JONATHAN COHN JANUARY 19, 2012
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[Guest post by Harold Pollack and Vivek Murthy]
Forbes has published another slam against health reform. This one is written by Sally Pipes, president, CEO, and Taube Fellow in Health Care Studies at the Pacific Research Institute. She is the author of a forthcoming book, The Pipes Plan: The Top Ten Ways to Dismantle and Replace Obamacare, put out by the conservative publishing juggernaut, Regnery. This follows Pipes’ previous volume, The Truth About Obamacare. We haven’t read this one; we presume the truth isn’t good.
Pipes fires standard broadsides against health reform, including the already-rebutted claim that because of the Affordable Care Act, “American families in the non-group market will see their premiums rise $2,100.” She also presents a more novel, in some ways more disturbing argument, when she claims that that America’s doctors oppose health reform:
Few people know more about our healthcare system than doctors working on the frontlines. Policymakers should pay heed to their indictment of Obamacare and revisit the disastrous law.
Pipes’ is probably right to say that “if physicians aren’t on board with Obamacare, it won’t work.” The rest of her argument is wrong.
To prove her point, Pipes cites a survey by the Deloitte Center for Health Solutions. This survey highlights physicians’ anxieties regarding both health reform and the broader trends within the health care system. It provides some intriguing results. Although Pipes implies otherwise, respondents actually split down the middle in their reactions to the new law. Forty-four percent believe that the Act is “a good start.” Forty-four percent believe that “it is a step in the wrong direction.” These responses strikingly differed across generational lines. Fifty-nine percent of physician-respondents between the ages of 50 and 59 believe that the Act is “a step in the wrong direction.” Only 36 percent of their counterparts between the ages of 25 and 39 gave the same response.
It’s hard to know what to make of these findings. According to Deloitte’s supporting materials, of the 16,537 physicians the firm contacted, 501 completed the survey. That’s a response rate of barely 3 percent. It’s not clear whom this tiny sample really represents.
A better way to gauge these issues is to examine how physicians and the organizations which represent them actually behaved during last year’s health reform. One wouldn’t know from Pipes’ article that the American Medical Association, the American College of Physicians, the American Academy of Family Physicians, the American College of Surgeons, the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American Osteopathic Association, the American Psychiatric Association, and the American College of Cardiology all endorsed last year’s health reform. These groups represent hundreds of thousands of physicians across a wide range of medical sub-specialties.
A key reason for these endorsements was the widespread recognition that our current health care system works poorly from the perspective of both physicians and patients – and the understanding that the new law was an important step in building a more effective health care system.
In the nearly two years since the Act was passed, we have heard many stories from colleagues around the country who belong to Doctors for America, an independent organization with which we are both affiliated. These physician are in private practice and academia, primary care and specialties, and in rural and urban areas. They are all seeing the impact of health care reform.
Heidi Sinclair, an internal medicine hospital specialist in Louisiana, noted that her hospital set up a discharge clinic to reduce avoidable hospital readmissions in anticipation of the law's delivery system reform pilots. Maggie Kozel, a pediatrician and teacher in Rhode Island, has seen more young adults - including her own children - who have now been able to get health insurance through their parent's insurance plans. Chris Lillis, an internal medicine physician in Virginia reported that his practice has received an increase in reimbursement thanks to the law’s primary care support provisions.
Particularly touching was a message we received from Ann Drum, a physician in Alabama, who has devoted her career to caring for the underserved. Dr. Drum suffers from a chronic illness herself, and, because of the regular and expensive intravenous therapy required for her disease, she was in danger of losing her health insurance as she approached her lifetime cap on coverage. The Affordable Care Act's provisions which ban lifetime caps mean that she and her patients need no longer live in fear of losing their health insurance because they are too sick.
There are many other stories too: A Tennessee specialist noted that his hospital has embarked on a major reorganization to focus on maximizing quality of care and reducing costs – all in anticipation of the law’s accountable care organization pilot programs. A Florida physician who owns a small private practice expressed relief that their state is finally getting grant support through the new public health prevention fund, to improve the screening and treatment of conditions such as hypertension. A North Carolina intensive care unit physician, who has seen heartbreaking cases of his patients denied care by insurers, told us of his sense of victory when he discovered the law provided his patients much needed protection.
Our personal correspondence conveys but a few of the many ways that physicians are starting to see the beneficial impact of the Affordable Care Act in their working lives.
That’s not to say physician enthusiasm for reform is universal -- far from it. Different specialties have different financial interests at stake. Like everyone else, physicians also hold diverse ideological views regarding the proper role of government and private enterprise in the health care system.
