JAMA Network | JAMA Internal Medicine | The Political Polarization of Physicians in the United States: An Analysis of Campaign Contributions to Federal Elections, 1991 Through 2012

 

Conclusions and Relevance Between 1991 and 2012, the political alignment of US physicians shifted from predominantly Republican toward the Democrats. The variables driving this change, including the increasing percentage of female physicians and the decreasing percentage of physicians in solo and small practices, are likely to drive further changes.

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Figures in this Article

Although few systematic analyses have been conducted on the political behavior of physicians in the United States, it is often assumed that they sit to the right on the political spectrum. Generalizing from the American Medical Association’s strong opposition to the 1965 passage of Medicare, the belief is that physicians share the wariness of Republicans about government interventions, particularly in health care.^1,2 Ostensibly, this outlook persists today.³

Given the scarcity of data and alert to the many changes in the composition and organization of the physician workforce, we examined physician contributions to presidential and congressional political campaigns from 1991 to 2012. Information on campaign contributions to federal elections is publicly available. The data illuminate patterns of support of physicians for Democratic and Republican candidates and how these patterns compare to those for all donors.

Between 1991 and 2012, campaign contributions in the United States increased substantially. Inflation-adjusted to 2012 dollars, contributions from all individuals increased from $716 million in 1991 to 1992 to $4.64 billion in 2011 to 2012, a 6.5-fold increase. Contributions from physicians increased at a greater rate, from $20 million to $189 million, or by nearly 9.5 fold.

We grouped contributions by the 2-year congressional election cycles. There are important differences in voter participation between midterm election years and presidential election years; for example, people with low incomes are less likely to vote in midterm elections.^4(pp130-133) Contributions also varied between midterm and presidential years, with greater contributions in presidential years.

Over our 22-year study period, the composition of the medical profession changed—most notably, there were more female physicians and fewer solo practitioners^{5- 7}—and politics in the United States became increasingly polarized.⁴ We hypothesized that the increased number of female physicians and the changes in medical practice altered the patterns of political partisanship within the profession.

JAMA Network | JAMA Internal Medicine | The Political Polarization of Physicians in the United States:  An Analysis of Campaign Contributions to Federal Elections, 1991 Through 2012

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JAMA Network | JAMA | Views of US Physicians About Controlling Health Care Costs

 

Physicians’ views about health care costs are germane to pending policy reforms.

Objective To assess physicians’ attitudes toward and perceived role in addressing health care costs.

…

Results A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” …

JAMA Network | JAMA | Views of US Physicians About Controlling Health Care Costs

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General Surgery News - Spam in a Can

General Surgery News - Spam in a Can:

For those of you who have been spending your days operating and taking care of patients instead of keeping up with the latest machinations from central planning to separate you from the fruits of your labor and control of your practice, ACOs are bundles of providers who will receive a global payment for a specific patient encounter, like a cholecystectomy. Who will bill, receive and divide the money is uncertain, except that it won’t be you, the surgeon. The only thing certain is that like diagnosis-related groups, the sustainable growth rate, and relative value units, this latest iteration in health care spending discipline will be gamed and ultimately relegated to the alphabet graveyard of designer cost-containment programs invented by health policy wonks who have an aversion to traditional medicine based on the private doctor–patient relationship. I’ll say this much for them: They are undeterred by their unbroken string of failures. Maybe they’re Cubs fans.

An interesting read, if you want to really appreciate the "old school" approach of a lot of our colleagues (this was sent to me by one). My thoughts:

Some interesting phrasing choices in this piece.

"outside secular influence"

"the surgical workforce has been transformed by macroeconomic factors from the ownership class to the labor class."

"Ownership and labor never agree on anything"

"Strip away the thin veneer of status, and the chief of surgery at Johns Hopkins and the junior surgeon at Kaiser both serve at the pleasure of a boss, punch a clock and take fire training and corporate compliance classes."

"you had the common values, aspirations and headaches typical of small-business owners."

"cookbook medicine" (Really? Who still thinks this way?)

Anyway, it all made me think of the Master-Slave morality dichotomy. Since Jesus was the epitome of the 'slave' side of this, I'm comfortable with my position, as is, I expect, is Dr. Russell.

And it also made me think of this great quote:

"A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it"

Max Planck

- Sent using Google Toolbar

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Doctors Soften Their Stance on Obama’s Health Overhaul - NYTimes.com

Doctors Soften Their Stance on Obama’s Health Overhaul - NYTimes.com:

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states.

