Salaried Physicians: Effects On Health Care?

Just saw a couple of New York Times articles, looking at the trend of physicians moving from private practice and into salaried positions.  The first is nearly a year old, and discusses the benefits of the trend for many physicians.  The benefits for many doctors is the ability to focus on medical care and less on business needs, while health systems (and maybe health care overall) benefit from lower costs that result from less duplication of services, (maybe) fewer tests and visits, and better doctor-to-doctor communication.  The second article is more recent, and discusses the continued trend as well as noting that salaried physicians tend to be more politically liberal.

The articles note the benefits to entering a salaried position: stable hours, focusing on medicine vs. business, etc; they also comment on some of the downsides: likely lower salaries when all is said and done, less individual say in practice policies, etc.  However, more and more young physicians are concerned about loan burdens and work-life balance, and the stability and reliability offered by a stable salary can be very appealing.

The second article does not discuss the leftward shift in physicians' politics once they become salaried in great detail, and doesn't provide much support to the claim.  But it is interesting to consider the future if the proportion of salaried physicians keeps increasing.  Is it possible that ideas such as a public option or a single payer system could gain further strength and additional support within medical organizations heading forward?

Upcoming Events

On July 1st (next Thursday), Virginia's Attorney General Ken Cuccinelli goes to court to defend his lawsuit alleging that the recently enacted Affordable Care Act (ACA) is unconstitutional.  As Cuccinelli tries to ensure that millions of Americans remain without true access to medical care and health insurance, activists will gather outside of the federal courthouse to ensure that the law's newly established patient protections and insurance regulations will be preserved.

I have been asked by the Virginia Organizing Project to say a few words regarding the benefit that I see this law will bring to patients in Virginia.  I thought I would jot some notes down here, and start organizing my thoughts:

--First, as a physician who cares for a large proportion of uninsured patients, the reforms enacted by the ACA will ensure that patients will be able to secure health insurance and access health care.  I have had to work with far too many patients whose medical problems have been uncontrolled--sometimes to the extent of threatening life or limb--because they have not been able to get routine and regular medical care.  The ACA will start providing access to insurance to uninsured people as early as this year, with access expanding over the next five years as the health insurance exchange is developed.  Also, small businesses start receiving tax credits this year in order to defray the cost of providing employees health insurance.  Finally, young adults will be able to stay on parents' policies until they turn 26, thereby ensuring that these young people can extend their education and/or begin their careers without having to worry about securing affordable health insurance at the same time.

--The previous administration enacted a Medicare Part D drug benefit program for seniors, but in order to hide the true cost (which was inflated by the law's requirement that Medicare could NOT negotiate for lower prices from drug manufacturers) the benefit included a "donut"hole.  This gap in coverage made seniors 100% responsible for their medication costs after reaching a certain level of expenses during the year, and the gap continued until patients reached a level of out-of-pocket costs deemed to require further assistance.  This gap complicates medical care, as seniors' drug costs shoot up during the donut hole and many have significant difficulties managing this sudden increase.  The ACA will start to provide some help in the form of $250 rebate checks this year, but the donut whole will start to close and continue closing until it is fully done away with.

--Health insurance reform will ensure that insurers actually have to provide health care to patients who carry their policies.  The policy of recissions, where insurers could drop your policy for any reason (even an honest mistake) despite the fact that you had paid up your policy will be eliminated.  Pre-existing conditions will be ended.  Insurers will be required to keep a certain medical-loss ratio, meaning that they will have to spend 80-85% of policy premiums (YOUR payments to the company) on providing health care--not salaries, bonuses, etc.  Preventive service coverage will be expanded, allowing patients to seek screening and health maintenance services and hopefully stop problems before they fully start.

--The ACA provides additional funding to public health, coverage for rural health care services and tax relief for health professionals working in underserved areas.  These services play critical roles in some of our nation's most isolated and/or economically marginalized communities and we desperately need to strengthen their ability to continue in these key roles.

These things are all scheduled to begin in 2010 and early 2011.  Over the next 7 years the law will see its full effects and I think that the nation, and patients as individuals, will be better off.

And I hope Cuccinelli's windmill-jousting ends next week.

Common Themes

Currently I am in the Dominican Republic, part of a 12-person medical service trip whose aim is to provide care to marginalized communities in Santo Domingo.  We have just finished 4 days of work in Paraiso, just north and west of town, and are taking a day to rest and reorganize prior to shifting our worksite to Los Mina, a neighborhood that merges into a shantytown hugging the banks of one of the city’s rivers.

When here, a few different things always strike me.  One is the fact that underserved communities face similar obstacles to care all around the world.  There are differences in degree and in quality, but common themes visible anywhere people lack necessary care:

--Inadequate medical workforce: healthcare systems are most efficient and have the best outcomes when primary care is a strong component of the system.  In inner city and rural America, as in Paraiso or Los Mina, primary care is notably absent and patients lack access to efficient and available primary care services.

--Importance of community determinants of health: whether it relates to unsafe neighborhoods in the US that keep our families and children from exercising and being physically active, the absence of sources for healthy foods (too many fast food restaurants and not enough fresh veggies and fruits), or a lack of potable drinking water and prevalence of parasitic stomach infections, individual health is heavily dependent on the broader community’s obstacles and resources.

--Improper healthcare interventions: in the US we tend to have an over-reliance on high tech interventions, whether medications or advanced testing and imaging studies—even if these interventions do not actually improve health.  In Paraiso, many patients seek care in more expensive private health care facilities and are prescribed expensive or unaffordable tests and medications.  In each case, the cost to the individual and (if insured) to the system is very great even though the actual outcomes are no better for the investment.  Alternative options—focusing on preventive care, wellness, and health maintenance would stand to provide a better return on investment but do not have the necessary influence or awareness to change general practice patterns.

--Those who are powerless lack influence: a self-evident statement, but one that needs to be noted.  Many of those living in Paraiso and Los Mina are squatters, lack title to their land, and are largely disconnected from the political system.  Similarly, minority and poor communities in the US (that make up the majority of our underserved communities) lack political heft and influence.  Without this influence, communities are hard-pressed to effect change on their own behalf.  Community-identified leaders (whether the official government leadership structure or influential community members) can work to organize the community to try and effect change, but to make change sustainable is very difficult when individuals are just barely making ends meet.  By partnering with communities in ways that identify and support their own resources and by providing assistance in ways that empower the community without imposing an outside agenda, it would appear to be possible to start creating structures that can have meaningful and sustainable results.

I suspect more commonalities will become evident as I reflect more on this trip.  I know that many of the experiences I have had and skills I have learned in rural and urban underserved communities stateside stand true in the Dominican Republic, and vice versa.  I hope that by my direct action, and by teaching students and working with communities, that a greater good can be advanced.