I am sitting here in my white lab coat with dirty sleeves (from use), thinking that there is no reason for a practicing physician to support the current health reforms before Congress.  Patients are going to have a rude awakening when their new insurance cards don’t give them the kind of access to doctors they are expecting. Doctors are too frustrated and marginalized to play ball with the president. Here are the reasons that every doctor I know is vehemently against Obamacare:

*  No comprehensive tort reform. Most surgeons I know are struggling with a constant fear of malpractice claims. Most have had at least two or three frivolous lawsuits in their careers to contend with. Most have spent hundreds of hours with lawyers going over the fine print of their records only to have the case settled. Most surgeons are now opting out of accepting insurances in order to afford their malpractice premiums which are often close to $100,000 yearly. Caps on pain and suffering are only one part of the problem.  32 states have some kind of tort reform already, but there needs to be a consistant federal mandate or doctors will hop from state to state.  In California, when caps of $250,000 were instituted, doctors’ premiums did not decrease until a second law compelled insurers to transfer savings to physicians. Nuisance suits can be blocked by creating boards of doctors and lawyers to review cases before they are brought (these boards already exist in Tennessee and Michigan). “Loser pays” statutes can be added (doctors win the vast majority of suits) so that liability insurance companies won’t force doctors to prematurely settle claims to avoid large legal fees.
*  The bills before Congress all include large Medicare cuts. The Baucus bill would cut Medicare by $500 billion over a decade. This will lead to cuts to hospitals who will then be compelled to cut patient services and doctor salaries. The moratorium for not cutting doctor reimbursements across the board by 21% as Congress is supposed to do is not likely to last. Medicare cuts to doctors will cause more to quit or game the system. A changeover from fee-for-service to bundled payments, as the Baucus bill envisions, will leave many doctors out in the cold when they are denied payment for a service that is considered unnecessary or redundant.
*  The growing doctor shortage – the Association of American Medical Colleges calculates we will be 125,000 doctors short by 2025 – does not leave us with the manpower to take care of an additional 30 to 40 million patients. Doctors will be more rushed than ever.          
*  The extension of Medicaid to 10 million more people as the Baucus bill proposes will be a disaster for doctors. Consider that Medicaid often pays doctors less than $10 per office visit. 50% of doctors don’t take Medicaid, and states have already been cutting Medicaid payments to hospitals because most states are having trouble funding Medicaid. Medicaid networks of services and service providers within hospitals are being cut, making it impossible for doctors like me to take care of these patients (we have nowhere to send them for services or procedures).

We doctors are being squeezed, marginalized, ignored, and criticized. Of course we aren’t happy. Of course we feel that it will impact our patients’ care.      

If there is a hardworking doctor out there who thinks the current health reforms are good for doctors or America, I don’t know her.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.” Read more at www.doctorsiegel.com

There are several reasons why I believe that most doctors are unhappy with the direction that health insurance reform is taking. I address several of these reasons in my oped in today’s NY Post (September 23rd, 2009). I will also outline them here. Suffice it to say that adding more patients to the health care turnstiles and promising them access to quality physicians when there is a growing doctor (and nurses) shortage and a growing doctor (and nurse) discontentment is problematic at best. The blanket of health insurance that Congress and the president envision is not long enough to cover the body of health care. If we pull it down to cover the toes, the head will be exposed. If we stretch it to cover the uninsured without dealing with cost or the doctor shortage, we will end up taking care away from those who currently have it and need it (the elderly and the disabled to name two groups who are endangered). Remember, physicians who aren’t functioning well have a negative impact on health care.

Reasons for doctor discontentment:

• No meaningful tort reform is included in any of the current bills under consideration in Congress. No shared liability with insurances or the government, no caps on pain and suffering, no review boards to limit nuisance suits, no “loser pays” allowance, despite the fact that physicians win the vast majority of suits.
• No significant subsidies to primary care education, despite the fact that there has been a decline in those choosing primary care of over 50% over the past decade.
• Big cuts to Medicare and Medicaid payments to doctors and hospitals of hundreds of billions of dollars in the bills, despite the fact that doctors are already cut to the bone in terms of increasing expenses and decreasing reimbursements.
• Cuts in payments for procedures and mechanical devices will put more pressure on doctors as patients express their (deserved) discontent, and there is nothing a doctor can do.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.” Read more at www.doctorsiegel.com

In the current push for national health insurance, expensive overuse of technology based on the defensive practice of medicine by doctors is being overlooked. Yet doctors often over-order tests and treatments for fear of missing a remote diagnosis. Doctors are afraid of being sued by the same aggressive trial lawyers who lobby Congress against real reform. Keep in mind that it isn’t just a dreaded error like removing the wrong kidney that motivates doctors to practice defensively, it is the fear of lawyers and having to meet with them as part and parcel of responding to arbitrary lawsuits. Doctors who have done nothing wrong can be targeted with frivolous suits that drag them into the lawyer’s office. The process of having your records scrutinized in an effort to determine how well you’ve documented things and if you’ve made errors can be instructive, but it can also be humiliating. This process can alter the way a doctor practices as he or she struggles to avoid the nightmare of legal exposure in future.

