How much administration is today's physician doing? - doctors involved in management of health care institutions

How Much Administration is Today's Physician Doing?

Recent studies have highlighted the growing importance of boundary-spanning roles for physician executives in balancing professional and managerial issues in health care organizations. One survey of physicians' managerial roles identified a number of basic tasks physician executives routinely perform, including improvement of medical practice within organizations, evaluation of physician performance, dealing with problems or differences among physicians, advising and/or motivating physicians, recruitment of physicians to organizations, improving quality of care, dealing with external medical organizations, and improving professional knowledge and skills.[2] Another study indicated that the key administrative roles played by physicians include setting organizational medical policy, ensuring quality control and peer review, establishing relationships with referring physicians, taking leadership in controlling patient care costs, and ensuring that medical practice is in accord with ethical principles. A more recent survey found that, in addition to traditional tasks of managing physicians and medical activities within organizations, significant time was being spent by physician executives on the issues of general management and governance and that this indicated an important change in their managerial roles.[3]

Most of what is known about physicians in management comes from surveys of individuals who are primarily engaged in this activity. Several of the studies cited above used the membership of the American Academy of Medical Directors (now the American College of Physician Executives) as the basis for their samples. A more recent survey, using the American Medical Association Physician Masterfile, drew upon a larger and more uniform definition of all physicians self-reporting that the majority of the hours they worked were involved with administrative activities. This yielded 13,828 physicians in 1985, three percent of all active practicing physicians in the United States.

The average age of this group was 54.2 years, the average years in administration was 18.6 years, and the average proportion of professional time spent in administrative activities was 64.9 percent. In terms of type of organization, 30 percent reported working for hospitals, 24 percent worked in educational institutions, 23 percent worked for government agencies, and the remaining 22 percent were employed by other health care organizations, such as HMOs, group practices or clinics, for-profit health care organizations, and industry.[4]

Very little is known, however, about the total numbers of physicians who have administrative responsibilities (as either a primary, secondary, or tertiary work activity), how these numbers have changed over time, how many total hours of work are spent in administrative activities by physicians, or how the relative proportion of physicians' professional time that is spent on administrative activities varies of different stages in their careers. Such information could begin to provide some insight into the growing scope of administration as an integral component of medical practice and the impact of administrative activity on the total number of physicians needed. The purpose of this study is to begin exploration of these issues.

Data

All data presented in the following analysis are based on information contained in the American Medical Association (AMA) Physician Masterfile for year-end 1977 and 1986. The Physician Masterfile contains current and historical data on all U.S. physicians and is widely considered to be the most complete and extensive source of physician-related information in the United States. In the Masterfile, major professional activity classifications are based on the number of hours worked per week, as self-reported by physicians on the Physicians' Professional Activities Questionnaire (PPA). PPA surveys are periodically conducted by the AMA, and the results are used to regularly update the Masterfile. According to the information provided in the PPA questionnaire, physicians' professional activities are categorized as primary, secondary, or tertiary in patient care activities (as either office-based practice or full-time hospital staff) and in nonpatient care activities (subcategorized into teaching, administration, research, and "other" activities) according to the rank order of highest number of hours for each activity. Administrative Activities in the PPA are defined to be reported by a "Salaried Staff Member or Executive of an Organization" and specifically exclude time spend on record keeping or office work connected with the management of the individual's medical practice. Some physicians may devote a very small amount of time in activities ranked fourth or fifth; these are not judged to be significant and are not reported in this study.

Data provided by the AMA for this report included aggregated statistics on the number of physicians and the total number of hours spent per week in administration as either a primary, secondary, or tertiary professional activity. In addition, these tabulations were provided by specified age groups: under 45 years of age, 45 to 65, and over 65. Full-time equivalents were calculated using the 1986 estimate of hours worked per week by all physicians from the AMA Socioeconomic Survey.[5]

Results

Table 1, page 4, presents data on the total number of physicians, by age group, who reported working in administrative activities in the years 1977 and 1986. The table is further divided to show the number of physicians whose reported hours determined that their primary professional activity was administration (i.e., the largest proportion of their professional time is spent in administration) and the number of physicians for whom it was a secondary or tertiary activity.

Table : TABLE 1 - Numbers of Physicians and Average Number of Hours Worked Per Week in Administration as a Primary or Secondary/Tertiary Activity by Age Group, 1977 and 1986

                              Numbers of Physicians
Primary Activity          1977        1986      %Change
 Less than 45            2,707       3,020         11.6
 45 to 65                7.702       8,941         16.1
 Over 65                 1,391       2,114         52.0
 Total                  11,800      14,075         19.2

Secondary/Tertiary Activity

 Less than 45           47,579      69,709         46.5
 45 to 65               72,370      85,756         18.5
 Over 65                 9,134      12,922         41.5
 Total                 129.083     168,387         30.4
                              Average Hours per Week
                          1977        1986       %Chabge

Primary Activity

 Less than 45             32.7        32.1          -1.8
 45 to 65                 34.8        34.3          -1.4
 Over 65                  33.3        33.3            .0
 Total                    34.1        33.7          -1.2

Secondary/Tertiary Activity

 Less than 45             5.7          6.8          19.3
 45 to 65                 5.7          6.3          10.5
 Over 65                  6.0          6.3           5.0
 Total                    5.7          6.5          14.0

These data indicate that the total number of physicians with their primary professional activity in administration increased a total of 19.2 percent from 1977 to 1986 (from 11,800 to 14,075 physicians). This rate of growth compares to an increase of 51.4 percent in the supply of all U.S. physicians over the same period.

