From campaign trails to coffee houses, it seems everyone has an opinion about the pros and cons of creating a national—or universal—health care system in the United States. But what do those in the day-to-day fray of medicine think about revamping the existing system?

That was exactly the question tackled by Aaron E. Carroll, MD, MS, director of the Center for Health Policy and Professionalism Research at Indiana University, and Ronald T. Ackerman, MD, MPH, associate director of the center. Both are with the Indiana University School of Medicine, and Carroll is also a board member for Physicians for a National Health Program.

Following up on a similar study they conducted in 2002, the two researchers randomly sampled physicians from the American Medical Association Masterfile, asking two questions designed to capture the medical professionals’ thoughts on the prospect of changing the country’s existing health care system.

They saw a 51% response rate on the 5,000 surveys mailed, for a total of 2,193 completed surveys. And they found that more physicians support the creation of government-financed national health insurance than they did just 5 years ago.

When looking at the profession as a whole, 59% of respondents supported legislation to establish national health insurance, with 32% opposed; and 55% were in favor of achieving universal coverage through more incremental reform, while 25% opposed that approach. Looking across categories, 14% of physicians were opposed to national health insurance, while supporting more incremental informs.

Where the results, which were published in the April 1 issue of the Annals of Internal Medicine, found extremes was in the subspecialties. More than 80% of psychiatrists were in favor of government legislation for national health insurance, while in surgical subspecialties, less than 50% supported it and fewer than 40% of anesthesiologists agreed it was a good idea. Radiologists were at the bottom of the list, with just 30% indicating support for such a dramatic change.

“I think that number is probably related to two factors,” said Carroll, who reiterates that the “why” behind answers was not examined in the research, and responses related to such are his opinion, not based on survey results. “For one, radiologists are not exposed to the uninsured in the same way that primary care physicians are, or even as some subspecialists are, because to some extent, to get to the point of the radiologists, you had to go through several layers of the health care system.”

He attributes the same reasoning to low “for” rates from anesthesiologists.

“The other factor is surgical subspecialists, anesthesiologists, and radiologists are among the most highly compensated physicians, and while probably the average physician would make the same amount of money under national health insurance, evidence from around the world shows that there is a movement toward the mean,” said Carroll, who adds that what typically happens in a single-payor system is clinicians currently at the bottom of the pay scale—primary care physicians—end up making a bit more money and the people at the top wind up making a bit less. “And of course, people vote with their pocketbooks.”

A Multifaceted Solution

Some radiologists agree that money may be a key motivator in this response.

“All of the procedural specialties have benefited from the current structure of fee-for-service, and while it’s not surprising that physicians are still looking at their own silos, I think it’s time we really take a global look at what is happening to health care costs, and think in global terms, rather than just looking at the impact on our own specialty,” said Vijay M. Rao, MD, professor and chair of the Department of Radiology at Thomas Jefferson University. “The current system is obviously not optimal: consumers are dissatisfied, providers are dissatisfied. Whether a national health plan is the answer, I’m not sure, but something needs to change.”

She believes that, in all likelihood, more than one feature of today’s system needs to be adapted.

“A single-payor system or a national health plan—that’s one aspect—but in addition to that, we also have to change the expectations of the consumer and we need to focus more on prevention rather than spending most of our health care dollars toward the end of life,” she said.

Also to be added to that list is tort reform, Rao said, because it leads physicians to practice defensive medicine, requesting exams and tests that would be otherwise unnecessary, solely to protect themselves in the event of a lawsuit.

“We are not putting patients at the front end of this. I think we need to become more patient-centric,” said Rao.

David C. Levin, MD, agrees with the idea that multiple solutions are likely necessary in order to get the system functioning properly. And in addition to the concern over lower salaries, “there has got to be tighter controls on self-referrals in imaging,” he said. Levin is the chairman emeritus of the Department of Radiology at Thomas Jefferson University Hospital. “Self-referral is where a lot of the growth is occurring and it is nonradiologists—the orthopods, the cardiologists, the urologists, the ENTs, and others—who are putting CTs, PET scanners, and MRIs into their own offices. That’s a huge problem, and there is no control over that now.”

