Volume 61, Number 3 - Summer 2010

 

By Steve Osborn

The public option and a single-payer system weren’t included in the health reform legislation signed by President Obama on March 23, but both proposals are still widely supported by Sonoma County physicians. The SCMA Health Reform Survey, conducted in mid-May, found that 78% of the physician respondents remained either strongly in favor (62%) or somewhat in favor (16%) of the public option, which would offer Medicare-type coverage to all patients, regardless of age. 

Equally striking was the level of support for a single-payer system that would finance all health care through a single insurance pool. Almost half the physician respondents (49%) strongly favored a single-payer system, and another 18% were somewhat in favor, for a grand total of 67%. In contrast, support for the actual legislation signed by President Obama was more tepid, with only 34% strongly in favor and another 39% somewhat in favor.

The 12-question survey was distributed on May 6 to all 1,051 physicians then practicing in Sonoma County, either by e-mail (753 physicians) or regular mail (298 physicians). Doctors were given two weeks to respond, and a reminder notice was sent a few days before the May 21 deadline.

The total number of responses was 195, for a response rate of 19%. The software used to distribute the e-mail surveys (Zoomerang) ensured that only one response was allowed per e-mail address. Even though the e-mail version of the survey was theoretically easier to complete and return, the response rate for surveys distributed by regular mail (20%) was somewhat higher than for those distributed by e-mail (18%).

The first 10 questions on the survey were multiple choice, and the last two were open-ended questions that allowed for written responses. There were four basic groups of questions. The first group (questions 1-3) asked about the physician’s demographics, including specialty, age, and mode of practice. The second group (questions 4-7) gauged the level of support for the legislation and some of its provisions, such as the Medicare Independent Payment Advisory Board, increases in Medicaid pay rates, and reductions in some Medicare payments.

The third group (questions 8-10) asked about elements that were not included in the legislation, such as the Medicare SGR formula, the public option, and a single-payer system. The final group (questions 11-12) asked physicians to identify issues that still need to be addressed and to offer other comments regarding health reform.

Results of the demographic questions indicate that the survey respondents are broadly representative of practicing physicians in Sonoma County (see Table 1). The number of physicians who identified their main medical practice as primary care (family physician, pediatrician, internist) was 43%, which corresponds almost exactly to the current figure of 44% in the SCMA physician database. That database tracks every physician practicing in Sonoma County, including both SCMA members and nonmembers.

The percentage of specialists in the respondents, 54%, was again close to the SCMA database figure of 56%. The slight discrepancy can be explained by the survey’s inclusion of an “other” category for government officials and other physicians who don’t have clinical practices. That category is not tracked by the SCMA database.

The results for age also parallel the SCMA database, with a few small differences (see Table 2). A somewhat lower percentage of respondents were 41-50 years old (22% vs. 28% in the database), and a somewhat higher percentage were 61-70 years old (29% vs. 19%). Both the respondents and the database describe a classic bell-shaped curve, with the highest total in the middle (51-60 years old) and the lowest totals on the edges (younger than 40 or older than 70).

Question 3 asked respondents to identify their mode of practice, another variable that is not tracked by the SCMA database. Fortunately, an SCMA physician access survey conducted in 2006 does give some basis of comparison (see Table 3).[1] The most notable difference is that a smaller percentage of the 2010 respondents are self-employed (42% vs. 49%) and a larger percentage are salaried (38% vs. 29%). These differences probably reflect changes in the local medical landscape over the past four years, rather than any difference between survey respondents and general physician demographics.

Given that the differences between the survey respondents and the SCMA database are so slight, and that the response rate was relatively high, the respondents appear to be representative of Sonoma County physicians. Like their fellow citizens, those physicians have strong opinions about the new health reform legislation, which they voiced in their answers to questions 4-7.

Question 4 gauged physicians’ general level of support for the legislation (see Table 4). As noted above, 34% were strongly in favor and 39% were somewhat in favor, for a total of 73%. The remainder were neutral (10%), somewhat opposed (8%) or strongly opposed (9%).

Questions 5-7 measured physician attitudes about specific aspects of the legislation, starting with the Medicare Independent Payment Advisory Board, which would regulate Medicare spending, including physician payments (see Table 5). The leading response here was “neutral” (29%), perhaps reflecting a lack of knowledge about the board and its functions. CMA strongly opposes the board, stating in a recent position paper that the board “… removes Congress’s accountability to physicians and seniors in the Medicare program. It mandates provider payment cuts if Medicare spending exceeds general health spending.”2 Nonetheless, almost half the survey respondents (46%) indicated that they were either strongly or somewhat in favor of the board. The remainder (24%) were opposed.

The responses to question 6, which asked about increasing Medicaid pay for primary care physicians, were less diffident (see Table 6). The level of support for the Medicaid provision was overwhelming, with 80% of physicians strongly in favor and an additional 11% somewhat in favor. 

