Bell Curve The Law Talking Guy Raised by Republicans U.S. West
Well, he's kind of had it in for me ever since I accidentally ran over his dog. Actually, replace "accidentally" with "repeatedly," and replace "dog" with "son."

Tuesday, September 15, 2009

What Doctors Like and Don't Like About Public Health Care

...And what it tells us about the source of opposition to the public option.

So I heard about this story on NPR's Morning Edition this morning and found it again on the Washington Post. The highlights are that some MDs and MPH types did a survey for the Robert Wood Johnson Center. They surveyed doctors in the US and asked them if they supported or opposed a public option, a public single payer or the status quo. A whopping 62.9% of them support a public option. Only 27.3% support a reform bill that does not include a public option. OK, ho hum. That's probably not that dissimilar from levels of support among similarly educated people (i.e. people with post-graduate degrees). But where the poll got interesting was where it talked about what doctors liked and disliked about the public (Medicare) and private insurance providers.

The doctors preferred private insurance for ease of paper work and because of how much they get paid. But they preferred Medicare for health care provision and minimal interference in their medical decisions. From this I speculate that many of the doctors who oppose a public option do so because they fear they will lose money or for other reasons completely unrelated to the provision of actual health care to patients.

It also shows you who the insurance companies feel then need to keep happy. They take pains to make payment and paper work doctor friendly. But go out of their way to set up a system that actually denies care as the default condition. They serve their own interests which is understandable. But the only group they seem interested in keeping happy is doctors. And they seem to have won over about a quarter of them.

Whether or not we get a public option is probably a finished debate now. We're not going to get it. And I doubt that if it had been released a month ago it would have done much to change the debate. The Tea-baggers, Birthers and Deathers and their backers in the Republican party and the Insurance industry had a plan to hijack the debate regardless of any references to reality or evidence. But it is interesting to see this poll now. It gives yet another piece of evidence about the nature of the opposition to health care reform. A lot of people have been making a lot of money on the status quo for a long time and they have used that money to acquire political influence and power. They won't go quietly into the night.


Anonymous said...

It's rather interesting that doctors like private insurance paperwork and think it is easy to submit and use.

The only doctor I've ever had without an office staff of at least 3 people was a psychiatrist. I'm not talking about nurses or medical technicians, I'm talking about the front-office staff who make appointments, process claims, do billing, etc. My dermatologist has a two-woman practice, and there are three people in the front processing claims. My OB/GYN practice appears to have about a dozen billing staff, including a manager who probably has to be paid decently and get benefits. Since there are 10 doctors in the practice, that is more than a one-to-one-ratio of doctors to claims staff.

Personally (and this is rich coming from someone who would like to move into management), I can't imagine anything more irritating that managing that front-office staff. Having had a few friends who have done these jobs, they are both exceedingly low paying (less than most nannies make) and rather hard to fill since $10/hour doesn't usually get you the most reliable set of people. Also it seems that most doctors tend to hire people who can only be described as exceedingly customer-service impaired. The receptionists almost invariably sound bored and irritated that you have interrupted their texting, seem unable to schedule patients (no, I can't come in at 10:30 on Tuesday morning if I told you I couldn't make a 10am appointment), often have colorful visible tattoos and "fashion" choices, and (this is most galling of all) a fair number seem unable to read, comprehend, or speak high-school level English. I'm not talking about an accent, even a heavy one. I'm talking about, "what you mean 'rash'?"

Dentists seem to do this sort of thing much, much better, and I really have trouble understanding why that is the case. Except, obviously, that dentists are awesome. :o)

I must be missing something.

-Seventh Sister

The Law Talking Guy said...

I have the feeling that "ease of paperwork" is sort of a nice cover for doctors who just want to say they prefer getting paid more. I have heard many doctors complain about private insurance paperwork regularly, in particular that each private insurer has different paperwork. The paperwork probably is easier than Medicare/Medical when compared one-on-one, but a comparison of all the different kinds of paperwork to a single medicare form is no comparison at all.

I know doctors in many areas resent the interference by private insurers that can dictate what care to give.

The Law Talking Guy said...

It's worth noting that the Obama administration courted doctors and pharmaceutical companies. They did not court private insurers nearly as hard. Not surprisingly, the pushback was all on the public option.

