Physicians' perspectives on health care reform

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Hopefully, this will be a useful catch-all thread instead of starting a new thread for every new article!

A Day in the Life of a Primary Care Physician: Prior Authorizations, Denials, and Delays in Treatment

by Dr. Aaron Fox

The national debate on health reform has uncovered innumerable "health care horror stories" in which cancer patients worry more about their bills than their malignancy or where pregnant women are laid off and dropped from their insurance soon before their due date. These stories are tragic, and unconscionable for the richest country in the world, however, as a physician, this is not my typical experience. Instead, what I see every day is patients with private health insurance who cannot afford the copays for their medications, delays in treatment as I grovel for prior authorization with a non-physician utilization reviewer, and patients stuck with huge bills for routine services that they thought they were covered for.

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I could fill many pages with stories like these of my patients whom are hard working, have private health insurance through an employer, but just cannot get the care that they need, because of unreliable coverage. It frustrates me that executives of health insurance companies spend millions on advertising to disparage public health insurance, and Republican politicians are stone walling meaningful health care reform because they are afraid that a public health insurance option would put private health insurance companies out of business. I do not care who provides health insurance for my patients. Whether they have public or private insurance, I just want them to get the best care possible. If private health insurance companies provide a high quality product, they will not be "forced" out of business by a public plan. It makes sense that competition between a public plan and private plans would lower costs, improve quality, and guarantee an option to those who do not have employer sponsored coverage. As a physician, I need to advocate for my patients. Private health insurance companies have thousand of lobbyists and millions of dollars to spend. So why do these companies need so many politicians, including Democrats, advocating for them as well? This is not about ideology. It's about patients who cannot afford their medications or who face bankruptcy due to medical bills. We need change, and this will only come with a guaranteed public health insurance option.

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Dear AMA: I Quit!

by Dr. Chris McCoy

The AMA seems to be fixated on the fact that Medicare and Medicaid payments are lower than other payers. Let's go back to the history again: because the AMA opposed the creation of Medicare, physicians were not represented at the table when the system was designed. As a great policy wonk once said, "If you're not at the table, you're on the menu." And thanks to the dismal leadership and short-sightedness of the AMA in the 1960s, physicians were not a full partner in the creation of Medicare. And we're still feeling the reprocussions of that today. And yet now in 2009, the AMA is going to repeat that mistake by opposing the public plan.

The health care system is broken, and physician leadership is needed now more than ever to help direct the reforms that are desperately needed. However, the AMA has not shown itself to be the organization to provide that leadership in restoring the profession of medicine. New physician leadership is needed to fully achieve a reformed health care system that works for our patients and for our country.

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The Prescription From Obama's Own Doctor

(NYT editorial on how Obama should tune out the AMA and listen to his own doctor)

the A.M.A. now represents only 19 percent of practicing physicians (that's my calculation, which the A.M.A. neither confirms nor contests). Its membership has declined in part because of its embarrassing historical record: the A.M.A. supported segregation, opposed President Harry Truman's plans for national health insurance, backed tobacco, denounced Medicare and opposed President Bill Clinton's health reform plan.

So I hope President Obama tunes out the A.M.A. and reaches out instead to somebody to whom he's turned often for medical advice. That's Dr. David Scheiner, a Chicago internist who was Mr. Obama's doctor for more than two decades, until he moved into the White House this year.

"They've always been on the wrong side of things," Dr. Scheiner told me, speaking of the A.M.A. "They may be protecting their interests, but they're not protecting the interests of the American public.

"In the past, physicians have risked their lives to take care of patients. The patient's health was the bottom line, not the checkbook. Today, it's just immoral what's going on. It's abominable, all these people without health care."

Dr. Scheiner, 70, favors the public insurance option and would love to go further and see Medicare for all. He greatly admires Mr. Obama but worries that his health reforms won't go far enough.

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Getting a second opinion on healthcare reform: There are voices besides the AMA

LA Times

When President Obama visited Chicago recently to discuss healthcare reform with the American Medical Assn., his reception was polite but not entirely friendly. After weeks of behind-the-scenes courting by the White House, the AMA had just come out against a public health insurance plan -- something the administration hopes will be included in healthcare reform.

It's easy to understand why elected officials court the AMA. For decades, the powerful group has opposed, and sometimes helped to kill, important healthcare reform efforts. Although less powerful than it used to be, it remains America's largest and best-known physician organization. If you're trying to win over doctors and want to be seen by voters as genuinely reaching out, the AMA's convention remains a required visit.

But lawmakers should take note: The AMA does not speak for all physicians. In the battle for the soul of American medicine, the AMA is often on the wrong side. At least, it's not clearly on the right side of key contested issues in this year's healthcare reform debate. If lawmakers really want to reach out to the medical profession, if the media really want to understand what doctors believe, we have some advice: Stop treating the AMA as if it's the only game in town.

At last count, the AMA claimed about 245,000 members, a number that has declined in recent years. Of these, 195,000 are practicing physicians. That's only about 20% of all practicing physicians in the U.S. The same day that Obama spoke to the AMA, seven national organizations representing physicians, medical students, residents and interns held a news conference to support a public health insurance plan. Membership in these organizations totals 215,000, a significant number even though the groups probably have some overlapping membership. As AMA membership declines, these growing organizations arguably represent the future of the medical profession. Their views are more in touch with the American public, which polls indicate overwhelmingly supports providing citizens with the option to purchase public coverage.

In our view, the AMA is stuck in an old model of special-interest politics -- one that represents an increasingly narrow segment of the medical profession. The doctors we know express many worries. Sure, they care about their incomes, but they care about other things too that strongly affect the well-being of their patients.

The group with which we are affiliated, Doctors for America, along with others, is working to support healthcare reform that works. We support the need for reform that eliminates unnecessary testing and rewards high-quality care. Doctors for America and other organizations are trying to educate their thousands of physician-members and urge them to engage in the political debate.

Politicians in Washington have yet to recognize the growing power and the grass-roots legitimacy of these new voices in medical care. By and large, these organizations aren't given a seat at the table. They are only just beginning to receive invitations to meetings in Washington. The media don't generally write about them.

We don't know precisely how many doctors support a public-plan option. Polls indicate broad support among doctors for universal coverage and for other progressive measures, and even the AMA has pulled back slightly from its outright rejection of a public plan. A sizable minority of physicians actually supports a single-payer plan.

From their vantage point on the front lines of American medical care, doctors see firsthand the need for reform. They see patients facing financial hardship because of medical bills. They see others who forgo needed treatments they can't afford. Doctors work within a fragmented system that makes it increasingly hard to provide the high-quality, attentive and compassionate care they were trained to give. They see their profession facing increasing public skepticism, fueled by accounts of wasteful practice patterns and by their profession's frequent and frank stance as a special-interest group.

Of course lawmakers should consult the AMA. But they should stop putting the group on a pedestal above other doctor organizations. Perhaps if politicians did so, the AMA might make greater efforts to move beyond its narrow stance as a special-interest group.

Doctors are right to worry about the economic impact that reform will have on their profession. They have every right to lobby lawmakers in the same spirit Archer Daniels Midland lobbies on ethanol. Some such lobbying is natural and justified. Over the years, though, the AMA has sometimes forgotten that other values matter too. As thousands of doctors are starting to realize, that's a poor long-term strategy for a great profession that so greatly benefits from the public's trust.

Rahul Rajkumar is a physician at Brigham and Women's Hospital in Boston. Harold Pollack teaches social service administration at the University of Chicago, where he chairs the Center for Health Administration Studies.