DOCTORS’ ATTITUDES ON THE FUTURE OF MEDICINE:
What’s Wrong, Who’s to Blame, and What Will Fix It
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ABOUT THE SURVEY
The survey was conducted by fax and online from April 18 to May 22, 2012. DPMAF obtained the office fax numbers of 36,000 doctors in active clinical practice, and 16, 227 faxes were successfully delivered. Doctors were asked to return their completed surveys by fax, or online at a web address included in the faxed copy. Browser rules prevented doctors from filing duplicate surveys, and respondents were asked to provide personal identification for verification. The response rate was 4.3% for a total of 699 completed surveys.
- Doctors from 45 states responded, in addition to 130 who did not provide their geographical information.
- Most are in solo or small group practice (81%) and office-based (89%) versus hospital-based (11%).
- Most of the doctors are mid-career (77%) and have been in practice between 11 and 30 years.
- Almost unanimous that medicine is on the wrong track, and overwhelmingly blame the government;
- Government-imposed solutions (PPACA, electronic health information) destined to fail;
- Highest numbers ever opting out of Medicare or refuse Medicaid;
- Vacuum in leadership in medical profession, feel abandoned by AMA & organized medicine;
- Corporate medicine (including hospital and insurance companies) is intentionally trying to destroy private practice;
- Doctors are pessimistic - failing financially & assume things will worsen;
- See doctors and patients as the solution - not government;
- Believe direct payment by patients will restore accountability & patient control;
- Restored autonomy, elimination of government involvement, increased patient responsibility and free market reforms are solutions.
- 90% say the medical system is on the WRONG TRACK
- 83% say they are thinking about QUITTING
- 61% say the system challenges their ETHICS
- 85% say the patient-physician relationship is in a TAILSPIN
- 65% say GOVERNMENT INVOLVEMENT is most to blame for current problems
- 72% say individual insurance mandate will NOT result in improved access care
- 49% say they will STOP accepting Medicaid patients
- 74% say they will STOP ACCEPTING Medicare patients, or leave Medicare completely
- 52% say they would rather treat some Medicaid/Medicare patient for FREE
- 57% give the AMA a FAILING GRADE representing them
- 1 out of 3 doctors is HESITANT to voice their opinion
- 2 out of 3 say they are JUST SQUEAKING BY OR IN THE RED financially
- 95% say private practice is losing out to CORPORATE MEDICINE
- 80% say DOCTORS/MEDICAL PROFESSIONALS are most likely to help solve things
- 70% say REDUCING GOVERNMENT would be single best fix.
DISCUSSION OF RESULTS & COMMENTS
Respondents were allowed to submit open-ended comments, and 178 did so. This discussion incorporates comments that are representative of those submitted.
1.Culture of Frustration
An overwhelming 9 out of 10 doctors say they think that the U.S. medical system is “on the wrong track,” and 8 out of 10 say that current changes make them think about quitting. Only 5% say that they are “re-energized” by the changes. These are all-time high numbers since the 1960’s. Said one doctor from Alaska: “I feel sorry for those who are valiantly trying to practice good medicine in such a dysfunctional system,” while others point out concerns about the coming crisis for the most sick and the poor as doctors bail out of the system.
Other representative comments include:
“I have been in practice for 28 years and medicine is now the worst for doctors it has ever been.” Orthopedist, TX
“I would not consider letting my teenagers become physicians. My husband is also a physician.” Anesthesiologist, WI
“Medicine is circling the drain. Heaven help us as we all age.” Sports Medicine, KS
2. Declining Patient-Doctor Relationship
Doctors lament the deteriorating patient-doctor relationship, once held sacred as the lynchpin of quality, compassionate medical care, with 85% saying that the relationship is declining, and only 10% say it is at least holding steady.
One respondent from Missouri writes: “Medicine is no longer about treating and taking care of patients. I spend more time telling patients about additional paperwork they need to fill out.”