Physicians are also similar to the general public in another way: While physicians are extremely knowledgeable about the health care systems in which they work, they’re not particularly knowledgeable about health care reform. Having spoken to thousands of physicians about health reform, we can attest that this is the case across regions, ages and ethnicities, and specialties. An important reason for this uncertainty has been the ineffectiveness of public education efforts to explain what the Affordable Care Act really does.
This is also an anxious time for physicians, for patients, and for others with strong stakes in American health care. Physicians are under new pressures to join larger care organizations and to adopt new technologies such as electronic health records. Physicians are unsure how their reimbursements will be impacted in the coming years. Health reform provides a plausible target for these anxieties, even though the law often has little to do with the underlying causes of physicians’ worries. Additionally, when physicians see persistent or new problems (e.g. rising insurance premiums in the last year or continued political shenanigans over Medicare’s Sustainable Growth Rate “doctor fix”), many blame Obamacare. Ironically, problems like these are often precisely the difficulties that the law seeks to address.
Will doctors support health reform? We suspect that the ultimate answer to this question won’t come from the thrust-and-parry of partisan debate. Doctors will support the new law to the extent that it becomes visible in their everyday lives, and make these lives better.
We believe that physicians will embrace the Affordable Care Act because the new law helps to address many critical issues that have long concerned physicians and patients—abuses and market failures in the provisions of health coverage, rising numbers of uninsured patients, variable quality, poor coordination of care, the erosion of primary care, and the lack of focus on prevention and public health. As the law’s main provisions kick in, physicians will see that it is, indeed, a big step in the right direction. We are sure that the new law will attract serious criticism. Real on-the-ground progress will provide the best rebuttal.
Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago and advisor to Doctors for America. Vivek Murthy is an attending physician at the Brigham and Women's Hospital and Harvard Medical School, as well as president and co-founder of Doctors for America.
6 comments
Thank you for this report. "An important reason for this uncertainty has been the ineffectiveness of public education efforts to explain what the Affordable Care Act really does." I can understand why. Imagine being a teacher at a public school where during your explanations, the kids get to yell: "Liar!" or "Kenyan Socialist" or "Death Panels! Death Panels" and just basically try to drown you out. How well would they do on the quiz?
- Nusholtz
January 19, 2012 at 3:21pm
Bingo, Nush. It's a lot easier to foment ignorance than foster intelligence. Combine this with the survey published today that says that conservatives trust Fox, and no other broadcast media outfit. Someone who thinks that Fox unmasks the lies of the NYT is not very likely to listen to the president or a spokesperson, except to berate him for lying (and for hiding his damn Kenyan birth certificate).
- GeoffG
January 19, 2012 at 4:56pm
hopefully with an Obama re-election and 30 million new paying patients who could then be able to go to family physicians instead of clogging an ER their tune will change, granted many might complain of being too busy (and that was actually a Republican complaint, that more people would use health care instead of recognizing that they are undesireables and should have the decency to die) but we can solve that by bringing in more physicians from abroad on H1Bs.
- blackton
January 19, 2012 at 6:47pm
blackton Time will tell, and it better start talking.
- Nusholtz
January 21, 2012 at 3:27pm
There are none so blind as those who will not see...... Pollack and Ross have created an opinion piece here that purports to represent reality, but it plays fast and loose with the facts and the result is a complete piece of fiction. Pollack and Ross do not in any way accurately represent what the large majority of physicians believe. First - the title “Doctors don’t hate Obamacare”. As evidence the author trots out a list of organizations, beginning with the AMA that support(ed) it. The author must surely know that only about 15% of physicians belong to the AMA, and that it has not represented mainstream thought in the medical profession for years. Case in point is Obamacare. A national survey of physicians conducted by Jackon and Coker (a physician placement firm) found that when presented with the statement “the AMA’s stance and actions represent my views” 13% agreed, and 77% disagreed. Specifically, when presented with the statement “I agree with the AMA’s Position on Health care reform” 13% agreed, and 70% disagreed. (http://www.jacksoncoker.com/news/News.aspx?sc_cid=AMA). The results of this survey are in agreement with my personal experience with my colleagues - the large majority hate Obamacare. So if the title would be “ALL doctors don’t hate Obamacare”, that would be correct. It is not 100% of physicians, but clearly a very large majority do. Misleading in the extreme, and sadly, the authors knew it from the outset. Purposefully misleading. And the author probably knows that the AMA is now fighting against at least portions of Obamacare that will increase