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Do doctors support health care reform? IBD says no, NEJM says yes

posted by Aziz Poonawalla

UPDATE 031810: Fox News falsely claimed that NEJM has a new poll indicating that doctors no longer support health reform; this is false. See here for details.

There’s an alarmist poll out from Investors Business Daily that makes the shocking claim that almost half (46%) of America’s doctors will quit under Obama’s proposed health care reform plan. The implications of such a finding – which runs counter to the American Medical Association’s own support of President Obama for reform – are that one result of reform would be that America’s doctors would revolt. But does this poll make any sense?

It turns out that the poll was a mail-in questionaire, not the usual phone-based poll. This is important because of selection bias; doctors who are predisposed to feeling threatened by proposed health care legislation will be more likely to respond. Also, mail-in responses tend to be skewed towards older repsondents, who also are more likely to be skeptical, or at least more willing to retire.

The poll itself was terribly written; one of the questions read, “Do you believe the government can cover 47 million more people and it will cost less and the quality of care will be better?” which is really three questions, and heavily biased towards skepticism (indeed, 71% answered No). It’s worth noting that the pollling outfit has a horrendous track record; polling demigod Nate Silver comments:

As we learned during the [Presidential] campaign — when, among other things, they had John McCain winning the youth vote 74-22 — the IBD/TIPP polling operation has literally no idea what they’re doing. I mean, literally none. For example, I don’t trust IBD/TIPP to have competently selected anything resembling a random panel, which is harder to do than you’d think.

Nate also notes that the poll hasn’t released any details of methodology, and bizarrely also says “responses are still coming in.” Responses are still coming in? Why would they release any results until all responses have come in? The percentages are utterly meaningless otherwise! Nate advises people to ignore the poll entirely; it’s going to be taken up by right-wing idealogues of course, but that was its intended audience from the beginning.

So what do doctors actually think? It’s worth re-stating up front that despite the misinformation dogma of the right, the proposed reform is in NO WAY a government “takeover” of healthcare. A govt-run health care system akin to Britain’s NHS is one in which doctors are employees of the state and paid from the government, there is no such thing as a private practice. Our reform, in total contrast, is about health insurance, ie who pays the insurance companies for the premiums. For the most part, in the US, the answer is that the cost is shared between employers and employees, whereas the government pays premiums for elderly people via Medicare. Even the most radical reform of this system, a single-payer system which would essentially eliminate the private health insurance industry, woud not aount to a government takeover of health care per se. Of course, a single-payer system is off the table and the so-called “public option” would only apply to a tiny fraction of people who dont qualify for/are unable to obtain insurance through other means. And even that modest reform is likely not going to be in the final package.

All of this boils down to the fact that due to misinformation by the Republicans about health care reform being a “government takeover”, it is likely that many people who oppose it think it will be something it isn’t. In other words, the misinformation campaign (“death panels!”) is working.

But tehre are polls of doctors out there that are reliable and not subject to the bias and error of the IBD poll. The latest issue of the New England Journal of Medicine, one of the pre-eminent medical journals in the world, has results of a truly scientific poll whose methodology is indeed rigorous and public, which looked at physicians’ views about the public option and expanding Medicare. Here is a summary of their findings:

20090914_keyh_f1_A.pngOverall, a majority of physicians (62.9%) supported public and private options (see Panel A of graph, at right). Only 27.3% supported offering private options only. Respondents – across all demographic subgroups, specialties, practice locations, and practice types – showed majority support (>57.4%) for the inclusion of a public option (see Table 1, online). Primary care providers were the most likely to support a public option (65.2%); among the other specialty groups, the “other” physicians – those in fields that generally have less regular direct contact with patients, such as radiology, anesthesiology, and nuclear medicine – were the least likely to support a public option, though 57.4% did so. Physicians in every census region showed majority support for a public option, with percentages in favor ranging from 58.9% in the South to 69.7% in the Northeast. Practice owners were less likely than nonowners to support a public option (59.7% vs. 67.1%, P<0.001), but a majority still supported it. Finally, there was also majority support for a public option among AMA members (62.2%).

