Guest column: End is near for independent oncology, cardiology practices | Green Bay Press Gazette | greenbaypressgazette.com

Guest column: End is near for independent oncology, cardiology practices | Green Bay Press Gazette | greenbaypressgazette.com:

Cardiologists and oncologists now struggle to generate enough medical revenue to cover their costs to run the practice and pay physician salaries. "Pay the physicians less," you say? Well, the problem is that the shortage of physicians is so severe that the price to bring a cardiologist or oncologist in is set at a market rate. If you underpay your own physicians, they leave to go to someone who will pay them the market rate; then you have no one to treat your patients.

It is estimated that by the end of 2012, 80 percent of all cardiologists will be employed by or leased to hospitals. Yes, it's the end of the small independent cardiology and oncology practice and it's happening right before our eyes.

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Health Affairs - 2 articles on the cost of private insurers to the system

Two articles from Health Affairs regarding the cost of Private Health Insurers, for profit and not for profit, to physicians' practices, bottom lines, time and aggravation.

Peering Into The Black Box: Billing And Insurance Activities In A Medical Group -- Sakowski et al. 28 (4): w544 -- Health Affairs:

"Billing and insurance–related functions have been reported to consume 14 percent of medical group revenue, but little is known about the costs associated with performing specific activities. We conducted semistructured interviews, observed work flows, analyzed department budgets, and surveyed clinicians to evaluate these activities at a large multispecialty medical group. We identified 0.67 nonclinical full-time-equivalent (FTE) staff working on billing and insurance functions per FTE physician. In addition, clinicians spent more than thirty-five minutes per day performing these tasks. The cost to medical groups, including clinicians’ time, was at least $85,276 per FTE physician (10 percent of revenue)."


What Does It Cost Physician Practices To Interact With Health Insurance Plans? -- Casalino et al. 28 (4): w533 -- Health Affairs: "Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. However, little information exists about the extent of these interactions. We conducted a national survey on this subject of physicians and practice administrators. Physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time. When time is converted to dollars, we estimate that the national time cost to practices of interactions with plans is at least $23 billion to $31 billion each year."

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Health Care Reform - Old School!

Donald J Palmisano was President of the AMA for the 2003-2004 term. You can jump to his bio at his company's website. Apparently he also sends out his opinions via an email newsletter which a friend forwards to me on occasion. Here is the newest one, and since I haven't responded line by line to the conservative arguments on health care reform in a while, I thought now would be a good time to do so. I'm in italics.

DJP Update 6-1-2009: Health System Reform & AMA - Additional Reflections; comments on recent AMA writings.

The advantages of being an American and living in the USA are many. One of the great liberties we enjoy is the First Amendment to the US Constitution (part of the Bill of Rights) : http://www.archives.gov/exhibits/charters/bill_of_rights_transcript.html
AMENDMENT I: Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.

I always find it ironic when conservatives quote the Constitution given the penchant for the authoritarian-submissive personality among them. If that seems gratuitous, sorry, but I am always irritated when conservatives quote the Constitution as if it's news to the rest of us.

Also, one of the advantages of being an AMA member and getting elected to be a delegate (or have the privilege, as I have, as a former AMA president) and to sit in the AMA House of Delegates is the right to discuss, debate, and yes, offer alternative views if one perceives the ship of state is heading in the wrong direction. That is part of leadership. Without the courage to enter the debate, one cannot earn the title of leader. Of course, one's view may be defeated but then you have the comfort of the wisdom of Kipling's poem "IF" and President Teddy Roosevelt's words in his famous speech at the Sorbonne in 1910. See page 56 of my book, "On Leadership..." or go to:http://www.kipling.org.uk/poems_if.htm and http://www.theodore-roosevelt.com/trsorbonnespeech.html

Interesting bit from the TR speech: "It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein."

This would, unfortunately, require us to look past the end of our noses for potential solutions and, as Churchill might say, "This is something up with which I will not put!"