That change could have a profound effect on the nation’s health care debate. Indeed, after opposing almost every major health overhaul proposal for nearly a century, the American Medical Association supported President Obama’s legislation last year because the new law would provide health insurance to the vast majority of the nation’s uninsured, improve competition and choice in insurance, and promote prevention and wellness, the group said.

As I pointed out here many times over the past couple years, doctors support health reform.

Follow the tags with this to find out more.

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NEJM -- Have Physicians Stepped Up for Reform?

NEJM -- Medicine's Ethical Responsibility for Health Care Reform -- The Top Five List

The medical profession's reaction has been quite different. Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians' income would not be negatively affected by reform.

It is appropriate to question the ethics of organized medicine's public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the "special interests" affected by health care reform, justify demanding protection from revenue losses?

Dr. Brody makes some interesting points about physicians' role in health care reform, including the general unwillingness of organized medicine to step up and make concessions on income or to vigorously work on the problem of practice variation.

He is only partially correct in his assessment of organized medicine's advocacy role this time around. I think it is a real accomplishment, an unprecedented consensus, that the ten largest physician organizations have come out in support of the House Bill, which includes many very important reforms including the public option.

What amazes me is that this has NO currency in the media. Does anyone know this fact? Does anyone realize how monumental this should be? So regardless of whether organized medicine has made the right offers or concessions in this current debate, the fact that they have stood up, in many cases with much pushback from conservative members and advocated for health reform is a big deal.

Secondly, even if organized medicine's endorsement of reform has not taken the form some of us would like (single payer, Bismarkian insurance), individual physicians, in surveys published in the NEJM have indicated overwhelming willingness to make a deal (i.e., accept a public option) and accept concessions.

a large majority of respondents (78%) agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data "to determine which treatments will be offered to patients.

...the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform.

So i would differ with Dr. Brody's assessment that physicians and organized medicine have not stepped up adequately.

The problem, as I see it, is that the media and the pro-reform contingent in Congress, have done an abysmal job of letting the public know that the people whose opinions they value most in this debate - physicians - are overwhelmingly in favor of reform.

What we see in the media are the conservative physicians in congress (Sens. Coburn and Barrasso, Congressman Boustany) who are ridiculously out of touch with mainstream physicians. Though in touch with the angry tea partiers and the admittedly sizable contingent of conservative American physicians (not accidentally all of these physicians practicing in high income specialties - ob/gyn, orthopedics and surgical subspecialties ), they do not represent the thinking of most physicians.

Furthermore, as Dr. Brody rightly points out, physicians have a higher duty to our patients than to our own narrow self interest. But here, again, physicians have acknowledged this in a formal way in the Charter on Medical Professionalism, published in 2004 by the American College of Physicians and endorsed by more than 50 major national and international medical organizations:

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category

It seems pretty clear that physicians have answered the call, but somehow, in spite of opinion polling showing how highly the public values our opinion, nobody has noticed.

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Testimony to GOP Doctors Caucus

I am giving testimony on Health Care Reform to the GOP Doctors Caucus on Thursday morning, Jan. 21, 2010.

UPDATE: My notes on the back and forth are posted here.

I am representing myself for sure, and, if I do well, will claim to be representing Doctors for America, as well (just kidding).

Here is my opening statement:

Thank you for this opportunity to speak to you today.

A study published recently in the New England Journal of Medicine[i] indicated that 78% of physicians “agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%).”

I was greatly encouraged by this study. But also, sometimes being a glass-half-empty kind of guy, I also was disappointed that 22% of physicians do NOT think they have a duty beyond their individual practice or owe a duty only to the patients in patients in front of them.

In 2004, the American College of Physicians and the American Board of Internal Medicine Foundation published the Charter on Medical Professionalism,[ii] which included language that very pointedly noted that physicians have a duty to social justice in health care:

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

It also states that we have a duty to improve access to care and to a just distribution of finite resources. The ACP reports that more than 50 professional organizations in America and around the world have signed on to this Charter.

I am pleased to say that the leadership of most of our medical professional organizations are now not only talking the talk, but walking the walk, and in an unprecedented manner, the 10 largest physician organizations are supporting health care reform that coincides with their stated goals of universal access to health care in America.

