THE TREATMENT APRIL 2, 2009
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Harold Pollack
is a public health policy researcher at the University of Chicago's
School of Social Service Administration, where he is faculty chair of
the Center for Health Administration Studies. He is a regular
contributor to The Treatment.
For years, the medical profession has lagged only the insurers as a designated bogeyman for many who favor health reform. If only doctors weren’t so overpaid and professionally dominant, we would have a cheaper and fairer medical system that would emphasize primary care rather than so much expensive poking, prodding, and scribbling on a prescription pad. At least so the arguments go.
Frequently enough in this drama, physicians’ visible organized presence, the American Medical Association, has willingly played a villain from central casting. My favorite example was when the AMA feared that immunization clinics would lead to socialized medicine. Medicare and other programs were pushed through Congress despite significant opposition from the very same medical providers who would later profit greatly from such legislation. Medical specialty organizations have wrongly opposed comparative effectiveness research. They fear--often quite accurately--that serious research would cast doubt on the value and cost-effectiveness of dicey medications, interventions, and procedures. Whatever the professions’ view might have been decades ago, increasing numbers of physicians have come to favor fundamental healthcare financing and delivery reforms. On the left, Physicians for a National Health Care Program boasts 16,000 members. Although single-payer remains a minority preference among doctors, attitudes have clearly shifted. The April 2009 Journal of General Internal Medicine includes an article by Dan McCormick and colleagues that documents this shift. In a nationally representative 2007 survey, only 9 percent of physicians preferred the current employer-based financing system. Forty-nine percent favored either tax incentives or penalties to encourage the purchase of medical insurance, and 42 percent preferred a government-run, taxpayer-financed single-payer national health insurance program. The majority of respondents believed that all Americans should receive needed medical care regardless of ability to pay (89 percent); 33 percent believed that the uninsured currently have access to needed care. Nearly one fifth of respondents (19.3 percent) believed that even the insured lack access to needed care. Some will be quick to dismiss this survey, which was conducted by single-payer advocates, and which achieved a dicey 50.8 percent response rate. I think the study is broadly correct. Today’s physicians are much more open than their predecessors were to fundamental changes. Most recently, Doctors for America has posted an “Open letter to Congress on the budget for healthcare reform," which reads as follows:
We, the undersigned physicians, strongly urge you to support President Obama’s proposed budget for a healthcare reform reserve fund. President Obama has presented a bold blueprint for health reform. It focuses on our most critical priorities: increased access to care that preserves patient choice reduced healthcare costs that would protect Americans from catastrophic medical bills improved quality care through better healthcare systems, information technology, and research. President Obama’s vision combines the best features of our current system with the reforms we need. These proposals and the values they represent are shared by millions of Americans. They are not Democratic or Republican values--they are American values. As physicians, we are at the frontlines of an increasingly fragmented and dysfunctional health care system. We need the tools and freedom to practice medicine as we were trained to do. Our patients need meaningful reform. So do we. The President has proposed an ambitious budget that makes a crucial down payment for health reform. We strongly urge Congress to keep the health reform reserve fund as proposed in the President’s budget. After many decades of false starts, we must make health reform a reality in 2009.
(Disclosure: I am an informal advisor to this group.)
This group is well-connected in Washington. It’s thus especially significant that they, like Jonathan Cohn, highlight the importance of the pending budget battle.
So far, more than 1,800 doctors and medical students have signed on. Many signatories might be considered usual suspects: Andy Calman of Physicians for a Democratic Majority, leading pediatricians and public health authorities. Other names, though, are less expected. A quick run-through yields Whitney Addington, President Emeritus, The American College of Physicians. There is Gregory Curfman, Executive Editor of the New England Journal of Medicine. There is Philip Pizzo, Dean of the Stanford University School of Medicine. A good number of signatories are at the pinnacle of the medical profession—the very luminaries whose predecessors were often the most dogged and effective opponents of needed reforms.Physician opinion is rapidly changing. One could say much more, but the basic reasons are clear from 50,000 feet. Doctors witness firsthand the cruelties and idiocies imposed by our fragmented system.Managed care organizations already impose the mindless paperwork and micromanagement physicians once feared would accompany a larger public role. Moreover, our healthcare system fails to honor basic values that physicians hold dear. Every day, general practitioners try in vein to find specialists for the Medicaid patient whose cancer diagnosis was delayed because she avoided preventive care. Oncologists watch that same patient struggle with five- and six-figure medical bills as she confronts a frightening illness. Urban providers witness overcrowded emergency rooms and a crumbling safety-net increasingly unable to provide patients with compassionate care or to provide healthcare professionals with a stable, attractive, and worthy environment to perform their work. Sure, there will be pushing and shoving within the medical profession before this thing is done. Specialists and primary care doctors have different interests and different perspectives regarding comparative effectiveness research or the degree to which public or private payers should exercise bargaining power over provider payment. There are generational, geographic, and specialty differences within medicine regarding a myriad of concerns. Without discounting these frictions, the medical profession is coming to see what many others have also seen. Our existing, increasingly dysfunctional healthcare system doesn’t just work poorly for patients. It works poorly for doctors and for many others, too. That’s one reason I am hopeful we will see a major reform, this year.
