By Walter Tsou, M.D., M.P.H
Director of the Mongomery County Health Department
- In the summer of 1996, a group of concerned physicians mailed 1,000 anonymous surveys to a random group of all licensed medical and osteopathic physicians in Pennsylvania. Unencumbered by advertising rhetoric or influences by medical marketers, the survey examined a cross section of Pennsylvania physicians’ attitudes and opinions about medical practice and health policy. Results of this survey should be of interest to medical societies and physician groups.
- A total of 288 physicians returned the survey. Demographic information showed wide diversity of practice location, specialties, and payment source.
- Physician satisfaction with medical practice showed a significant level of dissatisfaction. For a profession which has the highest economic standard in America, fully 35 percent were unsatisfied or very unsatisfied with medical practice. Closer analysis showed that those most likely to be dissatisfied were in practice for more than 10 years, paid mostly by fee for service, worked in urban locations and owned their practice. Surprisingly, a higher percentage of managed care patients did not seem to influence satisfaction with medical practice.
- When we asked what form of practice was preferred, overwhelmingly 81 percent chose private solo or group practice. Interestingly, only 6 percent would choose to be in a medical society directed HMO practice. This explains in part, why it is so difficult to organize a physician directed health plan.
- On the broader question of satisfaction with the American health care system, fully one half are either unsatisfied or very unsatisfied with the current system.
- While there may be considerable dissatisfaction, physicians are decidedly unclear about what solution is favored.
- About one third would like to see medical savings accounts and government paying for some of the uninsured as a preferable way to finance care. The current system of marketplace evolution, managed competition with competitive HMOs, was favored by 28 percent.
- The surprising and a close second most favored choice was single payer, national health insurance. Twenty-nine percent favored this plan, despite its total opposition by organized medicine and both political parties. A more detailed analysis found that physician attitude about health care as a guaranteed right was a major point of division. For physicians who supported the belief that health care should be a guaranteed right, 83 percent supported national health insurance. For the survey in general, physicians were surprisingly divided on this question. Fully, 44 percent felt that health care should not be a guaranteed right.
- Based on these findings, it would be incorrect for organized medicine to portray unanimity of support for just medical savings accounts. Physicians are decidedly indecisive and support a variety of reform proposals, including medical savings accounts, national health insurance, managed competition, and even the status quo. However, when physicians were asked if they would support a decrease in the rate of increase in Medicare and Medicaid (basically the proposals by Congress and Clinton), only 10 percent supported this plan. For Pennsylvania physicians, the current reform proposed by politicians is not a satisfactory choice.
- Finally, we asked physicians to prioritize those values which they believe are very important or essential for medical practice and our health care system. In loud and strong numbers, quality of care was their top priority. This was followed by malpractice reform, no doubt prominent in the minds of Pennsylvania physicians because of the CAT fund surcharge. Also highly valued was the freedom to choose one’s doctor. Declining support was mentioned for reduction in paperwork, medical research, and universal coverage. The smallest priority was given to the financing of medical education, which raises the question of how our society can win support for medical education when less than half of the physicians see it as a priority?
- The new for profit health care marketplace has different and conflicting priorities from those identified by physicians. Cost containment and the ability to restrict choice of physicians are part of managed care’s top priorities. Malpractice reform is not a market priority. Both the market and physicians claim quality as a priority, but differ in the price which should be paid for this quality.
- Physicians are even more confused than ever about what to do. Despite dissatisfaction with medical practice and more significantly, the health care “non-system,” physicians cannot agree upon a financing mechanism. Unable to unite behind a plan, physicians have been rendered impotent as the changes whirl around them. The market loves forcing discipline on this impotence.
- A major disappointment is the tepid embracement of universal coverage. Physicians as healthcare leaders should recognize this as the ultimate failure of the marketplace. It is time for physicians to educate themselves in an honest, open dialogue on solutions, not just complaints. Three years ago when JAMA published the AMA priorities for a health care plan, surprisingly a single payer plan came closest to meeting physician priorities based on independent analysis. In November, the DC Medical Society became the first medical society to formally endorse single payer. That single payer also addresses the problem of universal coverage should place it at the top of organized medicine’s priorities.
- Complacency in the face of chaos is an unacceptable choice.