But it is not only organized medicine in favor or reform, as most physicians support reform as well. Another survey from the New England Journal showed overwhelming support (63%) for either reform with a public option or straight up single payer health care.[iii]

It is estimated that 45,000 people die in America every single year due to lack of access to health care.[iv] Whether this is twice as high or half as high as the “true” number is almost immaterial, as it is unacceptable in any case. My experiences, and the experiences of my colleagues, convince me that this number is true, and perhaps even a gross underestimate. Every physician I know has stories of patients who ignored some illness or deferred seeking treatment due to lack of health insurance. I had a patient who was literally coughing up blood for months and had a severe cough for many more months before that before he finally came into the hospital with respiratory failure and advanced cancer.

And, just as in war there are multiples of wounded for every casualty, so too, in our struggle with illness, we see much more suffering that does not get counted. The cab driver supporting a family of five who ignores his diabetes (he knows that is what it is), because he is trying to get health insurance and knows this diagnosis will doom his chances. So he ends up in my ICU with severe diabetic ketoacidosis. The construction worker with a seizure disorder who cannot see a neurologist to adjust his medications because of lack of money to pay for his last visit. He develops uncontrolled seizures for the second time in a few months and ends up in the ICU on life support.

Every physician you know can tell you stories like this. And there are more than 800,000 of us in the US, so the 45,000 number strikes me as not only low for preventable deaths, but only the tip of the iceberg in terms of the human cost in physical suffering and anguish. Remember, all these patients had families who loved them.

I know you hear from many disgruntled physicians who are concerned and even fearful of change. It is unfortunate that this fear prevents many from listening to the “better angels of our nature,” and, instead of striving to improve reform as proposed, simply attack and reject any and all proposals on the table.

It is also worth noting that the changes Congress makes now will certainly affect me and my peers with gray hair, but these bills are really about physicians just starting practice, still in medical school or still just thinking about medical school. And, if you have kids, you know this: they don’t think like us. In medicine, in particular, surveys have shown that they view medicine as a chance to help people and serve society, and don’t have that “calling” to medicine as older generations did. They don’t expect to make a small fortune, but they do expect fair compensation for all they have had to go through to get through medical school and residency, financially and in opportunity cost. So, remember when you hear grumbling about reform, consider the source, and, to channel Yogi Berra, remember the future.

In this final minute, I do want to run through some particulars of what we like in the current House and Senate Bills and would like to see in the final reform bill:

1. Provide health insurance coverage for 96 percent of Americans while reducing the federal deficit by $30 billion.
2. Provide substantial subsidies to help make coverage more affordable for our patients.
3. Implement insurance market reforms to prevent individuals from being denied coverage because of pre-existing conditions, and to limit premium differentials based on age, gender and other factors.
4. Establish a public health insurance option to ensure there is adequate competition and affordable health insurance options in all areas of the country.
5. Provide a 10% bonus payment for all primary care providers and a 10% bonus payment for general surgeons and PCPs practicing in underserved areas to ensure a strong physician workforce.
6. Increase Medicaid payment for primary care services to at least Medicare payment rates and expand Medicaid.
7. Expand the National Health Services Corp and Title VII health professions training programs.
8. Expand the medical home pilots and other health care delivery improvement models in addition to creating the Innovation Center to focus on improving the health care delivery system
9. Invest billions to strengthen our public health system and focus on prevention and wellness.
10. Establish a new program to encourage states to implement alternatives to traditional medical malpractice litigation – the first step .
11. Create the Innovation Center and expand the medical home pilots – the kinds of health care delivery models that will improve care coordination and efficiency.
12. Create an Independent Medicare Advisory Board, isolated from the political process to ensure patients get the care they need, to make recommendations on cost containment and improvements.
13. Focus on prevention and wellness including reimbursement for an annual Medicare wellness visits, advance care planning, and eliminating the cost burden on patients for preventive services
    

So, in conclusion, I would ask all of you to strive for health care reform where our bottom line is quality affordable health care for everyone. Because ultimately, our goal is to reduce the number of deaths and needless suffering due to lack of access to care as close to zero as possible, and to leave our children with a better system than we inherited.

Thank you.

