September 26, 2017
What doctors want from health care reform

As the latest Republican replacement for the Affordable Care Act begins its death rattle, a growing number of physicians worry that any solution Washington proposes will not fix the nation's ailing health care system.
"Forget Republican or Democrat, when I look at the Affordable Care Act (ACA) or the Graham-Cassidy pathway, it doesn't matter," said Dr. Brian Hill, an Atlanta urologist, "because they are both doing a miserable job in helping people get health care."

"It's rearranging deck chairs on the Titanic," said Dr. Kevin Campbell, a North Carolina cardiologist who advises young doctors on how to build their practices. "Obamacare has been a disaster but I've seen nothing of substance to replace it from the Democrats. I see nothing viable from the Republicans."
"I'm not a fan of any legislation that Washington has come up with," said Dr. Keith Smith, who runs a cost-transparent surgical center in Oklahoma City. "The GOP version of the plan that they would inflict on all of us is like giving gin instead of vodka to an alcoholic and assuming something different will occur."
Informal surveys show growing concern
Insider surveys by physician recruiting firms and websites echo those sentiments. An email survey of 887 physicians released today by MDLinx, a physician news aggregator, found 54.7% oppose or strongly oppose the Graham-Cassidy plan, while only 19.8% support or strongly support it. About 25% of respondents were neutral.
Dozens of major medical associations, such as the American Medical Association, American College of Physicians, American Diabetes Association, American Heart Association and American Cancer Society, have released statements opposing the Graham-Cassidy replacement for the Affordable Care Act, and many opposed its predecessor..
In what's considered the final blow for the latest GOP proposal, the Congressional Budget Office released a partial report late Monday which said it would result in "millions fewer people with comprehensive health insurance that covers high-cost medical events."
But physician dissatisfaction with the Trump administration health care proposals goes back further than this latest iteration.
Released in July as part of the Medicus Firm's 2017 annual report on physician practice and relocation preferences, a random sample of 2,351 doctors from 50 states and more than 20 specialties were asked to more widely grade the Trump administration's impact on health care policy -- 55% of those who responded gave the administration a failing grade.
The Great American Physician Survey, done every year by Physicians Practice, which provides information and advice to physicians in private practice, found similar results from the 826 doctors in its survey released earlier this month.
"The highest percentage, 40%, say the Trump administration gets an 'F' in health care so far," said Gabriel Perna, Physicians Practice managing editor.
"These aren't scientific surveys," warned Dr. Benjamin Sommers, an internist and health economist at the Harvard T.H. Chan School of Public Health, because they don't statistically account for bias. "Doctors tend to be a difficult group to survey and get their opinions in a really scientific sort of way."
Because Graham-Cassidy is essentially similar to the prior GOP replacement bills, Sommers said he suspects that most physician views haven't changed.
"Those who dislike the Affordable Care Act and favor less federal oversight in health care and more state control will be happy with it," said Sommers. "Those who worry that cutting ... Medicaid and other health care programs will lead to millions of Americans losing health insurance will be very worried about the damage this bill could cause."
A move toward single payer?
Perhaps more surprising are the results of recent informal surveys that show an increased interest by doctors in a single payer system, such as the "Medicare for All" proposal from Bernie Sanders, Vermont's Independent senator and 2016 presidential candidate.
The MDLinx survey found just over 48% of physicians polled would support a single payer system, even though they thought it would lower their income and could possibly reduce the quality of care for their patients.
"I was really surprised," said Jim Stone, president of the Medicus Firm, a physician recruiting company. "Physicians have generally been a fairly independent group, they don't want anything dictated to them, and I find it shocking that we are even seeing this degree of acceptance for a single payer system."
A national survey released earlier this month by another physician staffing agency, Merritt Hawkins and Associates, also found 56% of 1,033 doctors either strongly or somewhat supported a single payer health care plan. While the poll is non-scientific, it's interesting when compared to past polling by the same group.
"This is a near reversal of a national survey of physicians Merritt Hawkins conducted in 2008, which indicated 58% of physicians opposed single payer at that time," said Phillip Miller, vice president of communications for Merritt Hawkins.
"This is not surprising at all to me," said Harvard Medical School's Dr. Adam Gaffney, who is also on the board of Physicians for a National Health Program, which supports "Medicare for All." "The ACA has not taken us where we need to be. And many doctors are unhappy with the wasteful health care system that predated the ACA.
"In my opinion 'Medicare for All' would help by giving us one set of rules. You'd have a national formulary. Regardless of who is in front of you, you'd know how they would be covered without going to their insurance company to see what they would cover."
Time to start over
"I'm not sure that a single payer is the best way to go, especially since the government has not done a good job so far," said Dr. Linda Girgis, a family physician who volunteers for SERMO, a leading social network for physicians.
In her South River, New Jersey, practice Girgis sees a lot of problems she feels are not addressed by any of the proposed plans.
"Patients are self-rationing their care. We had a mother and child who were both sick at the same time, and the mom canceled her appointment with me and only took her daughter to the pediatrician," said Girgis. "She could only afford the deductible for one of them."
Girgis places much of the blame on insurance companies, and would like to see any proposal in Washington improve transparency into their systems and oversight of their actions.
"Insurance companies are making poor decisions, denying certain tests and raising prices," said Girgis. "Patients are getting medications that may not be the best choice for them because that is what the insurance company will cover."
North Carolina's Campbell shares Girgis' concerns about insurance processes.
"I spend a great deal of my time as a cardiologist arguing on the phone with what the insurance companies call 'peer to peer' reviewers, and they are nowhere near my peers," said Campbell. "They will argue if a pacemaker is appropriate and they are not trained in cardiovascular medicine, much less in pacemaker surgery."
He, too, would like to see additional oversight of insurance companies, but doesn't stop there.
"Nothing has come out of Washington that even talks about regulating the costs of pharmaceuticals, one of the leading drivers of health care costs," said Campbell. "We also have no tort reform on a national level, so we're spending millions upon millions of health care dollars every single year ordering unnecessary tests because physicians are practicing 'defensive medicine' to protect themselves from predatory litigation for malpractice."
"I wish they would leave us alone and let the market work," added Smith, the Oklahoma City surgeon. "Central planning from Washington is a disaster. It has distorted free markets and just drives the price up for everyone."
Smith is part of a entrepreneurial physician movement toward fee-based service, with transparent prices that patients can see online. That, says Smith, allows his patients to shop for the best price and hold their doctor accountable for quality.
"In my world, if I don't provide a service that is valued, my doors are closed, and that's the discipline every other industry must face," said Smith. "And that's what I see as the problem. We don't have an open, competitive market where the patients know the price before they pay."
Atlanta urologist Hill agrees. He's developing a version of direct pay care with a reduced administrative burden that he hopes will cover the entire health care "ecosystem," from primary care to specialists, to lab work, tests and medications.
"Right now, I have to negotiate a contract with the insurance companies and hire a back office of coders and billers that I have to run everything through in order to get paid," said Hill. "And then the insurance company has to hire people to fight me trying to get paid.
"What if we do something different and start working directly with our patients?" asked Hill. "What if we got all those costs out of my office and I get to have a relationship with you, my patient, the person that I actually went to medical school to take care of?"
Hill's views that a new approach is needed were echoed in the informal MDLinx survey. When asked "What would be the ideal scenario for US health care?" nearly 38% said they wanted something completely new because none of the current options were feasible.
"As you can tell, doctors are frustrated," said Campbell. "We feel like our voices are not being heard. Health care reform the first time happened around us. This time it needs to listen to us."
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