Another bit, "The poorest way to face life is to face it with a sneer. There are many men who feel a kind of twister pride in cynicism; there are many who confine themselves to criticism of the way others do what they themselves dare not even attempt. There is no more unhealthy being, no man less worthy of respect, than he who either really holds, or feigns to hold, an attitude of sneering disbelief toward all that is great and lofty, whether in achievement or in that noble effort which, even if it fails, comes to second achievement."

This is always how I see the conservatives sneering at the idea of universal health care. To quote JFK, "We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too."


Enough time spent laying the foundation for the following. Consider this note a part of a "disconfirming opinion" as taught by Dean Donald Jacobs at Northwestern. Plus some praise too! Why has our AMA not put forth in writing to the world, and to those in government we negotiate with, our AMA policy of "unwavering opposition against the encroachment of government in the practice of medicine..." "including the right of physicians and patients to contract privately for health care without government interference." Or "It is the policy of the AMA: (1) that any patient, regardless of age or health care insurance coverage, has both the right to privately contract with a physician for wanted or needed health services and to personally pay for those services; (2) to pursue appropriate legislative and legal means to permanently preserve the patient's basic right to privately contract with physicians for wanted or needed health care services; ..." See multiple AMA policies below and if you want more on the same topic, go to the PolicyFinder at the AMA Website: http://www.ama-assn.org/ama/no-index/about-ama/11760.shtml Is there something that is not clear about the wording in our policy? I conclude no. Hasn't it been repeated enough times in various policies? Certainly.

He is absolutely right here, and I have posted about these AMA policies and the one about single payer in the past, just to serve as a warning that, when it comes down to brass tacks (in the AMA's case, when it comes down to its' (our) House of Delegates), the AMA policy remains staunchly conservative.

Here is the problem. Our government controls our fees. That is a violation of our liberty.

Really? I see conservative physicians posting all the time about opting out of Medicare and other insurance plans precisely so that the government and insurers cannot control our fees. Virtually every nation (Canada a partial exception) allows physicians to practice outside or alongside the national system.

Property rights are an important component of our liberty. We have to recognize that government has the right to decide how much money to spend on some benefit, BUT government doesn't have the right to determine what we charge for a service. AMA leaders for years have advocated defined contribution approach by government with ownership by the patient, and an array of choice of insurance options. Read some of the speeches of Dr. Stormy Johnson, Dr. Nancy Dickey, and mine. And of course, read anything you can find from another AMA president, Dr. Ed Annis, the gold standard for liberty in medicine. Not a price-control system that ends up creating loss of access to care for patients because the fixed payment is below the cost of delivering the service. Throughout history, price-fixing equals loss of availability of the product or service.

Isn't it just hilarious that in a nation of nearly 50 million uninsured and another similar number underinsured, in a nation where we are all at risk of financial ruin due to health care catastrophes, that he expresses concern over "loss of access?" "Throughout history," etc. Again, one does have to look past the end of one's nose to see that this is wrong, wrong, wrong.


AMA has been "at the table" and we are told our policy is being advocated. Great. But has this policy been advocated? Certainly not in our AMA writings. The quest to end the SGR payment formula is good and AMA has advocated that. Unfortunately, we still granted the government the premise that it has the right to control our fees.

First, as noted, you can opt out. You can opt out of the Private Health Insurance market too, except, oh, yeah, unfettered markets have led to dominance by one or two insurers in virtually every large market in the country.

Secondly, this reminds me of President Eisenhower's comments to his brother, "Should any political party attempt to abolish social security, unemployment insurance and eliminate labor laws and farm programs, you would not hear of that party again in our political history. There is a tiny splinter group, of course, that believes that you can do these things. Among them are a few Texas oil millionaires, and an occasional politician or businessman from other areas. Their number is negligible and they are stupid ." This is true of Medicare as well.