Christopher M. Hughes, MD, FCCP, FACP, FCCM
State Director, Pennsylvania, Doctors for America
Board of Trustees, Pennsylvania Medical Society

[i] Antiel, Ryan M., Curlin, Farr A., James, Katherine M., Tilburt, Jon C.Physicians' Beliefs and U.S. Health Care Reform -- A National SurveyN Engl J Med 2009 361: e23

[ii] Medical Professionalism in the New Millennium: A Physician Charter
Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine Ann Intern Med February 5, 2002 136:243-246

[iii] Keyhani, Salomeh, Federman, AlexDoctors on Coverage -- Physicians' Views on a New Public Insurance Option and Medicare Expansion. N Engl J Med 2009 361: e24

[iv] Health Insurance and Mortality in US Adults.Wilper et al. Am J Public Health.2009; 99: 2289-2295

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Physician's Perspective on Health Reform Slides

I updated my slides on physicians' opinions on health reform for a talk tonight for the Pittsburgh Chapter of Drinking Liberally.

The new slides are here. ( I hope I fixed the link!)

I had to strip out the slides of me (and Doctors for America) at the White House, and on our way TO the White House, already in our white coats in order to get under the 5 MB Google docs limit.

Cheers,

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NEJM -- Doctors on Coverage -- Physicians' Views on a New Public Insurance Option and Medicare Expansion

NEJM -- Doctors on Coverage -- Physicians' Views on a New Public Insurance Option and Medicare Expansion:

"Overall, a majority of physicians (62.9%) supported public and private options. Only 27.3% supported offering private options only."

I realized I didn't have this posted yet! The 3/4 of physicians ties in nicely with my estimate that physicians groups representing 3/4 of physicians also support health care reform in general and HR 3200 in particular.

The companion article is instructive, too.

a large majority of respondents (78%) agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data "to determine which treatments will be offered to patients.

...the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform.

This last bit is a bit interesting, as at our Pennsylvania Medical Society Board retreat we discussed this last bit and the overwhelming consensus, as best I could tell, was that this was not controversial, and that part of our jobs was making these determinations.

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Eight of Ten Largest Physician Groups Back HR 3200

(Original Title) "American Psychiatric Association voted unanimously to support H.R. 3200"

Medical News Today News Article - Printer Friendly:

The Board of Trustees of the American Psychiatric Association voted unanimously to support H.R. 3200, America's Affordable Health Choices Act, as the basis for health reform.

'In doing so, the APA is pleased to stand with the American Medical Association,' said a letter presenting the board's decision to the American Medical Association. 'The APA Board of Trustees also voted to support the concept of a public plan option based upon the voluntary participation of physicians and other healthcare professionals in the ongoing dialogue of health care reform.'

'While H.R. 3200 - like any bill - is not perfect, we recognize that it offers many positive benefits for psychiatrists and other physicians, and most importantly for our patients,' the letter said.

This now adds the 9th largest physician organization to be on board for HB 3200, including the AMA, ACP, AAFP, AAP, AOA, ACS, and ACOG.

For completeness, #8, the American Society of Anesthesiology and #10, the Amercian College of Radiology are still against reform until they get reimbursement "fixes."

#11, the American College of Emergency Physicians is still waiting for final form bills to commit.

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Daily Kos: A few anecdotes about medical care in America...

Daily Kos: A few anecdotes about medical care in America...

I posted this on DailyKos tonight. Please go read the rest and chime in!

On many levels, I hate to venture into anecdote territory when it comes to health care reform. I don't think it informs the debate in a helpful manner, and yet, it seems to be one of the two major arms of the conservative campaign against health care reform. First, they argue, look how awful it is everywhere else and how wonderful we have it here in America with THE Best Health Care System in the World (TM) and second, they find even Medicare, Social Security and unemployment benefits ideological anathema.

I can't do anything about the second one, but I do have something to
say about the first.

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The Health Care Blog: How to Rein in Medical Costs, RIGHT NOW

The Health Care Blog: How to Rein in Medical Costs, RIGHT NOW
From Dr. George Lundberg...

"So, what can we in the USA do RIGHT NOW to begin to cut health care costs?

An alliance of informed patients and physicians can widely apply recently learned comparative effectiveness science to big ticket items, saving vast sums while improving quality of care.

1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.

2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.

3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.

4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.

5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.

6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.

7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved."

My personal opinion is that all of these issues are not solely driven by economics, but just as often by being the path of least resisitance. It is generally easier to do the "next thing," rather than having difficult conversations about a CABG or intervention or chemo regimen or whatever, and the real risks and benefits to the patient in front of you. So rewarding patient care and outcomes and time spent or simply not rewarding so generously all of these procedures could go a long way as Dr. Lundberg suggests.