I suspect that the Dems will pass a public option in 2011 or 2013. Once the provision is divorced from a Big Healthcare Bill and the lies about Scary Government Takeover associated with Big Healthcare bill, it becomes a non-issue. Making public insurance available to those who want it and can't afford private insurance will not be hard then.

Raised By Republicans said...

Well, one of the things that seems certain to be included is a requirement that insurance companies accept people with "pre-existing conditions." That will put a dent in their profits I imagine and they will respond by jacking up prices.

Hopefully that will lead to a backlash against them. Democrats will have to start planning NOW for how to maintain control of the agenda in the next round. You know Republicans will blame any increases in costs on "reform" and demand a return to the current situation.

USwest said...

Democrats piss me off on this issue. They totally gave everything away without much of a fight. Obama angers me for the same reason. He talks and talks. Time to start acting.

Here is a great article in Rolling Stone on what has happened with health care refrom.

I am still wondering when Democrats will start acting like a majority party. All those blue dogs are screwing us. Time for some party dicipline.

Doctors I know often complain that it takes them 6 months to get insurance claims paid. And many complain that they spend more time on paperwork than on patient care. So I don't buy the idea that they think private insurace paperwork is easier. Often they contract their billing out to large billing organizations, which is a hassel for patients who have to contact one office for medical information and another is some distant land about the billing.

Doctor's aren't getting paid much now. I look at what they bill the insurance company and what they actually get paid, and I marvel at how they stay in business. The bill is $200, but the negotiatd, in-network allownce is $63. I give a $30 co pay. So all told, from a $200 visit, they get half of what they originally billed. That can't be a good deal.

Raised By Republicans said...

Part of what is driving this compromise is that in order to get the majorities they have the Democratic party had to expand its appeal. So that now, the Democratic party includes a wider range of ideologies and constituencies than it did before.

So in one sense, yes the Blue Dogs are screwing the left on health care. But at least they are Democrats now in those seats instead of Republicans. If those seats were still being held by Republicans there would be no bill at all, compromised or otherwise.

The mantra the liberal Democrats need to keep saying to themselves is "Don't make the perfect the enemy of the good."

As for Obama. It's really easy to over estimate the influence a President can have on the details of a particular bill. The details get hashed out in committee meetings and back room sessions to which the President has no official access. Then a bill is worked out and presented to the President without any possibility for him to amend it.

The best Obama can do in this situation is exactly what he is doing, travel around the country encouraging people to support the reform bill that eventually comes out of Congress.

Raised By Republicans said...

RE: "Doctors aren't getting paid much now"

Here is a list of average salaries (after expenses) for MDs listed by speciality

The lowest paid specialty is at $80,000. The highest is well over $300,000. The median household income in the USA is around $50,000.

USWest said...

So the comment I posted last night apparently didn't stick.

Let me see if I can recap what I wrote.

I don't think you can count doctors as the median household. For starters, many if not most are small business owners with high overhead costs. So while they may make upwards $200K a year, that may not be what they take home. In addition, $80K is good, but not great in many parts of the country, especially on the coasts. It may be more useful to compare doctor's wages to other like professionals. LTG, what does the average lawyer in practice bill per hour? When we looked into a lawyer for something, it was $300/ hour in addition to court costs.

My plumber likes to charge me $100 an hour. The car mechanic will charge $130/hour depending on which one I go to. And the auto mechanic has nearly as much overhead as a doctor's office. The machinery is expensive, and it has to be constantly upgraded (i.e. capital investment). There has to be staff and there are rentals fees for the space, and there is constant training that has to be kept up.

I know women who pay easily over $200 a the beauty salon for a cut,color, and style.

I don't object to doctors being paid more because we place a high value on their services.

As for Obama: For 8 years we had an administration that was very active in shaping legislation. So yes, the president can be proactive in shaping the legislation. Obama has over-learned the Clinton lesson. He doesn't want to be too interventionist, so instead, he errs too much on the side of caution. In addition, if it fails, he can point at Congress and say, "well, I left it to them."

I am willing to reserve final judgment until I see a final reform bill. But at this point, I am not optimistic nor am I impressed with Obama's performance on the issue. I think he is overwhelmed with so many issues and he is showing up late to the game. And as for the party, I stick to my first assessment. I am tired of being reasonable and making excuses for them. When you have a Finance Committee of 6 people, all who receive sizable contributions from Insurance companies (if the Rolling Stone article is accurate), stacked with conservative types,then you will not get the kind of bill we need. Everyone outside the DC bubble agrees that you need a public option. Inside the bubble, they don't have the courage to make it happen. And with the success of gerrymandering, you are getting congress people who are less likely to compromise. Thus, welcome to CA-style legislation. I predict that we will not get a compromise. We will get a watered down crap piece of legislation where the only major change is that Insurance companies will not be allowed to exclude those with "preexisting conditions" or to create new "preexisting conditions" when people try to use their coverage. Beyond that, little will change.