In a recent message from AMA, we are advocating a MEI index approach in the negotiations. If one negotiates and allows the other side to set the framework of the debate, you will lose every time (See "On Leadership...). Why do we let government continue to set the paradigm that we don't have a right to set our fees? Note the RECURRENT policies that direct action about privately contracting. AND reaffirmed many times! This is not optional. This is the command of the AMA House of Delegates, the policy setting body of the AMA. AND note the policy about government medicine. Why are we not speaking out against the "public option"? Medicare is going bankrupt, restricting our liberty, and we are not opposing expansion of government medicine? Why not? This is not optional based on our clear AMA policy. Thus you can see I do not share the enthusiasm of my friend Dr. Joe Heyman, AMA Board Chair, in his AMA opinion column dated June 1, 2009, entitled "Health system reform is coming -- and you all helped". I hope AMA's help has not sanctioned a public system enlargement.

He is right about this. In spite of some of the AMA leadership's conciliatory remarks, speeches, etc., AMA policy stands directly opposed to significant reform. The AMA Annual meeting is coming up June 13-17. It'll be interesting to see how that goes.


However, what I do strongly agree with is the praise he gives to the Litigation Center of the AMA and State Medical Societies. I served on that committee when I was on the AMA Board and it does outstanding work. It fights the abuses of managed care, medical liability injustice, and much more. I wish every doctor in America knew of the great work it does. I also applaud our AMA putting in earlier writings that we need medical liability reform and antitrust relief for negotiating against the monopsony power some health insurers have. However, all of this will be wasted if physicians end up as captives of a government takeover of medicine. Hard to compete against government when it has unlimited taxpayer dollars and the power to punish by mandates and tax treatments. Before agreeing to a "better system" read the fine print carefully. One person's version (or the government's) of "better" may be entirely different than ours. Just like some caps on "non-economic" damages are great and others are worthless. Fine print!

Medical liability is still a hot issue for many physicians. In a recent survey by the California Medical Association, 40% still thought it was their number one concern. I do not know the political make up of the responders to that poll [though 67% were in practice more than 20 years - MY cohort!], nor of physicians in general [95% were CMA members], but my guess is that the 40% who still list that as their top concern are the older, whiter, male-r, and more conservative members of the profession.

We have to ask why membership continues to drop and what needs to be done to end the internecine battles among the various specialties. Why join AMA if my specialty does everything for me, including lobbying? Of course we know why everyone should be an AMA member and the Litigation Center is just one of many reasons. If everyone could balance-bill for the additional amount needed, there would be no need for different specialties to run to Congress and say, "Give me more of the Golden Apple as I am the fairest." Remember Paris, the golden apple, and the three goddesses, Hera, Athena and Aphrodite? To the fairest goes the golden apple. The story ended badly and so will the present course our medical ship is on.

I think the answer about AMA membership is clear, but it is not at all the same answer arrived at by Dr. P. There are a large number of physicians who focus primarily on income or revenue and see medical liability premiums as a scourge to their take-home pay, but for most, this is not the focus of their lives, professional or otherwise. I would like to see us continue to make inroads into medical liability reform, but not through caps, but through honesty, alternative dispute resolution, and taking responsibility, as a profession, for our colleagues who have fallen behind.

On D-Day all allied forces agreed to land on the same coast of France and worked together for a common goal. Perhaps all physicians and every American citizen should watch the HBO special on Winston Churchill that played last night entitled "Into the Storm". Read about it at:http://www.hbo.com/films/intothestorm/ Outstanding and a gold standard how to rally the nation against what appeared to be overwhelming force directed against Europe. No appeasement; no giving up; no "You don't understand". Instead, a fight to the end for important principles.

I am prone to hyperbole as well, so will let this pass...

But on the larger point, D-Day was about solidarity, exactly what we who are advocating for serious, comprehensive healthcare reform are promoting. We are in this community, this society, this national life, together. There is no religion, no school of thought (I always have to add, "except Ayn Rand's") whose central message is "every man for himself."

As Uwe Reinhardt says, "Go explain to God why you cannot do this. He will laugh at you."

Review the following AMA policies on privately contracting and unwavering opposition to government medicine. Trust but verify. Here is your chance to verify. [DJP here sites the policies I linked to earlier.]