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450,000 Doctors Demand: ‘Heal Health Care Now’ -- Media Center -- American Academy of Family Physicians

450,000 Doctors Demand: ‘Heal Health Care Now’ -- Media Center -- American Academy of Family Physicians:

Today marks the launch of “Heal Health Care Now.” This Web-based initiative (HealHealthCareNow.org) consists of several elements, including a provocative video of family doctors speaking in support of the health system reform legislation Congress is debating currently. The video culminates with a call to action encouraging viewers to let their legislators know they stand behind nearly half a million doctors to support reform. The Web site also provides a quick and easy tool that encourages viewers to contact their legislators directly.

Also today, organizations representing 450,000 doctors signed and delivered a joint letter indicating their support of health care reform to Sen. Harry Reid (D-Nev.) and his colleagues in the U.S. Senate. The American Academy of Family Physicians along with the American College of Physicians, the American Osteopathic Association, the American Medical Student Association, Doctors for America and the National Physicians Alliance signed the letter which reads in part, “We are confident that the reforms being proposed will allow us to provide better quality care to our patients, while preserving patient choice of plan and doctor.”

Two national nonpartisan health care organizations — the AAFP and the Herndon Alliance — developed the online “Heal Health Care Now” initiative in a strategic effort to counter some of the most potent anti-reform arguments with the most trusted spokespersons — front-line family doctors. The AAFP represents more than 94,000 family physicians and medical students. The Herndon Alliance is a nationwide coalition of more than 200 minority, faith, labor, advocacy, business, and health-care provider organizations, including the American Nurses Association, the American Academy of Pediatrics, the AARP, the Mayo Clinic and Families USA.

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Presentation for Medicare 44th Anniversary

I gave a presentation in Avalon, PA on the occasion of the 44th Anniversary of Medicare, Thusday July 30, for Organizing for America. Thanks to everyone who came and were so kinly receptive to the talk, and of course to Terry, Al, Peter and Sylus for organizing things!

'>The slides are here.

The references in the slides are all on this blog somewhere, just search in the upper left hand corner to find them.

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ACC aghast at proposed cuts to cardiology payments in Medicare physician fee schedule for 2010

ACC aghast at proposed cuts to cardiology payments in Medicare physician fee schedule for 2010:

"Baltimore, MD - The US Centers for Medicare & Medicaid Services (CMS) has announced its planned 2010 Medicare Physician Fee Schedule (MPFS), colloquially known as 'the update,' which includes proposals expected to result in an overall payment cut of 11% for cardiology [1]."

Offered without comment, except to say scroll down and read the comments of the ACC members...

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AMNews: June 29, 2009. AMA meeting: AMA reaffirms stance in health system reform debate ... American Medical News

AMNews: June 29, 2009. AMA meeting: AMA reaffirms stance in health system reform debate ... American Medical News:

"Chicago -- Addressing what has become the hottest flashpoint in this year's health system reform debate, the American Medical Association House of Delegates at its Annual Meeting in June renewed its existing reform policies rather than declare a position on whether lawmakers should establish a new national federal health insurance plan that would compete with private insurers.

"Delegates agreed that the AMA should 'support health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice and universal access for patients.'

"Both supporters and opponents of the public plan concept wanted the Association to take a definitive stand on the issue. But after AMA Immediate Past President Nancy H. Nielsen, MD, PhD, warned that such a move could handicap the organization as it tries to influence the health reform debate, delegates backed away from those resolutions.

"Dr. Nielsen said the resolution that ultimately passed would allow her and AMA President J. James Rohack, MD, to keep the AMA engaged in the debate without restriction but with a clear directive to advocate for choice for both physicians and patients."

An encouraging sign for progressives at the AMA House of Delegates. I am pleased to be wrong in expecting the conservatives to win the day and the resolution that passed gives wiggle room to the AMA leadership.

It is worth pointing out that there will be much struggle throughout this process. AMA policy language stands largely against any reforms leading to any expanded role for government in health care and specifically declares that an "Unfair concentration of market power of payers is detrimental to patients and physicians," and labels single payer as such and calls for continued opposition by the AMA.