Raised By Republicans said...

My reading of the website I found was that the salaries were "after expenses" which I took to mean after all the overhead stuff you mentioned. I also think those are national averages so the $80,000 a year is a national average and shouldn't be taken to indicate that doctors in California make that much.

As for Bush and his influence on policy. He had simultaneous majorities supporting him in both houses of congress combined with a highly centralized and disciplined Republican party (at the time). Obama doesn't have the internal party discipline advantage.

If you were to amend your critique of the current situation to be "Democrats can't coordinate well" I'd probably agree with you. But attributing all (or even most) credit or blame for legislative problems to the President is a fundamental misunderstanding the legislative role of the Presidency in American law making.

"Everyone outside the DC bubble agrees that you need a public option."

That statement is not accurate. The best polls for the pro-reform side show that there is about 25% to 30% opposition to the public option. And depending on how the question is framed you can get that opposition level to go up to close to 50%. has done some good discussions of the variability in these numbers. So yes, support for the public option is overwhelming but it is not universal and opposition to it is probably concentrated geographically in certain districts - making it more likely that opponents can muster a disruptive if not blocking minority in Congress.

RE: The prospects for compromise... One person's compromise is another person's "watered down piece of crap." I think it is fair to predict that you will dissatisfied with the bill that results but if you ask me to predict wether or not we get some sort of significant change on health care policy in this country by the end of the year, I'd say the chances are good.

Anonymous said...

i couldn't resist making a comment on physician salary: physicians are actually paid less in California, most likely because many people want to relocate here. the free-market forces have driven salary way down in LA, where i practice. physicians are compensated sometimes 50-100% more in rural areas because of the desperate need in those communities, especially for specialists. while i'm not sure if those numbers on the above website include overhead costs for a private practice (i doubt it), they are pretty accurate at first glance. i would not agree with the assumption that physicians in CA make more than those figures...i'll bet they make a little less.

an another note, suggesting physicians prefer private payers "because the paperwork is easier" is a joke; it's because you have a chance of getting better reimbursement for your services. 6 months down the line of course. and you have to fight for every dime. but there's a chance. We would all prefer to deal with Medicare, which is easy and's just that they reimburse so poorly, most practices have to cap how many Medicare patients they can afford to treat. any amount >30-40% of your patient and you risk not being able to pay your staff of fabulous front office workers.

i'm encouraged that you pointed out how a majority of physicians support the public option. most physicians know the current system is broken, and unfair, and would love to get back to the idea that we should care for our patients as best we can, and earn a salaray commensurate with our years of training, 7-10 years of lost income potential while in school, and our educational debt. if incentivized to provide the best care we can, i'm certain we can keep our citizens healthy, instead of the embarassment we now face, where the USA spends more money than anyone for invasive, unnecessary care, and still be lag behind in the metrics which truly matter. here's hoping for some drastic reform, and soon.

--LA pediatrician

Raised By Republicans said...

LA Pediatrician,

Thanks for your input. I think the reference to the preference for easy paper work was a report from the poll I was referencing, not a conclusion I was offering.

It was along the lines of what do you like most about private insurance - and the answer was easy paper work.

USWest said...

"But attributing all (or even most) credit or blame for legislative problems to the President is a fundamental misunderstanding the legislative role of the Presidency in American law making."

I understand the lawmaking process, thank you. Checked and balanced into paralysis.

The President is head of the party. If he wants party "coordination", he can get it. But you know what they say about Democrats and discipline.

Furthermore, I'd be happier if I saw all that energy that people put out to get Obama elected come back to push for reform. Where are all the door knockers and phone callers now? It's time to start getting that level of participation back through mobilization. Getting Obama elected was the means, not the ends.

I should qualify my "everyone" statement to mean that everyone who has studied the issue from both the economic and policy end that I have heard on various news outlets seems to agree about the need for a public option. I wasn't meaning the general public. But then, I might not be listening to the right (in more than one way) news outlets.

Raised By Republicans said...

