They have health insurance but may not understand it

JAMA Network | JAMA Internal Medicine | The Political Polarization of Physicians in the United States: An Analysis of Campaign Contributions to Federal Elections, 1991 Through 2012

Conclusions and Relevance Between 1991 and 2012, the political alignment of US physicians shifted from predominantly Republican toward the Democrats. The variables driving this change, including the increasing percentage of female physicians and the decreasing percentage of physicians in solo and small practices, are likely to drive further changes.

Figures in this Article

Although few systematic analyses have been conducted on the political behavior of physicians in the United States, it is often assumed that they sit to the right on the political spectrum. Generalizing from the American Medical Association’s strong opposition to the 1965 passage of Medicare, the belief is that physicians share the wariness of Republicans about government interventions, particularly in health care.¹^,2 Ostensibly, this outlook persists today.³

Given the scarcity of data and alert to the many changes in the composition and organization of the physician workforce, we examined physician contributions to presidential and congressional political campaigns from 1991 to 2012. Information on campaign contributions to federal elections is publicly available. The data illuminate patterns of support of physicians for Democratic and Republican candidates and how these patterns compare to those for all donors.

Between 1991 and 2012, campaign contributions in the United States increased substantially. Inflation-adjusted to 2012 dollars, contributions from all individuals increased from $716 million in 1991 to 1992 to $4.64 billion in 2011 to 2012, a 6.5-fold increase. Contributions from physicians increased at a greater rate, from $20 million to $189 million, or by nearly 9.5 fold.

We grouped contributions by the 2-year congressional election cycles. There are important differences in voter participation between midterm election years and presidential election years; for example, people with low incomes are less likely to vote in midterm elections.⁴^(pp130-133) Contributions also varied between midterm and presidential years, with greater contributions in presidential years.

Over our 22-year study period, the composition of the medical profession changed—most notably, there were more female physicians and fewer solo practitioners⁵^{– 7}—and politics in the United States became increasingly polarized.⁴ We hypothesized that the increased number of female physicians and the changes in medical practice altered the patterns of political partisanship within the profession.

JAMA Network | JAMA Internal Medicine | The Political Polarization of Physicians in the United States: An Analysis of Campaign Contributions to Federal Elections, 1991 Through 2012

JAMA Network | JAMA | Views of US Physicians About Controlling Health Care Costs

Physicians’ views about health care costs are germane to pending policy reforms.

Objective To assess physicians’ attitudes toward and perceived role in addressing health care costs.

…

Results A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” …

JAMA Network | JAMA | Views of US Physicians About Controlling Health Care Costs

General Surgery News – Spam in a Can

General Surgery News – Spam in a Can:

For those of you who have been spending your days operating and taking care of patients instead of keeping up with the latest machinations from central planning to separate you from the fruits of your labor and control of your practice, ACOs are bundles of providers who will receive a global payment for a specific patient encounter, like a cholecystectomy. Who will bill, receive and divide the money is uncertain, except that it won’t be you, the surgeon. The only thing certain is that like diagnosis-related groups, the sustainable growth rate, and relative value units, this latest iteration in health care spending discipline will be gamed and ultimately relegated to the alphabet graveyard of designer cost-containment programs invented by health policy wonks who have an aversion to traditional medicine based on the private doctor–patient relationship. I’ll say this much for them: They are undeterred by their unbroken string of failures. Maybe they’re Cubs fans.

An interesting read, if you want to really appreciate the “old school” approach of a lot of our colleagues (this was sent to me by one). My thoughts:

Some interesting phrasing choices in this piece.

“outside secular influence”

“the surgical workforce has been transformed by macroeconomic factors from the ownership class to the labor class.”

“Ownership and labor never agree on anything”

“Strip away the thin veneer of status, and the chief of surgery at Johns Hopkins and the junior surgeon at Kaiser both serve at the pleasure of a boss, punch a clock and take fire training and corporate compliance classes.”

“you had the common values, aspirations and headaches typical of small-business owners.”

“cookbook medicine” (Really? Who still thinks this way?)

Anyway, it all made me think of the Master-Slave morality dichotomy. Since Jesus was the epitome of the ‘slave’ side of this, I’m comfortable with my position, as is, I expect, is Dr. Russell.

