Who Speaks for America’s Grassroots Physicians?

An Interview with Don Alexander, CEO of Tennessee Medical Association and Chair of Communications Committee of the Physicians Foundation (physiciansfoundation.org)

By Richard L. Reece, MD

Preface: When I speak of grassroots physicians, I am speaking of hundreds of thousands of independent American physicians who own their own practices. I am speaking of primary care and specialty physicians who practice in every hamlet, town, suburb, and city across America. I am speaking of physicians who supply most of America’s medical care.

Who speaks for them? Increasingly it is a 501 C3 charitable organization called the Physicians’ Foundation, founded in 2003 as the result of a class action settlement between state medical societies and major health plans. These plans originally funded the Physicians Foundation.

State medical societies are a powerful force in America because they are close to the ground and close to practicing physicians. Most of these grassroots physicians still practice solo or in groups of ten or less.

Before resigning in frustration as the first national “HIT Czar,” David Brailer, M.D. , whose mission was to develop an interoperable electronic health record system across the land, observed in a 2005 New York Times interview , “The elephant in the living room is what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.”

That was true then, and it is true today. Indeed, in my opinion, the successful implementation of the Affordable Care Act will depend to a large extent on how these grassroots physicians feel, react, and accommodate to the health reform law. If they cut back or withdraw to care for Medicare and Medicaid patients, the U.S. will have an access problem of monumental proportions.

To get a sense of the activities of the Physicians Foundation, I recently interviewed Don Alexander, CEO of Tennessee Medical Association for the last 15 years and Chairman of Communications Committee of the Physician Foundation since 2003.

Interview

What is the function of the Communications Committee?

Our charge is to use as many ways as possible to send to our various audiences messages about the Foundation, successes of the Foundation, and remind our audiences the mission of the Foundation. As you know, these days, there are many avenues for those communications. We use electronic communications as much as possible. We focus on narrowing down our messages, to keep our name out there.

Who are your audiences?

Our primary audience are physicians across the country, regardless of specialty or region.

Our second audience are those medical organizations who were part of the founding of the foundation, which came about as the result of the settlement of a class action law suit against national managed care organizations. These medical organizations include state medical associations, county medical societies. The entire federation of medicine then becomes our audience.

A third audience is the general public. They need to be aware of our efforts to help physicians compete in this medical practice world. Our goal is to make those practices more efficient, more patient friendly, more productive.

Fourth, (or lastly) we have a political audience, i.e., decision makers, in Washington and in states, and in state medical associations.

Those are the four main audiences we try to reach through our communication activities.

Are you primarily an educational organization?

We are not limited to education. We are also a research organization. We have major research projects as well as a grant-making organization highlighting best practices.

We try to educate our audiences on needs and issues physicians face in this modern practice world.

Talk a moment about your current projects, the results of which will be released in the next few months. The Foundation just issued $2 million worth of grants.

Yes, these grants had two different focuses – health information technology and physician leadership.

On the health technology side, we are seeking to find out what constitutes the best use of IT. Electronic medical records may make for more efficient and some feel better care, but whether IT will save money is an open question. Our grants will help us find what works best.

We see a pressing need for physician leadership at the grassroots level in the states. We’re focusing on the next generation of physician leaders. If the private practice of medicine is to survive, physicians must take the lead rather than complain about what third party payers are handing to them, and what politicians are doing to them.

To make physician leadership a reality, the Foundation has been working with Kellogg school of management at Northwestern to bring in physician leaders from various states for courses in leadership.

Exactly. We will be in our second round of those courses this coming spring. The first round was highly successful. Physician leadership is one of the Foundation’s cornerstones. We hope we’ll have physician organizations battling to take spots in those leadership courses.

Again, this is grassroots leadership – where the practice is, where the action is, medical societies, and medical staffs. This is filling a gap between the older generation and the younger generation. We’re excited about the results and anxious to communicate those results to our various audiences.

Another thing the Foundation has done is offer a grant to a Boston-based organization called Project Health, which now operates in seven major cities. Project Health helps doctors plug holes in social safety net created by poverty.

This is a project with a different twist from what medical organizations traditionally become involved in. Project Health acknowledges problems that other major foundations like Dartmouth, the Commonwealth Fund, and the Robert Wood Foundation don’t always recognize – that the social aspects of one’s life are directly related to health. One cannot treat just a child’s sickness, and expect it to be cured, without addressing conditions in the home - access to food, housing, unemployment, family issues, and medical transportation.

It is hard for physicians to address these issues because they are on a treadmill, just seeing patients. With Project Health, they can write “prescriptions” to be filled by college volunteers at Help Desks in various health care settings – hospitals and clinics – that direct patients to social services.

Project Health helps doctors help patients stay healthy by providing access to social services generally outside the immediate reach of physicians. Physicians cannot control the other needs of patients that adversely affect their health, but after are blamed for poor health outcomes.

Another thing the Foundation has put a lot of time, money, and effort into is highlighting the impact of health reform on physician practices. Because of the physician shortage, practices are already overloaded, and now they are expected to care for 34 million new uninsured and the 78 million baby boomers coming on board of Medicare in 2011 at the rate of 13,000 per day over the next 16 years.

How will they cope with these new demands?

That, of course, is the question. And everybody is struggling to find answers. There was a shortage even before we start adding new patients to the government rolls. Some answers are enhanced and proper use of mid-level practitioners. Overloading of physician practices and the stresses on those practices was not something that Congress, in its lack of wisdom, took into account when the passed the health reform acts.

