Where Physicians Stand Now on the Healthcare Debate: An Expert Interview With Robert J. Blendon, ScD

Wayne J. Guglielmo

September 29, 2009

September 29, 2009 — Physicians are playing a key role in the healthcare reform debate now roiling Congress. To get a better understanding of where physicians find themselves in this rapidly shifting debate, Medscape Medical News talked to healthcare pollster and analyst Robert J. Blendon, ScD, professor of health policy and political analysis at both the Harvard University School of Public Health and the John F. Kennedy School of Government in Boston, Massachusetts.

Medscape: In August, the American Medical Association (AMA) was among the first groups to support the combined House healthcare reform bill, which, among many other things, includes a public plan option and a provision to reform the sustainable growth rate (SGR), the complex and controversial formula the federal government uses each year to adjust Medicare rates for physician services. Was the promised SGR fix, as some have suggested, the very costly price of gaining the association's support?

Dr. Blendon: I never suggest motives for what people do. But the House [Tri-Committee] bill is one of the larger, more comprehensive versions of reform now being discussed, and the fact that the AMA is on record supporting it — with as much federal government intervention in healthcare as it contains — is really a first for the association.

Medscape: In a national survey of physicians published in September in the New England Journal of Medicine, more than three quarters of respondents agreed that they "have a professional obligation to address societal health policy issues." Does that finding square with your own understanding of physicians' beliefs?

Dr. Blendon: My view of that finding is much narrower than the authors'. In responding to the statement about their professional obligation, doctors were indicating their willingness to take part in something that affects their jobs, their hospital, and the future of their profession. So of course they should be involved. I didn't take doctors' response in the survey as a commitment to society to step back and do anything different from what they're already doing every day of their lives.

Medscape: The survey also found that surgeons, procedural specialists, and those in nonclinical specialties were less enthusiastic than primary care providers about some of the more controversial aspects of reform, including expanding access by reducing reimbursement for expensive drugs and procedures. Did this finding surprise you?

Dr. Blendon: No. When you talk about what a group supports or doesn't, you really have to be much more specific. Many physicians believe that the uninsured should be covered, that the administrative burden imposed by insurance companies is overwhelming, that malpractice is a serious problem in their lives, that there is a lot of duplication of procedures, and that there are other things that go on that should be fixed. But when you get down to diminishing their ability to make clinical decisions, diminishing their professional discretion, or lowering their incomes, they are not at all supportive.

Medscape: How will these divisions affect physician support as the reform debate moves forward in Congress?

Dr. Blendon: There may be some shift in physician support, especially if the final congressional bills end up dealing with some tough issues. For instance, some people in the Senate are saying that the government can't afford to fix the SGR — it's just too expensive and we have to cut back to something we can afford. Well, what happens to physician support if the bill that emerges from the Senate doesn't include a SGR fix?

Medscape: In his address before a joint session of Congress earlier this month, President Obama talked about addressing medical liability reform, although not in a way that many in the GOP and many physicians favor. Reflecting the President's position, the Baucus bill as it now stands would simply encourage the Senate to urge Congress to establish "a state demonstration program to evaluate alternatives to the current civil litigation system." How big a role will liability reform play going forward?

Dr. Blendon: That depends. If to reach the 60 votes they need, Democrats must win over members for whom a stronger malpractice provision is really important, Democrats may actually shift where they now stand on the issue. But if these [sought after] members make some other issue a higher priority, malpractice reform may not move beyond the President's commitment to do some state experimentation.

Medscape: Do you have a hunch one way or another?

Dr. Blendon: I have no idea whether some members will in the end place a priority on malpractice reform. But, even if they do, we could still end up with a bill with just very general language about state experiments, because historically liability reform has not been a high priority for the Democratic leadership in either House.

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