Connect with Hannah Neprash, Ph.D.
By Kara Hadge Prone | March 24, 2022
Through the lens of her training as an economist, Hannah Neprash, Ph.D., assistant professor at the University of Minnesota School of Public Health, studies the financial and non-financial incentives that influence clinicians’ behavior — and the resulting impact of their decisions on healthcare utilization, access, spending, and quality. Connections spoke with Neprash to unpack some of the macro-level trends that shape day-to-day life in the medical profession. The following conversation has been edited slightly for length and clarity.
What are some of the larger economic trends that are having the greatest impact on physicians’ experiences today?
Neprash: Early in the pandemic, there was a huge drop in visits as people stayed home. Visit volume largely recovered by the end of 2020, but you’re still seeing a lot of pent-up need for care in different parts of the healthcare system. So, clinicians are busy and getting busier, and it looks like a lot of people put off stuff that should be done on a regular basis — potentially folks are showing up [for care] with higher needs.
At the same time, of course, doctors and other clinicians in all settings haven’t really gotten a break and are, by all measures, just at the end of their rope. But folks were saying that a year ago, so it’s really hard to overstate, I think, the way that this has affected the medical profession.
And, of course, there are staffing shortages all over, so employers are really scrambling to retain their clinical workforce and keep people happy in an increasingly competitive, nationwide labor market. There are challenges no matter what your role is within the healthcare system at the moment.
That provides an incentive to employers to do what they can to retain their staff. What are some things that healthcare organizations could be doing to improve their employees’ experiences? What’s within their control?
Neprash: I’m an economist by training, so the first thing I have to say is, pay people more, because that’s the basic law of supply and demand, right? [Laughs.] But medicine is not something people get into to necessarily become billionaires. People get into it because they want to help humanity. And so, there are other ways to improve the quality of life for clinicians — in the broadest of terms, anything employers can do to make sure that clinicians are doing more of what they love and less of what they don’t seem to enjoy, such as the pajama-time EHR documentation that the athenahealth research team has documented. People don’t love doing documentation in their afterhours; they shouldn’t have to.
We’ve also seen an uptick in inbox messages during the pandemic. And that’s another ask on doctors’ time that isn’t the core practice of medicine. It might not be exactly what they love doing. So, anything you can do to align people’s time with their passion seems like a good investment if you’re trying to keep your workforce happy.
Anecdotally, another thing we’ve seen a rise in during the COVID-19 pandemic is the willingness of healthcare organizations to participate in more risk-based contracts. How do you see value-based care models moving healthcare in the right direction?
Neprash: For so long, we were stuck in this world of fee-for-service medicine where everybody was on a hamster wheel. You got paid some small amount for every pinprick, every little thing you did, and that doesn’t add up necessarily into the right care for the right person at the right time. Put broadly, value-based care tries to think about what people need over the course of a year and how to make sure that clinicians are compensated fairly for that. Sometimes the right thing might actually keep somebody out of the office. Doing the right thing for a patient shouldn’t harm a clinician financially.
The payment system for fee-for-service just incentivizes everybody to do more of everything, get people in for more visits, more tests. We know that there’s a lot of waste in healthcare, so value-based care tries to incentivize clinicians to do more of the high-value stuff, and less of the things that don’t contribute to people’s health or well-being.
On this topic of appointment volume, you looked at practice interruptions at the start of the pandemic, specifically when physicians stopped billing Medicare.¹ Can you tell me about some of the trends you saw and why you were interested in studying these patterns?
Neprash: Early on, there were all these stories about what was happening to the medical workforce — clinicians were retiring early or selling their practice because it just wasn’t financially viable; it was this huge shock to the system.
We wanted to see if there was evidence that doctors were leaving medicine in droves. We used Medicare data because almost everybody treats some Medicare patients. So pretty much all doctors who are currently practicing show up in the Medicare data at least a little bit, which meant that we could then quantify if they disappeared. We could look at practice interruptions and then look to see if those interruptions were permanent.
And what we found was that there was this huge spike. In April 2020, a ton of clinicians temporarily stopped practicing medicine — but most of them came back, so that was pretty reassuring. I don’t want to minimize the disruption to clinicians and to the medical workforce in general, but it was reassuring to us to at least see that the number of doctors [didn’t shrink dramatically], especially the number of primary care physicians. People interrupted their practice for a couple of months, but for the most part they came back to practicing medicine. Of course, the big limitation there is it doesn’t tell you anything about how they’re doing. It tells you that they’re still seeing patients, but how is their well-being? How burnt out are they? Do they still enjoy their job? What are their plans for the future? Those are very much open questions, and I think you can only really answer them by talking to people.
We’ve covered some of the pressures that clinicians are facing. Now let’s talk about how that impacts the patient care. You published a paper using athenahealth data a few years back showing that physicians are more likely to prescribe opioids later in the day or when appointments are running late.² What conclusions did you draw from that?
Neprash: I think the connection between time pressure, job dissatisfaction, and quality of care is super important. When I talk to physicians, even doctors who are facing high levels of burnout, their first priority is protecting their patients from their job dissatisfaction. And I really admire that; I think that is truly noble.
With that said, if some of that job dissatisfaction is coming from time pressure — you’re seeing too many patients, you’re constantly running late, you don’t have enough time with anybody — there’s a growing body of evidence showing that that does affect your decision-making in all sorts of ways. Whether it’s prescribing more opioids — or more unnecessary antibiotics is another place that it shows up — as something that’s essentially a “quick fix,” when the alternative might be a long conversation with a patient about physical therapy and how
that might help reduce their chronic pain.
So, I think that there’s definitely a connection, and it’s an opportunity for health systems to improve the experience of their workforce and their patients! This is something health systems can use their data to track. I love seeing efforts to quantify, say, opioid prescribing and visit volume, or more generally, the relationship between visit length and quality of care. I think that that’s really cool and that’s something a lot of places can do with their data.
¹Neprash, Hannah T., Ph.D., and Michael E. Chernew. 2021. “Physician Practice Interruptions in the Treatment of Medicare Patients During the COVID-19 Pandemic.” JAMA 326(13):1325–1328. doi:10.1001/jama.2021.16324
²Neprash, Hannah T., Ph.D. and Michael L. Barnett, M.D., M.S. 2019. “Association of Primary Care Clinic Appointment Time With Opioid Prescribing.” JAMA Network Open 2 (8): e1910373. doi:10.1001/jamanetworkopen.2019.10373.