Hottest Job in Healthcare Still Primary Care Physician

Part of the reason for the current shortage of family physicians harkens back to the perception in some medical circles just a few years ago that primary care was a specialty best to be avoided unless you wanted to work long hours for less pay.

For the seventh straight year family physicians topped the list of the 20 most sought-after specialties for recruiters Merritt Hawkins.

This should not surprise. It has been evident for the last several years that as healthcare reform eventually mandates a shift away from fee-for-service and rewards prevention, quality outcomes, and population health, primary care physicians will lead the way.

Another driver for the high demand is the growing numbers of service sites. Medical groups searching for primary care physicians increasingly find themselves competing against other medical groups, hospitals, community health centers, urgent care centers, retail clinics, academic centers, and government facilities.

It was fashionable in the 1990s and the Health Maintenance Organization era to refer to primary care physicians as "gatekeepers" who would map out and coordinate care strategies to reduce costs and waste. While the gatekeeper label might have gone out of fashion (or conjures up unpleasant thoughts of rationed care) the role clearly has come storming back.

Return of the Gatekeeper
"Everybody wants to be in primary care. The whole mantra with healthcare reform is wherever your patients are let's be there," says Kurt Mosley, vice president of strategic alliances at Irving, TX-based Merritt Hawkins.

"Back in the 1990s the whole issue was gatekeepers. I knew a CEO who had a sign on his desk that said 'He who retires with the most primary care doctors wins. ' And I think we are back to that."

Merritt Hawkins' 2013 Review of Physician and Advanced Practitioner Recruiting Incentives [PDF], the 20th edition of the survey, tracks the 3,097 recruiting assignments in 48 states the firm conducted from April 1, 2012 to March 31, 2013. The report shows that physician recruiters handled 624 searches for family physicians. General internal medicine came in a distant second with 194 searches.

Part of the reason for the current shortage harkens back to the perception in some medical circles just a few years ago that primary care was a specialty best to be avoided unless you wanted to work long hours for less pay.

"The problem is when all of those specialties started coming up years ago we started seeing all of these doctors making all of this money and there was a bias against primary care in medical school. Some of the faculty would say to students 'you are way too smart for primary care.' We bit off our own nose in spite of our face."

The report shows that demand for some medical specialists has decreased. Radiology, which was the most requested specialty from 2001 to 2003 did not make the top 20. Anesthesiology, also a one-time top recruiting assignment, also did not make the list in 2013.

Compensation Remains a Sore Spot
While family practitioners are in high demand, their average base salaries or guaranteed incomes of $185,000 remain near the bottom. Only pediatricians fared worse with an average base of $179,000.

"A key factor that people have to understand is that primary care is not necessarily growing in salary, but more specialties are coming down closer to them," Mosley says. "We used to talk about cardiologists in the $800,000 to $900,000 range. Now they are in the $500,000s and $600,000s. Also doctors in medical homes can make a heck of a lot more money because they are paid that base salary and they are paid a maintenance fee and they are paid the malady improvement fee. There are ways for doctors to make money. We are going to see it continue to rise."

Seventy-five percent of search assignments this year featured a salary with production bonus. Most such bonuses (57%) are based on a Relative Value Units formula. A growing number of production formulas also feature quality-based metrics. For example, 39% of the search assignments offered production bonuses that featured a quality-based component, up from 35% a year earlier.

By comparison, in 2011, fewer than 7% of recruiting assignments that offered a production bonus included payments based on quality-of-care metrics. In 2013 that number grew to 39%, which Mosley says illustrates the rapid shift away from rewarding physicians for the volume of services they provide and toward rewarding them for the value of services they provide.

Other Recruiting Trends
Nonetheless, quality measures averaged less than 10% of a physician's potential bonus in 2013 and volume is still the key driver of physician incentives. The survey identified these trends as well:

• For the first time in the 20 years Merritt Hawkins has been conducting their review, physicians' assistants and nurse practitioners were among the top 20 recruiting assignments.
• Also for the first time, geriatricians cracked the top 20 and are being actively recruited to supplement elder care traditionally provided by internists, pulmonary and palliative care specialists.
• Hospitalists ranked third among the top 20 search assignments, probably because their training and emphasis on coordinating inpatient care and reducing readmissions are aligned with the goals of new care delivery models such as accountable care organizations.
• Other hospital-based physicians, particularly emergency medicine physicians, are in increased demand, as data show that a greater prevalence of insured patients does not necessarily decrease emergency room visits – a significant trend as millions of the previously uninsured begin to obtain coverage through the Affordable Care Act.
• The trend toward hospital employment of physicians continues and represented 64% of search assignments in 2012/13, up from 11% in 2004.
• Demand for physicians is not confined to underserved rural areas. Merritt Hawkins worked in 48 states in 2012/13 and 49% of the firm's searches were in communities of 100,000 people or more, the highest percentage in the 20-year history of the review.