Though 98,000 people die in U.S. hospitals every year from medical mistakes, at the same time according to a recent Harvard study, 40 percent of malpractice lawsuits are not legitimate, though they lead to 15 percent of the money paid out. Often times the doctors who are sued did nothing wrong, while those who make mistakes too often escape retribution.

Most malpractice cases are won by doctors, but not before they endure the protracted painful process of meeting with lawyers. Many doctors quit medicine or become even more defensive and order more and more unnecessary tests as a result. I remember when the best urologist and one of the top cardiologists at my hospital quit practice abruptly because of extended lawsuits where they weren’t at fault.

On the defense side, lawyers may milk doctors for billable time, and on the plaintiff side, ambulance chasers thrive, creating and exploiting frivolous cases for profit. Many patients get unnecessary operations because of defensive medicine. C-section is on the rise and is vastly overdone because of doctors fearing lawsuits. There is a culture of fear that motivates doctors to practice defensively, which causes costs to skyrocket.

With the possible rationing of care that may occur in the name of cost control under an expanded system, malpractice could skyrocket as more and more tests and procedures are denied yet doctors continue to be blamed when something goes wrong. It is especially problematic that neither insurers nor the government have direct legal responsibility while at the same time turning down tests. Most doctors are too busy and too scared of being singled out to band together to protest this uneven system.

What is the solution? One solution is to create state review boards like Michigan or Tennessee to limit frivolous lawsuits. Doctors and lawyers can serve on these boards together and provide a barrier to nuisance suits. More peer review in the hospitals is also a good idea, regular mortality and morbidity conferences where doctors behavior is examined without the direct fear of lawsuits.

Capping pain and suffering awards would seem like a simple enough solution, but some patients truly deserve a high reward if they’ve been badly mistreated by a physician (as when the wrong organ is removed or a diagnosis is blatantly missed). A better initial approach is to target nuisance suits for destruction.

It is estimated that tort reform can lead to an initial savings of 2% on health care costs, without even considering the billions of dollars that will be saved by decreasing the defensive practice of medicine (based on overuse). But even with tort reform, the current plans for health insurance reform combined with decreased reimbursements to hospitals and doctors will lead to more and more patients being seen in shorter periods of time. This will lead to more and more medical mistakes, and more and more malpractice.

There hasn’t been much of a push yet to combine tort reform with the current health insurance reform initiative being considered by Congress. This could change. The Democrats could decide to add some tort reform (probably Caps to pain and suffering) as a sweetener to a bitter pill (or bill). This might cause more physicians to support the current health reform, but would do nothing to correct the larger problem of physician dissatisfaction, overwork, attrition, and scarcity, all of which lead to medical mistakes.

Plus, simply capping pain and suffering is not a guarantee that doctors will see their liability insurance premiums lowered. In California in the 1980s, when a cap on pain of suffering to $250,000 was first initiated, there was no overall savings to physicians. Instead, the insurance companies made more profits. It took an additional law to ensure that the savings was transferred to physicians in terms of lower premiums.  

It is the current insurance-oriented climate for practicing medicine that must be changed before doctors (and their patients) will reach any kind of comfort level or be able to cut costs in a reasonable way. Insurance of both kinds (private and public) is the problem, not the solution. Costs spiral upward because of doctors’ fear of malpractice and rush to see more and more patients in a short period of time amid shrinking reimbursements. The easiest way to do this if you’re a primary care doctor is to quickly refer a patient to a specialist of for an expensive test, jacking up costs. At the same time, patients are inclined to overuse their health insurance because they don’t pay for each procedure or as many have put it, because patients don’t have any “skin in the game.”

Tort reform is essential and must include not only caps on pain and suffering and reflected decreases in liability premiums, but also a way to ferret out nuisance suites. I am in favor of more peer review in the hospitals as well as a lawyer and doctor staffed board in every state to review claims before they are brought. I strongly believe that private insurance companies as well as the government (Medicare and Medicaid), should incur liability themselves for tests they decline.

But I do not think that any of this should be done as a way to manipulate physicians to support a kind of health reform that is not in our best interest, or in the best interest of our patients.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.” Read more at www.doctorsiegel.com

President Obama has mentioned many times that the health reforms he is proposing will not alter the health care of those who already have health insurance and want to keep what they have. But this is NOT the view of most practicing physicians — myself included. I may be one of the most vocal, but I am not alone.

