Doctors prefer the public option
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It isn’t very common that one detects a sea change among the practitioners of medicine. Last week the New England Journal of Medicine published a poll of thousands of American doctors across the spectrum of medicine, all specialties, ages, genders, regions and degrees of allegiance to the American Medical Association. They asked whether they favored the public option in health care reform. All across the board about 60% did, including AMA members, southerners and surgeons, the three most conservative groups. I arrived in the Florida in 1976 when it was still a typical Southern state. Every doctor had to be an AMA member to get on a hospital staff in those days. Most doctors were Southerners and the ones I dealt with the most were surgeons like me. They were a particularly conservative group. One did not even raise or discuss a liberal or even moderate political idea at the doctor’s table in the hospital cafeteria in those days.
What could have happened to these physicians to make them vote in line with the more liberal people in America, the so-called Democratic base, on health care? The answer is simple: the insurance companies’ ascendency in health care.
First, it has been estimated that forty percent of doctors’ revenues go to funding people who sit in our offices and handle all the diverse types of insurance forms from scores of health insurance companies. These folks spend an inordinate time on the phone arguing and cajoling representatives of the companies just to acknowledge that they received a claim, let alone approve one they have in hand.
For several years there existed gag clauses in doctors’ contracts with the HMOs that prohibited them from mentioning alternative forms of care with patients which the insurance companies would not provide. The gag clause of U.S. Healthcare read:
Physician shall agree not to take any action or make any communication which undermines or could undermine the confidence of enrollees, potential enrollees, their employers, their unions, or the public in U.S. Healthcare or the quality of U.S. Healthcare coverage.
This meant in practice that if you had a disease that required a newer and more effective treatment that the company would not cover your doctor couldn’t mention it to you. This was interference in the doctor-patient relationship that doctors resented regardless of their political orientation . The gag clause is a thing of the past but it tells you where these folks were coming from. One of the greatest fears of the doctors working under a gag clause was that they would get sued for not mentioning alternative forms of care, an absolute ethical obligation to the patient.
This brings us to the next issue. Under a law that was originally designed to protect employee benefits called ERISA, which was enacted by Congress in 1974, the insurance companies found a shelter against law suits for turning people down for care. It went all the way to the Supreme Court and it still exists. The Court declared in 2004 that ERISA preempted a Texas patient protection law. When doctors compare their lawsuit vulnerability to that of the insurance companies, the feeling of unfairness is acute.
Insurance companies had to be sued again and again by patients and doctors to reverse claim denials. The insurance companies could merge in dealing with a limited group of specialists, such as the neurologists and neurosurgeons in Southeast Florida in the 90s but the doctors could not bargain collectively. The playing field was severely tilted.
Add to all this the irrationality and quirks that doctors deal with daily that are too numerous to catalog here, and you have a deep seated antipathy to private insurance companies among physicians. Medicare is not an ideal organization to deal with but the office expense of dealing with them and the rarity of claim denials are tolerable. American doctors anticipate having to deal with public option insurance as a variant of Medicare. Political orientation is one thing, but the hassles of dealing with the health insurance companies and the legal threats have created something as close to unity among American doctors as I have ever seen.
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This was really interesting.
I knew about the percentage of doctors that supported the public option, but I had no clue as to their reasoning behind it.
I'd like to thank Ralph Deeds and JustanotherGirl for their kind words. If there are any questions about this post or the sources, just ask and I'll do my best to provide the answers and information
Excellent! I hope that a public option will be forthcoming. I thought the part about the gag clause was interesting and now I know the reason it was called a "gag" clause!
Interesting provider perspective, doc. I just finished a hub on some of the cost savings resulting from managed (behavioral) health care, and a couple months ago wrote one on managed pharmacy benefits. I am a behaviroal health care provider whose dream of private or public practice is not financially feasible, and have embraced managed care as a necessary evil in the war against rising health care costs. I like a world that is much less regulated myself, and have often wondered what costs are associated with hospitals having to pay salaries for jobs that only exist to feed data to insurance companies! I have to admit though, managed care does seem to play a valuable role in containing wasteful health care spending. The public option will be very managed care! I miss the day when I thought my visits with my PCP were private, too! So, no questions, doc, but an attempt to wrap my head around the whole big picture. Any thoughts, comments, information or perspectives you think would be helpful, would be most appreciated.
The savings of managed care plateaued years ago, Kim, mainly from getting patients out of the hospital sicker and quicker. This phenomenon has been well documented in Medicare patients with excessive rates of readmission within 30 days of discharge. Managed care provided a conduit for the flow of money out of the pockets of doctors into those of the insurance company executives. Those executives provided no additional service or societal benefit. They just got their expected remuneration for their political contributions.
Interesting. Thanks. I was thinking the re-admission rates had more to do with there being a gap in services available between acute inpatient care and outpatient; such as convalescent care - for people who need medical supervision and assisted living but not hospital care. If that's true, I assume it's not profitable and/or not affordable.
I had read the same explanation in the media several months ago. I was incredulous that they could be so naive about how insurance companies run things. As an insider I saw how the patients got pushed out the hospital door every day. I would often come into the room of a one day post operative patient who would be in tears because she was told she would have to pay for any additional days in the hospital. Meanwhile, she still required i.v. or i.m pain medication around the clock to control post operative pain. I once had a patient with a post operative wound infection that I deemed ineligible for discharge and recorded that in daily in the chart. One day the patient was gone--discharged by the hospitalist. These were very common events. I'm glad that CMS put a lid on some of this by refusing to pay for readmissions within thirty days but the insurers still get away with a lot.
Ralph Deeds Level 6 Commenter 2 years ago
Outstanding and credible information.