With regard to physicians working in administration as secondary or tertiary activities, the number increased from 129,083 to 168,387, and increase of 30.4 percent over the ten-year period.

The breakdown of these physicians by age indicates that the largest numbers are in the age group 45 to 65 for both categories of activity. The largest percentage increase in administration as a primary activity was seen in the over 65 age group (52 percent), whereas large percentage increases were seen in both the less than 45 age group (46.5 percent) and the over 65 group (41.5 percent) for secondary/ tertiary-level activity in administration.

Table 1 also presents information on the average number of hours worked per week in administrative activities by primary and secondary/ tertiary activity classifications and by age group. These data indicate that although the total numbers of physicians whose primary activity was administration grew by 19.2 percent overall, the average number of hours worked in administration per week for these physicians was approximately 34 hours in both years (showing a change of -1.2 percent overall from 1977 to 1986). Very little difference in terms of hours spent in administration was found among the various age groups for these physician administrators.

However, the average number of hours worked in administrative capacities per week for those physicians whose secondary or tertiary activity was reported as administration grew substantially from 1977 to 1986, an overall increase of 14.0 percent (from an average of 5.7 to 6.5 hours per week). The largest increase in average number of hours worked in administration was found in the youngest age category, which had an increase of 19.3 percent (from 5.7 to 6.8 hours per week). These data indicate that not only did the numbers of young physicians who work part-time in administration grow significantly (46.5 percent), but the average number of hours worked per week by those physicians increased substantially as well (19.3 percent).

Table 2, page 5, presents estimates of the number of full-time equivalent (FTE) physicians working in administration in both 1977 and 1986. These estimates were developed by multiplying the total numbers of physicians with administrative responsibilities by the number of hours worked per week in administration and then dividing by 56.8 hours, the reported average hours that physicians work each week. [6]

Table : Table 2 - Total Number of Full-Time Equivalent (FTE) Physicians in Administration by Age Group, 1977 and 1986

                               Number of FTEs
                           1977      1986    %Change

Primary Activity

 Les than 45              1,558     1,707        9.6
 45 to 65                 4,719     5,399       14.4
 Over 65                    815     1,239       52.0
 Total                    7,092     8,345       17.7

Secondary/Tertiary Activity

 Less than 45             4,775     8,345       74.8
 45 to 65                 7,262     9,512       31.0
 Over 65                    965     1,433       48.5
 Total                   13,002    19,290       48.4

Total FTEs in

Administration 20,094 27,635 37.5

The data show that the total number of FTE physicians in administration rose from 20,094 in 1977 to 27,635 in 1986, an increase of 37.5 percent. Much of this growth in fulltime equivalency in administration is represented in the extraordinary growth in the number of physicians involved in administrative activities as a secondary or tertiary activity. In total, the number of FTEs in this category increased from 13,002 in 1977 to 19,290 in 1986, a growth rate of 48.4 percent. Almost half of this increase was represented by younger physicians, who exhibited an increase of 74.8 percent in FTEs working as administrators on a part-time basis.

Discussion

The data presented here are the first that report on the growth in hours spent in administration for physician executives for whom it is a primary professional activity, as well as for the larger number of physicians reporting administration as a secondary or tertiary activity. In terms of numbers of physicians, 182,462 out of 459,000 total active physicians (39.8 percent) are engaged in some administrative activity, an increase of 29.5 percent over the past decade. The growth in numbers of physicians was greater for those in the secondary/tertiary activity category, as was the increase in average hours devoted to administration. This resulted in an overall 37.5 percent increase in FTEs devoted to administrative activity, with a 48.4 percent increase in the secondary/tertiary activity category compared to a 17.7 percent increase in the primary activity category. Even though these percentage increases are less than the overall increase in number of total physicians, they reflect the importance of the new specialty of medical management and underscore the increasing administrative roles that physicians are playing in many health care organizations.

With respect to physicians with administration as a primary activity, the data on the growth in the numbers of such physicians over the age of 65 indicate that a shift of professional activities to managerial roles may become an increasingly common career move for older physicians prior to retirement. Such a pattern of career moves for older physicians with regard to administrative functions is also likely reflected in the large increases found in the numbers of older physicians who work in administration as a secondary/tertiary activity.

The large percentage increases in older physicians in administration, however, reflect relatively few physicians or full-time equivalents. Of more interest is the growth in the numbers and full-time equivalents of younger physicians engaged in administration as a secondary/tertiary activity. For physicians less than 45 years of age, 6.8 hours per week may not seem like much time, but it does represent approximately 12 percent of average hours worked and grew almost 20 percent over the ten-year period.

Little is known about the nature of the administrative activity these hours represent, because all role surveys and task analyses have been of physicians who engage in administration as a primary activity.