1.  First of all, there is a critical and growing shortage of primary care physicians. Only about 2 percent of the current medical school graduating class is going into primary care. Those of us who already practice primary care are overwhelmed and many are quitting. The public insurances have the most trouble. Surveys show that 50 percent of doctors don’t take Medicaid, and in 2008, the Medicare Payment Advisory Commission found that 28 percent of Medicare patients looking for a primary care physician couldn’t find one. This problem will only get worse under any Obama plan. You may have new government-provided insurance, but you may not be able to find the doctors who take it. And if you do, they may be buried under a pile of paperwork, or be too busy changing over to the new Electronic Medical Records system to spend time with you.

2.  More than 150 million Americans have employer-provided health insurance. But if there is a public option, your employer may stop providing you with insurance. You may be compelled to take the public option, which will probably provide you with less real health care choices.

3.  If the public option grows bigger, because private insurers find they can’t compete, expect care to be rationed, as the government makes choices to try to contain costs. Reimbursements to doctors will be cut, as they have been under Medicare and Medicaid, but also, you may not be able to get dialysis if you are over a certain age, or you may have to wait on long lines for procedures, as they do in Canada.

4.  Bottom line — extending a system that already has too few primary care doctors who are overworked to the entire population does not bode well for prevention or quality of medical care. The costs will continue to spiral upward, and access will decrease rather than increase. A better approach would be to work on re-organizing the health care system towards prevention rather than intervention BEFORE expanding it. One way would be to pay for the education of primary care doctors and create a task force to treat the uninsured.

For more on my take on public health insurance and how doctors view it, check out my oped in Monday’s NY Post.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

Last week, I published an oped in the Wall Street Journal where I pointed out that extending health insurance (especially with a government option) to the entire population would be problematic unless the problem of doctors opting out of insurance under the current system is addressed.

In other words, health insurance doesn’t automatically mean health care, especially if you lack the caretakers to accept it.

This oped produced a firestorm of responses, from  letters to the Journal to hundreds of responses to the WSJ blog which published an abbreviated version, to hundreds of emails to my personal account. I discussed my oped on Fox News and Fox Business. Most of the responses were positive, and Rush Limbaugh read my oped on his radio show and praised it. The NY State Commissioner of Health is going to meet with me to discuss ideas.

Among my critics, some people lost sight of the point that I have not dropped Medicare myself, in fact I pointed out in the article that I take care of many Medicare patients who have left other doctors they were happy with because they dropped out.

Another criticism was that I don’t provide solutions. That is a fair comment, though my father always taught me that a person’s first responsibility is to identify a problem before considering solutions. In any case, here are some preliminary ideas that could help primary care doctors and keep them from opting out of an expanding system:

* Subsidize education and provide incentives for choosing primary care medicine as a career.
* Provide tax incentives for seeing Medicaid and perhaps Medicare patients.
* Do NOT take Medicaid funding away from hospitals to increase reimbursement to private physicians because this will have little impact and because taking care of Medicaid patients – who are often the sickest due to poverty – requires the kind of network you only find at the hospital and associated out-patient clinics.
* Increase physician reimbursement and decrease paperwork.
* Consider a system where insurance is less pervasive and is focused more on prevention and emergencies, with high deductibles to discourage overuse. The middle ground between prevention and emergency intervention can involve negotiated prices between doctor and patient, the way it used to be. Health Savings Accounts should also be considered.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

Can you believe that nine patients in the Austin, Texas-area used the emergency room 2,678 times over the past five years? This fact, reported by the Integrated Care Collaboration, is simply unbelievable until you consider that eight of the nine had a drug abuse problem, and were not doubt using the ER to make sure they had their fix of pain pills.

But this finding points to a larger problem; that our ERs are clogged, that they are often filled with patients for the wrong reasons, that ERs have a limited surge capacity in the event of a catastrophe. At a time when President Obama is considering expanding health coverage to all, the question is how to ease the overuse of ERs so more could be accomodated in a way that isn’t so expensive.

Consider that an average ER visit costs the hospital between $500 and $1000. Consider that ERs are NOT filled with the uninsured. A 2008 study showed that ONLY 14 percent of ER visits involve patients without health insurance. More than 50 percent of visits (most often for minor complaints) are for people who earn more than four times poverty level, and that 29 percent of the people going to ERs are not only insured, they also have regular doctors. Doctors that they can’t get in to see!

We have a growing shortage of doctors – especially primary care doctors. A Texas survey revealed that 60 percent of primary care doctors opted out of accepting Medicare last year. Approximately the same percentage of New York’s primary care doctors are also dropping Medicare. The increasing number of doctors dropping insurance will lead to even more ER visits, as will expanding the number of patients who are covered by insurance.

Imagine what will happen if we decrease reimbursements to doctors (and hospitals) further. ERs will be flooded, and no one will get taken care of.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com