Sunday, March 7, 2010

Health Savings Accounts - Medical Trends: Physician Mindsets and Microtrends as Reform Decision Nears

President Obama has called for an up and down vote of health reform this March before he departs on an Asia trip on March 17. Whether that vote will occur and what its results will be is uncertain.

The betting among conservatives is that Speaker Pelosi does not have the 216 votes needed to push reform forward. That bet may be based on wishful thinking.

Liberals and many moderates say, “Go ahead and make our day. Do not miss this historic opportunity.”

The final decision rests among Democrats, split among fiscally conservative Blue Dogs, who fear for their electoral lives and may vote “No,” and liberal members who think Obama has not supported their cause and who sense a historic opportunity slipping away.

Obama is seeking to split the difference and even to mollify a Republican or two by giving lip service to a few of their cherished ideas.

In the words of Drew Pearson, that famous columnist of yesteryear, “The Washington Merry-Go-Round goes round and round and where it stops no one knows.”

America’s physicians are divided between resignation and defiance. In 2012, or thereabout, government will pay for more than 50% of health care, and some 40% of doctors, more primary care than specialists, see a one-payer system as inevitable – even desirable.

But 60% of doctors, more specialists than primary care doctors, prefer a market-driven, consumer-centered system featuring health plan marketing across state lines, malpractice reform with caps and health courts, private contracting between patients and doctors, and health savings accounts with high deductibles.

Among doctors what is missing is national leadership. The AMA, with only 15% of doctors belonging and the other 75% saying the AMA does not represent them, has fallen into disarray. Some physician organizations, such as, the social networking site with 115,000 participants, and the Association of Physicians and Surgeons with only 3000 members but a loud voice, are dismissive of the AMA.

Other organizations, such as The Physicians Foundation, born out of a winning settlement with national HMOs in 2003, are seeking through a relationship with Northwestern’s Kellogg Management Institute , to form a national leadership center to train doctors to be national leaders. The Foundation’s strength is that it represents some 650,000 doctors who belong to state and local medical society. Its weakness has been getting its message out that doctors can make a positive difference to improve care on the national scene.

Out of this climate of uncertainty, indecision, and political paralysis has arisen anti-government forces and attitudes as manifested in the raucous town halls of last August, the rapidly emerging Tea Party movement, 75% of whom are college graduates, the voice of angry conservatives and independents as seen in the Virginia, New Jersey, Massachusetts, and Texas elections, and the widespread perception that an election debacle awaits Democrats in November.

Out of this chaos have also emerged some micro trends among physicians. I hesitate to call them megatrends because of the fragmentation and division among physician camps and among younger and older physicians. The things these camps share is a sense of frustration and the feeling that something, almost anything, has be done to rein in costs, raise reimbursements for Medicare and Medicaid, slay the malpractice beast, and give doctors more voice in their own business and private lives.

These micro trends, positive and negative for the national health and well-being,rest on these choices.

• A choice for a more remunerative, less stressful practice environment and more satisfying lifestyles. Towards these ends, young doctors are choosing the ROAD (Radiology, Ophthalmology, Anesthesia, and Dermatology) specialties, and the young. mid-career physicians , primary care and specialists alike, are opting for hospital employment.

• A choice not to enter primary care specialties - family practice, general internal medicine, and pediatrics. A recent survey indicates only 2% of medical students are entering these specialties.

• A choice not to see new Medicaid and Medicare patients, or those HMO/PPO members, who do not adequately pay for the cost of doing business.

• A choice to opt out of third party relationships – cash only and concierge practices, non-clinical employment, or hospital employment - to reduce overhead, to relieve themselves of the burdens and hassles and time required to deal with those third parties, and to avoid malpractice expenses and worries.

• A choice to choose a career at a Locum Tenens physician, a growing under-the-radar movement whose opportunities, enjoyments, and beartraps are explained in a recent book Have Stethoscope, Will Travel. Staff Care Guide to Locum Tenens (Practice Support Resources, 2009).

• A choice, or perhaps I should say a myriad of choices, to adopt and apply the new Internet-based information and marketing technologies – EMRs, IPods, all-purpose handheld computer phones, remote monitoring devices, data entry algorithms software, Twitter, and Facebook, and all manner of wireless gadgets – as essential tools of practice.

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