THE TREATMENT SEPTEMBER 15, 2009
Today the New England Journal of Medicine released two articles exploring physicians' beliefs about health reform.
The first, by Salomeh Keyhani and Alex Federman, explored physician preferences about the broad policy options for expanding insurance coverage and Medicare. This April, a nationally representative sample of more than 5,000 physicians was asked which of three options they would most strongly support:
1. Public and Private Options: Provide people under age 65 the choice of enrolling in a new public health insurance plan (like Medicare) or in private plans.
2. Private Options Only: Provide people with tax credits or low-income subsidies to buy private insurance coverage (without creating a public plan option).
3. Public Option Only: Eliminate private insurance and cover everyone in a single public plan like Medicare.
Physicians being the pathetically unreliable respondents they are, only 43 percent returned the survey. That's not great. Yet the results and the response rate are consistent with prior surveys. Among responders, 63 percent favored option #1, the public plan option. 9.6 percent favored the public option only. The remaining 27.3 percent favored exclusively private options.
Physicians' support for the public plan option has rightly been emphasized in today's press coverage. Physicians have many complaints and questions about Medicare. Yet when they are asked to compare the program head-to-head with private alternatives, few prefer an exclusively private approach to health reform.
Physicians were asked a second question that has gotten less attention than it should: Whether they believed that adults between the ages of 55 and 64 should have the option of buying into Medicare. Fifty-eight percent supported this option.
Medicare buy-in raises complicated problems, but this is a very promising approach, made even better by its simplicity. Policymakers, physicians, and the public understand what this is, how bills would be paid, who would implement it. I hope that Democrats advance serious proposals to allow such buy-ins. Buy-ins could solve huge problems for a population old enough to contract chronic illness, yet still too young to qualify for Medicare.
Such a program could also be extremely valuable to firms and to state and local governments struggling to meet health benefit obligations negotiated decades ago when health expenditures were far lower than they are today. Especially if Republicans and conservative Democrats water-down or remove good public plan options from the 2009 health reform bill, progressive Democrats should be back the next day with a buy-in proposal.
The second article, by Antiel and colleagues is also based on Spring 2009 representative surveys of U.S. physicians. (Full disclosure, the second author, Farr Curlin, is a University of Chicago colleague.) These authors' results are culled from an eight-page survey of physicians' moral and ethical beliefs in medical practice. As above, the response rate of 51 percent isn't great, but is typical in physician survey work. It's gotten less attention because the results are less directly useful in this fall's political debate. That's too bad.
In these surveys, physicians report more varied and ambivalent findings about central issues of health reform. The below table is drawn from their results.
"Every physician is professionally obligated to care for the uninsured and underinsured"
"I would favor limiting reimbursement for expensive drugs and procedures if that would expand access to basic health care for those currently lacking such care."
Seventy-three percent of physicians surveyed believed that they have a professional obligation to care for the underinsured. Physicians had more varied reactions to the idea of limiting reimbursement for costly interventions to expand access to basic care. Two-thirds at least moderately agree with this idea, though not without some ambivalence in doing so. Many indicated "moderate" (40 percent) or "strong" (14 percent) moral objections to the use of cost-effectiveness data in determining which treatments should be offered to patents.
Antiel and colleagues find--as did Keyhani and Federman--key differences across specialties. Primary care providers were more likely than radiologists, surgeons, and other specialists to believe that physicians are obligated to care for the underinsured. For not entirely altruistic reasons, primary care providers were more likely to favor limiting reimbursement for expensive treatments to expand access to basic care.
Differences in self-professed political ideology were even greater. Conservatives were markedly less likely than liberals to believe that physicians are obligated to care for the underinsured., markedly less likely to favor limiting reimbursement for costly interventions to expand access to basic care, and markedly more likely to object to the use of cost-effectiveness data to limit treatment.
The medical profession is changing. It is more receptive than it once was to fundamental reform. This change has not come evenly, and the profession is not a monolith. As health reform makes the transition from high-altitude political and moral issues to the ground-level mechanics of benefit packages and provider reimbursement, conflicts within the medical profession will become more public and more heated. Real resources are at stake. Competing valuable approaches to health care also conflict.
It won't be easy to change a medical care economy that grossly favors specialty care over primary and preventive care. Better than almost anyone, physicians understand the necessity, but also the difficulty, of this task.