Part of the problem with electoral success in the US is that when your party grows, it tends to get more ideologically diverse. It's also harder to control. If you try, you end up handing control of a large and diverse party to a single faction (the mistake the Republicans made in the Bush years) and that can alienate exactly the voters who made your party so successful in the first place.

Obama is having walk a fine line here. On the one hand he clearly favored a public option. On the other he was dealing with a Democratic leadership in the Senate that was more conservative than him and over whom he really has no control at all.

Bush had a very narrow ideological base with big enough numbers that they can sabotage any Republican's election chances if they so chose. The left wing of the Democrats can do that to some but not all Democrats. I doubt Harry Ried is that concerned about a challenge from the left for example. Look what happened with Lieberman. The left actually beat him in a primary and he still got reelected by running as the centrist and picking up moderate Republican votes.

What do you propose Obama do (should have done) to coerce reluctant Blue Dogs to change their views of the public option?

USWest said...

Granted, he is walking a tight rope. That is true about all the issues he is talking about. One thing that I would have liked to see is the White House proposing specific legislation into the fray. It proposed grand principles, but stopped at that. I would have liked to see Obama encourage the mobilization of his supporters to challenge that loud group of tea baggers. He needed his grass roots. I didn't see that. I do like that he is taking advantage of popular media like Letterman now. I wish he would have done that sooner. That is how you will get to the masses, more so that speeches at target groups that are highlighted on the evening news. You have to build popular support at the base. I don't think he did that.

One thing that strikes is me is something that I was reminded of this morning while listening to NPR. Most of the Blue Dogs are from the South and West. It so happens, according to this morning's report, that these are the places where there are the most uninsured. The uninsured are also the least likely to go to town halls or to vote, for that matter. They are a little busy trying to earn a living.

I am not big on the argument that a lot of this is racially motivated. I do think that Republicans are following Blue Dogs back toward the "small government is better" argument. You hear that theme on the student loan issue as well.

Look,health care is part of a much deeper philosophical issue with me. I am getting impatient and I am not expecting big things from reform because I don't want the disappointment when it doesn't pan out. We are still discussing the same issues that we've been discussing for 30 years. We keep discussing, but nothing gets fixed. From the environment to health care, it hasn't changed. I work in government. And in government, from the very small issues to the very big issues, promises are made, great ideas espoused and agreement on the problems are reached. Debate on resolutions ensues,and ensues and ensues. Then one day, compromises made, and implementation of a watered down policy is frustratingly incremental, always deferring the hardest changes for some distant future. We always tell people that in the "long run" this will benefit you while in the short run, you suffer. And the long run never comes and "In the long run we are all dead." I see it and live it every day. I see a lack of political courage and will to truly resolve problems. It is in the subtly of compromise that the strength of the solutions are lost. Incrementation demands patience. But boy, oh boy, when it is about sending people to war or funding a pet program, the government can suddenly become very nimble.

Anonymous said...

LA Pediatrician -

Thanks for chiming in about the salary stuff - it can seem pretty murky for non-medical people (or at least to me).

Do you think pediatricians and other kinds of primary-care doctors get the shortest end of the stick when it comes to the current paperwork system?

It seems like our pediatrician has to run a tremendous patient volume in order to keep afloat, especially considering how much of it is probably not reimbursed (phone calls, filling out stupid health forms for schools, talking otherwise educated parents out of dubious "natural" practices).

Looking at the explanation of benefits we receive from our health plan, it also seems that they feel compelled to bill very high for certain things in order to make up for receiving essentially no compensation in other areas.

While the care we receive is quite good, I suspect other doctors(like anesthesiologists) have to put up with far less rigamarole in that department.

-Seventh Sister

Anonymous said...

Seventh Sister,

Primary care doctors are responsible for so much, and are reimbursed so little, it makes me sick. Thank goodness I work for Kaiser, who pays me a reasonable salary, lets me do my job unencumbered by B.S., and incentivizes good common sense preventative care. All the data supports preventative care and early detection as being not only the "right" thing to do, but also the most cost-effective. But it is so hard to convince new graduates to go practice primary care, because that system is stretched to the breaking point.