And it also made me think of this great quote:

“A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it”

Max Planck

– Sent using Google Toolbar

Doctors Soften Their Stance on Obama’s Health Overhaul – NYTimes.com

Doctors Soften Their Stance on Obama’s Health Overhaul – NYTimes.com:

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states.

That change could have a profound effect on the nation’s health care debate. Indeed, after opposing almost every major health overhaul proposal for nearly a century, the American Medical Association supported President Obama’s legislation last year because the new law would provide health insurance to the vast majority of the nation’s uninsured, improve competition and choice in insurance, and promote prevention and wellness, the group said.

As I pointed out here many times over the past couple years, doctors support health reform.

Follow the tags with this to find out more.

NEJM — Have Physicians Stepped Up for Reform?

NEJM — Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List

The medical profession’s reaction has been quite different. Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians’ income would not be negatively affected by reform.

It is appropriate to question the ethics of organized medicine’s public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the “special interests” affected by health care reform, justify demanding protection from revenue losses?

Dr. Brody makes some interesting points about physicians’ role in health care reform, including the general unwillingness of organized medicine to step up and make concessions on income or to vigorously work on the problem of practice variation.

He is only partially correct in his assessment of organized medicine’s advocacy role this time around. I think it is a real accomplishment, an unprecedented consensus, that the ten largest physician organizations have come out in support of the House Bill, which includes many very important reforms including the public option.

What amazes me is that this has NO currency in the media. Does anyone know this fact? Does anyone realize how monumental this should be? So regardless of whether organized medicine has made the right offers or concessions in this current debate, the fact that they have stood up, in many cases with much pushback from conservative members and advocated for health reform is a big deal.

Secondly, even if organized medicine’s endorsement of reform has not taken the form some of us would like (single payer, Bismarkian insurance), individual physicians, in surveys published in the NEJM have indicated overwhelming willingness to make a deal (i.e., accept a public option) and accept concessions.

a large majority of respondents (78%) agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data “to determine which treatments will be offered to patients.

…the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform.

So i would differ with Dr. Brody’s assessment that physicians and organized medicine have not stepped up adequately.

The problem, as I see it, is that the media and the pro-reform contingent in Congress, have done an abysmal job of letting the public know that the people whose opinions they value most in this debate – physicians – are overwhelmingly in favor of reform.

What we see in the media are the conservative physicians in congress (Sens. Coburn and Barrasso, Congressman Boustany) who are ridiculously out of touch with mainstream physicians. Though in touch with the angry tea partiers and the admittedly sizable contingent of conservative American physicians (not accidentally all of these physicians practicing in high income specialties – ob/gyn, orthopedics and surgical subspecialties ), they do not represent the thinking of most physicians.

Furthermore, as Dr. Brody rightly points out, physicians have a higher duty to our patients than to our own narrow self interest. But here, again, physicians have acknowledged this in a formal way in the Charter on Medical Professionalism, published in 2004 by the American College of Physicians and endorsed by more than 50 major national and international medical organizations:

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category

It seems pretty clear that physicians have answered the call, but somehow, in spite of opinion polling showing how highly the public values our opinion, nobody has noticed.

Testimony to GOP Doctors Caucus

I am giving testimony on Health Care Reform to the GOP Doctors Caucus on Thursday morning, Jan. 21, 2010.

UPDATE: My notes on the back and forth are posted here.

I am representing myself for sure, and, if I do well, will claim to be representing Doctors for America, as well (just kidding).

Here is my opening statement:

Thank you for this opportunity to speak to you today.

A study published recently in the New England Journal of Medicine[i] indicated that 78% of physicians “agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%).”

I was greatly encouraged by this study. But also, sometimes being a glass-half-empty kind of guy, I also was disappointed that 22% of physicians do NOT think they have a duty beyond their individual practice or owe a duty only to the patients in patients in front of them.

In 2004, the American College of Physicians and the American Board of Internal Medicine Foundation published the Charter on Medical Professionalism,[ii] which included language that very pointedly noted that physicians have a duty to social justice in health care:

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

It also states that we have a duty to improve access to care and to a just distribution of finite resources. The ACP reports that more than 50 professional organizations in America and around the world have signed on to this Charter.

