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Getting a seat at the reform table

July 2009

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.