The current system still reimburses very handsomely for procedures, things that you can't argue happened (whether they were necessary or not is another matter). Thus, incomes for anesthesiologists, specialists who do procedures, and surgeons remain high, while preventative care is not valued at all. The insurance company can reimburse a private practice pediatrician almost nothing for a 30min well-child visit, and we have to see 40 or more kids in a day to make ends meet. I don't want to sound like I'm whining that physicians don't make enough money; we do. But patients deserve more time with their doctor, and they deserve our full attention...7 minutes for a follow-up visit is not acceptable. I don't think I could work in today's private practice conditions, and I can't blame my peers for wanting to go into areas of specialty that still reimburse well.

I'm sure many hospitals and physicians over-bill, to try to fight back, or try to cover for all the instances when you will never be reimbursed for what you do. This is clearly unethical and I'm ashamed that my colleagues have lost the moral high ground perhaps, but I do believe this is the way of things now. All I can say is it is refreshing to work for my employer, whose emphasis on primary care and prevention should be a model for reform that might work in this country. If we can create a public insurance plan, or expand Medicare (or MediCal, the CA version) to properly reimburse for care, and create common-sense incentives for doctors and patients alike that encourage HEALTH, we will have succeeded.

--LA Pediatrician

Raised By Republicans said...

"Thus, incomes for anesthesiologists, specialists who do procedures, and surgeons remain high, while preventative care is not valued at all."

LA Pediatrician, I recently heard on NPR an analyst suggest that if this reform forbids insurance companies from dropping or denying people with pre-existing conditions that it would lead to the big health insurance companies really starting to spend money themselves and lobby hard for prevention - especially for things like diabetes. What are your thoughts?

Anonymous said...

RBR, im my opinion, this is the key to reform: incentivizing good practices that are in the patient's best interest. It just so happens that prevention, screening, and early detection of serious illnesses is also cheaper for everyone in the long run. But insurance companies have found an even cheaper solution than that idyllic one: DENY payment for care, or DENY/DROP coverage altogether. When they can skim the cream off the top (healthy patients paying premiums) they can make a killing. And when only a portion of our population is invested in healthcare, we get the current mess: rising premiums, decreasing reimbursements, late diagnoses, concierge service, and no one cares as long as they get their MRI without a waiting list.

Essential to any meaningful reform is forbidding this ridiculous "pre-existing condition" clause that they have. We as a society cannot in good conscience let this continue. But a for-profit entity will always find a way to cut costs, even when it is morally objectionable, like with denying coverage. The insurance companies are saying that if they are mandated to drop the pre-existing conditions rule, then all citizens should be mandated to carry insurance, thus increasing the pool of premium payments to pay for the increased coverage. Sounds like a great idea to me. And if the insurance companies can't drop you, they might as well keep you healthy and productive as long as possible.

If you believe that healthcare decisions are more important than which flat-screen TV to buy, I feel they should not be influenced by profit margins and stockholders. That, of course, is the bigger question: what role, if any, should corporations have in healthcare in this country? If you ask me, they should have very little.

--LA Pediatrician

Raised By Republicans said...

So if you had to choose between a public option and eliminating the "pre-existing conditions" loop hole for the private insurance companies which would you choose?

Anonymous said...

The public option. But that's my left-leaning bias. I have seen our health care system ravaged by these greedy people, and I want the people to take it back. Regarding healthcare, Canada, the UK, and Scandinavia beat the pants off us, hands me, i've been there. we're just too scared to do anything that might be construed as socialist.

Like a lot of Republican ideas, eliminating the pre-existing conditions loophole sounds like a great idea, and addresses a fundamental problem, but it does not take away profit-making from the decision process. Human nature being what it is, I would choose the option that leaves the most power in the hands of the patient, and their doctor, free from concerns about money, as much as that is possible.

There will always be private insurance in this country, if you want to pay for it. There are still people who think it's worth a 400% mark-up to go to USC instead of UCLA. But forcing them to compete with a not-for-profit entity like Medicare or the new public option...that's what these big corporations are really afraid of. Make 'em sweat.

--LA Pediatrician

Raised By Republicans said...

My concern would be that if you got the public option without eliminating the "pre-existing condition" loophole, all the sick people would end up on the public plan and the healthy people would end up on the private plans until they got sick and dumped. That would threaten the fiscal integrity of the public plan wouldn't it?

From a policy perspective (and this isn't an area in which I am especially expert) it seems that the public option would lose a lot of its advantage if it were not implemented in combination with eliminating the pre-existing condition thing. But eliminating the pre-existing condition thing has benefits all by itself even if those benefits would be greater in combination with a public option.