Interestingly enough, however, the AMA has endorsed the principles of Medical Professionalism of the ABIM, ACP-ASIM and European Federation of Medicine. This Charter unequivocally advocates the physicians role in promoting social justice, fair distribution of finite resources and promoting fair access to care.

I am sure my conservative colleagues would argue that this can all be achieved by a more libertarian/Randian approach to health care, but I think, finally, that the number who believe that is growing smaller by the week.

Certainly polls indicate that most physicians now recognize that our system is broken and that the cure is not rearranging the deck chairs on this sinking ship and clinging to a heyday that hasn't offered us or our patients much "hey."

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Dr. Chris McCoy: Dear AMA: I Quit!

Dr. Chris McCoy: Dear AMA: I Quit!:

"Dear American Medical Association,

"I recently had the opportunity to read your response to the Senate Finance Committee proposal [pdf] for health care reform, and it is clear to me that I cannot remain a member in your organization. Please remove my name from your membership rolls, effective immediately.

"In reading the response, I was frustrated and disheartened by the fact that you couldn't get through the second paragraph before bringing up the issue of physician reimbursement. This merely highlights how the AMA represents a physician-centered and self-interested perspective rather than honoring the altruistic nature of my profession. As a physician, I advocate first for what is best for my patients and believe that as a physician, as long as I continue to maintain the trust and integrity of the profession, I will earn the respect of my community. The appropriate financial compensation for my endeavors will follow in kind."

Read on. I agree with everything he says here, and yet, until the AMA House of Delegates meeting this week has concluded, I will withhold judgement and retain my membership.

If the floor fight at the House of Delegates takes shape as I predict, the old (literally) guard will get reaffirmation of every anti-reform policy reaffirmed and get an anti- public option policy added and will force the AMA leadership (progressive as they might be) to act like the AMA of old and start fighting reform.

We'll see. I have friends in leadership in AMA and they say it has changed.

We'll find out very soon.

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From our friends at the South Carolina Medical Association

Dear Colleague, [This was sent to the members of the SCMA - my comments are in italics below.]

The momentum that has been building in support of a nationalized health care system appears to be overwhelming. With health care overhaul bills on the fast-track in Congress, and with a new and powerful administration determined to pass legislation this year, the deck is stacked against us. We’ve been told to sit in the corner and watch while the “experts” figure out how to fix health care. The problem is that the “experts” who are fixing health care are the same people who have run Medicare into insolvency and created a Medicaid system that is inefficient and ineffective.

The federal government is kicking us down the road toward indentured servitude. Envision a world where each decision you make for every patient has to be approved through the laborious channels of government bureaucracy. Imagine the federal government dictating to you which patients yo can and cannot see and which treatments you can and cannot provide—not just for Medicare patients but for all of your patients. Consider what it will be like to be reimbursed for all of your patients at levels significantly less than current Medicare.

Physicians have been offered a seat at the table so long as we sit still with our hands folded in our laps and keep our mouths shut. Dutiful compliance and inaction are no longer options. The muzzle that the Feds placed on us must be removed and the decibel level of our voices must be raised so that we are unmistakably heard. We’re not suggesting a strike, but anything short of that is the kind of bold and thunderous statement we need to be making right now.

The leadership of the South Carolina Medical Association senses the anger and the building resentment and confusion that physicians are currently experiencing. Our commitment to channeling these strong feelings into action is strong and will not lessen. W will not stand silent and watch while the federal government destroys our health care system. In the next few weeks, we will be laying out a course of action to ensure that our voice is heard. Be ready to act quickly, speak loudly, and fight for your career and the health care freedoms your patients deserve.

[Signed by the President and Chair of the Board of the SCMA]

Wow. They must be practicing in paradise down there in South Carolina. No problems, everybody's insured, getting great preventive and chronic care, nobody goes bankrupt from health care expenses, etc. Maybe we all should move there. Because, you know, in the rest of the country we have ridiculous bureaucracies, rules, and non-physicians telling us what we can do and who we can see and what we can charge already, only they are our private health insurance companies.

But here is the money quote, "Consider what it will be like to be reimbursed for all of your patients at levels significantly less than current Medicare. " And that' really what it boils down to for so many, doesn't it? And besides, the answer to this question is that, if I don't have to hire a team of staff to fight with PRIVATE insurers to get reimbursed, to get prior approval, to jump through all of their hoops, maybe that reimbursement would result in a higher net reimbursement. And at least Medicare doesn't tell my patients whether they can see a physician because he's not on the right panel.