I am pleased to say that the leadership of most of our medical professional organizations are now not only talking the talk, but walking the walk, and in an unprecedented manner, the 10 largest physician organizations are supporting health care reform that coincides with their stated goals of universal access to health care in America.

But it is not only organized medicine in favor or reform, as most physicians support reform as well. Another survey from the New England Journal showed overwhelming support (63%) for either reform with a public option or straight up single payer health care.[iii]

It is estimated that 45,000 people die in America every single year due to lack of access to health care.[iv] Whether this is twice as high or half as high as the “true” number is almost immaterial, as it is unacceptable in any case. My experiences, and the experiences of my colleagues, convince me that this number is true, and perhaps even a gross underestimate. Every physician I know has stories of patients who ignored some illness or deferred seeking treatment due to lack of health insurance. I had a patient who was literally coughing up blood for months and had a severe cough for many more months before that before he finally came into the hospital with respiratory failure and advanced cancer.

And, just as in war there are multiples of wounded for every casualty, so too, in our struggle with illness, we see much more suffering that does not get counted. The cab driver supporting a family of five who ignores his diabetes (he knows that is what it is), because he is trying to get health insurance and knows this diagnosis will doom his chances. So he ends up in my ICU with severe diabetic ketoacidosis. The construction worker with a seizure disorder who cannot see a neurologist to adjust his medications because of lack of money to pay for his last visit. He develops uncontrolled seizures for the second time in a few months and ends up in the ICU on life support.

Every physician you know can tell you stories like this. And there are more than 800,000 of us in the US, so the 45,000 number strikes me as not only low for preventable deaths, but only the tip of the iceberg in terms of the human cost in physical suffering and anguish. Remember, all these patients had families who loved them.

I know you hear from many disgruntled physicians who are concerned and even fearful of change. It is unfortunate that this fear prevents many from listening to the “better angels of our nature,” and, instead of striving to improve reform as proposed, simply attack and reject any and all proposals on the table.

It is also worth noting that the changes Congress makes now will certainly affect me and my peers with gray hair, but these bills are really about physicians just starting practice, still in medical school or still just thinking about medical school. And, if you have kids, you know this: they don’t think like us. In medicine, in particular, surveys have shown that they view medicine as a chance to help people and serve society, and don’t have that “calling” to medicine as older generations did. They don’t expect to make a small fortune, but they do expect fair compensation for all they have had to go through to get through medical school and residency, financially and in opportunity cost. So, remember when you hear grumbling about reform, consider the source, and, to channel Yogi Berra, remember the future.

In this final minute, I do want to run through some particulars of what we like in the current House and Senate Bills and would like to see in the final reform bill:

Provide health insurance coverage for 96 percent of Americans while reducing the federal deficit by $30 billion.
Provide substantial subsidies to help make coverage more affordable for our patients.
Implement insurance market reforms to prevent individuals from being denied coverage because of pre-existing conditions, and to limit premium differentials based on age, gender and other factors.
Establish a public health insurance option to ensure there is adequate competition and affordable health insurance options in all areas of the country.
Provide a 10% bonus payment for all primary care providers and a 10% bonus payment for general surgeons and PCPs practicing in underserved areas to ensure a strong physician workforce.
Increase Medicaid payment for primary care services to at least Medicare payment rates and expand Medicaid.
Expand the National Health Services Corp and Title VII health professions training programs.
Expand the medical home pilots and other health care delivery improvement models in addition to creating the Innovation Center to focus on improving the health care delivery system
Invest billions to strengthen our public health system and focus on prevention and wellness.
Establish a new program to encourage states to implement alternatives to traditional medical malpractice litigation – the first step .
Create the Innovation Center and expand the medical home pilots – the kinds of health care delivery models that will improve care coordination and efficiency.
Create an Independent Medicare Advisory Board, isolated from the political process to ensure patients get the care they need, to make recommendations on cost containment and improvements.
Focus on prevention and wellness including reimbursement for an annual Medicare wellness visits, advance care planning, and eliminating the cost burden on patients for preventive services

So, in conclusion, I would ask all of you to strive for health care reform where our bottom line is quality affordable health care for everyone. Because ultimately, our goal is to reduce the number of deaths and needless suffering due to lack of access to care as close to zero as possible, and to leave our children with a better system than we inherited.