Some clarification of terms is needed here between administration and management, as well as regarding the term physician executive, manager, or administrator. Dictionary definitions of administration and management do not reveal differences in the terms, but, in practice, administration refers to more routine internal functions whereas management connotes more senior strategic activities with external as well as internal components.

The terms physician or clinical administrator, physician executive, and physician manager are used fairly interchangeably in current practice. Detmer[6] has made the distinction between the physician manager, who is a full-time executive with no clinical responsibilities, and the clinician executive, who spans the boundary between full-time administrators and full-time clinicians. We prefer the term physician executive here because the term clinician is often used to include other clinical executives, such as nurses and dentists. We intend it to refer to the role described by Detmer but do not necessarily exclude individuals who are no longer engaged in clinical practice, because many full-time executives still make active use of their clinical knowledge.

We would conceptually exclude from the definition managers who possess the MD degree but whose administrative responsibilities do not involve clinical expertise at all, as well as physicians in practice with minor administrative functions, such as committee work or other activities requiring only a small amount of time. We believe the requirements for Fellowship in the American College of Physician Executives (boards in a clinical specialty, substantial clinical practice experience, increasing managerial responsibility, and demonstrated managerial knowledge) reflect the spirit and concept of the term physician executive well.

For physicians in the primary category, therefore, the term management and the title physician executive seem to fit the emerging boundary-spanning roles of major importance to their organization. For the others, are the functions being performed routine administrative tasks or are they similar managerial tasks carried out less frequently? The PPA Questionnaire asks that tasks associated with practice management be excluded. This would render less likely the possible explanation of increases in paperwork and regulatory requirements for the increases in reported secondary/tertiary administrative activity. In addition, the fact that only 39.8 percent of physicians are represented here and that the average hours per week have increased more for younger physicians suggests that activities other than routine paperwork are reflected in these reported hours.

With regard to the impact of physicians in administration on overall physician requirements, one recent analysis projected a growth in the number of physicians in administration from 13,828 in 1983 to 24,000 in 2000.[7] This figure apparently reflected physicians in the primary activity category and was based on the 3.3 percent annual growth rate seen between 1979 and 1983. These physicians were subtracted from the total expected supply for the year 2000 (along with other categories of nonpatient care physicians) to arrive at a total supply of patient care physicians at that time. This period showed an unusually high growth rate for physicians in administration; similar AMA data reveal a 9.4 percent increase from 1975 to 1980, 13.1 percent from 1980 to 1985, and 4.1 percent from 1983 to 1986. Data from this study may be useful in considering these projections, because we observed a significantly lower growth rate of 1.9 percent per year over a longer period. The use of average hours worked and number of FTEs in administration allows for more detailed examination of total physician effort devoted to administration and suggests that growth will be greater in the secondary and tertiary category if trends over the past decade continue.

Future research is clearly indicated, particularly in understanding the nature of the administrative/ managerial activity by physicians engaging in it as a secondary or tertiary work activity, with special attention paid to the activities of younger physicians. We believe these results underscore the growing importance of medical management as an important component of modern health care delivery. It will be important to test our belief that physicians in these expanded managerial roles will assist their organizations in providing health care that is efficient outcome-oriented, and of high quality.[8]

REFERENCES

[1.] Hillman, A., and others, "Managing the

Medical-Industrial Complex." New

England Journal of Medicine, 315(8):511-3,

Aug. 21, 1986.

[2.] Slater, C. "The Physician Manager's

Role: Results of a Survey." In: The

Physician in Management, Schenke, R.

(ed.). Tampa, Fla.: American College of

Physician Executives, 1980, pp. 57-69.

[3.] Kindig, D., and Lastiri-Quiros, S. "The

Changing Managerial Role of Physician

Executives." Journal of Health Administration

Education, 7(1):33-46, Winter

1989.

[4.] Kindig, D., and Lastiri-Quiros,

S. "Administrative Medicine: A New

Specialty?" Health Affairs, 5(4):146-56,

Winter 1986.

[5.] Center for Health Policy Research.

Socioeconomic Characteristics of Medical

Practice. Chicago, Ill: American Medical

Association, 1986.

[6.] Detmer, D. "The Physician as Corporate

Practitioner and Corporate Leader." Duke

University National Forum on Hospital

and Health Affairs, 1984.

[7.] Schwartz, W., and others. "Why There

Will Be Little or No Physician Surplus

Between Now and the Year 2000." New

England Journal of Medicine 318(14):892-7,

April 7, 1988.

[8.] Kindig, D. "The Role of Administrative

Medicine." Hospital and Health Services

Administration, 34(1):1-3, Spring 1989.

David A. Kindig, MD, PhD, is Professor and Director, Programs in Health Management, University of Wisconsin Medical School, Madison, Nancy Cross Dunham, MS, is Project Director, Department of Geriatrics, St. Mary's Hospital Medical Center, Madison. The authors wish to thank Ms. Gene Roeback of the American Medical Association's Department of Data Release for special assistance with the hours-worked file; without her cooperation and support this study would not have been possible.

COPYRIGHT 1991 American College of Physician Executives
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