Overall, 58.3% of respondents supported an expansion of Medicare to Americans between the ages of 55 and 64 years (see Panel B of graph, online). This support was consistent across all four specialty groups, with proportions in favor ranging from 55.6% to 62.4% (P=0.08).

P-values! I swoon. This is a far more reliable study that can and should be taken seriously by policymakers. The full article at NEJM is worth a read, especially the discussion and conclusion, where they note that the support for a combined public/private solution even extends to physicians in the conservative south, physicians with a financial stake in their practice, and members of the AMA (which has historically opposed reform, but has supported the House legislation this time around).

The rationale for physician support for health insurance reform is intuitively obvious; by increasing the number of insured people, more patients are created who will make use of physician services. As the poll notes, support ranges across all physician specialties and practice types. Clearly, physicians as a group understand the difference between health care reform and “government takeover”. Granted, opponents of health care reform who insist otherwise aren’t exactly brain surgeons, though.

Related: Also see James Joyner’s comments on the IBD poll and the discussion at LOG. Meanwhile, NPR has a story on the NEJM-published poll.



  • Keith

    The NEJM poll methodology is a joke: one of the first rules of survey methodology is that you don’t give respondents a chance to cop out and choose the middle ground (unless, of course, that’s the result you’re looking for). Respondents have a natural aversion to choosing “extreme” responses. Consequently, when presented with an odd number of choices, we would expect people to be more likely to choose the central one. The NEJM poll gave only three choices: 1) single-payer; 2) mixed public-private; and 3) private only. In addition to the problem presented by having just three options, the options are skewed to the left. The opposite of a single-payer plan is a completely private plan, with no Medicare/Medicaid, not even for the old or poor.
    A better question would have four, balanced options, thereby forcing respondents to fall on one side of the middle. These options could have been something like: 1) single payer (Medicare/Medicaid for all); 2) Public option for some (Medicare for the old, expand Medicaid eligibility) with private coverage for the rest; 3) Medicare/Medicaid for the old and poor (no expansion) with private insurance for everyone else (including subsidies for those not eligible for Medicaid but too poor to afford insurance); or 4) private insurance for everyone (subsidies for the poor, switch those from Medicare/Medicaid to private insurance).

  • JD

    Two points:
    1) Yes, we need more info about the TIPP/IBD methodology. But did you actually read the NEJM article (the supplement describing methodology)? If you had, you would know that the NEJM data is also “still coming in.” You would also know that the NEJM poll was, like the IBD/TIPP one, a mail-in survey.
    2) Take it for what it’s worth (maybe the evil IBD folks are lying), but no other polling outfit has more closely predicted the outcomes of the last two presidential elections than TIPP/IBD. http://www.investors.com/NewsAndAnalysis/Article.aspx?id=452833&Ntt=IBD%2FTIPP+Takes+Top+Honors+Again

  • Mike

    “President Obama’s speech last week really moved me. Despite what my colleagues think of me. If what he says is what will EXACTLY happen, how can I not hope and work towards that cause”? Mike Oliphant runs a small Utah health insurance website http://www.benefitsmanager.net/SelectHealth.html and http://www.dentalinsuranceutah.net whom deals with hundreds of people on a day to day struggle to be approved for health insurance. “I get hopeful that I can finally tell people they can qualify for coverage REGARDLESS of their pre-existing medical condition”. Mike’s concern is that Obama’s people won’t deliver what he urges on areas within his speech. “I really have been moved by this guy and wish we could just talk so he could understand the frustration of a health insurance agent. I have been involved on a political level within the state of Utah and their struggle for health care reform. I have seen and regrettably been part of politics at work. I have learned lessons through baptism of fire with politics. For instance, I struggled against House Speaker Clark and H.B. 188 because that was what I was urged to do from our industry (that was all I knew). But after awhile and countless meetings with state and private carriers in Utah, I began asking myself if I was doing the right thing. I realized over time that House Speaker Clark really means what he says and is hard nose about getting reform done in Utah. I got that there wasn’t any behind the scene conspiracy scheme or personal objective of Mr. Clark. His bill makes allot of positive changes in the “health insurance reform” world of Utah. He claims that reform just doesn’t stop there, it must continue through “health care reform”. You see, there is a major difference between the two reforms. Clark “gets it” but I really worry that Obama’s administration doesn’t because if you have noticed the subtle language change of dropping “health care reform” and going to “health insurance reform”. See more about what Utah has accomplished here which utilizes private carrier involvement with true reform. If you can believe it, they reached it with an objective of $500,000. Perhaps the feds should take a look at Utah and House Speakers Clark’s bill 188. http://www.prweb.com/releases/utah_health_insurance/health_care_reform/prweb2614544.htm. Now I find myself on the “other side” of the fence furthering Utah’s cause. Let’s hope we don’t all have a mental breakdown nationally and just take a honest look at the proposals.