SCMA, what is the solution? Or aren't there any problems with the health care system in South Carolina.

Maybe they're still all practicing in Mayberry in the 1950's, but for the rest of us, we need to fix this broken system!

I ranted further over at dailykos...

Wow. This is not about healthcare reform with these people. These are like the Japanese soldiers found on islands 20 years after WW II, still fighting against the Yankees. They are opposing a Soviet medical gulag, entirely a figment of their imaginations and deep paranoia. Lively debate, eh?

But, to the letter's substance, and frankly, its' ignorance.

Nationalized, or singe payer, if that's what they mean, is pretty much off the table according to the guys in charge of the process like Baucus. It would be nice to have the momentum for that, but although there are vocal supporters at the grass roots level, the powers that be will not hear of it. But sadly, I doubt they even know what they mean when they say "nationalized." I am sure they have some conceptual bogey man system hybrid of the UK, Canada, and the old Soviet Union in their heads, but I am equally certain they have not spent more than 10 minutes actually learning any comparative health care, even bothered to investigate the systems in Germany, France, Australia and elsewhere.

"The deck is stacked against us." Is that against patients, physicians, insurance companies, who? Who is the deck stacked against?

"We've been told to sit in the corner..." Really? The message I've heard from Congress and the White House is that they value and want physician input. Maybe they don't want bat-shit crazy input, but they want input.

"The same people who have run Medicare into insolvency..." Um, that would fall quite largely on the shoulders of physicians. We have abdicated our role in shaping health care policy and controlling spending and reducing unwarranted and dangereous practice variation and having realistic end-of-life discussions with our patients and so on. We have also not called BS on the private insurers who steal health care dollars in the name of private enterprise and we have taken the money of Pharma for ou meetings and lunches and pretended they were spending all that money on R & D and not on recruiting cheerleaders. Literally recruiting cheerleaders.
But I'm with them on the Medicaid thing.

"The federal government is kicking us down the road toward indentured servitude." Seriously? Don't you guys have private health insurance companies in South Carolina? But really, this letter is not about health care, this is a stale ideology in its last throes.

"Physicians have been offered a seat at the table so long as we sit still with our hands folded in our laps and keep our mouths shut. "
Again, one has to have reasonable views to expect to be listened to seriously Foaming at the mouth like Zell Miller and Sean Hannity does not invite reasoned discussion. But listen, all of the physician supporters of single payer have much more to gripe about than the SCMA. At least organized medicine is participating in discussions, while PNHP has to have a major grass roots insurrection just to get invited to the White House photo-op. If anybody has the right to gripe about exclusion, it's the progressives, not the conservatives.

"The leadership of the South Carolina Medical Association senses the anger and the building resentment and confusion that physicians are currently experiencing." I expect this is true. SC represents a far more conservative population than most states (it's in the top 10 most red states), and so their phsyicains likely are more conservative as well. So, fine, make your case, but we will not sit quietly by and let you screw up the best chance for health care reform we've had in this country's history.

The final line about fighting "for your career and the health care freedoms your patients deserve." Again, maybe I'm practicing in a dark dystopic bit of America, but around here, that ship has sailed. Our patients, even the insured ones, have little choice in doctors or hospitals. They only go to whom and where their plan allows. No "freedom" there. And our careers? Whose careers? Your primary care physicians careers? Really? I'll let my colleagues decide who you're really looking out for. My bet is that you're looking out for your failed ideology, not for physicians or patients.

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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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U.S. Physicians’ Views on Financing Options to Expand Health Insurance Coverage: A National Survey

U.S. Physicians’ Views on Financing Options to Expand Health Insurance Coverage: A National Survey:

MAIN RESULTS

1,675 of 3,300 physicians responded (50.8%). Only 9% 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% 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%); 33% believed that the uninsured currently have access to needed care. Nearly one fifth of respondents (19.3%) believed that even the insured lack access to needed care. Views about access were independently associated with support for single-payer national health insurance.

CONCLUSIONS
The vast majority of physicians surveyed supported a change in the health care financing system. While a plurality support the use of financial incentives, a substantial proportion support single payer national health insurance. These findings challenge the perception that fundamental restructuring of the U.S. health care financing system receives little acceptance by physicians.

This is the article referenced in the post below this one on physicians and physicians' organizations views on health care reform. The full article is here and in PDF.

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