Question 7, about reducing Medicare payments for certain diagnostic imaging services, drew a more mixed response (see Table 7). While more than half the respondents (52%) were strongly or somewhat in favor of the reductions, almost one-fourth (23%) were neutral, with the remainder opposed. Once again, most of the respondents’ sentiments ran counter to the views of CMA, which is opposed to the reductions.[2]

The health care legislation has drawn almost as much attention for what it excludes as for what it encompasses. Accordingly, the survey measured physician attitudes about three exclusions, starting with the Medicare Sustainable Growth Rate (SGR) formula, which has produced several threatened cuts to physician reimbursements in recent years. While most physicians (55%) were strongly or somewhat in favor of repealing the formula, a remarkable 29% were neutral (see Table 8). As with question 5, which drew a similar number of neutral responses, the results may indicate a lack of knowledge about the topic.

Neutral responses were far fewer for the next two questions, which measured support for the public option and a single-payer system. As noted above, 78% of physicians strongly or somewhat favored the public option, and 67% strongly or somewhat favored a single-payer system. 

The level of support for the public option varied across demographic lines (see Table 9). [Note: Because of rounding, not all columns add up to 100%.] Primary care physicians, for example, were more likely to favor the public option than specialists (87% vs. 70%). Likewise, salaried physicians (82%) were more likely to favor the public option than production-based (79%) or self-employed physicians (74%).

Demographic differences were also evident in the level of support for a single-payer system (see Table 10). The most notable difference was that primary care physicians were far more likely to favor a single-payer system than specialists (81% vs. 57%). Differences in support between self-employed (67%), salaried (69%) and production-based physicians (69%) were negligible, however.

Unlike the first 10 questions, the last two were open-ended queries that asked physicians to identify issues that still need to be addressed (question 11) and to offer other comments regarding health reform (question 12). More than 140 physicians answered question 11, and almost 100 provided comments for question 12. The complete text of all responses to both questions has been posted in the “Resources” section of the SCMA website at www.scma.org/resources.

Question 11 asked, “In your opinion, what are the most pressing issues that still need to be addressed by health reform?” The responses—some of them quite lengthy—covered the entire gamut of health reform, but the following themes dominated:

• Insurance reform
• Improved coverage and access
• Cost containment
• Single payer and public option
• Tort reform
• Strengthening primary care

Insurance companies, long the perceived villain in the health reform debate, came under heavy fire, from a blunt “Insurance companies are raping our patients” to a more measured “The profit going to private health insurance companies takes money away from the delivery of health care.” Nobody had anything good to say about for-profit insurers, and several physicians advocated for their removal from health care.

Many doctors called for improved coverage and access, using phrases like “coverage for everybody,” “uniform delivery of health care,” and “all coverage should be the same.” One phrase seemed particularly apt, given the complexity of the issue: “Access to health care, not health insurance.”

Cost containment elicited many comments as well. Physicians wrote about “perverse incentives that continue to exist,” about “eliminating wasteful spending on technology, procedures, pharmaceuticals that are not evidence-based,” and about “fraudulent practices and overbilling.” Several doctors suggested specific methods for reducing costs and curtailing spending.

Single payer and the public option continued to elicit strong support, even though they were already covered in the survey questions. Comments ranged from a moderate “public option to make health insurers honest” to a more radical “We need truly socialized medicine so that we can get big business OUT of medicine!”

Tort reform, which drew little attention during the health reform debate, is still on the minds of many physicians, one of whom listed the top three reform priorities as, “1. Tort reform. 2. Tort reform. 3. Tort reform.” Another lamented “the litigious tone of medical practice, which leads to excessive prescribing, testing and referrals.”

A final common theme was the need to strengthen primary care. One doctor complained about “inadequate reimbursement for primary care, especially regarding coordination of care and preventive health.” Another wrote that “providers should get paid for keeping people healthy.”

Many other suggestions were offered, from the practical to the philosophical. Some began with statements like, “The entire paradigm in which medicine is practiced needs to change” or “The entire payment system needs to be scrapped.” Another neatly summarized a common sentiment: “Ethically and morally, we must get profit and greed out of health care.”

The survey concluded with question 12, which asked, “What other comments do you have regarding health reform?” The answers to this question tended to be general, in contrast to the specific reforms suggested in question 11. The comments ranged from the pessimistic (“too little, too late”) to the more upbeat: “In time, I believe it will result in a stronger economy and stronger and healthier individuals … even if it means more regulations.”

Among the many comments received, three seemed to encapsulate the general mood. The first offered some self-reflection: “We have allowed health care reform to be co-opted as a political battleground, when it should have been an ongoing physician-directed movement to modernize our health care system and correct its current injustices.” 

The second comment posed a wry question: “Why is it that my premium for health care for my family is increasing but my reimbursement rate is decreasing?”

Finally, the third comment typified the spirit of acceptance that allows people to move on after a long debate: “It’s way past time for some type of reform and while not perfect, it’s better than no reform at all.” 

1. Melody C, “Access to Sonoma County Physicians,” Sonoma Medicine, 57;2:7-11 (Spring 2006).
2. California Medical Association, “Pros and Cons of Health Care Reform,” cmanet.org (2010).