians in non-institutional practice environments, the weight given to productivity measures rose along with group size. Physicians employed by group or staff-model HMOs rated patient satisfaction surveys, quality measures, and practice profiling as more significant incentives than did those in solo or two-physician practices. Physicians who were eligible for bonuses tended to consider all factors as important to their compensation relative to those who were not eligible for bonuses.

Career Satisfaction

Forty-three percent of physicians indicated they were "somewhat satisfied" with their overall medical career, and 39 percent reported being "very satisfied" (see Table 3). Levels of career satisfaction tended to differ according to physician and practice characteristics. Physicians who had been in practice for more than 20 years gave more polarized responses: they were more likely to express either very high satisfaction or very high dissatisfaction compared with their less experienced colleagues. Pediatricians and both medical and surgical specialists reported higher career satisfaction than general internists, family practitioners, psychiatrists, and obstetrician/gynecologists. Physicians earning higher incomes also indicated greater satisfaction with their careers.

Acceptance of New Patients

On average, nearly half of physicians' practice revenue originated from public sources — approximately 31 percent from Medicare and 17 percent from Medicaid.

Whether practices accepted new patients depended on patient insurance type as well as physician and practice characteristics (see Tables 4a, 4b, and 4c). In general, practices were far less willing to take on new Medicaid patients than new Medicare or privately insured patients.

Just over half of physicians (53%) said their practices were accepting all or most new Medicaid patients; 28 percent reported turning away all new Medicaid patients. Nearly nine in 10 physicians (87%) indicated their practices were accepting all or most new privately insured patients, and close to three-quarters (74%) reported their practices were open to all or most new Medicare patients.

Several patterns emerged relating physician and practice traits to the acceptance of new patients. Black physicians showed a greater likelihood of accepting new Medicaid patients. Medical and surgical specialists were more inclined to accept new patients regardless of insurance type, potentially because of the episodic nature of the services they typically deliver — in contrast to primary care physicians who provide continuous care across a patient's conditions. Psychiatrists, however, were considerably less likely to accept new patients irrespective of insurance status. Group practices, particularly those with six or more physicians, along with institutional practices were more open to new patients across all insurance categories. Similarly, physicians in rural areas reported that their practices were more likely to accept new patients (findings not shown).

Managed Care Contracts

Notwithstanding anecdotal accounts that many physicians have withdrawn from insurance networks, the overwhelming majority of physicians (87.6%) maintained managed care contracts in 2008 (see Table 5). Furthermore, nearly 70 percent reported holding five or more managed care contracts (findings not shown).

Relative to physicians with one or more managed care contracts, those without any managed care contracts were more likely to have practiced for over 20 years, work fewer than 40 hours weekly, lack board certification, operate in solo or two-physician practices, be located in the western United States, and describe their practice environment as non-competitive.

Physicians who chose not to contract with managed care plans had several options available: treating only patients covered by insurance products without provider networks (such as fee-for-service Medicare), running cash-only practices, or serving managed care patients as out-of-network providers who could balance bill patients for charges exceeding insurer allowances for out-of-network services.

Among specialties, psychiatrists were significantly less likely to hold managed care contracts — roughly one-third had no managed care contracts at all — possibly reflecting both low reimbursement rates and the heavier utilization management burden imposed by health plans and managed behavioral health companies that many psychiatrists encounter. This pattern may also be related to psychiatrist shortages in numerous areas. In contrast, pediatricians were more likely to participate in managed care networks — only 4.8 percent reported having no managed care contracts — likely because Medicaid managed care plans constitute a major source of coverage for children.

Charity Care

In 2008, slightly under six in 10 U.S. physicians (59.1%) reported delivering charity care — defined as free or reduced-cost services — to patients experiencing financial hardship (see Table 6).

On average, physicians who delivered charity care devoted 9.5 hours to such care in the month before the survey, which translates to slightly over 4 percent of the time they spent on all medically related activities.

The provision of charity care varied substantially across physician and practice characteristics. Surgical specialists (73.5%) were the most likely to offer charity care, most probably because many are required to be on call at hospitals where they encounter uninsured patients requiring emergency services. Pediatricians (45.6%) were the least likely to provide charity care, perhaps because fewer children lack insurance coverage thanks to more expansive public coverage eligibility.

Charity care levels were highest among physicians in solo or two-physician practices (71.5%). By comparison, physicians in larger groups, HMOs, and institutional practices — where charity care policies are typically established at the organizational level — were considerably less likely to provide charity care.

Physicians at the highest income tiers reported the greatest provision of charity care: 67 percent of physicians with practice incomes above $250,000 delivered charity care in 2008, compared with 54.7 percent of physicians earning under $150,000. Physicians who provided charity care were also more likely to have been practicing for over 10 years.

Notes

1. Sager, Alan, and Deborah Socolar, Health Costs Absorb One-Quarter of Economic Growth, 2000-2005, Data Brief No. 5, Boston University School of Public Health (Feb. 9, 2005); Eisenberg, John, "Physician Utilization: The State of Research About Physicians' Practice Patterns," Medical Care, Vol. 40, No. 11 (2002).

Funding Acknowledgement

The 2008 HSC Health Tracking Physician Survey and this research were funded by the Robert Wood Johnson Foundation.

Data Source

This Data Bulletin presents findings from the Center for Studying Health System Change (HSC) 2008 Health Tracking Physician Survey, a nationally representative mail survey of U.S. physicians providing at least 20 hours per week of direct patient care. The physician sample was drawn from the American Medical Association master file and encompassed active, nonfederal, office- and hospital-based physicians. Residents and fellows were excluded, along with radiologists, anesthesiologists, and pathologists. The survey captured responses from more than 4,700 physicians, achieving a response rate of 62 percent. Estimates from this survey should not be compared to estimates from HSC's prior Community Tracking Study (CTS) Physician Surveys because of changes in the survey administration mode from telephone to mail, question wording, skip patterns, sample structure, and the population represented. More detailed information on survey content and methodology can be found at www.hschange.org.

Sources and Further Reading

The following resources provide additional context on physician workforce data, practice patterns, and healthcare delivery discussed in this survey:

Robert Wood Johnson Foundation: Health Research and Data -- The Robert Wood Johnson Foundation funded the 2008 Health Tracking Physician Survey and continues to support research on physician workforce and healthcare delivery.

AMA Physician Masterfile -- The American Medical Association's comprehensive database from which the physician survey sample was drawn.

KFF: Physicians by State -- Kaiser Family Foundation data on the geographic distribution of physicians across the United States, providing context for the workforce findings in this survey.

CMS Physician Fee Schedule -- Medicare physician payment information from the Centers for Medicare & Medicaid Services, relevant to the survey's findings on physician revenue sources and managed care participation.

Health Affairs: Health Workforce Research -- Peer-reviewed studies on physician supply, specialty distribution, and practice organization published in Health Affairs.