In 1976 (yes, 1976) I testified before the U.S. House of Representatives' Ways & Means Committee opposing the government takeover of medicine and opposing a single-payer system. Representative Rostenkowski was the chair of the committee. Since that time, I have not found any evidence to change that view and I now have had the opportunity, thanks to AMA, to visit the Canadian Medical Association and the British Medical Association's annual meetings and learn directly from the doctors there about government promises and the failure to keep them. Check out one of my writings about this at: JAMA -- Proposals for US National Health Insurance, December 3, 2003, Palmisano 290 (21): 2797. It contains the following:-----In June 2003, the Chairman of the British Medical Association characterized his nation's single-payer health care system as "the stifling of innovation by excessive, intrusive audit . . . the shackling of doctors by prescribing guidelines, referral guidelines and protocols . . . the suffocation of professional responsibility by target-setting and production line values that leave little room for the professional judgment of individual doctors or the needs of individual patients."4 His strong words come from long experience with a single-payer health system.------I also witnessed how the government breached the promise in Section 1801 of the Medicare law, ("Prohibition Against Any Federal Interference"), not to interfere with the practice of medicine. See Notes section of my book, "On Leadership..." at pages 255-258.

Yes, if you ignore everything wrong in our system, every other system looks awful. If you ignore every good thing in every other system around the world, our system looks great. If you focus on Canada and Britain, the two countries that perform near the bottom in the world for health care system performance (you know, down there close to as poorly as we do), our system looks pretty good. On the other hand, if you look at the high performing systems with great outcomes, satisfied patients and physicians, great high tech medicine and great primary care and low cost, we don't look so hot.

This is the same ignorant line of reasoning promulgated by the Right Wing Noise Machine, Health Care Edition.

Most importantly, I have seen the sacrifice of the brave men and women who fight for our USA to preserve our liberty. I had the privilege during my tour of duty at the time of the Vietnam War to treat them at our airbase when they rotated back to the USA for 6 months. And I write about other military heroes in my book. Surely we cannot dishonor them by giving up our liberty. Sounds too strong? Have at it.

Oh, yeah, conservatives loves them some soldiers. That's why they're in our US Socialized Medicine system, the VA. You know this one. [In the interest of full disclosure, I have a friend whose son has PTSD, from Iraq, and the VA is failing him. We need to put pressure on our Congress to step up and make this right.]

Let me end this discussion by again recommending that everyone read "The Road to Serfdom".The author is F.A. Hayek, the co-winner of the Nobel Memorial Prize in Economics in 1974 and recipient of the Presidential Medal of Freedom in 1991.Here is what the back cover of the paperback edition (ISBN-13: 978-0-226-32055-7) of "The Road to Serfdom - The Definitive Edition", edited by Bruce Caldwell, says:"For F.A. Hayek, the collectivist idea of empowering government with increasing economic control would lead not to a utopia but to the horrors of Nazi Germany and fascist Italy."The original text was in the book was written in 1944. Think about it. At the start of Chapter Nine, he has two quotes: Here is one: In a country where the sole employer is the State, opposition means death by slow starvation. The old principle: who does not work shall not eat, has been replaced by a new one: who does not obey shall not eat. ---Leon Trotsky (1937) Think about how that applies to medicine. Would it not be better to bring about change in medicine by testing rather than just getting an idea and implementing it for the whole nation? Imagine if we gave patients new drugs without proper testing. I believe there would be many disasters. As Louis Pasteur said,"Imagination should give wings to our thoughts, but we always need decisive experimental proof. "The debate in our Land of Liberty is upon us. We may hear things that are not true. As scientist, it is our duty to insist on due diligence. As George Orwell said, "In a time of universal deceit, telling the truth becomes a revolutionary act." It doesn't have to be universal deceit, it can be universal failure to do the homework and testing and a rush to pass bills. It can be erroneous statistics with sampling errors and failure to compare apples vs apples. You get the idea. The quest for truth can be a lonely path. Leaders must courageously pursue it. Let's be a revolutionary for truth!--

One would think this is a satirical critique on the modern conservative-authoritarian movement, the failure of regulation of the marketplace, and the interjection of commercial interests into medical research, but sadly, no.

Liberals are anti-authoritarian, for goodness sake. You think Thomas Jefferson was a conservative authoritarian?!?

