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July 28, 2009

Getting a seat at the reform table

I was somewhat discouraged by a conversation that rolled across my computer screen the other day. It started with a message from a physician with one of the sections of the American Academy of Pediatrics, exhorting members to get involved in the political debate and support the House of Representatives' version of health care reform.

Immediately, the listserv messages started flying back and forth, not in favor of the measure, but against it. Some of those messages were well thought-out, expressing doubts about the process or just wanting to wait for details to emerge in a final bill before taking a stand. But others were frankly hostile to the physician and colleague who'd posted the original message.

I am not surprised that doctors have strong opinions. After all, it’s not easy going through all of our schooling and training, and education begets intellectual character. But in the middle of the most important debate in this decade and possibly decades to come, doctors—just like members of Congress—appear divided.

I suspect most concerns stem from the fact that if Medicare reimbursements decrease, as has been proposed in some versions of reform, some physicians' income may go down. “We already pay enough for exorbitant malpractice protection, and we work an excessive number of hours," some say. "Now they want to cut our pay?”

The number of medical students headed into higher-paying specialties continues to grow because the high cost of all that schooling and training casts a long shadow over many doctors' careers. Many of us finish school with tens (or hundreds) of thousands of dollars in student loans. “And now,” they might say, “they want to cut Medicare reimbursement?”

I sympathize with these arguments. The main reason I went into pediatrics was to make children feel better. But I also chose pediatrics because of the Clintons' attempt at health reform, a plan that would have increased payment for primary care and prevention vs. that of specialties that do procedures. And I still carry a nagging burden of student loans that, if I had gone into a higher-paying specialty, might have been paid off by now.

Despite these concerns, this is not the time to put individual or specialty-based interests ahead of the big picture. This is not the time for bickering between rural and urban doctors or between primary care providers and specialists. (I wonder which side hospitalists would take on that one…).

Lawyers, pharmaceutical companies and politicians have for decades exploited the simmering divisions between us for their own advantage. One reason why I'm frustrated with the American Medical Association is that we have no national voice that truly represents physicians and effectively advocates for our interests.

Now that the AMA has reversed its initial opposition to any reform plan, it is time to galvanize our disparate positions and concerns into a single voice. We should take a page from the hospital and pharmaceutical lobbies, which agree to millions of dollars of lost revenue not for some altruistic purpose but to gain a seat at the table.

What did they gain? The pharmaceutical industry has been able to exclude any discussion of drug re-importation from the debate. Hospital associations stand to gain millions from newly insured patients and relief from caring for the uninsured for free.

Doctors should do the same thing. Let’s set aside our opposition to these plans, not for the greater good (well, not exclusively for the greater good) but to gain a seat at the table. When Congress and the President look at tort reform or where to set reimbursement rates or how to cut the costs of medical education, they will remember if we sacrificed a little to gain a lot.

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4 Comment(s)

Lucian DeNicola wrote:
Regardless of what form "Reform" takes, it must include a "public option" if we are to control cost.
Jacksonville, Fla. | Thu, Jul 30 2009 17:05 PM

Ruben J. Nazario wrote:
I agree. Unfortunately, it looks like that option is losing steam in Congress in favor of some sort of health insurance cooperative ... it would be interesting to see if these can control costs as well as a straight-up public plan.

Fear of a public option as being a step away from a government takeover of health has fueled opposition. As Paul Krugman wrote in the New York Times today, people don't recognize how involved the government already is on the health care system.

Thanks for your comment!
Fairfax, VA | Fri, Jul 31 2009 09:57 AM

James Anderson wrote:
I respectfully disagree with Lucian DeNicola’s statement that “Reform” must include a “public option.”

Two primary initiatives that need to be considered prior to the government taking more control over our health care system are tort reform and interstate trade for insurance companies. By allowing insurance companies to operate across state lines, the free market system will function more effectively and efficiently. The value of tort reform goes without saying.

As Mr. President recently said in one of the town hall meetings, “UPS and Fed-Ex are doing just fine. It’s the Post Office that’s always having problems.” Do we really want government running our health care?

Woodstock, GA | Sat, Aug 15 2009 13:47 PM

Brian Kennedy wrote:
Yes the government is already very involved in health care. Perhaps that is at least part of the reason (I would suggest a big part) that health care costs are so high. People get angry not just because their salaries may be affected. Most of the people complaining are not doctors. They see the government "option" as it is and realize they will lose more control of their own health care.

It might be a good idea to read the op ed that the Whole Foods CEO wrote. If President Obama proposed the eight point plan outlined there, I would be fully behind it.
Ann Arbor, MI | Tue, Aug 18 2009 07:04 AM


About Ruben J. Nazario, MD
Ruben J. Nazario, MD, is now medical director at Inovalon, a health care data analytics company, and is medical editor for Elsevier's First Consult. A pediatric hospitalist, Dr. Nazario is a veteran of both community and academic pediatric hospitalist programs. All material represents his own views and does not reflect the views of his employer.
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