Why Are Doctors Working Fewer Hours?

After remaining steady for nearly 30 years, the number of hours that an average physician works each week dropped sharply in the last decade. Understanding why is particularly important at a time when Congress is struggling at the last minute to prevent a 21% cut in Medicare payments.

Between 1977 and 1997, non-resident physicians worked an average of about 55 hours per week, according to a new study in this week's Journal of the American Medical Association. From 1998-2008, however, that dropped to about 51 hours per week.

That's still a pretty busy workweek, and physicians certainly deserve a little reprieve. But the drop in hours means patient access is a little more limited (it's the equivalent of losing 36,000 doctors from the workforce), and it adds to challenges of meeting patient demand when provider shortages are predicted for the near future.

What happened in the late 1990s to cause the sudden change in work habits?

If you've been following physician workforce trends you might guess that it is simple demographics. Female physicians tend to work fewer hours and have been entering practice in greater numbers. Younger Generation X physicians in general tend to have a different philosophy about medicine and place more emphasis on work-life balance than their predecessors.

But that isn't what the researchers found. Work hours declined across demographic groups—for both male and female physicians, younger and older physicians, and regardless of whether the doctors were employed or independent practitioners.

Decreases in hours were larger for younger physicians, so the lifestyle preferences may have been one of many drivers of the change. But the study authors found a different correlate to the drop in hours: Reimbursement rates.

Inflation-adjusted physician fees dropped by 25% between 1996 and 2006, and the hours worked by physicians strongly correlated with the fee index from the prior year. Researchers went a step further and found that physician hours worked were lowest (49 per week) in the metropolitan areas with the lowest fees.

Correlation doesn't imply causation, of course, and there are many possible explanations for the overlap. Physicians have become much more productive in recent years, for example. Although fees decreased 19% and hours worked dropped 5% between 1995 and 2003, inflation-adjusted physician income declined only 7%, suggesting physicians are able to earn more in less time these days.

However, the authors of the study think the reimbursement decline is a big reason for the drop. "When fees decrease, a physician earns less for working an additional hour, all else equal, and may have less incentive to work long hours," they write.

They go on to conclude that, "Further reductions in fees and increased market pressure on physicians may, therefore, contribute to continued decreases in physician work hours in the future."

Which brings me back to the looming Medicare payment cut. Congress has until next Monday to permanently fix the SGR formula or delay the scheduled 21% cut.

The American Medical Association and other physician groups obviously want the former, and they have boldly campaigned against short-term fixes in favor of real solutions. But that is risky considering a bill that would have fixed the SGR-driven problems failed to pass in the Senate last fall.

Congress has become dysfunctional, and government spending has become such a hot-button political issue that it is difficult to muster support for things worthy of our dollars. As of this writing, it looks like the best Washington can offer for now is delaying the cut until March 28.

But if policy makers don't get their act together and the cut goes into effect, or if they only put another Band-Aid on this growing gash in the healthcare system, the research about physician work hours may be telling of what's to come.

Theoretically, if reimbursement fell by 21%, a lot of physicians would work 21% longer in order to maintain current incomes. But that's not going to happen. It just isn't worth the extra stress, effort, and resources for a lot of doctors.

Instead, they're just going to work less, and patient access will ultimately suffer.