It's just not worth wasting the time on.
*sigh*


---I look forward to the debate at the June AMA House of Delegates in Chicago. Watch for "Resolution 203 - Right to Privately Contract" at AMA June Meeting in Reference Committee B. Resolve two of that resolution deals with the right to restore fairness to negotiations with the private health insurers and the government. There are at least 19 state and specialty co-sponsors. This resolution elevates the issue to highest priority. The people of America need to know what is at risk with their medical care. If we don't sound the alarm, I believe other grassroots groups will take the leadership for a clarion call to action and the world will wonder what happened to our AMA.

Well, I hope the HOD has the chutzpa to smack these people down once and for all, but I'm not counting on it.

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QUALITY: Doctors Oppose Insurer Control Over Patient Care Decisions | New America Blogs

QUALITY: Doctors Oppose Insurer Control Over Patient Care Decisions New America Blogs:

"Some doctors have decided they are fed up and not going to take it any more.California pain specialist Dr. Bradley Carpentier is among them.

"While Republican strategists stir up fears about government meddling in health care, the San Francisco Chronicle reports on doctors like Carpentier who are concerned about insurance companies that come between them and their patients."

Go read the rest.

The EMC Research Study is here.

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COST: Is This What They Went to Med School For? | New America Blogs

COST: Is This What They Went to Med School For? New America Blogs:

Excellent summary by Joanne Kenen at New America:

"Two new studies released this week online by Health Affairs examine how health care providers, particularly physician practices, interact with insurers. One study found that doctors personally spend the equivalent of three full weeks a year on billing and related insurance information. The overall cost to their practices (their time as well as other medical and clerical personnel) was about $31 billion a year (in 2006)—which as study author Larry Casalino noted, was about six times what we spent at the time on the State Children's Health Insurance Program and nearly 7 percent of total national expenses on physician and clinical services. Primary care practices spent more time on these administrative tasks than specialists. Very little of the data—only about two hours a year for the doctor—pertained to quality data.

"The second study looked at the billing and insurance-related activities at one large multi-site, multi-specialty California group practice. The cost (in physician and clerical time) turned out to be $85,276 per physician, or 10 percent of operating revenue. (And that excluded the time the doctors spent recording procedure and diagnosis codes). And this California practice isn't bogged down in paper; they already use electronic medical records for both clinical and billing data. (Some older studies, before medicine began its slow and not always so steady migration to Health IT, showed even more time and money spent on administration in the days of pure paper.)"

Additionally, from the second paper:

Impact of complexity. Previous reports have suggested that the complexity inherent in the current multipayer financing system is responsible for increasing the administrative burden associated with medical groups' transaction processing.15 During our interviews, informants frequently described the contributions of complexity in the payment system to billing and insurance burden. For example, the patient population of our study site is covered by hundreds of insurance plans, each with its own rules about benefits covered and under what conditions, payment rates, and often billing procedures. This complexity adds burden to billing and insurance tasks, including procedure coding, drug formulary authorizations, discussions with patients, submission and appeal processes, and receipt of payments. The complexity also increases the chance for error and dispute, increasing the likelihood of payment follow-up and collections. Even high-deductible plans, which might appear to avoid administrative burden for initial services during the year, impose billing/insurance costs because each service, including those within the patients' deductibles, must be evaluated and processed.

I've also classified this under Physician Income and Physician Autonomy, because these burdensome duties and their concomitant expenses impact both significantly. If you think your PHIs are paying you more than Medicare, you need to factor this into the equation.

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The Health Care Blog: POLICY: Oh Canada

The Health Care Blog: POLICY: Oh Canada

"This article is about Canada's health system and its relationship to the US health policy debate. It is not meant to be an endorsement of Canada's system, or an endorsement of single payer for the US."

Very well done, but a few years old. Most of the information is still pertinent. Very nice, very detailed compare/contrast piece on US vs. Canadian Healthcare systems.

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Essay - Fed Up With the Frustrations, More Doctors Change Course - NYTimes.com

Essay - Fed Up With the Frustrations, More Doctors Change Course - NYTimes.com:
"Not long ago, fed up with what he perceived as a loss of professional autonomy, Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens.

