February 04, 2016
4 min read

Regulatory burdens contribute to physician occupational burnout

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The vast majority of ophthalmologists opt in as a provider for Medicare because so many of our patients are older than 65 years. Less so for Medicaid, depending on the state. In Medicare, doctors have several choices. They can be a participating provider in Medicare, a nonparticipating provider in Medicare, opt out of Medicare or, according to Jeffrey Liegner, MD, but controversial and rare, if in a small practice with fewer than 10 employees, consider becoming a non-covered entity. In my experience, most ophthalmologists are quite altruistic and dedicated to the best interest of the patients in their practice and community. Patients older than the age of 65 have 10 times the eye pathology of those younger than 65, and almost all of them are enrolled in Medicare, including the wealthy. Thus, if an ophthalmologist wants to be available to a broad array of patients in the community, participation in Medicare is mandatory.

Most of us want to provide quality care to friends and neighbors regardless of income. Many, if not most, patients could not afford us if we opted out of Medicare and switched to a cash-pay-only model. Select physicians, especially those who focus on cash-pay elective procedures such as refractive corneal surgery, refractive cataract surgery, cosmetic plastic surgery and the like, can definitely make a good living and simplify their lives by opting out of Medicare and for sure Medicaid. However, while we all must consider the economics of practice, most of us also want to be available to even the poorest members of our community, often providing care for many without insurance at no cost. This is the culture in our practice, Minnesota Eye Consultants, and while some of us could opt out and do fine financially, all of our doctors participate in Medicare and our state’s version of Medicaid/MinnesotaCare.

One might then ask, why would any dedicated altruistic ophthalmologist consider opting out of Medicare, thereby reducing the ability of many patients to gain access to their care? In my opinion, good physicians are being driven out of Medicare, and in many cases out of practicing medicine altogether, by an over-reaching and punitive regulatory environment. While most of us can quickly name the three branches of the federal government created by our constitution — executive, legislative and judicial — there is a fourth branch of federal government created by Congress with enormous power that significantly impacts our practices, our patients and our quality of life. This fourth branch is the vast array of federal regulatory agencies, including the powerful CMS and FDA. Our Congress has delegated enormous decision-making authority to these agencies, and some of their decisions are, in my opinion, a significant factor in physician occupational burnout, which in turn is the major factor driving doctors to consider opting out of Medicare or even the practice of medicine itself.

Examples of the regulatory blitz being faced by today’s physician include an amazing alphabetic array beyond the comprehension of even the best informed doctor. They include the Resource-Based Relative Value System (RBRVS), the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM), Meaningful Use (MU) and electronic health record (EHR) regulations. HIPAA is now followed by the more recent Medicare Access and CHIP Reauthorization Act of 2015, which apparently will merge PQRS, VBM, MU and EHR with variable weighting into something called the Medicare Incentive Payment System (MIPS) that will somehow be used to punish and occasionally reward physicians for achieving the so-called triple aim of the Affordable Care Act (ACA): quality outcomes, happy patients and reduced cost. However, when one dissects these regulations, they appear to primarily reward only one of the three aims: reduced cost.


We have the option of joining one or more accountable care organizations and accepting an alternative pay model. We are told the fee-for-service model of reimbursement, which we have all practiced under for centuries, will be a historic footnote in the next decade. All of this is somehow overseen by an all-powerful, and hopefully to patients benevolent, but most likely to doctors malevolent, Independent Payment Advisory Board, which is, as named, totally independent of any accountability to or oversight by anyone.

In the face of all these external challenges, we are seeing physician occupational burnout. Many ophthalmologists say they enjoy their practice, yet a lot report they suffer from some level of physician occupational burnout. In addition, this dangerous malady is more frequent in younger and female physicians, who represent the doctor of the future.

Research shows that occupational burnout is caused by perceived loss of control and autonomy, excessive workload, reduced monetary and subjective rewards, separation from community, a perception of reduced fairness in the rules governing one’s work environment and a decreasing sense of value. The physician with occupational burnout feels helpless, hopeless and inadequate. We practicing ophthalmologists are at high risk for this syndrome. The resultant outcome is a physician who is tired, lacks enthusiasm, is frustrated, angry and even cynical, loses confidence, feels ineffective, may become clinically depressed or chemically dependent, and is less efficient and reliable in his or her patient care.

In the face of these symptoms, some carry on, some opt out of Medicare, some opt out of the practice of medicine altogether, and tragically some become depressed and commit suicide. The physician with occupational burnout is not the physician I want caring for me or my family. It is also not the physician I want to be myself. Unfortunately, many ophthalmologists are already suffering from physician occupational burnout, and every year the number increases. The triple aim will never be achieved with a disillusioned, depressed and dysfunctional physician providing the care. It is time for Congress and our regulatory agencies to carefully consider the impact the ever more challenging regulatory environment is having on the health, performance and commitment of us physicians in the trenches who will be needed to provide the care our patients need and deserve.