Most Docs Prefer a Public-Private Combo for Health Reform: Survey

Ken Terry

October 30, 2020

Two thirds of physicians recently surveyed by the Physicians Foundation support a two-tiered healthcare reform plan that combines private insurance with a "single-payer" option.

In the survey of 1270 physicians that was conducted September 14-28, 67% of the respondents selected the two-tiered system as their best or next-best choice. On a four-point scale, only 11% gave this plan their most unfavorable rating.

The second-most favored option in the survey was maintaining or improving the current ACA-influenced system. Forty-nine percent of physicians selected this approach as the best or second-best direction for healthcare.

A market-driven system featuring health savings accounts with high-deductible plans was chosen by 45% of respondents as one of their top two alternatives. Thirty percent of respondents selected this as their top option, but 42% gave it the most unfavorable rating. Younger, female, and employed physicians all liked this idea less than older, male, and independent doctors, respectively.

A single-payer, Medicare for All system was the first or second choice for only 40% of the respondents. Nineteen percent of the doctors gave Medicare for All the highest rating, and 38% gave it the lowest rating. Again, the biggest supporters of this system were younger, female, and employed doctors.

Gary Price, MD, president of the Physicians Foundation, told Medscape Medical News that before the pandemic, physicians were "gravitating toward a single-payer plan," partly because they were frustrated with the challenges of dealing with multiple private and public payers. But the experience of the pandemic changed some doctors' attitudes, he said.

"Many physicians are unhappy with the federal coordination of the response to the pandemic," he explained. "I think this may have led them to rethink concentrating all the power for public health in one federal agency."

Why did employed and female physicians support Medicare for All more than independent and male doctors? Price said he suspects that employed doctors are more insulated than independent physicians from the billing and preauthorization requirements and financial constraints that Medicare imposes on practitioners.

Women doctors, he said, spend more time on paperwork than their male counterparts do, according to previous Physicians Foundation surveys. Perhaps getting rid of most of that paperwork by going to a single-payer system appealed to them, he suggested.

Reimbursement for Risk

The Physicians Foundation survey also asked questions about what kinds of policy steps should be taken immediately to ensure high-quality, cost-efficient care for all. Most respondents said it was important or very important to:

  • Reimburse physician-directed efforts to address social determinants of health

  • Simplify or streamline prior authorization for medical services and prescriptions

  • Prevent or eliminate surprise billing

  • Reimburse physicians for providing telemedicine services

  • Provide insurance coverage for COVID-19 diagnosis and treatment

  • Simplify access to integrated mental health services

Price said there has been a significant increase in the percentage of physicians who believe their efforts to address social determinants of health should be reimbursed.

"Physicians have recognized for a while that social factors can have a big role in patients' health and outcomes," he explained. "The entire system has been trying to figure out who should take risk when patients get sick. And increasingly, that risk has been shifted to physicians. But there hasn't been any attention paid to social determinants of health and how that impacts outcomes and the risk that physicians have. So physicians have been saddled with this risk without being able to intervene in these social areas that have a big impact not only on outcomes, but on how much care costs."

Addressing Health Inequity

Over the next 2 to 5 years, most survey respondents said, it would be important or very important to:

  • Reduce health inequity/inequality of access

  • Clarify the effect of pharmacy benefit managers on drug costs

  • Establish price transparency for medical services

  • Determine the impact of health systems and hospital consolidation on healthcare cost and quality

  • Increase the number of physician leaders in key decision-making positions

  • Provide affordable health insurance coverage that ensures improved access

The support for increasing the number of physician leaders in decision-making roles, Price said, was principally based on doctors' desire to have a greater effect on government policies and regulations. The COVID-19 pandemic, he noted, has affected physicians' attitudes in this regard.

"There have been very public battles between expert physicians and people with little or no scientific background being leaders in the public response," he said. "It's been very frustrating to physicians that informed scientific fact isn't playing as big a role as they think it should."

Most doctors are concerned about the consolidation of the industry into fewer players, he said, because they know — and studies show — that it has driven up health costs. Independent doctors who join healthcare systems see this immediately, he said, in the higher fees their new employers charge payers.

Many of the physicians who say that the effect of consolidation on costs should be studied are employed by these systems. "I think they are aware of [the impact of consolidation]," Price said. "But they aren't threatened by it the way independent practitioners are."

The Physicians Foundation survey was the third in a three-part series about the effect of COVID-19 on US physicians. The earlier surveys assessed how the pandemic affected physicians' practices and their patients, and the impact of COVID-19 on physician well-being.

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