Friday, June 26, 2009

The Physician Foundation, Obama, Doctors, and Health Reform - Who Speaks for Doctors?

As the health care debate builds towards a crescendo and my book Obama, Doctors, and Health Reform (, 2009) hits the streets, I am thinking of a new book, to be called Who Speaks for Doctors?

• Patients, of course, 89% of who say they are satisfied with doctors, but patients are not noted for having powerful advocacy groups. The most powerful of these groups, AARP, weighs in on the side of the Obama administration and favors reducing physician income.

• The American Medical Association, but only 15% of 20% belong to the AMA, and the AMA has been neutralized by trying to be everything to everybody. One of the offshoots of the AMA, the Reimbursement Update Committee, sets coding fees for doctors and favors specialists.

• The four major primary care societies representing family physicians, internal medicine, pediatricians, and osteopathic physicians, representing about 30% of physicians. They are having some impacting health reform aimed at “revitalizing” primary care.

• The specialty societies, collectively representing perhaps 60% of American physicians. They tend to represent their specialized interests, particularly their awesome technologies, which have becoming a driving inflationary force, often for the good.

• The academic establishment, representing America’s 130 medical schools, all of whom belong to the American Association of Academic Colleges. A powerful organization, but one which tends to be sympathethic but disconnected from the interests of practicing physicians. Publications such as New England Journal of Medicine and Health Affairs tend to reflect their positions on reform, which tend to liberal.

• The Medical Group Management Association, representing practice managers and physician leaders, in medical groups across the U.S. and perhaps 300,000 physicians in those groups. Publishes an annual survey showing the stagnant incomes and growing overhead of American doctors.

• The Physicians Foundation, which represents perhaps 650,000 physicians in state and local medical societies, and which defends practicing physicians, has issued a national survey reflecting the state of demoralization of primary care physicians, and seeks a more prominent place at the health reform table.

• Medicare and Medicaid, which does not represent doctors but pays them at rates averaging 20% below private plans. These programs are popular with the public, but are open-ended entitlements with no effective cost controls, and their costs are rising at a 34% higher rate than the private sector.

• Lastly, there are lone wolf physicians, who publish in national publications, like the New York Times, USA Today, or the Wall Street Journal, and who try to inform the public what is really occurring on the ground from the individual practicing physician’s point of view. Below is a sample of what one physician, an internist from Washington, D.C., had to say about conditions on the ground.

A Doctor’s Reflection on Health Reform, WSJ, June 23


Dear President Barack Obama and Members of Congress:

I understand that you have undertaken the Herculean task of repairing the health-care system in the United States. As a physician who has practiced medicine for the past 19 years, I think you would benefit from hearing about my experience. I am a board-certified internist with a specialty in endocrinology who currently practices in Washington, D.C. I also provide primary care to many of my patients.

There has been much concern about the rapidly rising cost of health care. I am convinced that costs have increased for a few reasons. First, there are simply more patients in the system. The baby-boom generation has gotten older and now requires care for chronic medical problems. Second, we have unparalleled levels of obesity in our country. This has led to a massive increase in diabetes, hypertension and other chronic problems.

If we could prevent even a small percentage of people from becoming obese and developing these conditions, the costs of health care could go down far enough to cover everyone's insurance. To that end, we need incentive programs to encourage healthy eating and exercise. Vending machines and fast food should be banned from our schools. Children should be provided with meals that are low in saturated fat, refined carbohydrates, and sugar.

Another major issue is reimbursement. You may find this hard to believe, but when I first started practicing medicine in 1990 I received more payment for an office visit than I am currently receiving. This has occurred despite the increasing cost of practicing medicine, which is the result of rising malpractice premiums, rents, staff salaries, professional membership fees, license fees, and costs needed to comply with various new regulations. What other profession has experienced a reduction in reimbursement over the last 20 years?

I feel strongly that if doctors are reimbursed more for office visits, they will spend more time with patients. This will lead to fewer referrals by primary-care physicians and result in lower health-care expenditures. Currently, harried primary-care physicians don't have the time to delve into medical problems with a hint of complexity. So patients who could be dealt with if more time was available are referred to specialists or expensive radiology studies.

I have heard that physicians may be mandated to participate in a government-run health plan. I sincerely hope that this is not true. First of all, it sounds unconstitutional. As free individuals and citizens of this country, physicians should not be forced to participate in any plan. We have paid for our professional training and worked hard to distinguish ourselves. We owe no debt to the government. If you want physicians to participate in your plan, give them the right incentives and they will flock toward your program.

Electronic medical records have been praised as a way to save money and avoid duplication of tests. It's true that electronic medical records will save some money, but not as much as you probably are counting on. In my practice, if a patient tells us he had a test performed, we call the physician or medical facility to retrieve the results. But a standardized electronic platform will likely be useful for physicians and should lead to better care.

Contrary to what you may have heard, my experience is that smaller practices provide better patient care than larger practices. There are no economies of scale in medicine. If you hire more physicians, you need to hire more support staff to deal with the increased work demands. Larger practices with less support per physician often end up providing worse service. They also require office managers, and sometimes even managers of managers, all of which just bloat costs.

I worked in a university multispecialty practice for seven years before establishing my own private practice. At the university practice, I found that patients' requests often went unfulfilled. Phone messages didn't get to me, and charts and laboratory tests were routinely lost. In my own practice, my fingers are continuously on the pulse of my staff and patients. Because I can overhear how staff interact with patients, I can intervene rapidly if patients are not getting good service. We routinely have patients transferring to us from larger multispecialty practices where they often wait for hours to be seen, aren't called with their test results, and their phone calls are ignored.

The idea that multispecialty practices lead to better referral patterns is erroneous. If I need to refer a patient to a physician in another specialty, I choose the best physician I know to meet that patient's needs. When making the referral, I consider the physician's clinical competence and the potential chemistry between that physician and the patient. I am not constrained by a limited choice of referral options dictated by a multispecialty group.

When I refer a patient, I fax or mail over pertinent notes, lab work and radiology results so that the specialist knows the patient's problem and doesn't need to perform additional unnecessary tests. The specialists that I refer to either call me or write comprehensive consultation letters so that I am aware of their treatment plan and can coordinate future care with them.

I have also heard that Medicare will be looking to recoup money by increasing oversight of fraud. My fear is that fraud will be poorly defined and a simple miscoding of an office visit will be misconstrued as fraud.


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