The Foundation has a skeptical view of whether future physicians can take care of this wave of new patients. You certainly cannot heap more red tape, more hassles, and more expense on them because you will drive physicians out of federal programs and out of the health care system. We think things are going to get worse before they get better. Congress was so caught up in politics; they didn’t consider the patients or physicians’ practices.

One of the major contributions of the Foundation has been the survey last year of 300,000 primary care physician and a current survey of 40,000 physicians of what they perceive and how they will respond to reform. For the first time, these large in depth surveys give us a useful and precise handle on doctors’ attitudes, reactions, and actions in response to reform.

That’s a big part of goal – to communicate what these surveys are saying. It’s scary to read what physicians across the country are saying. If you put more pressure on my practice, if you force me to do what I can’t afford. I will quit seeing government-sponsored care. The decision makers aren’t listening;. They simply don’t believe physicians will cut back on seeing patients or they will retire or quit practice.

And they don’t believe there will be an exodus of doctors from Medicare and Medicaid programs?

They proved that when they said we are going to slash physician reimbursements, and they kept playing games with SGR (Sustainable Growth Rate) formula).

For politicians, underpaying doctors is a calculated gamble. Policy makers, decision makers, and politicians know physicians are dedicated to their patients, and they know the last thing they will do is forsake their patients. They may not forsake their patients, but many will say, “I’m getting out of the practice of medicine.” Our surveys indicate doctors will cut out certain future segments of care, but will not totally forsake current patients

Do you foresee, maybe in the next three or four years, a massive access crisis with an accompanying political crisis?

Mass exodus, I don’t think so. But more than anybody ever predicted. It depends on where physicians are in their practice life, where they are in their careers.

If they think they can continue and provide quality medicine, they will continue to practice, but when they feel they cannot take care of patients as they were trained to do, or if somebody interferes with care, they will either cut back or change careers.

How do you communicate your concerns to the world at large? I know you are working with the Global Strategy Group to reach a wider media audience.

As volunteer members of the Physicians Foundation board, we need professional help- with communication strategies, media contacts, marketing know-how. We have contracted with the Global Strategy Group, and they have helped establish a greater media presence.

We want to reach as many people as possible with our limited resources- through press release, media contracts, and an Internet presence. The Global Strategy Group helps us narrow down and get our message out there.

Part of your message, as I see it, is to highlight what’s going on in the physician world and to put it n a bright light that the public and others haven’t really understood or seen before.

That’s quite a challenge. Pick up any medical magazine, or any publication at random off the news rack, and you’ll read conflicting opinions about health care. To get the physicians’ message out there is extremely difficult. People still love their own doctor. They rate physicians highly, but beyond their own physician, they see physicians in general as having financial means. They are reluctant to embrace the positions of medical organizations. Yes, it’s hard to educate the public, not only the intricacies of care but on why the system is broken.

Add to that the fragmented media world – with talk radio, TV talking heads, bloggers, the Internet, and the social media – and it must be tough to reach all your audiences concurrently.

It’s impossible. The media is open 24 hours a day, is hungry for information, particularly bad news, which sells better than good news. The media does not report the news any longer. It sees its role as “creating the news.”

Overall, do you think the Foundation is making progress? You’ve got these thoughtful reports, constructive grants to improve care, and insightful physician surveys coming out, and you’re telling the world what the life of physicians are all about.

We are making progress. We’re telling our audiences of what we’re doing, and we’re informing them of the benefits of what we’re doing.

People sometimes forget that universal coverage without universal access to doctors is meaningless. Doctors remain the backbone of the health system. These self-evident truths have to be clearly articulated and set forth.

We have a great pool of knowledge on how to make the system better, and if we can keep the patient-doctor relationship intact, we will survive. If you put wedge between doctors and patients, the health system will suffer and begin to crumble.

Let me end by asking you about Tenncare, and Tennessee’s experience with a federal Medicaid-based program designed to help the uninsured, poor, children, and disabled adults.

The failure of that program, started in 1993- 1994, which resulted in runaway costs, near bankruptcy of the Tennessee state budget, and non-participation of many if not most of Tennessee’s physicians. That experience must give you pause and skepticism about the prospects of national reform efforts.

Don’t get me started. I’ve been intimately involved with Tenncare for over 15 years, and I could talk all day and night about it. Tenncare is a precursor to what the present health reform is all about.

When Tenncare started, we had about 800,000 people on the Medicaid rolls. We added another 500,000 people. The State said we will add a half-million people, but we’re not going to put any more money into the program. We will manage our way through this, and we will save money.

Tenncare was a disaster. You have to put more money into it, or physicians won’t participate. The managed care organization took 15% off the top with no real oversight, and they paid doctors 30% on the dollar for taking care of patients.

The Tennessee Medical Association tried to delay the implementation of Tenncare through the courts, but it was put in place practically overnight.

It’s been a catastrophe. A lot of small businesses stopped covering employees. They switched them to Tenncare. Suddenly Tenncare’s future was to eat up 40% of the state’s budget. The present governor has taken people off the rolls that don’t belong there, but it still a case of how not to provide healthcare. When Tenncare kicked in, the number of “uninsurable ” went from 12,000 to over 100,000.

In a lot of ways, the Tenncare experiment may forbode what will occur with present reform, only there are 34 million people, not 12,000. The burden to care for them will fall on hospitals and doctors. National reform will only work if physicians get a fair and honest reimbursement. Otherwise physicians will not be able to sustain their practices and stay in medicine, and ultimately it is the patients who will suffer.