Is the public plan option supported by doctors?

by Emily P. Walker, Washington Correspondent, MedPage Today

A solid majority of physicians favor creating a new public insurance option that would operate alongside existing private plans, according to a survey published online in the New England Journal of Medicine.

medpage-today About 63% of doctors, across a smattering of specialties and in various geographic regions, support a public insurance option. That figure is in line with national consumer polls that have shown the majority of Americans support a public plan.

While most physicians’ groups have voiced a collective opinion on the issue, the opinions of individual doctors are less clear.

“Given the enormity of the current effort to reform healthcare and its potential effect on the future of generations of Americans, policymakers need to hear the views on the whole range of physicians on the key elements of reform,” wrote Salomeh Keyhani, MD, and Alex Federman, MD, MPH, from the Mount Sinai School of Medicine in New York.

To examine individual perceptions, Keyhani and Federman collected data from 2,130 physicians from the American Medical Association’s Masterfile and stratifed the responses of those doctors into four groups: primary care doctors, medical specialists, surgical specialists, and other specialties.

Physicians were asked which options they most support: a public option only; private options only; or a mixture of private and public insurance options.

The majority of physicians (63%) said they support a mixture of public and private plans — a cornerstone of the plan President Barrack Obama outlined in his recent address to Congress.

Meanwhile, 27% of respondents said they favored offering private insurance plans only, but creating subsidies to help low-income people afford insurance.

Just 10% favored a healthcare system in which a public, government-run plan was the only insurance option, which would mean private insurance companies would no longer exist in their current form.

Primary care physicians were the most likely to support a public option, while those in fields with less patient contact, such as radiologists and anesthesiologists, were less likely to support a public option, although 57% of those specialists still supported a public option.

Doctors who own their own practices were less likely than non-owners to support a public plan (58% versus 67%; P<0.001).

Physicians who are paid salary only tended to support adding a new public plan more than physicians who are paid through billing insurance companies or the government (69% versus 59%; P<0.001).

Support of the public plan was fairly universal across geographic regions as well, but the biggest majority of support came from those practicing in the Northeast (70%).

Among AMA members, about 62% of respondents supported the public plan.

“Support of the public and private options was consistent across a wide range of physicians, including those from the traditionally conservative southern regions of the United States, those with a financial stake in their practice, and members of the AMA, despite that group’s history of opposition to reform efforts” the article’s authors concluded.

The AMA — which has fought past reform efforts, including the creation of another public program, Medicare — has offered its support for legislation in the House, which would create a public option. The data from the new survey suggest that view is consistent with individual AMA member views.

The plan outlined by the Senate Finance Committee does not contain a public insurance option. It would set up state-by-state cooperatives, which would allow patients to pool together to purchase insurance, and to have an ownership stake in their insurance plan.

There are no plans in Congress that would establish a single-payer system.

The study authors point out several limitations to their survey, including a low response rate of just 43%, however, they add there were no significant differences between the characteristics of responders and non-responders.

The study authors reported no relevant conflicts of interest.

In a second Perspective, also published Monday online in NEJM, researchers sought to gauge physicians’ personal attitudes about healthcare reform.

For that survey, researchers led by Ryan Anteil of the Mayo Medical School mailed an eight-page questionnaire about moral and ethical beliefs in medical practice. Physicians were asked to respond to how much they agreed with the following statements:

* “Addressing societal health policy issues, as important as that may be, falls outside the scope of my professional obligation as a physician.”
* “Every physician is professionally obligated to care for the uninsured and the underinsured.”
* “I would favor limiting reimbursement for expensive drugs and procedures that would help expand access to basic healthcare for those currently lacking such care.”

The survey also asked for physicians’ moral perceptions on using cost-effectiveness data to determine which treatments are offered to patients.

Of the 991 returned surveys (a response rate of 51%), 78% of respondents said that addressing societal health policy issues is in the scope of professional obligation of a physician.

About 73% said physicians are obligated to care for the uninsured and underinsured.

Most respondents (67%) said they would favor limiting reimbursements for expensive treatments to expand access. Not surprisingly, surgeons and sub-specialists were more likely to oppose cutting payment for pricey procedures than were primary care doctors.

A little more than half (54%) said they were morally opposed to using cost-effectiveness as a factor in deciding which treatments a patient should receive.

As would be expected, there were differences between physicians who described themselves as “conservative” or “liberal” on social issues.

Liberals agreed more strongly that doctors have an obligation to address societal issues, and that physicians are obligated to care for the uninsured and underinsured, and that cutting reimbursements for expensive procedures should help pay for reform.

Conservatives, however, tended to object more strongly than liberals to using cost-effectiveness data in making clinical decisions.

The authors say the data suggest that efforts to mobilize physicians can increase their sense of professional responsibility, but “also that such efforts may encounter considerable opposition from some quarters of the profession, particular to elements of reform that impinge on physicians’ decision-making autonomy or threaten to reduce reimbursement for the costly interventions they provide.”

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