Many Doctors Feel Angry, Undervalued by Warren's Health Plan

Alicia Ault

November 11, 2019

Democratic presidential candidate Elizabeth Warren's proposal to help pay for Medicare for all by curbing physician fees is mostly drawing anger and dismay from doctors, although some continue to support the notion of creating a single-payer, government-run health system.

Much of organized medicine has been on record as opposing a single-payer system, and now many doctors have taken to Twitter and other social media platforms ― some to voice their disdain for Warren's plan, others to voice their doubt (and some, support).

Warren announced in her plan that was released on November 1 that she'd hold physician fees to roughly what Medicare pays and increase primary care physician pay while decreasing pay of many specialists. The plan is based on a report prepared for the Medicare Payment Advisory Commission in January 2019 titled, Analysis of Disparities in Physician Compensation.

"Does she not calculate the massive egress of physicians from the field with such a pay cut?" said radiologist Stephen Poole, MD, in commenting on a story by Medscape Medical News about the Warren proposal.

"If such a plan were enacted, those close to retirement would retire en masse," he commented.

Speaking in his role as a Fox News medical correspondent, internist Marc Siegel, MD, of NYU Langone, New York City, said during a recent interview on the network that "doctors will be paid up to 40% less, many will leave the profession, there will be an enormous doctor shortage."

Internist Stacey Wells, MD, expressed dismay that physicians were targeted. "You would think since we literally save lives on a daily basis, sometimes sacrificing our own personal lives and families, that we would be held to a certain financial esteem ('You're a doctor? Wow, you DESERVE every penny you earn!')," commented Wells on the Medscape story.

"Suddenly I'm afraid of a future in which we won't be able to attract the best talent into the medical field because salaries will be too low to cover the growing astronomical burden of our student loans," she said.

Michael McClurkin, MD, MPP, a psychiatry resident at Yale University, tweeted that he was a Medicare-for-all supporter but that "if physicians take a pay cut across the board, medical school/residency should be restructured to reduce debt burden."

In a tweet response, Philip A. Verhoef, MD, PhD, FACP, FAAP, a board member of Physicians for a National Health Program, called McClurkin's proposal "a nice idea," adding, "but there's no reason to think physicians would take a 'pay cut across the board.' "

Verhoef claimed that physician pay would "not be compromised under #MedicareForAll," and added that "Canada's docs get paid more on average than US docs."

Neurosurgeons: Medicare Doesn't Cover Costs

One of the specialties targeted as "overpaid" by Warren is neurosurgery. Neurosurgeons have high practice expenses — including some $250,000 per year in malpractice premiums — and significant debt, accumulated during the average 15 years it takes to become board certified, said Katie O. Orrico, director of the Washington office of the American Academy of Neurological Surgeons (AANS).

Two thirds of respondents to a recent yet-to-be-published AANS survey said that if they had to accept Medicare rates for all their patients, they wouldn't be able to cover practice expenses.

A quarter said they weren't sure if the rates would be enough to cover expenses, and only 7% said they'd be able to cover costs, Orrico told Medscape Medical News.

Reimbursement for all patients at the Medicare rates "would be significantly problematic" for the AANS membership, she added.

Warren's suggestion that reimbursement also needs to be rebalanced between primary and specialty care is nothing new and has been happening slowly through changes in the Medicare physician fee schedule, noted Orrico. But some 85% of neurosurgeons in the survey said Medicare already undervalues their profession, she said.

Opposition to Single Payer

The AANS wouldn't comment specifically on Warren's proposal but has been on record since 2009 as being opposed to a single-payer plan, Orrico said.

Similarly, a spokesman for the American College of Radiology (ACR) — another "overvalued" specialty — told Medscape Medical News the organization would not comment on the Warren plan. But he noted that the ACR is a member of the Partnership for America's Healthcare Future, which is against a single-payer system.

After Warren gave details on how she would pay for Medicare for all, the Partnership called it unaffordable. "Lawmakers should build and improve upon what's working and come together to fix what's broken ― not start over from scratch with an unaffordable one-size-fits-all system controlled by politicians that forces Americans to pay more and wait longer for lower-quality care," said Lauren Crawford Shaver, executive director, in a statement.

The American Academy of Orthopaedic Surgeons (AAOS) ― yet another overpaid specialty, according to Warren's plan ― also opposes single-payer plans but would not comment on Warren's proposal. The AAOS backs wider, affordable access, and said in its position statement on health reform that "it is important that policy makers avoid creating new unaffordable programs that repeat past mistakes."

The AAOS noted that Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP) all have problems with respect to sustainability that have led "policy makers to erect bureaucratic impediments to care and reimbursement rates that make it difficult for providers to cover the cost of care."

The Association of American Medical Colleges (AAMC) told Medscape Medical News that the organization is concerned about Medicare's future. The program is projected to be insolvent by 2026, said Leonard Marquez, the AAMC's senior director for government relations and legislative advocacy.

Even under the current program, "reimbursement rates fail to cover the cost of care for teaching hospitals, and their overall Medicare margins are negative," Marquez said.

The AAMC "cannot comment on the specifics of any candidate's proposals," he said, adding that "we believe Congress should work to strengthen the ACA and that all states should expand their Medicaid coverage."

Dead on Arrival?

Because Warren has laid out a specific payment plan for Medicare for all — one that targets multiple constituencies through higher taxes — it seems to have received more attention than the Medicare-for-all program backed by candidate Bernie Sanders, the Vermont senator.

To some in Washington, Medicare for all seems destined for failure, in part because it would represent such a monumental upheaval. "I have to believe that Elizabeth Warren is smart enough to know that this doesn't have a chance," Robert Laszewski, of Washington-based Health Policy and Strategy Associates, told Medscape Medical News.

Writing on Medium, candidate Joe Biden, in an apparent thinly veiled reference to Warren, called her approach "representative of an elitism that working and middle class people do not share: 'We know best; you know nothing. If you were only as smart as I am, you would agree with me.' "

Biden said he had "proposed the most progressive, transformational ideas in this campaign." Sanders told ABC News that his plan was more progressive than Warren's, in part, he said, because her payment proposal would hurt job creation.

The Hill quoted several Democratic senators as saying they did not support Medicare for all and that they doubted such legislation would receive a vote if Warren was president.

"I'm for universal coverage, I'm for building on the Affordable Care Act," Ben Cardin (D-MD) told the publication. But, he said, "My preference is to move forward on a public option."

Public support for Medicare for all also appears to be dwindling. From a high of 59% in support in 2018, to fell to 51% in October, according to recent data from the Kaiser Family Foundation. President and CEO Drew Altman, PhD, however, said in a November 6 column for Axios that "it's still a powerful idea among many Democrats."

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