Politics aside, doctors universally fed up with insurers

U.S. physicians are torn over what the government should do to make health care more available and affordable, but they're surprisingly like-minded about one perceived scourge - the insurance industry.

As the U.S. Senate considers the health-care bill that narrowly passed the House over the weekend, polls and pundits have tried to gauge doctors' support for change.

The most up-to-date national survey of physicians, published in September in the New England Journal of Medicine, found that most favored expanding health coverage to the uninsured through a government-sponsored program - the so-called public option. The House bill included this choice for needy individuals and small businesses, but it faces tough opposition in the Senate.

Another survey, published last month in the same journal, found 70 percent of Massachusetts doctors support that state's three-year-old reform law, which increased public options, and created a government-regulated health insurance exchange.

But polls are tricky. Doctors' views depend on what they're asked, who is asking, and when. And polls may not gauge how hot-button health issues such as abortion and malpractice trump support for more coverage.

One opinion, however, is heard again and again, regardless of physicians' politics, specialty, or income:

"My colleagues and I spend an inordinate amount of time on the phone arguing with insurance companies for therapies we know are right. It's reached a breaking point," said John Maris, chief of the oncology division at Children's Hospital of Philadelphia.

"I'd take less salary if I could have less paperwork and less fighting with insurance companies to get what my patients need," said Nicholas A. DiNubile, a Havertown-based knee surgeon and sports medicine expert with Premier Orthopedics, one of Pennsylvania's biggest orthopedic practices.

Although these two physicians sound like echoes when it comes to insurance companies, they disagree about reform. DiNubile opposes a public option, while Maris supports it.

Indeed, Maris was among 150 physicians who formed a white-coated White House backdrop last month as President Obama promoted his vision, which includes expanding publicly funded coverage.

Surveys aim to get beyond such symbolism, but some ask questions that are philosophical or theoretical, making the results hard to interpret.

In September, for example, the New England Journal published a survey of a sample of American Medical Association members in which a majority agreed that physicians "are obligated to care for the uninsured or underinsured." What does that mean in practical terms? The survey didn't ask.

In 2007 - well before Obama was in the White House - a survey of a sample of AMA members found that "in principle," 59 percent supported replacing the whole U.S. health insurance system with a single public plan like Medicare.

Yet a single national public plan was the least favored approach - just 10 percent of doctors endorsed it - in the survey conducted this year. Of the 5,100 AMA members queried by researchers from Mount Sinai School of Medicine, 63 percent supported a combination of public and commercial options. The remaining 27 percent wanted only commercial options.

The researchers said this strong support for a public-commercial combo - which was consistent across specialties, practice locations, and demographic subgroups - "should be carefully considered by lawmakers as they finalize legislation."

Unless, that is, those lawmakers don't think the AMA is a good barometer. As physicians Elizabeth Lee Vliet and Richard Amerling have pointed out, only 17 percent of U.S. doctors belong to the AMA.

In a recent op-ed, Vliet and Amerling cited an unspecified poll result that 66 percent of physicians oppose congressional proposals for government-sponsored health care.

The AMA itself came out in support of the House bill. But yesterday, some prominent AMA members were pushing to rescind that backing because the bill doesn't address matters such as malpractice reform.

In any case, doctors' disenchantment with the insurance industry seems to transcend all other views. They decry health plans for restricting and denying care, interfering in medical decisions, and imposing administrative burdens.

"The enemy is the insurance companies," said Sean Green, a family physician in Ardmore. "They're in business, and their business is making money."

David Asch, a physician and professor of health-care economics at the University of Pennsylvania, described a study that found most physicians willing to switch to a slightly less effective cancer screening test to reduce costs - but only if they thought the savings would lower patients' premiums.

"Physicians who thought the money went to insurance companies were less in favor of the cheaper test," Asch said.

Clearly, what physicians think is influenced by their frustrations and fears. The House Republican Doctors' Caucus, made up of former medical professionals, warns that expanding public insurance options would result in decreased access, interference, more red tape - pretty much the same things that doctors blame on commercial insurers.

Arnold S. Relman, a professor emeritus of medicine at Harvard University, believes the fundamental problem with the current system is that doctors have a financial incentive to over-prescribe tests, procedures, and visits because doing so increases their income.

Many physicians would not disagree. Green, for one, lamented that medicine has become "a volume business."

"Having insurance seems to drive up the cost of care," Green said. "Patients come into the office or call for every little thing. I'm a poor businessman, because I discourage my patients from coming to see me for every little cold, headache, or back pain."

As for fixing the mess, well, that wasn't covered in medical school.

"I'm not an expert in health-care economics," Maris said. "The status quo is no longer acceptable. We need to be creative. I leave it to my colleagues to figure out the details."

The devil is in those details, says Jacob S. Hacker, a Yale University political-science professor (Ph.D., not M.D.).

"This is the Catch-22 of health-care reform," he wrote in a 2007 opinion piece in the New England Journal. "It is the very failings of our insurance system that make dealing with those failings so devilishly hard."