Doctors largely blame their loss of control over their practices for that declining relationship, as 9 out of 10 say they have LESS autonomy than they expected to have when they started practicing. “Get back to the doctor patient relationship. Eliminate all the middle men parasites” (Family Practice, AZ)
Another threat to the relationship is the doctors’ inability to guarantee patient privacy in this era of electronic medical records (EMR). Two out of 3 answer that electronic medical records (EMR) compromise medical privacy and confidentiality. “Electronic medical records should be trashed or at least not connected to outside electronic world to help avoid confidentiality abuse” writes a neurologist from Missouri. As might be expected, psychiatrists are the most vocal in their opposition; one from Texas says "doctors have to fight for patients’ rights to control the flow of their health information in electronic health systems.” Another from Massachusetts sees no wiggle room: “EMR has no place in a psychiatric practice.”
Others point out how the electronic medical systems interfere with doctor-patient communication: “Patients are constantly complaining about my colleagues being too rushed, looking only at the EMR and ‘not caring’ about them,” writes an endocrinologist from Florida.
3. Ethics vs. Money
Doctors say that they are frequently caught in a bind of choosing between practicing at the highest ethical level that puts their patients first and the relentless pressure to ratchet down costs. They say the difficulty is exacerbated by government regulations and insurance company contracts that micromanage their medical decisions. Six out of 10 say it is getting harder to adhere to the Hippocratic ethic of medicine, while only 2% say it is getting easier.
One-third report it is about the same, but cross-tabs of results show that many of those are doctors who are in independent, direct practices with no insurance contracts and no participation in government programs, such as Medicare and Medicaid, where they have no third-party interference nipping at their heels.
Doctors also believe that cost-cutting tactics imposed by government are unlikely to do so, and even if they do accomplish some short term savings, will do so at the long-term cost of quality of care. Seven out of 10 say “Pay-For-Performance will NOT reduce costs, and 2 out of 3 say it will NOT improve quality of care.
The use of so-called “physician extenders” may cut costs, but doctors say again, that patients will suffer the consequences. Two out of 3 say that giving nurses more responsibilities will worsen the quality of care.
4.Too Many Hands in the Cookie Jar While Doctors Squeak By
One of the most dominant themes in the open-ended comments was the negative impact of third-parties contracts, whether with and with the government or insurance companies. Doctors believe that too many people are skimming their cut of health care dollar without providing any useful service or actual medical care, while paying doctors less and less. And they say that the impact on patient care is devastating.
Writes one from Pennsylvania: “[Insurance] overanalyzing physician decisions with non-qualified RNs is tedious and delays really necessary treatment.” And from an orthopedist in Minnesota: “Doctors have lost control and are being told what to do by hospitals, insurance companies and the government who only care about money – not patients.”
These concerns are reflected in doctor’s financial circumstances. Two out of 3 say they are either just squeaking by or are losing money, and 51% expect that to worsen in the next 5 years.
Doctors describe the “hassle factor” and see it as an intentional tactic by insurance companies and the government to squeeze more money out by delaying payment to the doctors:
“…using hassle factor tactics is actually part of their business plan. (hassle ---> frustration ---> patient drops complaint & pays more - and during the period in question, the money in play earns interest for the insurance company)” - Geriatrician, NY
Lawyers are tied for third place with third-party payers in the rankings of who is most to blame for the current problems in medicine, and tort reform was a close fourth for what would most improve medicine. “Ban ambulance chasing lawyers from advertising and encouraging lawsuits with no risk to plaintiffs,” writes one doctor.
5. The Endangered Species & The Corporatization of Medicine
“Medicine has become big business and doctors have become workers who are exploited by big business.” (Psychiatrist, CT)
Doctors say private practice is looking like an endangered species, to be run out of business by the increasing power of corporate medicine. Ninety-five percent say medicine is becoming too controlled by large corporations, including giant hospital systems, large hospital-controlled groups and what they view as collusion of corporate medicine and insurance. “What a mess…hospitals that have become corporate and want ALL of the money they can get from EVERY patient at EVERY encounter” writes a family practitioner in Florida.
Traditionally lone wolves, doctors in solo- or small-group private practice feel mounting pressure to join large groups or hospital systems because of economics and the preferred deals they can negotiate with insurance companies. Others are looking to “share the pain” of the regulatory and administrative burdens. A California general surgeon says “I was in solo private practice for 20 years before reluctantly taking a salaried job at our county hospital.”