He also believes insurance companies should shoulder some of the blame for rising health care costs, saying that “even the so-called nonprofit [health care plans] are making huge profits. I think health plans have a role; I’m not saying we should abolish them, but their profits have to be more tightly controlled.”

In addition to possible salary changes, the advent of extremely long wait times to see physicians as a result of national health care is also a concern for many. Others who resist universal health care believe the number of uninsured individuals is overinflated, because the total number of those without insurance includes individuals between jobs (typically without insurance for only about 4 months) and noncitizens, as well as healthy individuals who can afford health insurance but choose not to buy it.

Many estimate the true number of those who are unable to obtain or afford health insurance at around 7% of the US population, a number far lower than the 47 million often cited.

Another factor for radiologists could be their personal history with advice given from a national level.

“From the late ’80s till now, the predictions were that we should train fewer radiologists because we would need half as many as we have now—and then all of a sudden we have a shortage of radiologists,” said David Seidenwurm, MD. “I think most physicians, including radiologists, are in favor of universal coverage, and we are going to it in a uniquely American way, but I think radiologists would have more confidence in the process if conventional wisdom about our specialty had not been wrong so often before.”

Dana Hinesly is a contributing writer for Axis Imaging News. For more information, contact .

A Closer Look at the Carroll/Ackerman Study

Not many issues spark such passionate debate as national health care, so it is no surprise that the study published in the April 1 issue of the Annals of Internal Medicine by Aaron E. Carroll, MD, MS, director of the Center for Health Policy and Professionalism Research at Indiana University, and Ronald T. Ackerman, MD, MPH, associate director of the center, has met with some criticism. Both are with the Indiana University School of Medicine.

An article appearing online in the American Medical News1 quotes Edward L. Langston, MD, chair of the AMA Board of Trustees, as saying, “It’s difficult to draw conclusions from the survey because of possible confusion over its terminology” because “the study does not define national health insurance or incremental reform, both of which can be interpreted in a variety of ways.”

The survey consisted of just two questions—querying about support for governmental legislation to establish national health insurance and achieving universal coverage through more incremental reform—and, in fact, it did lay out the specifics, according to Carroll.

“We did actually define it. There is a header for the first question that said that, for the purpose of these questions, we wanted [them] to think of national health insurance as the government financing all health care,” he said.

In full, the introductory paragraph reads, “Although proposals for national health insurance may offer different strategies for service coverage, service delivery, and cost-containment, please answer the next two questions assuming that the principal goal of any national health insurance proposal is to arrange health care financing for all US citizens.”

“We did not define incremental reform and universal coverage, but we weren’t polling the general public, we were polling physicians—and I think you’d be hard-pressed to find a lot of physicians who don’t understand what incremental reform is,” said Carroll, adding that “[when creating surveys], you are always toeing the line between having a survey that is readable and one that people can do in a reasonable amount of time, versus making sure that everybody understands it.”

Efforts are also made to ensure that questions do not produce a desired set of results, but instead gather information that is most representative.

“When you do a survey, it is a very complicated because there are ways to drive people to the answers you’re looking for, if you want to—and we didn’t want to do that,” said Carroll, who is also a board member for Physicians for a National Health Program. “We really wanted to make it fair. So this time, we wanted to give two options and to have national health insurance be the less conservative one.”

To this end, the 2005 survey’s second question about “achieving coverage through more incremental reform,” was different from the questionnaire distributed in 2002.

“With the second question on the first survey, we actually pushed it even further and [gave] a completely single-payor [scenario], excluding any kind of private coverage. We felt afterwards that by giving two options and actually making the national health insurance the more conservative, we might have actually driven more people to answer that question than might otherwise have,” said Carroll. “A lot of people … are much more in favor of achieving universal coverage through incremental reform—increasing the safety nets, providing some tax subsidies—to try to get toward universal coverage, but not go all the way to national health insurance.”

—Dana Hinesly

Reference

  1. Trapp D. More physicians backing national coverage—study. Psychiatrists, emergency physicians and pediatricians showed some of the strongest support for government-organized health insurance. American Medical News. April 21, 2008. http://www.ama-assn.org/amednews/2008/04/21/gvsb0421.htm. Accessed June 10, 2008.