New Internists Are Choosing Hospitals Over Outpatient Settings

Newly certified internists commonly choose to practice medicine in hospitals rather than outpatient settings, suggesting that the outpatient primary care physician shortage will escalate, according to a study published in the Annals of Internal Medicine.

Researchers from the American Board of Internal Medicine (ABIM), Beth Israel Deaconess Medical Center, and Harvard Medical School identified nearly 70,000 general internists certified between 1990 and 2017 using ABIM’s board certification database. They also used Medicare fee-for-service claims data through 2018.

Between 2008 and 2018, the percentage of internists who worked as hospitalists increased from 25 to 40 percent. The share of internists who practiced only in outpatient settings rose during this time as well, going from 23 percent to 38 percent.

These increases contributed to a significant decline in mixed practice physicians that see patients in both hospital and outpatient settings, falling from 52 percent to 23 percent between 2008 and 2018.

By 2018, 71 percent of newly certified general internists practiced in a hospital setting, while 8 percent practiced as outpatient-only physicians. Meanwhile, 95 percent of more experienced internists practiced in outpatient-only settings and never in hospitals.

The study results suggest that these career choices remained steady throughout the years. In 2013, 86 percent of hospitalists had been in the same type of practice five years later. Retention rates were similar for outpatient-only physicians.

Additionally, 86 percent of internists certified in 1999 remained in the same practice five years later, as did 85 percent of internists certified in 2012. The retention rate fell to 57 percent for mixed practice physicians.

“We are concerned that this trend is not sustainable and that outpatient primary care physician shortages will accelerate as outpatient-only physicians begin to retire with few additional mixed practice physicians who have been bolstering the outpatient capacity over the past decade to replace them,” Bradley Gray, PhD, senior health services researcher at ABIM, said in a press release emailed to RevCycleIntelligence.

A dwindling primary care provider shortage, fueled by career choices and retirement, means patients may face barriers to accessing primary care services.

“The physician-created boundaries between hospital and outpatient care creates urgent problems for health systems and private practices to ensure seamless patient care between settings,” Bruce Landon MBA, MSc, professor of health care policy at Harvard Medical School and professor of medicine and practicing internist at Beth Israel Deaconess Medical Center, stated in the press release.

While new internists commonly choose hospitals over outpatient practices, hospitals are also frequently acquiring physician practices.

Between January 2019 and January 2022, hospitals acquired 4,800 physician practices, increasing the number of hospital-owned practices by 9 percent, a report from Avalere found.

A study from Health Services Research also found that physician reimbursement was significantly higher for physicians working for a hospital compared to what independent physicians received for the same services.

The COVID-19 pandemic has exacerbated workforce shortages in every healthcare setting. The Association of American Medical Colleges (AAMC) predicted that primary care will see a shortage of 17,800 to 48,000 physicians by 2034.

This will likely worsen as older primary care physicians retire and few young internists choose to practice in outpatient settings.