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We sit down with Ben Kornitzer, a physician executive, to delve into the pressing issue of physician burnout in health care. Discover how burnout impacts patient care and contributes to a growing physician shortage, especially in primary care. Ben shares valuable insights on the drivers of burnout, the promise of value-based care as a solution, and success stories from physician groups embracing this approach.

Ben Kornitzer is a physician executive.

He discusses the KevinMD article, “Physician burnout is a threat, no different from the spread of a virus—here’s how to fix it.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Ben Kornitzer. He’s a physician executive. Today’s KevinMD article is titled “Physician burnout is a threat, no different from the spread of a virus: Here’s how to fix it.” Ben, welcome to the show.

Ben Kornitzer: Thank you for having me, Kevin.

Kevin Pho: We’ll talk about your article in a little bit. Just briefly share your story and journey before we start.

Ben Kornitzer: Sure. I’m a primary care physician, and my own practice is really focused on the care of homebound older adults. When I was seeing patients back in New York City, I had a backpack and I was going door to door, into the projects of Harlem and the apartments on Fifth Avenue and Park Avenue, seeing homebound older adults, and I felt that that’s really my calling. About four years ago I was introduced to a company called agilon health that focuses exclusively on older adults around the country, and I said, wow, there’s got to be a better way to deliver care across the country to all these seniors who are really lonely and vulnerable. So it’s been a great journey over four years. We’ve gone through a pandemic, and we’re learning a tremendous amount about value-based care. As we’ll talk about today, there are significant implications for how seniors are getting care, but also for how physicians are practicing and how they’re feeling increasing burnout.

Kevin Pho: All right, so let’s jump right into that, because how seniors are receiving care and physician burnout are pretty prevalent topics that pretty much all primary care physicians face today, and I’m a primary care physician myself. Your KevinMD article is titled “Physician burnout is a threat, no different from the spread of a virus: Here’s how to fix it.” How did your article come together?

Ben Kornitzer: Yeah, really coming out of COVID. This was just a major trauma to the entire health care system. Physicians were working 80-plus hours a week under really challenging circumstances. Financially, there was a point, and I’ve talked to many of our physician partners about this, where they didn’t know if they could make it. They didn’t know if they could literally make payroll, because there was a period when patients weren’t coming in. So it really was a reflection point in health care, where people had to decide what they wanted to do and how they were going to provide care going forward.

Coming out of the pandemic, we saw 30,000 adult primary care physicians leave the practice of medicine. That’s never happened before, and we don’t have a pipeline that can replace those physicians. At the same time, we know that we have an aging population. The senior population in this country is going to go up by about 50 percent between 2020 and 2040. So these are older patients, they’re more complex, and there is not going to be a workforce to take care of those patients unless we do something radically different. We also know that burned-out physicians don’t provide the same level of care. They don’t do as well in terms of listening to their patients, and they don’t do as good a job coordinating care. So maybe it was a bit hyperbolic, but the point is that if we’re going to deliver care to our country, we should be just as concerned about the impact of physician burnout as we are about any major pandemic.

That being said, I’m an optimist. I think the burnout story is concerning to all of us. I don’t think I know a single physician who hasn’t experienced some level of burnout; it just goes with our training, from residency on. But I’m optimistic. I actually think there’s light at the end of the tunnel, and I hope that’s the message people take away.

Kevin Pho: So you mentioned that with burnt-out physicians, the care they give patients isn’t as good. What’s some of the data? Are there studies that really quantify that?

Ben Kornitzer: Yeah, there are a number of studies that look at things like physicians’ ability to have empathy, which really decreases significantly as they get more burnt out. We also see it in how they’re interacting with their patients, in terms of listening to them versus spending time looking at the EMR. And I think any one of us who has worked with colleagues has seen that after a certain point, physicians who are burnt out just lack that ability to communicate with and care for patients in the same way.

Kevin Pho: So you mentioned that the way physicians are reimbursed, value-based care versus fee-for-service, also plays a role as a driver of burnout. So talk more about that.

Ben Kornitzer: Yeah, my perspective is that physicians went into medicine because we love what we do. There’s a sense that we really want to have an impact on our patients and do something good by them. And I think that there’s a certain moral hazard, or moral injury, that comes from practicing medicine in today’s fee-for-service environment. We’ve all been lucky to train in what I consider the best health care system in the world, but take a look at our outcome statistics. Our infant mortality is the same as Cuba’s. We’re not anywhere in line with other First World countries, either in Scandinavia or Western Europe. I think all of us have seen discoordinated care, patients who are bouncing back and forth to the emergency room, patients who can’t afford their medications. All of that is really part of the failures of our fee-for-service system.