“I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.”

When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.

“But managed care is like a magnet attached to you,” he said.

He continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ”"

But if they were Government Bureaucrats, now that would be intolerable...

BTW, I included this post with the category of Rationing Healthcare because it does become rationing by attrition. Physicians often are so frustrated by the battles they fight hourly with Private Insurers, they cave in and provide less than optimal care.

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Most Minnesota doctors like single-payer health care, academic study finds | Twin Cities Daily Planet | Minneapolis - St. Paul

Most Minnesota doctors like single-payer health care, academic study finds Twin Cities Daily Planet Minneapolis - St. Paul:

"In his years as a physician, he has seen a sharp change in how physicians look at health care. “Having lunch with other doctors used to mean listening to conservatives griping about the government. Now lunchroom talk is that single-payer would be a good idea,” said Adair.

A recent survey through the University of Minnesota and St. Olaf College found that 64 percent of Minnesota’s physicians support a single-payer system much like the Minnesota Health Plan. Another 25 percent said that health savings accounts were the way to go, and only 12 percent thought that the current system of managed care was adequate.

“I personally feel very angry and frustrated when I know my patients are not getting the care that they deserve,” said Dr. Elizabeth Frost, a supporter of the Minnesota Health Plan. “I hate saying to people, ‘you need this test or this study,’ all the while knowing they don’t have insurance and likely don’t have a lot of savings either.”

Of the reasons that a single-payer system is so attractive to the majority of physicians in Minnesota is that the current multi-payer, managed-care system often gets in the way of physicians’ ability to provide the care that they swore an oath to provide."

The following point is also made:

"Because of [these] barriers people often under-use the system, “as opposed to the overuse that people erroneously cite as a significant problem in the current system,” said Settgast. “This under-use leads to unnecessary human suffering and also financial waste because the cost of caring for a patient with a stroke far exceeds the cost of effectively managing someone’s high blood pressure.”

Please click on "Moral Hazard" (along the right of this blog) to see more about that last point. But the bigger point is true in my expereince too: physicians are tired of this "system" we now have and are ready to take a chance on change. It would make an interesting poll for the AMA to undertake...

UPDATE: The findings section of the paper, from Minnesota Medicine.
Findings A majority of respondents (72%) were male with a median medical school graduation year of 1979. Nearly half (46%) practiced primary medicine, followed by medical specialty (35%), surgical specialty (12%), and general surgery (6%). More than three-quarters (79%) worked in a metropolitan setting, and nearly two-thirds (65%) practiced in a clinic.
Of the 390 respondents who answered the question about which financing system would offer the best health care to the greatest number of people for a fixed amount of money, 64% said they favor a single-payer financing system, 25% preferred HSAs, and only 12% preferred managed care (Figure 1). Figures 2, 3 and 4 offer a closer look at who prefers those financing structures by sex, geographic location, specialty, and type of practice.
A single-payer system was favored by women physicians over men (female, 76%; male, 59%; p=.003); more male physicians than female preferred HSAs (male, 30%; female, 16%; p=.004). The percentage of male respondents who favored the current managed care system slightly exceeded that of female physicians (12% versus 9%; p=.553).
Geographic setting was also significantly associated across the 3 choices. Urban physicians favored a single-payer system over their rural and suburban colleagues (71%, 60%, and 54%, respectively; p=.009). Rural physicians preferred HSAs over suburban and urban physicians (34%, 32%, 17%; p=.002). Managed care garnered less than 15% support overall, with 14% of suburban physicians, 12% of urban doctors, and 6% of rural respondents favoring it; p=.217). Thus, urban physicians had the most support for a single-payer system and the least for managed care. Rural physicians were relatively enthusiastic for HSAs but least supportive of managed care.
When looking at physicians’ responses across medical specialty, those practicing primary medicine most favored a single-payer system (74%); general surgeons least favored such a system (36%). Conversely, general surgeons most favored HSAs (55%), and primary medicine physicians least favored them (20%). Managed care found greatest support among physicians who practiced a medical or surgical specialty (17% each) and the least among those who practiced primary medicine (6%). Of those who favored managed care, the significant split was specialists over generalists (17% and 7%; p=.001).
Physicians also were asked who should be responsible for providing access to health care. Nearly all (86%) believed it is the responsibility of society through government to ensure access to good medical care for all, regardless of ability to pay. Only 41% held that the private insurance industry should continue to play a major role in medical care financing and delivery.
Using a regression model, we found that physicians who agreed that it is the government’s responsibility to ensure access to medical care were significantly more likely to favor a single-payer financing system (OR 13.51; CI 2.85, 64.15; p=.001). Those who believed the private insurance industry should continue to play a major role in financing medical care were significantly less likely to favor a government-run system (OR 3.45; CI 1.35, 8.33; p=.009