  • AD,MD

    As always, the truth of the discrepancy between IBD and the NEJM is probably somewhere in the middle, and I agree that the NEJM article may have had better methodology. So let’s assume that 40% of physicians oppose health care reform, and that only 20% would quit due to Obama’s plan. For the sake of the argument, let’s assume that only 10% of physicians would quit, but 10% would drop out of federal progarms (Medicare/Medicaid.)
    Given that the goal of Obama’s plan is to add roughly 35 million new patients to the system, a loss of 20% of physicians from federal programs would be a disaster. At present, roughly 1/3 of primary care physicians do not accept new Medicare patients because they lose money on the reimbursements, and in some locales that figure is 2/3ds. Wait times for medicare appointments often range up to 6 months. If the number of physicians dropped by 20% while the number of patients rose by 10%, the results would be, effectively, a loss of care for a huge proportion of the population, and it would be concentrated among the elderly, who need care most often.
    One thing that neither poll addresses is the general lack of knowledge that academic physicians, especially, but many private physicians as well, have about the insurance system that pays them. In academics, physicians are completely separated from billing processes, as the academic institution they work for handles all billing, and their pay is usually some sort of salary in combination with a productivity bonus. My 10 year experience in academics led me to believe that as many as 75% of those physicians have no idea how their pay is arrived at, and another 10 or 15% have only a vague notion. Department leadership typically understand the process, but it’s a total crap shoot outside of that small circle. The academic centers themselves prefer it that way, because the fact is that they siphon enormous sums – sometimes up to 40% or more – of physicians’ reimbursements off the top and divert the funds to everything from administrative costs to research. The siphon is referred to somewhat vaguely as “the Dean’s Tax” in most places. In large group private practice, the situation is often similar, although the percentages of physicians who understand the process is probably higher.
    It is only in small group and solo practices that one finds physicians who actually understand the dynamics of the billing process, and if you look at the Sermo physicians forum as an example, you see that it is those doctors who are rebelling hardest against the proposed changes. These are the physicians who understand the extent to which the government is undervaluing our services. Even so, if one accepts that 40% of physicians oppose Obama, it demonstrates that physicians may not have to understand the details in order to smell a rat.

  • Dr. B

    It appears this article is a case of the pot calling the kettle black.
    The obvious bias here is against the IBD poll.
    The reality is almost always in the middle of two very opposed groups.
    From my personal point of view, the current proposals on the table in DC are all guaranteed to increase costs, worsen/delay/ration care and make for lots of unhappy folks- even those that surrently thinkthis is all a great idea.
    If the current “reform” is enacted, I will likely be leaving medicine as I currently practice, and begin practicing alternative health care-in an affordable, hassle free fee for service model. Insurance, big pharma, and the government will be out of the relationship between me and my patients.

