Doctors on Coverage — Physicians’ Views on a New Public Insurance Option and Medicare Expansion

Salomeh Keyhani, M.D., M.P.H., and Alex Federman, M.D., M.P.H.

In the past few months, a key point of contention in the health care reform debate has been whether a public health insurance option should be included in the final legislation. Although polls have shown that 52 to 69% of Americans support such an option,¹ the views of physicians are unclear. Physicians are critical stakeholders in health care reform and have been influential in shaping health policy throughout the history of organized medicine in the United States.²

The voices of physicians in the current debate have emanated almost exclusively from national physicians’ groups and societies. Like any special-interest group, these organizations claim to represent their members (and often nonmembers as well). The result is a well-established understanding of the interests of physicians’ societies but little, if any, understanding of views among physicians in general. Faced with this absence of empirical data, we conducted a national survey of physicians to inform federal policymakers about physicians’ views of proposed expansions of health care coverage.

In April 2009, we obtained data on a random sample of 6000 physicians from the American Medical Association (AMA) Physician Masterfile, which includes current data on all U.S. physicians. We excludedphysicians from U.S. territories because health care reform may not be as relevant to them, and we excluded physicians in training because of their limited experience with insurance; a sample of 5157 physicians remained. We categorized physicians into four groups: primary care physicians (in internal medicine,pediatrics, or family practice); medical subspecialists, neurologists, and psychiatrists; surgical specialists and subspecialists; and other specialties. The survey instrument we used was developed with the input of an expert panel, and we conducted cognitive testing and pilot testing to ensure its clarity and relevance. (More detailed information about our methods can be found in the Supplementary Appendix, available with the full text of this article at NEJM.org.)

Survey respondents were asked to indicate which of three options for expanding health insurance coverage they would most strongly support: public and private options, providing people younger than 65 years of age the choice of enrolling in a new public health insurance plan (like Medicare) or in private plans; private options only, providing people with tax credits or subsidies, if they have low income, to buy private insurance coverage,without creating a new public plan; or a public option only, eliminating private insurance and covering everyone through a single public plan like Medicare. We also assessed the level of physician support for a proposal that would enable adults between the ages of 55 and 64 years to buy into the current Medicare program — a strategy that the Senate Finance Committee has proposed.

Data were also collected on additional variables that might be associated with preferences for different expansion options, such as time spent on clinical duties each week, whether physicians owned their own practice, salary status, and type of practice. The survey has been in the field for approximately 2 months (June 25, 2009, to September 3, 2009). All available data were analyzed on September 4, 2009. A third survey wave was initiated on August 27, 2009.

The final sample included 5157 physicians, but 221 of them had an incorrect or incomplete address or were deceased. Of the remaining 4936 physicians, 2130 returned the survey — a response rate of 43.2%. Women made up a smaller proportion of respondents than of nonrespondents (26.8% vs. 31.2%, P<0.001), and the average age of respondents was 1 year older than that of nonrespondents. There were no significant differences associated with practice location (census division or urban vs. rural setting), practice type, or specialty group. There were no significant differences in the characteristics of respondents to different survey waves (for details, see the Supplementary Appendix).

Overall, a majority of physicians (62.9%) supported public and private options (see Panel A of graph). 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). 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. Practiceowners were less likely than nonowners to support a public option (59.7% vs. 67.1%, P<0.001), style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; "> it. Finally, there was also majority support for a public option among AMA members (62.2%).

Physicians’ Support of Options for Expanding Insurance Coverage and Medicare.

Panel A shows the proportion of survey respondents who favored public options only, those who favored both public and private options, and those who favored private options only. Panel B shows the proportions of respondents (according to their medical specialty) who supported, opposed, or were undecided about the expansion of Medicare to include adults between the ages of 55 and 64 years. The proportion of support was consistent across all four specialty groups (P=0.08).

Forget the Goggles: Chlorophyll Eye Drops Give Night Vision

Seeing in the dark could soon be as easy as popping a pill or squeezing some drops into your eyes, thanks to some new science, an unusual deep-sea fish, and a plant pigment.

