Divergent views: New England Journal of Medicine Intelligentsia vs. Practicing Doctors

It amazes me how the views of NEJM authors in its “Perspective” section diverge from the views of practicing physicians.

NEJM pieces favor federally directed care and look kindly on the health reform law. Practitioners are profoundly skeptical and negative about many provisions of the new law. In different surveys, some 80% to 90% of physicians say they will severely restrict or refuse to accept Medicare or Medicaid patients.

Perhaps this divergence is inevitable. NEJM contributors tend to be lawyers, PhDs, or MD academics hailing from the Boston-New York- Washington- West Coast policy making, academic, progressive metropolitan complex. Practitioners are MDs or DOs, who come from everywhere – the South, Midwest, Southwest, the outlying East, and rural regions in between.

As I ponder differences in points of view, I recall the words of General George Patton when asked if he read the Bible. He responded,”Every God Damn day!” Likewise I read the NEJM every God Damn week. It is the Bible of America’s policy making elite. Its aim is to politically transform health care and to remake a vast U.S. medical industry into its image of how things ought to be, as directed from Washington.

NEJM authors trust Washington to do the right thing. Practitioners do not. Nearly 90% of doctors feel they were not adequately represented during the debate running up to passage of the health bill.

To make my point, here are three articles appearing in the July 29 NEJM.

One, S. Rosenbaum and J. Gruber, “Buying Health Care, the Individual Mandate, and the Constitution.” Rosenbaum is from the Department of Health-Policy, School of Public Health and Health Services, George Washington University Medical Center, Washington, D.C. Gruber hangs out at the Massachusetts Institute of Technology in Boston. Rosenbaum is a lawyer, and Gruber is an economist. The thrust of their article is that the health reform act is necessary is “to end pervasive discriminatory insurance practices while making health care affordable.” Attaining this goal, they maintain, is not possible without the individual mandate. The law, they say, ensures access to affordable coverage for most and rationalizes economic behavior for all. Practitioners disagree. They feel the new law will limit access because doctors do not have the time or resources to deal with the flood of new patients, and Congress does not and will not provide them with what it takes to carry out health reform mandates.

Two, Henry Aaron, PhD, “The SGR for Physician Payment – An Indispensable Abomination,” Aaron is from the Brookings Institute, a well-known think tank in Washington, D.C. It is usually described as “liberal.” The SGR was enacted in 1998 to hold down growth of Medicare physician fees. It ties fee growth to the GDP. As usual because of physician outcries about SGR unfairness, Congress has extended SGR for 6 more months. Congress, Aaron says, will never abandon the SGR entirely because of the necessity to reduce the federal deficit. Further, the threat of letting it take effect is a useful leveraging point to compel doctors to join accountable care organizations, promote bundle payments, and cooperate with health reform. His attitude is that the SGR is an “indispensable abomination” - something Congress needs to enforce reform. In surveys, practitioners indicate the SGR is indeed an abomination, or Obamanation, that stiffens their resistance to health reform.

Three, Yuting Zhang, PhD, Katherine Baker, PhD, and Joseph Newhouse, PhD, “Geographic Variation in Medicare Drug Spending,” The three authors are from Departments of Health Policy at Universities of Pittsburgh and Harvard. In their opening sentence, the PHDs assert, “The widespread geographic variation in Medicare spending has garnered a great deal of attention in the health care debate, both as a marker of inefficient resource use and a window into potential strategies for improving the quality of value of U.S. health care.”

The idea, which has evolved from the Dartmouth Institute, is that if only we could homogenize and standardize treatments and fees in different sections of the country, quality would improve and costs would drop. The authors note that pharmaceutical spending accounts for 20% of Medicare costs. They do not reach any conclusions as to how Medicare can reduce pharmaceutical spending or overall regional variations, nor do they suggest how physicians can help. As for practitioners, they are skeptical centralized Medicare programs can ever reach down to the level of physician-patient interactions or will ever take into account or understand differing socioeconomic or practice conditions in different sections in the country.