Physicians' sense of autonomy in employed settings and their ability and inclination to operate an independent practice have dually declined in recent years, becoming a central concern for physicians across specialties.
Just 44% of physicians owned their own practice in 2022, compared with 76% in the early 1980s, according to the American Medical Association.
Around 61% of employed physicians said they have moderate or no autonomy to make referrals outside of their practice or ownership system, and 47% said they adjust patient treatment options to reduce costs based on practice policies or incentives, according to a survey from NORC at the University of Chicago.
The decline in physician autonomy may also be connected to lower satisfaction in their careers and higher rates of workplace burnout. Physicians in hospital-led settings are particularly unhappy with their employment. Physicians employed in hospital-owned practices are nearly three times more likely to report dissatisfaction than their peers in physician-owned practices, according to Bain & Co.'s "Frontline of Healthcare Survey." The Bain & Co. report also highlighted that nearly 25% of physicians in health system-led organizations are debating a change in employers, compared to 14% in physician-led practices.
Additionally, 78% of physicians in physician-led practices reported effective organizational processes and workflows, compared to 59% in hospital-led organizations. Of physicians in physician-led practices, 81% reported satisfaction with their involvement in strategic decision-making, compared to just 50% in hospital-led practices.
Despite this, hope remains for physicians who may be interested in shifting toward independent practice or seeking a higher sense of autonomy in their current practice setting.
"Sadly physicians realize, or think, that their power is gone and it's not," Susan Baumgaertel, MD, an internal medicine physician in Seattle, told Becker's. "I think that they have to think about options of where they really want to envision putting their incredible time, energy and experience and expertise into, in terms of helping patients."
For 25 years, Dr. Baumgaertel worked as a physician and had ownership stake at The Polyclinic in Seattle, a multispecialty physician practice now owned by Optum. The facility is currently rebranding itself as Optum Care Washington. She left the Polyclinic in 2021 to start her own independent practice, myMDadvocate, which serves as a multifaceted telemedicine and healthcare navigation hub.
She encourages physicians to explore their options and think creatively about what a shift in practice setting might look like for them.
"I feel like many [physicians] are unaware or just feel frozen, and they don't know what their next steps might be if they want to kind of pivot in their career," she said. "[I]t doesn't mean abandoning medicine, [it] just means doing it a different way."
Dr. Baumgaertel bills for her time at her practice, likening her business model to that of a lawyer billing for hours worked. She had initial concerns that her model would only be accessible to a wealthier clientele, as her services are not covered by insurance. Instead, she has found that patients across a range of income levels deeply value having consistent access to a trusted physician — without all of the administrative hurdles that have become synonymous with healthcare access today.
"There's this whole direct-care revolutionary movement that has been going on for quite some time, and this kind of dovetails with that," she said. "I feel like it's my true north. It's being true to myself, and that's so important."
Her model allows her to prioritize her relationship with patients without interference from payer policies or overburdensome administrative processes.
"The physician patient relationship … it's a very intimate relationship," she said. "And no person or entity should come in between the physician and patient. A physician's loyalty is always to their patient. I think that this relationship has crumbled for so many reasons, the list is so long, but I think that reclaiming physicians autonomy is the foundation for curing the ills of our healthcare system."
She believes that expanding direct-care models is a promising way to empower both physicians and patients, as it centers the patient-physician relationship and transparent pricing for services. While her practice focuses on primary care, she believes this model is applicable for specialties as well.
"This is not a concierge, 'we'll shine your shoes and get you coffee and brush your hair and then charge you 1,000 bucks a month,'" she said. "No, this is usually a very nominal [monthly] fee. But in return, you get access. And that is probably the thing that patients can't stand the most, is they can't get to their doctor because they're booked way out for weeks, months and so then they get someone who's not their doctor."
Her model is also rooted in her own positive experiences as a patient in addition to her career as a physician.
"I see a direct, primary-care physician, and when I need help, she's there for me. There's no screaming at me if I send a MyChart message, because I know that on both sides of it, you can kind of overwhelm your doctor," she said. "But when I go in, I never have to worry about a bill. Nothing gets billed. If we can get rid of insurance, if we can not have insurance be the middle man, then that takes away the poison of this relationship. We can actually breathe and be there for someone in ways they need it. And that is what we need to reclaim."