In the 1990s, marine biologist Ron Douglas of City University London discovered that, unlike other deep-sea fish, the dragonfish Malacosteus niger can perceive red light. Douglas was surprised when he isolated the chemical responsible for absorbing red: It was chlorophyll. “That was weird,” he says. The fish had somehow co-opted chlorophyll, most likely from bacteria in their food, and turned it into a vision enhancer.

In 2004, Ilyas Washington, an ophthalmic scientist at Columbia University Medical Center, came across Douglas’s findings. Washington knew that the mechanisms involved in vision tend to be similar throughout the animal kingdom, so he wondered whether chlorophyll could also enhance the vision of other animals, including humans. His latest experiments in mice and rabbits suggest that administering chlorophyll to the eyes can double their ability to see in low light. The pigment absorbs hues of red light that are normally invisible in dim conditions. That information is then transmitted to the brain, allowing enhanced vision.

Washington is now developing ways to deliver chlorophyll to human eyes safely and easily, perhaps through drops. He believes that a night-vision drug would be most useful on the battlefield, so it is no surprise that the U.S. Department of Defense is funding his work. “The military would want this biological enhancement so they don’t have to carry nighttime goggles” during operations in the dark, he says.

Vital Signs The Sneaky Pain That Fooled 6 Experts

Forty-two-year-old Russell McCoy was energized and sweaty as he finished a three-mile run around his neighborhood. He headed straight for his refrigerator and cracked open a diet soda, downing it in a couple of swigs. Holding the empty can, he backed toward the garbage pail, pivoted, shot, and scored. Then pain, sudden and excruciating, lanced through his left hip. He bent over, aware that he had twisted something the wrong way. Breathing deeply, he felt a little better. A few hours later, though, he tried to run a few strides and almost yelped from the pain. For the next two weeks, he took it easy. But the hip didn’t get better.

I first saw Mr. McCoy in June, two months after the soda-can episode. He had already been to another doctor, who was convinced this was “referred pain”—in other words, pain in one body area that is actually the result of a problem in another. According to that doctor, Mr. McCoy had strained his lower back muscles and was experiencing it as hip pain. A week of an anti-inflammatory medicine and stretching exercises for the lower back had not helped, however. An X-ray of the hip a month later showed no sign of arthritis or fracture, and an MRI of the lower back hadn’t revealed much either, just a small disk bulge that seemed unrelated to the pain.

Over the two months since the injury, my patient told me, he had gained 10 pounds. He wasn’t exercising because it hurt too much. He wasn’t sleeping well, either; the hip ached when he lay on his left side. He sucked his breath in sharply when I pushed on the greater trochanter, the bony outer part of his upper left thigh.

His main symptom—the sore spot on his hip that hurt when pressed—was typical for trochanteric bursitis, inflammation of the greater trochanter’s bursa. A bursa is a fluid-filled sac that allows adjacent tissues to glide over each other. When injury or overuse irritates the bursa, any pressure or movement around it will cause pain. I recommended treating the inflammation with a cortisone injection.

My patient cringed at the thought of a needle poking into the painful area. Instead, he decided to seek yet another opinion, this time from an orthopedic surgeon. Like the first doctor, the surgeon believed the symptoms originated in the lower back. He had Mr. McCoy see a physical therapist, who thought the back had nothing to do with it and that he had strained a muscle in his hip. The next stop was a chiropractor, who worked on both hip and back with no improvement.

Finally, four months after our first visit, Mr. McCoy was back in my waiting room. His belly now bulged over his belt, and he grimaced each time his left foot hit the floor. “I’m ready for the injection,” he said. “Let’s go for it.”

I had him lie on his right side, located the most tender area on the top of his left thigh, and injected a mixture of anesthetic and cortisone. Injections like these are among the few procedures that can give almost instant relief. The anesthetic numbs the sore area immediately, and the steroid kicks in within two days. If the anesthetic helped, it would support my diagnosis, and we could be pretty sure that the steroid would work. If the anesthetic didn’t help, then it probably wasn’t trochanteric bursitis after all.

I held my breath as he took a few steps. He winced. The injection had not worked.