  • http://doc2dochealthcarereform.com TruthSquader

    Mr. Poonawalla of the “City of Bugss” has some explaining to do.
    He criticizes the IBD physician survey which has results he doesn’t like, stating, “It turns out that the poll was a mail-in questionaire.’ In contrast, he posits that the NEJM survey, which he likes, “has results of a truly scientific poll whose methodology is indeed rigorous and public.” Yet in their methodology appendix, the NEJM authors state, “The mailed survey was sent in three waves.”
    Mr. Poonawalla also tut-tuts the IBD survey, because, “responses are still coming in.” In the appendix, the NEJM authors tell us, “The third wave of the survey was initiated on August 27th, 2009.”
    Poonawalla asserts that “despite the misinformation dogma of the right, the proposed reform is in NO WAY a government ‘takeover’ of healthcare.” Well, as articulated in the ‘dogma of the right’, it actually IS: The fines levied against employers for NOT providing health insurance are much lower than the costs of providing insurance. No sensible business will continue providing private insurance; Employees will be dumped into the government “option”. Hmmm . . . . I wonder if that little datum was made known to respondents of the ongoing mail-in NEJM survey.
    Every time a “pundit” (or pretender “pundit”) asserts a survey is biased and another is not, you can be sure he is lying. Ask any statistician: every survey is biased. It cannot be helped. The only question is in which way.
    Poonawalla is obviously a pretender pundit. Worse, he is also obviously an idiot: He states, “The rationale for physician support for health insurance reform is intuitively obvious; by increasing the number of insured people, more patients are created who will make use of physician services.”
    Everyone, anybody, Mr. Poonawalla, do you know any physician who is looking for more patients? Do you know any who is not already overworked?
    Poonawalla seems big time into the assessment of supporting credentials. As health care analyst, statistician, and general authority, what are his?

  • Reeshiez

    You stated that in England there is no such thing as private practice. Thats wrong. England has a parallel private system. Some employers provide health insurance coverage for their employees to visit private doctors. Others do not. Check your facts first before writing anything.

  • Boetica

    Ha Ha! I have to laugh at the author’s critisizm of studies he doesn’t like. I’ve talked to one physician who sings the praises of the NHS (I doubt that he would be waiting for chemotherapy after a cancer diagnosis), I talked to a Candian physician in 1991 who told me many Canadian doctors don’t like the system. I’ve talked to a doctor who was trained in Canada, worked in France, and now practices in the US who knows full well what this so-called ‘reform” means. Physicians will be subjected to lower reimbursement and higher taxes, with no tort reform to boot. All this will result in lower satisfaction for those who practice medicine, not to mention a lower standard of living. Do people actually believe their taxes won’t go up exponentially? When is the last time Barack Obama or Nancy Pelosi actually told the truth? There are many things the government could do to reform health insurance which costs little to nothing. Instead politicians want to bankrupt the country. Ask yourself why.

  • Boetica

    Ha Ha! I have to laugh at the author’s critisizm of studies he doesn’t like. I’ve talked to one physician who sings the praises of the NHS (I doubt that he would be waiting for chemotherapy after a cancer diagnosis), I talked to a Candian physician in 1991 who told me many Canadian doctors don’t like the system. I’ve talked to a doctor who was trained in Canada, worked in France, and now practices in the US who knows full well what this so-called ‘reform” means. Physicians will be subjected to lower reimbursement and higher taxes, with no tort reform to boot. All this will result in lower satisfaction for those who practice medicine, not to mention a lower standard of living. Do people actually believe their taxes won’t go up exponentially? When is the last time Barack Obama or Nancy Pelosi actually told the truth? There are many things the government could do to reform health insurance which costs little to nothing. Instead politicians want to bankrupt the country. Ask yourself why.

  • Liz

    The doctors claiming they will leave their profession if HCR passes are laughable. Apparently they think they can go to work for Macy’s and pay their student loans and support their lifestyle. I don’t have a problem with opposition to the bill, I’m not thrilled with it myself, but let’s not make empty threats.

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    Well in every health care organization we have found that health experts are always worried to provide quality and advanced health care service to the people in affordable cost; therefore in my point of view this is totally useless to debate on this topic that doctors are not supporting health care reform programs.

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