federal control. http://www.forbes.com/sites/davidwhelan/2011/11/16/the-ama-finally-takes-a-stand-against-obamacare-thinking-in-washington/ Also, to be perfectly clear, the AMA in no way represents the feelings of the majority of physicians. Currently less than 20% belong to the organization. They cannot claim to represent anywhere near a majority. If you doubt any of this, simply google “Obamacare Doctor Opinions”. Notice this is not a slanted request: straight up request for any opinions at all. You will quickly see the general flow of doctors opinions is strongly against Obamacare. Next item quote: ‘Pipes fires standard broadsides against health reform, including the already-rebutted claim that because of the Affordable Care Act, “American families in the non-group market will see their premiums rise $2,100.” Let me rebut the rebuttal. Nothing like actual evidence. My wife and I carry our own non-group health insurance. High deductible HSA plans with no changes over the years. 2008 cost: $5815.51. 2011 cost: $9420.31. Difference = 3604.80. That is real. Your assertions are not. The author spends a large amount of space discussing Doctors for America and its support for Obamacare. The group was initially known as “Doctors for Obama”. Do you think that readers should be convinced that “doctors” (as in the majority) are in favor of Obamacare, when your major source is a group who already supported it? Would it be convincing evidence that the majority of doctors support Obama, if you found that 100% of members of “Doctors for Obama” supported Obama? Then the author gets into anecdotes. No point in rebutting anecdotes. Here is what I (a real in-the-trenches physician) see. In the 1980s, the government began making real efforts to control costs through medicare with reductions in reimbursements. These efforts were ham-handed, and just like price and wage controls always do, introduced dramatic distortions into the market. Specifically: the cognitive work of primary care physicians was devalued relative to the procedure based work of many specialists. The result was that your average Primary care doc could not afford to spend more than 15 minutes per patient, or he/she was bankrupt. (Have you noticed how difficult it is now to talk to your physician (not a nurse) on the phone? For those younger than 40: it wasn’t this way in the 60’s.) The non-market distortion that resulted was that physicians banded together into very large groups so that they could take advantage of ancillary income streams, such as their own labs, own physical therapy departments, and own imaging centers. They would then self refer their patients and reap income from the additional work that they referred to themselves. I am in a position to observe this self referral, and I cannot overemphasize how serious this problem is from an economic standpoint. As but one example, my mother went to an ENT physician for a problem, and had a CT scan at the physician-owned facility, despite the fact that she had had the same test only 1 week prior. All readers should question actively if they actually need a test when their physician gets a cut of the action. At least 30% of the time, you do not need it. Scary words: “Just to be sure”. Why this works is that for most patients, with more tests you feel better cared for. And besides, it is covered by insurance, no cost to you. So you feel as if you are owed the exceptional and most expensive care, you already paid for it! Even this has not been enough to sustain many practices, and in the last 2 years there has been a run for the exits: a large number of physicians have quit private practice to become employees of the large health care systems in their city. “Good” you might think, “they will protect us from this over utilization” Hardly - in the employment contracts are economic incentives to the physicians to refer patients for tests - the more referrals the hospital gets, the more the doctor makes. How does Obamacare take care of this? It doesn’t - not at all. Within Obamacare are ACO’s - Accountable Care Organizations. What are these? Well, they are the Mega-Hospitals. Obamacare promotes the emergence of Mega-Hospitals that would employ all physicians. They will form large and very effective lobbying efforts that will be certain to safeguard their income stream. My list of scoundrels primarily responsible for high medical costs: Patients with unrealistic expectations, Drug companies, Insurance companies, Hospitals, self-referring physicians, and trial attorneys. Big winners in Obamacare: Insurance companies, Drug Companies, Hospitals, and trial lawyers (because they were never even in the discussion -their income stream was assumed to be safe). The list of those untouched by Obamacare and those responsible for high health care costs are nearly identical. Welcoming the feds in to clean up the problem is non-sensical. In many ways the attempts to manage medicine from Washington are the cause of the problem. So we have the situation similar to the fireman who sets fires so that he can heroically put them out later.
- pshaffer
January 21, 2012 at 10:25pm
This just in: A recent survey conducted by the Kaiser Family Foundation found insurance premiums for family policies rose to more than $15,000 a year in 2011. That's an increase of $1,300 over the past year for the average policy, the highest single-year premium hike since 2005, according to Kaiser. http://www.ocregister.com/opinion/administration-337579-obama-year.html Is there such a thing as negative (less than zero) credibility?
- pshaffer
January 30, 2012 at 6:58am