--Harold Pollack
10 comments
1. Physician support varies widely by specialty, with as expected high income surgical subspecialties being more oppposed, and primary care specialties being more supportive. It should also be similarly pointed out that the AMA is down to hainv only about 27% of American physicians being members, and disproportionately surgeons. Many physisicans associate with their specialist sociaty or state medical society and not the AMA.
2. Even an AMA poll last year found that physicians preferred Medicare to private insurance.
3. Lest we forget there is public opion polling showing strong support for single payer among the general public: Associated Press/Yahoo News Poll, Dec. 14-20, 2007
PDF page 15: l.yimg.com/.../yahoo2topline.pdf
Which comes closest to your view?
"The United States should continue the current health insurance system in which most people get their health insurance from private employers, but some people have no insurance" = 34%
"The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers" = 65%
Refused / Not Answered = 2%
Interestingly, when offered essentially the same universal program is offered alone without the comparison to the current system, but with the single payer name, the numbers from the same 2007 AP/Yahoo News poll was lower but still a majority:
"Do you consider yourself a supporter of a single-payer health care system, that is a national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?"
YES = 54%
NO = 44%
REFUSED/NOT ANSWERED = 2%
Opposed to this presumably non-basied polling done for news organization, Celinda Lake's polling done for pro-pubic-option/anti-single payer found support for public option and not for sinlge payer. I suspect polling done byand for AHIP might have different results too.
- DrSteveB
April 3, 2009 at 9:02am
A study published in a March 2008 issue of Annals of Internal Medicine reported that a 2007 poll of 2,193 physicians nationwide indicated that 59 percent supported “government legislation to establish national health insurance.”
Fed up with constraints put on their professionalism and ability to practice compassionate patient-centered medicine, many doctors have become cynical, or –what is worse--passive. They grumble or retire early. In a recent PBS interview with Charlie Rose, Atul Gawande, MD, said he was disheartened to hear physicians, especially older doctors, say they wish they had chosen a different line of work.
There is another option, doctors can individually and collectively demand real reform. Physicians and other health care professionals can join Physicians for a National Health Program.
Politicians respect the opinions of doctors; a visit from a group of MDs from their own district has clout.. Politicians who take their counsel only from the lobbyists for the AMA may not know that the AMA represents only a minority of American physicians (as Dr SteveB has pointed out).
I recommend the docudrama “Prairie Giant.” It’s not great cinema but it depicts the doctors’ initial resistance to the Tommy Douglas reforms in Canada. It also reminds viewers of the meaning of words like “humane,” and “equitable” and the Hippocratic Oath..
- hmseil01
April 3, 2009 at 12:55pm
in _vain_, not "in vein." Maybe Pollack's thinking of his last visit to a hematologist.
Anyway, good post. Let's hope the docs finally get on board. Curious to know how many GOPers now see single payer as the only truly pro-family, pro-business replacement for our Rube Goldberg kloodge of a non-system.
- teplukhin2you
April 3, 2009 at 3:50pm
What I want to see from the medical profession more than anything else is the understanding that they are, individually and collectively, partly responsible for the decline in the delivery of medical care.
I say this as a 57-year-old health care consumer who has been intimately involved with his own health care as well as that of his daughter, wife and ex-wife, and mother. Much of the care that we have received from doctors, in a word, sucks. The professionalism that I took for granted thirty years ago has largely disappeared. The original post states: "Nearly one fifth of respondents (19.3 percent) believed that even the insured lack access to needed care." Given that it should be blatantly obvious to anyone with a pulse that the insured lack access to needed care, this data point confirms the medical profession's appalling failure to come to grips with its own cognitive dissonance.
On this day, I (whose employer-based coverage is the envy of everyone I know) wait in vain for my doctor to return a call from a pharmacy to refill my blood pressure medication. I take a generic version a common BP med; I've been taking it for 10 years; I had high BP before I began taking it but it works--my BP is now within the normal range. I ran out last Thursday. My doctor won't return calls from the pharmacy. Does he want me to stop taking the medication? Apparently so, even though he hasn't measured my BP in over a year. This makes a lot of sense, if I just passed a caterpillar on a mushroom smoking a hookah.
Email my doctor, you say? Ha, that's a good one!
My doctor's negligence is typical, in my experience. Doctors think that patients should regard them spending 15 minutes with us as a gift from God. It's too much for them to fax paperwork to a referred physician, so we have to fill out the same information every time we visit a new MD. (Paper! What a quaint, efficient medium!) As to this alleged concern that doctors have about access for some patients, that conflicts with my experience, especially in my role as helping my wife, a former Medicaid patient, and my mother, a Medicare/supplemental patient. Both were treated like dirt.
