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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PAFP/F: Access to Primary Care in Pennsylvania

Survey findings from the Pennsylvania Academy of Family Physicians, January 2013

PAFP/F: Access to Primary Care in Pennsylvania

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PLOS ONE: Healthcare Reform and the Next Generation: United States Medical Student Attitudes toward the Patient Protection and Affordable Care Act

PLOS ONE: Healthcare Reform and the Next Generation: United States Medical Student Attitudes toward the Patient Protection and Affordable Care Act

Of medical students surveyed, 94.8% agreed that the existing United States healthcare system needs to be reformed, 31.4% believed the PPACA will improve healthcare quality, while 20.9% disagreed and almost half (47.7%) were unsure if quality will be improved. Two thirds (67.6%) believed that the PPACA will increase access, 6.5% disagreed and the remaining 25.9% were unsure. With regard to containing healthcare costs, 45.4% of participants indicated that they are unsure if the provisions of the PPACA will do so. Overall, 80.1% of respondents indicated that they support the PPACA, and 78.3% also indicated that they did not feel that reform efforts had gone far enough. A majority of respondents (58.8%) opposed repeal of the PPACA, while 15.0% supported repeal, and 26.1% were undecided.

Conclusion

The overwhelming majority of medical students recognized healthcare reform is needed and expressed support for the PPACA but echoed concerns about whether it will address issues of quality or cost containment.

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JAMA- AIM | Physicians' Opinions About Reforming ReimbursementResults of a National SurveyReforming Reimbursement

Physicians' Opinions About Reforming Reimbursement Results of a National SurveyReforming Reimbursement

Results

The response rate was 48.5% (n = 1222). Four of 5 physicians (78.4%) indicated that under Medicare, some procedures are compensated too highly and others are compensated at rates insufficient to cover costs. Incentives were the most frequently supported reform option (49.1%), followed by shifting payments (41.6%) and bundling (17.2%). Shifting payments and bundling were more commonly supported by generalists than by other specialists. There was broad support for increasing pay for generalists (79.8%), but a proposal to offset the increase with a 3% reduction in specialist reimbursement was supported by only 39.1% of physicians.

Conclusions

Physicians are dissatisfied with Medicare reimbursement and show little consensus for major proposals to reform reimbursement. The successful adoption of payment reform proposals may require a better understanding of physicians' concerns and their willingness to make tradeoffs.

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Physicians' Views of the Massachusetts Health Care Reform Law — A Poll — NEJM

Physicians' Views of the Massachusetts Health Care Reform Law — A Poll — NEJM:

Of 2135 practicing Massachusetts physicians who responded to the poll, 70% said they support the Massachusetts Health Care Reform Law, whereas 13% oppose it.

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Temperatures Rise Over Costs Of Care | Worcester Business Journal

Temperatures Rise Over Costs Of Care | Worcester Business Journal: Higher Sentiment For ‘Single Payer’?

Presumably, doctors are more familiar than the general public with the pressures driving up health care costs, and an overwhelming majority of them also say there needs to be some government involvement in the health care system. A survey by the Massachusetts Medical Society this fall found that 41 percent of doctors thought the best option for health care reform in the U.S. would be to adopt a single-payer system like Canada’s. That number was up from 34 percent in 2010.

Another 23 percent favor a mix of public and private plans, while 17 percent support reforms along the lines of the 2010 national health care reform act, including an individual mandate like Massachusetts’. Fifteen percent favor a system in which insurers can sell limited-benefit and high-deductible policies and the government gives subsidies to help low-income people buy insurance.

Lynda Young, president of the Massachusetts Medical Society (MMS) and a Worcester pediatrician, said doctors who favor a single-payer system may see it as a way to avoid administrative burdens. She noted that a recent article in the policy journal Health Affairs found that Canadian doctors spend two or three hours a week on administration, compared with about 10 to 15 hours for doctors in the U.S.

Pretty remarkable, especially when you look at the numbers in the graph. 41% plus 23% for 64% favoring either single payer or a 'public option' added to the current mix. 17% OK with the PPACA as it is, and another 15% seeming to favor high deductible plans.

That's a grand total of 81% favoring PPACA at least, the distinct minority,  with the significant plurality favoring single payer. Wow.

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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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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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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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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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"Doctors, too, are ready for CHANGE" | The Register-Guard | Eugene, Oregon

"Doctors, too, are ready for CHANGE" The Register-Guard Eugene, Oregon:

"For most of the last century, no single group was a bigger obstacle to universal health care than organized medicine. Today, perhaps no single group stands more united in support of some form of universal coverage.

"Before their lost battle against President Lyndon Johnson and Medicare, the opposition of major medical organizations and individual physicians guaranteed doom for various state and presidential efforts to establish either a national health plan or other means to achieve universal health insurance.

"Now, surveys reveal that overwhelming numbers of physicians resent the current crazy patchwork health care system, which fixes their reimbursements, regulates and too often denies patient care, and piles physicians with paperwork so unending and from so many directions that the average doctor has little time left over to challenge the status quo.

