Honest discussions about what doctors think about health reform are all too rare. One reason is that doctors are aware of the current economic environment, know they have relatively safe well-paying jobs, and are reluctant to get into public arguments about it. Of course, there's also an obligation to be a patient advocate, and there are so many patients affected by health reform (and lack of health insurance, which impacts their ability to access the system) that it's hard not to have an opinion. So, let's see where things stand with the docs - and why.
The professional societies have pretty much all weighed in (I interviewed some prominent ones here a year ago in the health reform run-up - see Interview With Dr. Judith Palfrey, FAAP, President Elect, American Academy of Pediatrics and Interview With Dr. Lori Heim, FAAFP, President Elect, American Academy of Family Physicians, for example.)
my dusty unused MD bag
I wrote about my dusty unused MD bag back in June when we were discussing the (then) AMA's opposition to health reform. They've since come around, as have most other medical associations and groups (see this very long list, for example.) But you'll look in vain for the support of the American College of Surgeons. In fact, the ACS came out in full throated opposition.
In addition, the groups stressed the importance of addressing several issues in any final health care reform bill, including extending health insurance coverage to more Americans and repealing the broken current Medicare payment formula known as the sustainable growth rate (SGR). In the letter, the organizations also expressed opposition to a proposal to create an independent Medicare commission that would have policy-making authority over the program and, thereby, likely have a negative effect on patient access to quality, efficient health care. The letter also expressed support for measures that promote well-designed and tested quality improvement initiatives, incorporate medical liability reform, address surgical workforce problems, and ensure appropriate Medicaid payment rates. Finally, the organizations expressed opposition to controversial scope-of-practice proposals that could confuse patients about the significant variations in training, education, and expertise between qualified physicians and other health care providers.
That opposition from surgeons (not from all surgeons, some of whom post here, but from their professional organization) needs to be kept in mind when you read stories like this (generally involving high priced specialists):
Last month a Republican urologist in Florida posted a sign on his office door telling his patients that if they voted for President Obama, they should "seek urologic care elsewhere." Despite later admitting that he knew little about the new law, the sign added: "Changes to your healthcare begin right now, not in four years."
The Daily Caller reports that another doctor has pulled a similar stunt. Arizona dermatologist Joseph Scherzer put a sign outside his office warning his patients that he will be closing his doors because of the new law. "If you voted for Obamacare, be aware these doors will close before it goes into effect," the sign reads. Scherzer — a self-described conservative — claims that the "stress" the law will supposedly impose will cause him to close up shop:
"I’m absolutely serious [about stopping practicing] and it’s not just because I’ll be nearing 65," Scherzer said. "The stress is what would push me out the door." [...]
Scherzer said the bill’s emphasis on punitive measures for physicians not following government-prescribed treatment methods under Medicare would increase his anxiety level to the point he would no longer be able to practice medicine.
Let's just say that dermatology (even in Arizona) is not considered one of the more stressful branches of medicine, like trauma surgery or neonatology are. The American College of Surgeons is a lot more honest and open about their objections, and it isn't stress: it's about the money that doctors get paid. See this bit here from the ACS statement?
... [surgeon and anesthesiologist] groups stressed the importance of addressing several issues in any final health care reform bill, including extending health insurance coverage to more Americans and repealing the broken current Medicare payment formula known as the sustainable growth rate (SGR). In the letter, the organizations also expressed opposition to a proposal to create an independent Medicare commission that would have policy-making authority over the program and, thereby, likely have a negative effect on patient access to quality, efficient health care. The letter also expressed support for measures that promote well-designed and tested quality improvement initiatives, incorporate medical liability reform, address surgical workforce problems, and ensure appropriate Medicaid payment rates. Finally, the organizations expressed opposition to controversial scope-of-practice proposals that could confuse patients about the significant variations in training, education, and expertise between qualified physicians and other health care providers.
I highlighted the parts that you can translate as "how much are you going to pay me?"
First of all, just about all doctors are upset with Medicare cuts and the "broken current Medicare payment formula known as the sustainable growth rate (SGR)". It's a formula based on a variety of factors that take into account the cost of doing business, but is intimately tied to GDP and not what things actually cost.
Separately, HHS figures something called the Medicare Economic Index (MEI). The MEI is the annual estimated increase in the cost of medical practice. The AMA and other organizations have traditionally felt that the MEI is a better gauge of what fees should be, and not the SGR.