Despite the existence of effective pain medications, doctors as a rule won't prescribe them. So we have the scenario where people with chronic conditions must live with the near 24/7 pain that those conditions cause, despite the existence of safe and effective analgesics. This speaks to the ignorance and/or paranoia on the part of their doctors. My wife faces debilitating pain for the rest of her life because her Medicaid doctor (at one of the top teaching hospitals in the world, supposedly) mangled her first hip operation (the two follow-up operations, to correct the first, were duds). Think she can get meds to keep her from bursting into tears several times a week? Think again.
As to the argument that doctors are the victims of some sort of professional bait and switch--"We thought we'd be helping people!" they lament, as they chew the nearest scenery--the reality of non-care (I don't like to use the silly, inaccurate "care" in this context) has been evident to anyone entering medical school in the last 20 years. I don't buy this excuse, at all. Doctors who lament their profession's faults yet continue to be co-opted into abetting those faults, even though they can quit at any time (and lose a sizable chunk of change by doing so) are simply being disingenuous, to put it gently.
There's been one great exception to this poor service in my recent history. A dozen or so years ago, I was working at a new job and decided to try a doctor near where I worked. I was getting the usual piece-of-dirt treatment until the doc read my information form and noticed that my job entailed editing clinical study reports from studies that his medical group was doing (my company was the sponsor). You would have thought I was the one millionth customer in the check-out line, that balloons would drop and a chorus line would start high-stepping out from the medical records room. From then on I got the rock-star treatment: never a wait of more than a few minutes at the front desk; plenty of face time with Doc, specialty doctors dropping by like sommeliers ("Laparoscopic cholecystectomy? Anderson Valley chardonnay?"). Imagine that: me, an employee of a company shooting them a few hundred grand in clinical trial money, getting superior service? Go figure.
And while the doctor is on rounds, the nurses will pick up the slack, right? Try again: after her third hip operation, the only way my wife could get someone to come into her hospital room to change her sheets (no one had responded to her pleas for assistance, so she was lying in her own urine, for the second time in two days) was to throw everything on her nightstand out into the hall.
People say it will be a good thing when everyone is covered. This is like saying, "Gee, McDonalds doesn't have restaurants in every county in the U.S. We need to fix that!" Yes indeed, it will be a wonderful day when every man, woman, and child in America, regardless of age, pre-existing condition, or economic or employment status, enjoys the same terrific, attentive, comprehensive, compassionate care that I get. Big whoop.
- williamyard
April 5, 2009 at 1:50pm
Just wanted to pipe up and offer that you seem to have found some especially crappy docs there, Bill. Perhaps it's because I'm a pediatrician, and people don't generally go into peds unless they (inexplicably) like children and actually care about them, but I would never dream of treating a patient or their family in the manner you describe. It's something I work quite hard at, actually, being accessible, attentive, compassionate, etc.
I'm not a member of the AMA, because I consider it a part of the problem. (The fact that it sells physician prescription data to pharmaceutical companies for marketing purposes should tell you all you need to know. I've lobbied for reform in our state law since I moved to Maine.) I am 100%, full-bore in favor of single-payer health care. Have been for years.
- drdannyu
April 6, 2009 at 10:00am
Why have you not fired your doctor? His poor service and your anger will not combine to form a positive therapeutic relationship, for your hypertension or for anything else. Of course, as a medical student, my bias is that you seek out a younger physician, fresh out of residency. The entitlement instinct generally is centered in white male docs, middle age and up, who remember the lordly days of 1960s-80s medicine.
- mcorey.geo
April 6, 2009 at 10:02am
tep, I'd like to see more experimentation at the state level before we let the feds create a different kluge of a system.
Even if we wave a wand and cover 46 million people, our current shortage of primary care docs will take awhile to fix. And Obama has been long on access, short on cost control, at least so far.
We'll see - it's early.
- butchie b
April 6, 2009 at 11:45am
teplukhin2: Sorry for the "in vein" thing. Ugh don't know how that happened. Thanks for the great comments.
- hpollack
April 6, 2009 at 12:25pm
The corportazation of medicine. It is a business. Ask the thousands od administrators that address the bottom line for "nonprofit". Ask the many physician employess of these corporations how their salaries are ties to productivity,another word for profit. Doctors are not the ones in charge. The administrators of theses corporations with multiple hospitals and many doctors are in charge. Doctors do not run their own profession,.Many of them with their societies have become emasculated sheep at the hand of the legal profession and governemt regulators who theraten them with financial and personal ruin if they don't follow directions. Money,Money Money is the name of our healthcare system. But its one of the few "industries "that growing.
- davidlheber
April 6, 2009 at 4:40pm
Harold Pollack, a public health care expert at the University of Chicago, is a Special Correspondent
- Anonymous
July 1, 2009 at 11:39am