So in addition to working hard, because I think it’s not necessarily the hours that physicians put in, it’s the feeling that those hours aren’t resulting in the type of impact, the better outcomes, that patients really want. What I want, at least as a physician, is to know that my patients with diabetes are being well controlled, so they don’t get retinopathy, they don’t get nephropathy, they don’t crash into dialysis, and certainly they don’t get lower limb ischemia and amputations. If we don’t have the ability to create a health care system that can get really, really good outcomes, it’s tremendously demoralizing to physicians.

What I’ve seen, at least with the physicians I work with, is that if they can get better outcomes for their patients, if they can spend more time with their sickest patients, with less of that hamster wheel mentality where it’s all about churn, we’ve found that’s really invigorating for physicians. It energizes them, it inspires them. Even thinking back to the darkest days of COVID, when physicians were putting in 80- to 100-hour weeks, physicians were energized. They felt motivated, they were rallying around something, and it galvanized the care community, because they really rose to the challenge. So again, I don’t think it’s the amount of heavy lifting that physicians and other care team members do. I think it’s the sense that a lot of that heavy lifting really isn’t lined up with better outcomes for patients. And that’s where I think there’s a significant opportunity for us to question what we’re doing now and hopefully do something differently.

Kevin Pho: Now, for those who aren’t familiar with how physicians are paid in the outpatient setting, give us a 30-second primer on what fee-for-service is and how it can potentially lead to worse outcomes.

Ben Kornitzer: Yeah, so fee-for-service is literally being paid for each unit of activity that you do. A patient comes in, you drop a billing code, you do an X-ray or a test or a lab, and each of those has a code. Just like an auto mechanic is paid for each thing they do, physicians in a fee-for-service model are paid for each thing they do, and so what it really incentivizes is volume, right? The more you do, the more you get paid. In value-based care, which is what I and my colleagues at agilon health and our partners across the country really focus on, you are incentivized to have better outcomes for your patients. If those patients do better because they’re not having strokes, they’re not having heart attacks, they’re not crashing into dialysis, if you’re doing a better job keeping them well, that’s actually where you get compensated. And I think the moral and emotional connection that physicians have through really deep relationships with their patients all stems from being able to practice in a model that incentivizes them to do the right thing. We know that returns the joy to the practice of medicine. No one went into medicine because they really wanted to spend their days staring at an EMR, dropping billing codes.

Kevin Pho: Now give us a sense of the percentage of older adults, say adults over the age of 65, who have insurance that pays on a fee-for-service system versus those who are paid for under a value-based system.

Ben Kornitzer: Yeah, so nationally, first of all, almost all seniors in the U.S. are covered by Medicare. Approximately half of those patients are in a Medicare Advantage plan, which is a private insurance plan that often gives the opportunity for more value-oriented care, and the other half are in traditional Medicare. At agilon health, where I work, we participate in that MA opportunity to really focus on value, but also in traditional Medicare, where there are some innovative pilots, innovative programs that the government sponsors, where essentially the physicians who work with us, and with others across the country, can be responsible for the full cost and quality of care for their population.

Kevin Pho: So give us a sense, from a primary care standpoint, of what a day in the life would look like if everyone were under some type of value-based system. Walk us through a typical day. What exactly would that look like?

Ben Kornitzer: Yes. Let me start with what a typical day is in a fee-for-service practice. In a fee-for-service practice, if you want to keep the lights on, you’re seeing 25 to 30 patients a day. You’re seeing a lot of commercial patients, many of whom are actually quite well, because commercial insurance pays more, and you have to pay your rent, your utilities and your office staff. You’re on this hamster wheel, you may not be able to keep the lights in your office on, and you certainly don’t have a lot of resources.

In a value-based care world, maybe you’re not seeing 25 or 30 patients; maybe you’re seeing 15 to 25 patients a day, and you’re spending more time with the patients who are sicker. You’re surrounded by resources like pharmacists, social workers and care managers. You have access to all sorts of technology that tells you what the patient sitting in front of you right at this moment needs. Should they be put on guideline-directed therapy for CHF? Is this someone who may benefit from palliative care, or early intervention for renal care? And then you literally have care pathways and team members who can assist you with all that, so you’re really working in a team environment.

It’s also the fact that you’re not just spending your day thinking about the patient in front of you that you’re billing for. You’re responsible for an entire population of patients. So you usually start your day by asking, who am I worried about? Not just the 20 or the 15 patients on my schedule, but who’s the patient who doesn’t have money for the bus ticket to come in and see me, or who’s the patient who was just discharged from the hospital, whom I need to do a home visit for? So you have the ability to begin to think very differently about what it means to be a physician, and I think that time, and that opportunity to deepen your relationships and really see better outcomes for your patients, makes a huge difference.

