Why Physicians Won't Unite to 'Rescue' Medicine

Leigh Page

Disclosures

September 04, 2014

In This Article

Doctors Have a Right to Be Concerned About Income

Health reform has also divided physicians. The debates over the ACA have prompted many physicians to think about ways to improve the entire healthcare system, including changes in payment methodologies, whereas other physicians prefer to focus on managing their practices. Reconciling these opposing camps has become a problem.

In 2010, the year in which the ACA was passed, an influential commentary[14] ran in the Journal of the American Medical Association (JAMA), asking physicians to consider whether they are behaving like "knights, knaves, or pawns." The commentary drew applause from many physicians, but doctors who cared about their income saw it as an affront. The piece said that "pawns" and "knaves" only attend to their own self-interests, forcing the creation of bureaucratic requirements making sure that they do the right thing. In contrast, 'knights" take everyone's interests into account and can thus be trusted to function as independent professionals.

Many practicing physicians unapologetically spoke up for their right to be concerned about their income. Dr. Knope, the concierge physician in Arizona, rejects the "knights, knaves, or pawns" thesis. "Physicians should act out of enlightened self-interest," he said. "If you want to talk about knights, a knight is someone who shows strength," he said. "If I'm strong, I'm in a better position to help my patients. If I am a beaten dog and feel put upon, how am I going to help anyone?"

Dr. Grumet said physicians tend to feel apologetic about looking out for their own interests, but they shouldn't feel that way. "Beginning in medical school, it's ingrained in you that you need to forget your own needs and be selfless, and stay up all night taking care of patients," he said.

The other side of the debate -- the physicians who focus on the entire healthcare system -- is not limited to employed or nonpracticing physicians making policy, as some of their critics contend. Dr. Roland, for example, doesn't think the ACA went far enough and supports a single-payer healthcare system. "The current system based on commercial insurers wastes a huge amount of resources," he said, tapping into the hostility that many physicians feel toward commercial insurers.

In the past, the AMA was often seen as a staunch defender of physicians' own interests, but lately it's been distancing itself from that image. "I can't tell you how many people think the AMA is just a trade organization fixated on pocketbook issues," said outgoing AMA President Ardis Hoven, MD, in a speech[15] at the AMA Annual Meeting in June. She went on to say that the AMA "brought national attention to the plight of the uninsured" in the 2008 election cycle that swept President Obama into office and led to passage of the ACA.

The AMA still pursues some key monetary issues, such as its $350 million settlement in 2012 with United Healthcare on its out-of-network policies, but many of its newest initiatives center on helping doctors get used to new payment arrangements, such as shared savings and bundled payments,[16] and the use of integrated care in such arrangements as the patient-centered medical home.

The AMA has created a new section for physicians involved in integrated care,[17] set up an advisory committee[18] on new delivery and payment models, and appointed a new vice president[19] in charge of "physician satisfaction and new payment models."

But most physicians are still skeptical of these new arrangements. In a 2013 survey released in JAMA,[20] only 7% of physicians expressed enthusiasm for eliminating fee-for-service payments and 65% were not enthusiastic about bundled payments.

These physicians -- more interested in income and reimbursement issues than in pioneering new payment methods -- are the constituency that Docs4PatientCare is looking for. Dr. Scherz said this sizeable group of physicians is being ignored. "Many medical organizations have strayed away from helping physicians with the demands of running a practice," he said.

On the other hand, new national organizations have sprouted up and are attempting to represent physicians who welcome health reform and the new care arrangements that come with it. The National Physicians Alliance believes that "physicians have an important role in ensuring a strong and viable public health system," its Website said. And Doctors for America represents physicians "working together to improve the health of the nation and to ensure that everyone has access to affordable, high quality health care," according to its Website.

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