"Add to all this the frustration arising from working for no pay to coordinate care and provide care after hours, from struggling with the cost of health care insurance for their own employees, and from seeing their uninsured and underinsured patients go without recommended care, and what emerges is widespread physician support of radical reform.

"More than four-fifths of physicians now agree that our health care system either needs fundamental changes or should be rebuilt completely."

Keep reading, this is a nice summary of where the specialty societies are coming down on health care reform, and it is encouraging...

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Millennial [Generation] Physicians

From the last slide of a lecture on the characteristics of the Millenial Generation in Medical School.

Listening to a talk recently, the speaker indicated that the Millenial generation has distinct views of work/life balance compared to us older docs. They value time off and independence. They value work and the marginal benefits of longer hours to achieve higher income as simply not really worth it.

I hope this portends some good for the profession, though the trend towards not viewing medicine as a calling may alarm some. I tend towards the Millenial view, however, seeing my profession more as a way of contributing to the world than as a true calling. And it looks like that is the majority view of my generation, the Boomers.

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AMNews: April 21, 2008. More physicians backing national coverage -- study ... American Medical News

AMNews: April 21, 2008. More physicians backing national coverage:

"Physicians who support 'government legislation to establish national health insurance'
-------------------------2002-------------2007
All specialties------------49%--------------59%
Psychiatry---------------64%--------------83%
Pediatric subspecialties---71%--------------71%
Emergency medicine-----53%--------------69%
Pediatrics----------------64%--------------65%
Internal medicine--------56%--------------64%
Medical subspecialties----50%--------------63%
Pathology----------------n/a---------------60%
Family medicine----------44%--------------60%
Ob-gyn-------------------48%--------------58%
General surgery----------52%--------------55%
Surgical subspecialties----37%--------------45%
Anesthesiology-----------35%--------------39%
Radiology----------------n/a---------------30%

I will try to get more of the details to the original article from the April 1 Annals of Internal Medicine tomorrow, as I can't access it here at home tonight.

Update: here is the link to the Annals page. Actually not much more info there but here is the full results summary:

Results: Of 5000 mailed surveys, 509 were returned as undeliverable and 197 were returned by physicians who were no longer practicing. We received 2193 surveys from the 4294 eligible participants, for a response rate of 51%. Respondents did not differ significantly from nonrespondents in sex, age, doctoral degree type, or specialty. A total of 59% supported legislation to establish national health insurance (28% "strongly" and 31% "generally" supported), 9% were neutral on the topic, and 32% opposed it (17% "strongly" and 15% "generally" opposed). A total of 55% supported achieving universal coverage through more incremental reform (14% "strongly" and 41% "generally" supported), 21% were neutral on the topic, and 25% opposed incremental reform (14% "strongly" and 10% "generally" opposed). A total of 14% of physicians were opposed to national health insurance but supported more incremental reforms. More than one half of the respondents from every medical specialty supported national health insurance legislation, with the exception of respondents in surgical subspecialties, anesthesiologists, and radiologists. Current overall support (59%) increased by 10 percentage points since 2002 (49%). Support increased in every subspecialty since 2002, with the exception of pediatric subspecialists, who were highly supportive in both surveys.

The spin in the AMA News article is predictable (poorly worded survey questions), and, OK, fine, maybe some didn't mean exactly as they answered. We've all taken surveys, and it is true, you can only answer the question that is asked.

But look at some of these numbers because they are astounding. When 45% of physicians in surgical subspecialties (we're talking orthopods, urologists, and neurosurgeons here!) and 55% (!!!!) of general surgeons answer this way, there is a problem.

AMA Policy is against single payer. But AMA policy is determined by it's House of Delegates. This is a very democratically structured body, but frankly, delegates are far older and more conservative than all other AMA members and AMA members are older and more conservative than physicians as a whole, so this is a problem that will take a leader from within the AMA leadership to take up and champion. Which, knowing the culture a bit, would be courageous, but history making.

Putting this together with the Minnesota and Jackson and Coker surveys, we may finally be acheiving critical mass.

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Jackson and Coker Physician Survey on "Universal Healthcare"

Survey details:

"As a result, Jackson & Coker commissioned a survey to determine the opinions of health professionals, especially practicing physicians, on the topic of healthcare reform. The survey results convey their views and advance the ongoing debate at this point in the presidential election cycle."

Jackson and Coker is a physician recruiting firm. I actually got an e-vite to this survey and took it. Most respondents were in practice 15 years or longer, making them likely significantly more Republican and "conservative," so take it with a tablespoon of salt.

I frankly didn't find many surprises in it, much like surveys done by "The Factor" or Lou Dobbs, but I did find a ray of hope in the morass:

When asked, "Should health insurance be controlled by the government or private companies?"
25% said "The Federal Government" and 39% said "Private companies with government oversight."

That gives a surpisingly large (can I say overwhelming?) 64% majority in this survey who sound like they would accept a Single Payer system in the sense of something like a Medicare-for-All system of government contracted payers.

Wow. The seeds are there.