They also point out that doctors previously ran the hospitals, but that now the corporate-system hospitals pull the strings, all to the detriment of patients. “The power of hospitals is huge and has destroyed physician's autonomy and his ability to demand improvements in health care,” write a general surgeon in North Carolina. And from a family practitioner: “When the airlines were taken over by business instead of being run by pilots, the industry went to hell. Same thing has happened to ‘healthcare’-- doctors used to run hospitals and their practices. Now they are ‘providers.’
A good number are responding by bailing out of private practice and the accompanying hassles of running their own business in exchange for the security of mid-level salaried positions as employees of those systems: “As a solo doc, I am being forced out of my practice by the bureaucracy…Those that suffer will be the patients” (Ophthalmologist, PA)
One doctor sums it up with his apology: “I sold my soul to a hospital. Sorry!”
6. Leadership Vacuum & the Faltering AMA
Doctors have very little expectation of any support or solutions from organized medicine and their professional associations. More than half (57%) gave the American Medical Association a failing grade – an F – for the job it has done representing them and their concerns. A “D” was awarded by 17%, and only 3% deemed their work to be worth an A. “The AMA sold out,” says a pain management specialist in Missouri, and others made veiled references to reports of the AMA’s “deal” for their support of the Affordable Care Act:
“There should be much less cronyism and favoritism between medical organizations and government. The PPACA is a monstrous bill designed to give government COMPLETE control over our lives…” (Endocrinologist, FL)
National specialty groups and state/local medical societies fared a little better, earning ranking of “C.”
But the doctors did single out a few groups for high marks – most of them engaged in political advocacy, such as the Christian Medical Association, Physicians for a National Health Plan, Docs 4 Patient Care, the Association of American Physicians and Surgeons, and the Doctor Patient Medical Association.
While the public positions of most professional associations are largely unpopular with the doctors, many are afraid to speak out. One out of 3 says they are hesitant to voice their opinions about health care politics, policy or legislation because of reaction from their patients, colleagues or administrators.
7. Separation of Medicine and State
Hands-down, doctors blame government involvement in medicine for the current problems in medicine, and are not shy to say they want it out. Two out 3 doctors ranks government involvement as the top reason, one-half rank health plans/insurance as the top reason (see #8 below), and third-party payers and lawyers are tied for the third highest ranking at 40%.
The reasons cited range from the deluge of regulatory compliance that siphons time away from patient care, to de facto rationing achieved through complex payment schemes, to cushy relationships that favor corporations and special interests in medicine:
“Unfortunately as regulations have increased there has been a direct impact on the cost of care increasing.” (Anesthesiologist, KY)
“American healthcare is finished. The damage done by government/corporate control is irreversible…Only the powerful will have decent medical care (government employees)
“Government gets away with rationing by making doctors the scapegoats when someone alleges that an ACO made a profit by skimping on care.” (Internal medicine, NH)
They say that the government second guesses them and treats them like cogs in a machine. “I did not go to school for 25+ years to be computer programmer for Federal Govt.” writes a Florida ophthalmologist.
Doctors say that a key government provision in the Affordable Care Act – the huge expansion of Medicaid enrollees – is likely to backfire, as almost half (49%) say they will stop accepting Medicaid payments.
Medicare draws even more complaints. Three-quarters (74%) say they will stop accepting new Medicare patients or leave it completely. Another 27% say they will start restricting services to their current Medicare patients. “I wish I could opt out completely,” writes one. Another: “Will stop as soon as I can afford to.”
Surprisingly, it’s not just the lower payments that send them running, as 52% report that they would or might be willing to treat some of those patients for free. “I want to focus on what is best for my patients and not what a government official deems cost effective...I would be willing to do charity care weekly for the poor and underinsured if there was tort reform,” writes a family practitioner in Washington state.
Not surprisingly, 71% of the doctors say that reducing government regulations and mandates is “most important” to improve medicine right now. (Second highest is “increased patient responsibility.” See # 9 below).
