Why Doctors Don't Fear ObamaCare

In a recent New York Times column commemorating the 40th anniversary of the first moon landing, Tom Wolfe described a distraught President Kennedy preoccupied with the political cause du jour -- the so-called "space race" then under way with the Soviet Union. Wolfe quotes Kennedy "muttering, 'If somebody can just tell me how to catch up. Let's find somebody -- anybody ... There's nothing more important." He kept saying, 'We've got to catch up.' Catching up had become his obsession."

Sound familiar? It should. The cause of health care reform has become a similar obsession for the current occupant of the Oval Office. Last week President Obama used the following appeal in an attempt to stiffen the resolve of Congress and the public: "Now is not the time to slow down. We are going to get this done. We will reform healthcare. It will happen this year. I'm absolutely convinced of that." Since then, he has repeated more or less the same message every day, hoping to overcome the growing resistance to the cost of this ambitious cost-reduction program.

And yet, one hears little criticism of the plan from the one group with the most to lose from health care cost controls -- physicians. It has been estimated that a "public option" insurance plan modeled on Medicare would be likely to enroll 131 million people and result in physician income declining by as much as 15% to 20%. Yet rather than objecting, last Thursday the American Medical Association sent letters to three House committees openly endorsing the legislation. What's going on?

Let's begin by reminding ourselves that despite the extensive hand-wringing about the ills of American healthcare, these legislative proposals are getting whittled down to pretty standard fare -- recycled insurance reform proposals that we've seen many times before: universal coverage with a matching mandate to purchase, insurance exchanges and portability, and a proposal to create a new additional tax-supported government insurance program, the "public option." For physicians, these ideas are neither new nor unwelcome.

It tends to get overlooked in our zeal to castigate ourselves for not having a "universal health care system like the other industrialized countries," but government programs already account for more than half of the nation's health care expenditures. Doctors don't particularly like them, but they know that in the end they will get paid. The idea of solving the problem of the uninsured by enrolling them in an expanded Medicare - if that is what we end up doing - therefore doesn't hit with a lot of impact. The only radical parts have been the cost estimates and the tentative proposal (now believed to have been withdrawn) that Medicare fees be reduced even further.

Physicians are also well aware of the fact that in the health care marketplace, it is they who determine need and consumption, not pricing or competition. Although it is starting to change a bit, it is the physician telling the patent that they are ill and need certain treatment that primarily results in reimbursable health care expenditures, not ordinary consumer behavior. (Would you want chemotherapy because Sloan Kettering was advertising a special?) As long as physicians control the determination of the "medical necessity" of care and what is considered "appropriate care" is community based, they will continue to be the controlling players.

For some reason the architects of ObamaCare have stopped talking about what changes in this traditional authority they have in mind, so physicians are assuming there are none. If that is correct, then an opportunity for real reform is being missed. A compensation system that rewards physicians for providing better care, or reimburses providers for complete episodes of care rather than piecemeal services would be quite popular with most physicians.  And it would have a dramatic effect on measures of quality and cost effectiveness. But the kinds of changes being discussed are things like global budgets that are obviously directed at controlling costs and are viewed by physicians as being unworkable - little more than political eyewash.

Even insurance itself isn't purchased in a real market. For those who obtain medical insurance as an employee benefit, they don't "purchase" it at all. They select from a limited menu of carriers and coverage plans provided by their employer. The purchasers of individual policies are real buyers, but they're usually limited to the one or two carriers in their local area who offer this type of policy. A third group -- enrollees in one of the government programs -- do not get to choose at all. They are matched on the basis of a particular qualifying attribute -- age, income, level of disability, or presence of a special need. It is this enrollment restriction in current government programs - the need to qualify for them - that the public option in ObamaCare seeks to change. Once established this new government program will be able to sell coverage to anyone for a price.

This will create a problem for the traditional private carriers who have to compete with the government program, but again, will have minimal impact on doctors. Physicians have long advocated for changes in insurance that will liberalize underwriting, improve access to care and support quality improvement. From their perspective, this will be an acceptable solution (as long as physicians are paid for caring for these new patients.) Ironically, as ObamaCare, faced with growing criticism and diminishing public support has promised to do less, physicians have liked it more.

There is little for a physician not to like about universal coverage and allowing insurance exchanges to offer a greater choice of carrier. Forty-four years of experience dealing with the Medicare program has taught them that over the long run it's a good deal to accept fee limits in exchange for broader coverage - particularly when the government does such a poor job of capping volume, maintaining treatment standards, or even policing outright fraud (estimated to be running $60 B a year in the current Medicare program). From the point of view of the practitioner in the trenches, Medicare-level fees are a grind, but never having to ask a patient if they are insured is a very good thing.

But wait you say, I thought ObamaCare was also promising to "attack excessive costs?" Isn't this where the rubber hits the road? Isn't a good part of "excessive health care costs" really doctor fees? Perhaps, but doctors never think that their fees are the ones being referred to as "excessive." Moreover, they calculate that reducing health care services to control costs will never be politically acceptable in the US. We may want the UK's per capita expenditure on health care, but we're not prepared to accept what the citizens of the UK do to achieve it. On this one, doctors may know their patients better than the politicians do.

You can also forget about implementing the "clinical appropriateness standards" long favored by academics and health care policy experts unless the political class is intent on repeating the Managed Care nightmare of the 1990's. The private carriers learned how difficult it is to impose restrictions in care or the substitution of less expensive treatment modalities when the doctor and patient are not voluntarily cooperative. Those who try initially lose in the court of public opinion, and eventually in court period. Physicians have been through this before and aren't worried about it now.

So what is going to happen with health care reform? Is this finally the national health care program progressives have been demanding for decades or will it just turn out to be Kabuki political theater? If you ask your doctor, they will tell you that at long last America is going to make sure that everyone has health insurance. Having everyone in the insured risk pool, with no more coverage denials based on pre-existing conditions, is a major advance, even if it means that healthy young singles will no longer be allowed to risk not spending the money to purchase health insurance. Your doctor will consider that a fair trade. And if it turns out that the new insurance exchanges allow buyers to purchase health coverage across state lines, making the insurance market much more competitive, your doctor will like the new order even more. But don't expect him to describe a bigger Medicare program as "reform" or to tell you that you're going to like the care you'll receive under it.