Kevin Pho: Now, from a physician standpoint, how do we get to that scenario? Because in my clinic we have a hodgepodge of all these different insurers. I have fee-for-service Medicare, I have Medicare Advantage, I have private insurers, they each have different rules, and it seems like we’re a few steps away from what you’re describing. Tell us about some of the obstacles we have to overcome to achieve that vision.

Ben Kornitzer: Yeah, so I think that physicians have historically been relatively passive in terms of developing larger national health care systems. If you’re an employed physician, you often have a list of patients that you have to see. So I think the opportunity is to really lean in, whether you’re part of an independent physician group or an employed physician group, or you work for a health system, and have your voice heard: We don’t want to be compensated based on volume, right? RVUs are the traditional way that physicians have been paid. We often call them not relative value units but reverse value units.

And I think the thing that physicians should decide is where they want to work, right? There are organizations that are fully based on value-based care models. We have 35 partners around the country, often the leading primary care groups in their areas, and each of those groups has committed to 100 percent value-based care for all of their seniors. We’re not alone; there are many other groups in the country that share that vision. So as physicians think, what do I want to do with my time, who do I want to work with, they should run to places that really care about value. That should be a yardstick they use to evaluate what they’re doing. I think people should find out what they’re passionate about, and if there are things that you love to do with your patients, that’s really what should be guiding you.

And I think the last thing is, no matter what type of model you’re currently practicing in, always have the patient be your North Star. If you think through, in this moment, with this patient right across from me, what can I do to help them have a better outcome, that’s what value-based care is. And I think if we can get to that place, seniors will do better, but it will also return that joy to the practice of medicine, and I think that is probably the best tonic, the best salve, we have for the burnout pandemic that we’re all suffering.

Kevin Pho: Now give us a sense of the penetration of value-based or complete value-based systems. You’re in Massachusetts, I’m in New Hampshire, so let’s say in the Northeast market, how common is it to have a complete value-based care system?

Ben Kornitzer: I think outside of early markets like California, the penetration of value-based care is actually pretty light. I think the majority of our country is still stuck in that legacy fee-for-service model. And I would anticipate that over the next five to 10 years, we’re at the point where things transition. Patients are aging, so folks who had panels made up mostly of commercial patients will see that flip over the next decade, and you’re probably going to have more seniors than patients under the age of 65. So the economics are changing dramatically. The reimbursement levels that people are seeing for commercial patients are decreasing significantly. But also our knowledge of what value-based care looks like, and our ability to leverage AI and other technology to identify the really sick patients, I think that’s going to be transformative as well.

There’s this great picture that a colleague showed me of the last helicopter leaving after a war, and you see people just hanging in midair. You don’t want to be left behind. This is where the world is going. So I would suggest that folks who are really passionate about health care, and better care for patients, find homes that really focus on value.

Kevin Pho: Now, I know that the federal government, through the Affordable Care Act, has some pilot projects regarding Medicare to include more value-based elements. Is that enough? Are they doing enough?

Ben Kornitzer: I think they’re doing a great job. I think there is unanimous bipartisan support for value. I think the road to get there, and to transition us from a fee-for-service to a value-based model, is challenging. But having interacted closely with leadership at CMS, they believe in this deeply, they believe in it passionately, and they have been great partners in figuring this out. I can tell you that for our own population, we have almost 100,000 patients with traditional Medicare in a full-risk model called ACO REACH, and they just reported the results from that: nearly 10 percent savings for our senior patients. That means fewer hospital visits, fewer emergency room visits and fewer unnecessary procedures or tests, really better outcomes for patients. That’s a huge improvement in care, and all of it really came about because of the partnership with CMS.

Kevin Pho: We’re talking to Ben Kornitzer. He’s a physician executive. Today’s KevinMD article is titled “Physician burnout is a threat, no different from the spread of a virus: Here’s how to fix it.” Ben, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Ben Kornitzer: Yeah, I think the take-home messages are, one, that the North Star should always be the patient. If you really care about where health care is going, always ask yourself the question: What is the best outcome this patient can have, and what can I do? There are procedures that we see that don’t offer benefit to patients, so if you’re doing those procedures, ask yourself what you should be doing instead to keep patients with heart failure out of the hospital, and what you should be doing to make sure that diabetic patients don’t develop ischemia.

The next thing I would really advocate that people focus on is how they’re spending their time. There is nothing more valuable than the deep relationship between a physician and their patient. The physicians in our model spend the most time with their sickest patients. They really emphasize listening to patients and working in a team. So to the extent that physicians can reinvest that time, and reinvest in working in a team environment with pharmacists, social workers and advanced practitioners, I think it will bring a lot of joy back to the practice of medicine, and it will go a long way toward providing the care we’re going to need as our population ages and we see more complexity.

Kevin Pho: Ben, thank you so much for sharing your time and insight, and thanks for coming on the show.

Ben Kornitzer: Great, thank you.