“Only the free market will fix this mess. We need to eliminate government and government-protected corporate greed from medical care.” (OB/GYN, TX)
“Less government will mean better and less expensive medical care. Government is the problem. Are there any long term Government run programs that aren't riddled with inefficiency and corruption?”(General Surgeon, IL)
“The federal government needs to get the HELL out of the practice of medicine. Here's the bottom line: you cannot give away free medical care. Until they stop entitlements, this whole system is doomed, unfair, and chaotic.”(Internal Medicine, WA)
“Government at any level should have no role in medicine except medical licensing and business licenses. Period!” (Orthopedist, MN)
8. Insurance vs. Medical Care
Doctors clearly understand what Washington does not – that a piece of paper that says you are “covered” by insurance, or “enrolled” in Medicare or Medicaid does not translate to actual medical care when doctors can’t afford to see patients at the lowball payments, and patients have to jump through bureaucratic hoops. “The major problem is the politicians equating health ‘insurance’ with ‘health care,’” writes a family practitioner.
About three out of 4 (72%) say the ACA individual insurance mandate is unlikely or will not improve access to actual medical care.
And they report that insurance companies are often barriers to reforms that would give patients tools to find and negotiate for more affordable care. Fifty-nine percent would post prices or consider posting them, but 40% report that their insurance contracts gag them from disclosing prices.
But the crucial issue for the doctors is that third-party payment by insurance companies instead of direct payment from payments not only increases the costs care by adding compliance costs for them, but also hands over power to the insurance companies to ‘call the shots’ and micro-manage treatment through the power of the purse. “I spend 6-8 hours weekly trying to get insurance companies to cover most of the cost of medications that my patients need,” writes one psychiatrist.
“Decrease power of insurance companies to dictate health care.” (General Surgeon, MN)
“[We] take time away from patient care to do coding for the benefit of insurers. (Neurologist, MO)
9. Patient, Heal Thyself
Doctors say that many problems in health care could be fixed if patients would get more involved, take more responsibility for their health, and pay for their care themselves instead of asking doctors and other medical professionals to file the insurance claims and wait for payments. “More patient involvement” was ranked as a “most important” factor by 68%, just behind reducing government regulations and mandates.
“Patients would be more thoughtful consumers if they had more ‘skin’ in paying for health care. This is why lots of patients who never took generics are now taking them.” (OB/GYN, OH)
“Patients need to take responsibility for their own good health. They should not believe that they can live any lifestyle they desire and have others pay for their health misfortunes that result from this lifestyle.”
“The best chance for controlling cost is limiting government interference and increasing patient responsibility for cost. If the patient pays at time of service and files an insurance claim on their own, it reduces the likelihood of superfluous utilization, AND reduces insurance company denials since the patient is following up on their own claim. Also, removing insurance purchasing from employers makes insurers responsible to policy holder, not employers.” (General Surgeon, GA)
10. Physician 2.0: Back to the Future
Many doctors seem to have reached a tipping point and are ready to rally against forces they see as threats to medicine. “I think that the doctors need to stand up and fight with a united front instead of taking these changes lying down,” writes a podiatrist in Florida.
One of the ways of fighting back gaining traction is to change the very structure of their practices. Even though private practice is under tremendous pressures, doctors believe a return to direct practices as a way to restore ethical, affordable medicine, and to put patients’ back in the driver’s seat along with their doctors.
A cardiothoracic surgeon in Florida spells it out:
“The most important thing would be to eliminate third party payments. Patients and physicians should decide what tests need to be done and what treatment will be administered. The patient should pay the physician for service. Whether they then get reimbursed is between the patient and the third party payer. This would put patients and physicians in charge.” (Cardiothoracic Surgeon, IA)
Doctors want patients to value their services as they would any others. Explains one:“People pay for car repairs before they get their car without problems. If people paid for their care they would get better care.” And another: “Women spend hundreds on hair treatments and give a tip on a regular basis.”
It’s clear that doctors are ready to team up with patients to create a new/old paradigm. “Physician 2.0” is a reinvention of the old time country doc, and those who have already shifted into it express the most satisfaction with medicine. Four percent of the survey respondents report they have already moved to direct practices:
“I am opted out [of Medicare & Medicaid] and cash based for 12 years now as an internal medicine practice. I have never been busier, deliver a high quality consultative product, am financially secure, and cannot wait to go to work every day..” (Internal Medicine, MN)
“I opted out of all insurance 6 years ago and really enjoy practicing medicine again. I have found that many people that do not have insurance are quite happy to pay a reasonable fee for their care.”(Family Practice, SC)
Based on this survey, more are expected to follow in their footsteps.