Tuesday, May 26, 2009

Are physicians truly on board with health care reform?

The Portland (Oregon) Register-Guard reports that physicians "are as eager as their patients" to reform health care, with surveys revealing "that overwhelming numbers of physicians resent the current crazy patchwork health care system, which fixes their reimbursements, regulates and too often denies patient care, and piles physicians with paperwork so unending and from so many directions that the average doctor has little time left over to challenge the status quo." The authors write, approvingly, that the American College of Physicians is "the medical organization perhaps most vocal in support of universal health care coverage."

Most of the physicians I know are hugely dissatisfied with status quo. ACP has channeled such frustrations into a powerful call for a better health care system that provides all Americans with access to affordable coverage and to a primary care physician.

Still, I wonder if physicians will be on board with health care reform when Congress begins producing the details of legislation. My sense is that most physicians urgently want health care reform and believe strongly that all Americans should have affordable health coverage. But they worry that instead of improving "the current crazy patchwork health system, which fixes their reimbursements, regulates and too often denies patient care," health care reform will be more of the same, or worse.

Physicians' hearts and minds are still very much in play, and it would be a huge mistake for President Obama and Congress to take them for granted. Democratic and Republican pollsters alike tell us that physicians' views on health care reform could be decisive in determining if the public will be behind the effort, because voters are much less likely to support health care reform if told that it will result in the "government" taking decisions away from their own doctors.

There are two specific questions that I think could make or break health care reform with physicians:

1. Will health reform pay them fairly for their services? No, physicians don't care only care about money, but they do expect to be paid a fair rate. They will be much less likely to support health care reform if it fails to put an end to the annual cycle of Medicare payment cuts caused by the Sustainable Growth Rate (SGR) formula. Primary care physicians may turn away from health care reform if it offers only a token increase in payments, instead of re-structuring payments to make primary care a competitive career option. Other specialists may balk if increased pay for primary care comes solely out of their pockets. Physicians of all stripes are less likely to support a bill that includes a "public plan" option if the public plan would pay them based on these same flawed Medicare payment rates, and drive other payers to do the same.

2. Will health care reform reduce the administrative burdens and paperwork requirements that drive physicians mad? Physicians will wildly embrace health care reform that streamlines billings and reduces the hassles associated with health plan interactions and second-guessing of clinical decisions. But health care reform that adds more pre-authorization requirements, second-guessing and paperwork, all in the name of controlling costs, will drive doctors away in droves.

If President Obama and Congress want the support of physicians, they will produce health care reform that pays physicians fairly for their services, restructures payments to support primary care doctors, reduces hassles and second-guessing, and yes, provides all Americans with access to affordable health coverage. I think they will also be more likely to have the support of the general public, which pollsters say will be taking their cues from doctors as they make up their own minds.

Today's question: What could make doctors turn for or against health care reform?


Brad F said...

The key element you overlooked is whether patient's care what their doctors think, when their health care costs are growing at obscene rates, are unemployed to the tune of 10%, are having their coverage dropped, and the spinmeisters go to work.

I think not.

Jay Larson MD said...

If the status quo is not changed significantly with health care reform, it will be the demise of primary care. In the past 6 months 8 primary care physicians have left the Helena community, which is about 1/3 of the primary care work force. This is the status quo at work. Patients are not served well if they get insurance but have nowhere to go for their care other than Urgent care clinics and ER’s. All ready in Helena the ER is getting overwhelmed with patients with chronic illness and no primary care physician. For health care reform to be successful, patients have to benefit. Isn’t that what health care all about? It is not a benefit to patients if their doctor is strangled to death by the system.

So far the best hope for primary care docs is HR 2350, which deals with student loans, reimbursement and paper work. Right now the only thing on the table is a 5% increase in Medicare reimbursement. That is like fixing a crumbling concrete foundation with Elmer’s glue.

Robert J. Sobel, M.D. said...

It is reassuring to hear that there is an attempt to hear our voices. The don'ts that you outline are indeed key. The forces of creating another bureaucracy to administer information technology or quality initiatives must be countered, or we really are doomed regarding independent private practice.

Regarding the do's, we must get some real help on the cost issues. We shoot ourselves in the feet when we try to get things right but create a medical regimen whose costs dwarf those of our services. For ancillaries integral to primary care (labs, etc.), we should have Medicare reassess their payment more favorably, as a margin to the physicians is budget neutral (if current payments shift directly to the physicians from the referral labs).

The true cost drivers that can be much more favorably attacked are drug costs and the derivative managed care fiasco. The latter can be simply outlawed (publicly-traded for profit insurance, pharmacy benefit interference in medical practice, disease management harassment [harsh but true] of our patients, our staff, and ourselves). Regarding drugs, we need a careful re-working where a simplified, brand only landscape emerges that functions under a regulated royalty financing system. New and old could co-exist, without the global budget being bubbled via new drug and technology costs and the administrative apparatus that has failed to grow them.

As long as our behavior is the focus of misguided reforms, physicians will see what this means and opt out. Patients are already being financially coerced to the extreme and, when appropriately informed, they will not support the development of more such failed policies either.

Unknown said...

Another element that is not being addressed in all this is the cost of medical education which is on the verge of topping $200,000 to become a licensed physician. Medical school tuition cost is increasing at an alarming rate each year with no end in sight. If health care reform can't pass without adequately addressing physician pay...it cannot pass without adequately addressing educational costs. It is a HUGE consideration when some medical students begin to choose a specialty and why some student opt away from primary care. NO, it's not all about the money. The general public, politicians and those driving the reform cannot point the finger and say physicians are not being altruistic when policies so severely restrict a physician's ability to pay off a tremendous debt. Altruism is a nobel thing when the cost of such sentimentality is managable. However, it approaches lunacy when a physician must run the risk of bankruptcy and watch his own love ones suffer as he takes care of others because he cannot afford to provide for his own family. And if politicians say that they're talking all this into account as well, they're not being entirely truthful. Recent legistlation was inacted that removed a resident's ability to defer federal education loans while in Residency, leaving only forebearance as an option. What this means is a Resident's student loans are still accruing interest while in residency. This may not be a big deal if the loans are relatively small. But, if the loans are $150,000-$200,000 carried over a 3-year period (the shortest residency available)...the increase to debt-load increases to increadible amounts. Yet, that is what politicians felt was acceptable. This in conjunction with recent cuts in Medicare reimbursement leads one to ask, "Are those pushing reform in Washington D.C. really looking at the big picture? Are they going to pass legislation that makes sense?" In my eyes, the answer is "No."