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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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Political self-characterization of US women physicians

Social Science & Medicine : Political self-characterization of US women physicians:

"The political self-characterization of US physicians, especially including women physicians, has been poorly described. We used data from the 4,501 respondents to the Women Physicians' Health Study (WPHS), a stratified random sample of US women M.D.s surveyed in 1993–1994, to assess US women physicians' political characteristics. US women physicians were most likely to consider themselves politically moderate (36.6% of respondents). More considered themselves liberal (28.4%) or very liberal (8.8%) than considered themselves conservative (20.5%) or very conservative (5.8%). US women physicians predominantly bring moderate and liberal voices to political discourse. Organizations that wish to attract US women physician members should consider promoting less conservative policies."

from Erika Frank at Emory (1999) (she's now at UBC, Vancouver, where she did the study of med students, below).

And another one...

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Political Self-characterization of U.S. Medical Students

Political Self-characterization of U.S. Medical Students:

"RESULTS
Among these medical students, 5% self-characterized as politically very conservative, 21% conservative, 33% moderate, 31% liberal, and 9% as very liberal.” Being male, white, Protestant, intending to specialize in Surgery or anesthesiology/pathology/radiology, or currently or previously being married significantly (P≤.001) increased the likelihood that a student self-identified as very conservative or conservative. Disagreement or strong disagreement with the statements, “I’m glad I chose to become a physician” and “Access to care is a fundamental human right,” were also both associated with being very conservative or conservative. Being more liberal was reported by blacks and Hispanics; those intending to become ob-gyns, psychiatrists, and pediatric subspecialists; and atheists, Jews, and adherents of eastern religions.

CONCLUSIONS
U.S. medical students are considerably more likely to be liberal than conservative and are more likely to be liberal than are other young U.S. adults. Future U.S. physicians may be more receptive to liberal messages than conservative ones, and their political orientation may profoundly affect their health system attitudes."

from Erica Frank, Jennifer Carrera, and Shafik Dharamsi

A little more on this topic. There is hope!

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Physicians views on Single Payer

This is not new data, but I am just trying to get as much information into this blog as I can. So here we go, first from Archives of Internal Medicine in 2004, by Himmelstein and Woolhandler of PNHP:

Single-Payer National Health Insurance: Physicians' Views

Danny McCormick, MD, MPH; David U. Himmelstein, MD; Steffie Woolhandler, MD, MPH; David H. Bor, MD

Arch Intern Med. 2004;164:300-304.

Results Of 1787 physicians, 904 (50.6%) responded to our survey. When asked which structure would provide the best care for the most people for a fixed amount of money, 63.5% of physicians chose a single-payer system; 10.7%, managed care; and 25.8%, a fee-for-service system. Only 51.9% believed that most physician colleagues would support a single-payer system. Most respondents would give up income to reduce paperwork, agree that it is government's responsibility to ensure the provision of medical care, believe that insurance firms should not play a major role in health care delivery, and would prefer to work under a salary system.

Conclusions Most physicians in Massachusetts, a state with a high managed care penetration, believe that single-payer financing of health care with universal coverage would provide the best care for the most people, compared with a managed care or fee-for-service system. Physicians' advocacy of single-payer national health insurance could catalyze a renewed push for its adoption.

A response from Dr. Palmisano of the AMA

The Danger of Single-Payer Health Insurance
Donald J. Palmisano
Arch Intern Med. 2004;164(20):2281-2282.
EXTRACT FULL TEXT

Dr. Palmisano cites Dr. Ian Bogle in his "Outgoing speech as Chairman of the British Medical Association Council." Available at: http://www.bma.org.uk/ap.nsf/Content/ARM03chcouncil.

and a survey published a year earlier to make his case: "Support for national health insurance among US physicians: a national survey." Ann Intern Med. 2003;139:795-801.

Regarding the former, England has a National Health Service, not a single payer system, though I always urge us to learn from the faults of other systems. We are not doomed to repeat the mistakes of others (unless we're stupid).

Regarding the second study, which Dr. P argues "found that only 26% supported a single-payer system," here is the results section of the abstract:

Results: Sixty percent of eligible participants returned a survey. Forty-nine percent of physicians supported governmental legislation to establish national health insurance, and 40% opposed it. Only 26% of all physicians supported a national health insurance plan in which all health care is paid for by the federal government. In analyses adjusting for differences in personal and practice characteristics, physicians in a primary care specialty, physicians reporting that at least 20% of their patients had Medicaid, and physicians practicing in a nonprivate setting or in an inner-city location were statistically significantly more likely to support governmental legislation to establish national health insurance.

The editors' notes from the journal:

With the exception of family practitioners, anesthesiologists, and surgical subspecialists, more than half of physicians in major specialties supported national health insurance. Support was highest among pediatricians, psychiatrists, and general internists.

With all due respect to the authors, these questions were as clear as mud. I am very engaged and strongly favor single payer, but I don't know how I would have answered these questions. I'd suggest: "Would you favor expanding Medicare to all citizens?" for instance.

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