One of the uncomfortable truths of medicine is that we compete against one another. We have a shared history, having gone through the crucible of training together—in some cases even in the same program, at the same time. Many of us are friends. Some of the things that attracted me to our specialty and that I continue to be enamored by are the intellect and kindness of our members.
Explore This IssueJuly 2022
But we must also grapple with the fact that as high-minded, compassionate, and friendly as we are, we still compete with one another. And our organizations’ growth aspirations and our shared marketplace’s competitive dynamics have real implications for the complexion of our workforce.
Transparent outcome data, with appropriate controls, that patients care about should replace the current quality mandates put out by CMS. These transparency changes allow for more efficient allocation of capital—patients will choose to go where they perceive the value is, and workforce changes will follow. —Andrew J. Tompkins, MD, MBA
One of the most basic structural elements of our workforce is our practice environment (hospital, private practice, academic center, etc.). Where job seekers go will largely depend on work availability in these environments, which, of course, will vary geographically and over time. Even group size is changing over time, with unique otolaryngology practices on the decline and a trend toward larger practice size (Otolaryngol Head Neck Surg. 2022;6:1–6). Whether from competitive dynamics, practice expenses, or real-term decline in physician fee schedule payments, job creation through solo practice is waning. Therefore, job opportunities are increasingly set through the labor demand in these larger practice environments, which are based on things like referral volume, subspecialty need, and advanced practice provider (APP) integration. Of these items, referral volume is paramount for creating job opportunities. The upshot is that if referrals aren’t growing in a given practice environment, the preferences of a job seeker matter little—they have to take what’s available.
Medical Market Details
Before exploring competition for patient visits, we should take a step back and examine what competition looks like in a normal workplace market. In a normal market, competition occurs based on consumer value. Firms jockey to provide different products to different market segments at different costs. Better quality and/or lower cost usually wins, and the consumer wins. Transparency of quality and cost is vital to optimizing consumer value.
Unfortunately, we don’t operate in such a market. We operate based on referral control with hidden quality and cost. Worse yet, we have disparate payments for the same service based on service location, with asymmetric inflation figures applied annually by our government. In 2020, for example, Medicare paid the average hospital 2.3 times more money for a level 3 follow-up visit than they did an average private practice (American Medical Association Current Procedural Terminology code 99213, HCP Code Set G0463, CMS.gov 2020 payment files). Keep in mind, patients also pay that higher cost sharing for arguably the same service, and they have no idea how much they’re paying in advance. Normal markets don’t operate like this.