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AlterNet: 10 Myths About Canadian Health Care, Busted

AlterNet: 10 Myths About Canadian Health Care, Busted:

"2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning -- and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.

I'm both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I'm in a unique position to address the pros and cons of both systems first-hand. If we're going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.

To that end, here's the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they're made of."

Read on...

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Crooks and Liars » Nataline Sarkisyan passes away. Shame on Cigna!

Crooks and Liars » Nataline Sarkisyan passes away. Shame on Cigna!: "We [Crooks & Liars] posted this story yesterday with an update to the heartbreaking result. While battling CIGNA for a new liver, her family and friends fought and protested until CIGNA finally gave in, but it was too late—the seventeen-year-old Nataline Sarkisyan died."

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Exhausted

From a note on my patient's chart today:

Dr. _______
Mrs. ________ has exhausted her SNF [Skilled Nursing Facility] coverage. She has used her full 100 days and does not qualify for Medical Assistance [Medicaid]. She would have to privately pay for an SNF and she cannot afford this.

Doctor's Reply: What can I do about this?

Response: The patient and family are aware and husband says he will hire help but cannot afford private pay at SNF.

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France's model healthcare system - The Boston Globe

France's model healthcare system - The Boston Globe:

"National health insurance in France stands upon two grand historical bargains -- the first with doctors and a second with insurers. Doctors only agreed to participate in compulsory health insurance if the law protected a patient's choice of practitioner and guaranteed physicians' control over medical decision-making. Given their current frustrations, America's doctors might finally be convinced to throw their support behind universal health insurance if it protected their professional judgment and created a sane system of billing and reimbursement. French legislators also overcame insurance industry resistance by permitting the nation's already existing insurers to administer its new healthcare funds. Private health insurers are also central to the system as supplemental insurers who cover patient expenses that are not paid for by Sécurité Sociale. Indeed, nearly 90 percent of the French population possesses such coverage, making France home to a booming private health insurance market."

I think that, except for the hard core ideologues, physicians would by and large accept this bargain.

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WSJ 2006 "The Doctor's Office" on Single Payer

Government-Funded Care
Is the Best Health Solution

Multiple Insurers, Multiple Plans
Create Expensive, Draining Hassle
April 18, 2006:

"Doctors in private practice fear a loss of autonomy with a single-payer system. After being in the private practice of family medicine for 8 1/2 years, I see that autonomy is largely an illusion. Through Medicare and Medicaid, the government is already writing its own rules for 45% of the patients I see.
The rest are privately insured under 301 different insurance products (my staff and I counted). The companies set the fees and the contracts are largely non-negotiable by individual doctors.
The amount of time, staff costs and IT overhead associated with keeping track of all those plans eats up most of the money we make above Medicare rates. As it is now, I see patients and wait between 30 and 90 days to get paid. My practice requires two full-time staff members for billing. My two secretaries spend about half their time collecting insurance information. Plus, there's $9,000 in computer expenses yearly to handle the insurance information and billing follow up. I suspect I could go from four people in the paper chase to one with a single-payer system."

It's so obvious that it hurts.

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People's Weekly World - Assessing America’s health care system

People's Weekly World - Assessing America’s health care system:

Review of: "Practicing Medicine without a License!
The Corporate Takeover of Healthcare in America "

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