The discrepancy between SGR and MEI leads to gross underpayment, and is recognized by Congress as something that needs fixing. This slide comes from an AMA presentation on the topic (click for bigger graphic):
You read about it regularly in headlines like "Bunning Blockade Leads To 21 Percent Fee Cut For Doctors" and stories like:
A 21 percent cut in Medicare physician reimbursement took effect April 1, and now area patients and doctors are fighting back.
Paul Orta lost his left leg 15 years ago due to complications with diabetes. Disabled and unable to work, Orta found a doctor who accepted Medicare and helped fit him for a prosthetic, also partly paid for by Medicare. But, Orta’s problems haven't gone away.
"At this moment, I have problems with my right leg. I had surgery couple of weeks ago. They're telling me I might lose it," Orta said.
The SGR was intended as a brake on rising Medicare costs, but was tied to GDP and not the actual cost of medical care. If medical care costs rise faster than the GDP or inflation (and they generally do, especially in a recession), then reimbursement will disproportionately drop relative to what it costs to run a practice or take care of a patient. That's why docs are always upset about it (I don't see Medicare patients but my colleagues do.)
The key here is that this argument predates the current health reform bill (see, for example, the Medicare Improvements for Patients and Providers Act of 2008, H.R 6331, which passed with wide bipartisan majorities and overrode a Bush veto)
The Medicare Improvements for Patients and Providers Act of 2008 temporarily blocks a scheduled 10% cut in payments to physicians from Medicare, the federal government’s health insurance program for Americans ages 65 and older. Instead, the bill grants a 1.1% raise to the physicians for 2009. The legislation provides incentives to doctors for the use of electronic prescriptions and for reporting on quality of care. The Act extends through 2009 the Qualifying Individual Program that pays the Medicare premiums of low-income beneficiaries. The legislation also increases the amount of assets that applicants are able possess and still qualify for the Medicare Savings Program, which helps low-income beneficiaries pay the costs of Medicare benefits. The bill expands coverage of mental health services and authorizes the Secretary of Health and Human Services to cover new preventive services.
and is never a reason or excuse to claim that Obama's initiative is the root of the problem.
As it happens, other cost-savings proposals in the bill are under attack from the surgeons as well.
See this part?
...opposition to controversial scope-of-practice proposals that could confuse patients about the significant variations in training, education, and expertise between qualified physicians and other health care providers.
That's about Physician Assistants and Nurse Practitioners. (And as it happens, I interviewed them, too - see Interview With Patrick Killeen, President Elect, American Academy of Physician Assistants and Interview With Thad Wilson, President, American College of Nurse Practitioners. I was busy last summer!)
It turns out that there is little diminution in quality when patients are seen by NPs and PAs in most circumstances, and patients really enjoy the extra time and speedy appointments. And this AP article directly tackles turf issues.
The medical establishment is fighting to protect turf. In some statehouses, doctors have shown up in white coats to testify against nurse practitioner bills. The American Medical Association, which supported the national health care overhaul, says a doctor shortage is no reason to put nurses in charge and endanger patients.
Nurse practitioners argue there's no danger. They say they're highly trained and as skilled as doctors at diagnosing illness during office visits. They know when to refer the sickest patients to doctor specialists. Plus, they spend more time with patients and charge less.
"We're constantly having to prove ourselves," said Chicago nurse practitioner Amanda Cockrell, 32, who tells patients she's just like a doctor "except for the pay."
On top of four years in nursing school, Cockrell spent another three years in a nurse practitioner program, much of it working with patients. Doctors generally spend four years in undergraduate school, four years in medical school and an additional three in primary care residency training.
Medicare, which sets the pace for payments by private insurance, pays nurse practitioners 85 percent of what it pays doctors. An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60.
The health care overhaul law gave nurse midwives, a type of advanced practice nurse, a Medicare raise to 100 percent of what obstetrician-gynecologists make — and that may be just the beginning.
The bottom line here is that when you hear about a doctor claiming he or she is going to have to turn away patients because of health reform, chances are it's a highly paid (and conservative Republican) specialist who's doing some turf protection at the expense of an honest discussion of the issues, using health reform as an excuse to vent about professional anxieties that would exist if Obama had never been elected. Are the issues real? Sure, at least at some level. But so are the solutions, and it's going to require the government to implement them if they have any chance of helping doctors, and by extension, their patients. NYT, 4/15/10:
Congress on Thursday approved legislation that would keep unemployment checks flowing to jobless Americans, and President Obama immediately signed it...
The legislation also provided temporary extension of the federal flood insurance program and averted a 21 percent cut in doctor fees paid by Medicare.
It's true for every doc, no matter where you stand politically. And that, my friends, is something every doc knows.