Healthcare reform: who speaks for doctors?

My partner showed me an interesting piece from the Wall Street Journal. In it, Daniel Henninger (a journalist without a twitter account!) argues that doctors have largely been left out of the health care reform debate.  His own paper, he complains, has failed to take doctors into account, relying instead on the opinions of CEOs:

A Wall Street Journal story the day after the Supreme Court ruling examined in detail its impact across the “health sector.” The words “doctor,” “physician” and “nurse” appeared nowhere in this report. The piece, however, did cite the view of one CEO who runs a chain of hospitals, explaining how they’d deal with the law’s expected $155 billion in compensation cuts. “We will make it up in volume,” he said.

I have no doubt that he is an experienced journalist and that he properly researched his piece by interviewing a diverse group of physicians. Right?

I appreciate someone speaking up for doctors.  We aren’t particularly organized and don’t have an agreed-upon interest group (a minority of doctors belong to the AMA). But who is this Fox News contributor to tell doctors how we should feel about health care reform?

There is no general agreement among doctors about what Obamacare means for us and our patients. There is broad frustration (I believe) about many of the so-called reforms that began before Obamacare was a twinkle in Barak’s eye. Insurers, both private and public, have mandated confusing system of incentives and penalties.  And here is where Henninger happens to get it right—sort of:

We’re all pressed for thinking time these days, but the one group we should make sure has time to focus on what’s in front of them is doctors treating patients. Instead, they’ll also be doing mandated data dumps for far-off panels of experts.

I make the attempt to collect and enter data for at least three completely different “incentive” programs. This sucks away money and more important takes time away from my patients. These systems are superficially designed to improve patient care, to ensure that I am following the most up-to-date guidelines for patient care. But what they really are designed to do is make money.  My primary responsibility is to my patients, not to insurance companies, and if I lose money by setting aside paperwork, I can at least sleep better at night.  I agree that these data-collection programs as designed are onerous. But Henninger’s next assertions are unfounded, inflammatory, ridiculous, and counterfactual:

This isn’t just a fight over insurance companies. It’s about the people at the center of health care—doctors. Affordable Care Act will damage that most crucial of all life relationships, that between an ill person and his physician. Barack Obama’s assertion that we all can keep our doctors is false. You could line up practicing physicians from here to Boston to explain to Mr. Romney why that is so.

There is nothing stated or implied in the Affordable Care Act that would prevent someone from keeping the doctor they had before implementation. The insurance companies have been forcing the paperwork on us for years. And the people at the center of health care aren’t doctors, but those we serve. If ACA helps us to serve more people and serve them better, it will be a success.


  1. A big point being thrown around is about wait times under more comprehensive health care systems.
    Naturally, if you’re uninsured, wait times are infinite.
    What do you think of wait times in the US, and if you have the knowledge, in comparison to other countries such as Canada?
    I figure that if we were to adopt a single payer system, wait times would naturally be higher, as more people would be able to seek treatment instead of dying or suffering from their ailments.

    • I think wait times are a first world complaint. They’re a distraction. It’s rarely relevant in the first world democracies in a medically significant way, but a whine we do when we don’t get what we want when we want it.

  2. cricemd

     /  July 11, 2012

    Constitutionality arguments aside (the government can now force us to do just about anything they deem in the public interest as long as there is a tax affixed), I absolutely agree that expanding access is fundamental to a solid healthcare system. However, a number of critical issues remain unaddressed.

    First, most people in the public sphere appear willing to discuss the hard fact of rationing. The current rationing system (employed or wealthy get care, un- or underemployed don’t) is obviously not a good one. But “everyone gets everything” is also untenable- the GDP just isn’t large enough. Thus some advanced services must be denied at some point in order to assure basic services for more people. For example, 80-year-old patients with advanced cancer perhaps should not, or in rare cases only, get advanced chemotherapy, ICU admission, etc. This hits close to home, as my own grandmother is suffering from lung cancer, so I understand the personal issues. No doctor would want to deny the patient in front of them any service, but when you look at the population as a whole, this becomes a necessity. Rationing absolutely has to go hand-in-hand with a large public system. Hence, longer lines, denial of some services, etc. The American public must learn to accept the fact of limited resources.

    This brings up another point- doctors, in general, are trained to take care of individual patients, not to address large-scale public health decisions. Epidemiologists may be the exception, or doctors who have sought additional training in public health. Is it any wonder we aren’t contributing enough to the discussion?

    Finally, expanded insurance access will require expanded primary care providers. But as Medicaid/Medicare reimbursement for primary care services dwindles and paperwork and the worry of malpractice increases, who would choose this path? I truly respect those who answer this calling. However, with current trends continuing, I think we will find more and more people having to see NP’s or other mid-level providers at their “Medical Homes” instead of doctors.

    • Technically, no. It’s just the commerce clause. The Bill of Rights still applies.

      I do have issues with it, though. If healthcare is standardized, who decides the standards? Because judging by the supplement industry alone, I don’t trust the federal government to do so.

    • Physicians do have a duty to society in general, but it is secondary. Rationing is another first world illusion. There is no reason everyone needs to have every known treatment at every moment.

  3. For someone like me the ACA is the guarantee I’ve longed for my whole working life – that no one will ever again be able to deny me insurance because of my pre-existing condition (type 1 diabetes since age 12). And no one will ever again be able to limit the types of care I need due to lifetime caps or threaten to drop me (as Humana once did) because I “cost too much.” Maybe there’s a need for a translational data position? I’m thinking of a new person in the office who could take the doctors’ data and input it into the incentive programs. This would solve at least a part of the unemployment problem for some too – like me, someone who’s never worked in a doctor’s office but have spent plenty of time volunteering in hospitals and have worked with data all my life. Just a thought.

    Thank you Dr. Pal on behalf of all patients who have a chronic illness and who depend on a good, caring physician to help them fight on.

  4. becca

     /  July 11, 2012

    The right-wing talking point is “Obamacare will increase the number of medicaid patients so much that doctors will be forced out of business. Unreimbursed expenses are already a problem. EVERY doctor who is ALSO a businessman (i.e. not an academic) is worried about this”. It’s not true, of course (though there’s a valid point buried in there), but that’s the claim being made.
    And if the doctors won’t speak for themselves, don’t worry, Glenn Beck’s got you covered.

    • There’s a poll that came up recently and is being touted by the usual right-wing propagandists that claims 83% of doctors are considering leaving healthcare because of the bill, although the credibility of the poll is in question.

      • JustaTech

         /  July 11, 2012

        83%? That would sort of imply that 83% of doctors are only in it for the money and don’t care about patients, which I find highly unlikely at best.

        I think that we have to admit that until we live in a post-scarcity society, healthcare and healthcare policy will always be imperfect

    • Stupid question: From a business perspective, is more customers ever a bad thing? If you think of it, a business is little more than a virus expanding its range: “You like my service. You tell your friends.” (Advertising, of course, makes for a more aggressive virus.)

      The funny thing is, at the same time, it’s going to raise the patient-to-doctor ratio, but it also means doctors will make less money…how?

      And that’s even if you assume doctors are sociopaths. My ethics professor summarized it as this:

      If you’re here to help people, you’ll be a good doctor.
      If you’re here to make money, you’ll be an adequate doctor.
      If you’re here to make people perfect, you’ll be a horrible doctor.

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