Thank you.

Christopher M. Hughes, MD, FCCP, FACP, FCCM
State Director, Pennsylvania, Doctors for America
Board of Trustees, Pennsylvania Medical Society

[i] Antiel, Ryan M., Curlin, Farr A., James, Katherine M., Tilburt, Jon C.Physicians’ Beliefs and U.S. Health Care Reform — A National SurveyN Engl J Med 2009 361: e23

[ii] Medical Professionalism in the New Millennium: A Physician Charter
Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine Ann Intern Med February 5, 2002 136:243-246

[iii] Keyhani, Salomeh, Federman, AlexDoctors on Coverage — Physicians’ Views on a New Public Insurance Option and Medicare Expansion. N Engl J Med 2009 361: e24

[iv] Health Insurance and Mortality in US Adults.Wilper et al. Am J Public Health.2009; 99: 2289-2295

Physician’s Perspective on Health Reform Slides

I updated my slides on physicians’ opinions on health reform for a talk tonight for the Pittsburgh Chapter of Drinking Liberally.

The new slides are here. ( I hope I fixed the link!)

I had to strip out the slides of me (and Doctors for America) at the White House, and on our way TO the White House, already in our white coats in order to get under the 5 MB Google docs limit.

Cheers,

NEJM — Doctors on Coverage — Physicians’ Views on a New Public Insurance Option and Medicare Expansion

NEJM — Doctors on Coverage — Physicians’ Views on a New Public Insurance Option and Medicare Expansion:

“Overall, a majority of physicians (62.9%) supported public and private options. Only 27.3% supported offering private options only.”

I realized I didn’t have this posted yet! The 3/4 of physicians ties in nicely with my estimate that physicians groups representing 3/4 of physicians also support health care reform in general and HR 3200 in particular.

The companion article is instructive, too.

a large majority of respondents (78%) agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data “to determine which treatments will be offered to patients.

…the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform.

This last bit is a bit interesting, as at our Pennsylvania Medical Society Board retreat we discussed this last bit and the overwhelming consensus, as best I could tell, was that this was not controversial, and that part of our jobs was making these determinations.

Eight of Ten Largest Physician Groups Back HR 3200

(Original Title) “American Psychiatric Association voted unanimously to support H.R. 3200”

Medical News Today News Article – Printer Friendly:

The Board of Trustees of the American Psychiatric Association voted unanimously to support H.R. 3200, America’s Affordable Health Choices Act, as the basis for health reform.

‘In doing so, the APA is pleased to stand with the American Medical Association,’ said a letter presenting the board’s decision to the American Medical Association. ‘The APA Board of Trustees also voted to support the concept of a public plan option based upon the voluntary participation of physicians and other healthcare professionals in the ongoing dialogue of health care reform.’

‘While H.R. 3200 – like any bill – is not perfect, we recognize that it offers many positive benefits for psychiatrists and other physicians, and most importantly for our patients,’ the letter said.

This now adds the 9th largest physician organization to be on board for HB 3200, including the AMA, ACP, AAFP, AAP, AOA, ACS, and ACOG.

For completeness, #8, the American Society of Anesthesiology and #10, the Amercian College of Radiology are still against reform until they get reimbursement “fixes.”

#11, the American College of Emergency Physicians is still waiting for final form bills to commit.

Daily Kos: A few anecdotes about medical care in America…

I posted this on DailyKos tonight. Please go read the rest and chime in!

On many levels, I hate to venture into anecdote territory when it comes to health care reform. I don’t think it informs the debate in a helpful manner, and yet, it seems to be one of the two major arms of the conservative campaign against health care reform. First, they argue, look how awful it is everywhere else and how wonderful we have it here in America with THE Best Health Care System in the World (TM) and second, they find even Medicare, Social Security and unemployment benefits ideological anathema.

I can’t do anything about the second one, but I do have something to
say about the first.