It had been six months since Mr. McCoy first hurt his hip, and now we were right back where we started. I had run out of ideas. The physical exam, the X-ray results, and the injection had ruled out the common causes of hip pain—arthritis, bursitis, fracture, referred pain from the lower back—but he still couldn’t run. In many situations, the search for a cause of pain ends without an answer, and we change our focus to pain control. But I was not ready to give up.

Apologizing for adding yet another doctor into the mix, I suggested a rheumatologist—a joint specialist—who then sent Mr. McCoy for a procedure in which an anesthetic, followed by cortisone, was injected directly into the ball-and-socket part of the hip joint. This, too, failed to relieve the pain.

It had been six months since Mr. McCoy hurt his hip, and now we were back where we started. I had run out of ideas.

We had not yet addressed the slight disk bulge that appeared on the MRI of Mr. McCoy’s lower back. I didn’t think it was the culprit, but we had no other leads. Disk bulges are notoriously tricky to interpret because they are common in people both with and without pain; in fact, they appear on MRIs of people without back pain roughly 50 percent of the time. So it isn’t easy to decide whether a bulge justifies the discomfort, expense, and radiation exposure of additional tests, or even surgery.

Mr. McCoy’s neurosurgery appointment wouldn’t happen for another two months. While he waited, I suggested he return to the physical therapist for a cane and some hip exercises.

When I saw him a month later, in January, I had to blink a couple of times. He wasn’t limping. He wasn’t using a cane. He was smiling.

What he told me was so utterly unexpected, so simple, that I was at a loss for words. “I have a short leg,” he explained. “The physical therapist measured my legs, and my right one is about half an inch shorter. He gave me a heel lift and it’s working like a charm.”

I had not learned about leg length discrepancy (LLD) in my training, and it seemed that none of the other clinicians Mr. McCoy saw had considered it either. But leg length discrepancies are common. According to some studies, up to 70 percent of people have a slight difference in the length of their legs; one person in a thousand has a difference of nearly an inch. In most cases, the difference goes undetected.

There are two kinds of LLD. Structural discrepancies, which can be congenital or the result of a fracture or hip replacement surgery, involve an actual difference in the length of the bones. Functional discrepancies, on the other hand, are caused by muscle weakness or stiffness in the pelvis, ankle, or foot—the legs are the same size but function as if one is longer. Mr. McCoy probably had a lifelong mild leg length discrepancy that never bothered him until he hurt his hip. The pain changed the way he walked, and all of a sudden the discrepancy mattered.

My patient’s LLD was small enough that it had never caused an obvious limp, at least until now. But there was another clue that nobody had noticed. “I looked at the soles of his shoes, and one was more worn,” the physical therapist told me. “If the right leg is shorter, you tend to walk on the outer part of that foot, to extend the leg. On the other side, to make the longer leg feel shorter, you flatten out that foot. You can learn a lot from the soles.”

One common method used to check for a structural leg length discrepancy involves running a tape measure from a point on the pelvis to the ankle bone several times and then averaging the numbers. To check for a functional discrepancy, a physical therapist will measure from the belly button to each ankle bone. Some doctors recommend taking a special X-ray to verify the measurement; others believe that the degree of accuracy achieved with an X-ray is not worth the radiation exposure and is not necessary with small discrepancies.

Physical therapists often give a patient with hip pain and a small LLD a heel lift or even an insert from a sneaker to try for a week or so. What makes the treatment tricky is that a heel lift doesn’t always work. As with those incidental disk bulges on MRIs, a leg length discrepancy may have nothing to do with the pain; since a slight difference in leg lengths is so common, it would be easy to make the mistake of treating the pain with a heel lift when there is another reason for it, like arthritis or bursitis. And some people have had an LLD for so long that they’ve compensated by holding their pelvis at a certain angle. In those situations, a heel lift that is used for more than a week may end up causing pain rather than relieving it.

For some people, the search for relief from hip pain never ends. Luckily, that wasn’t the case with my patient. The heel lift did more than match the length of his legs. It lifted his spirits.

Anna Reisman is an internist in West Haven, Connecticut. The cases described in Vital Signs are real, but names and certain details have been changed.

Woman’s Blindness Cured By Tooth Implanted in Her Eye

Nine years ago, Sharron Thornton’s hair and nails fell out, while her skin developed a blistering rash. Turns out she was suffering from a very rare condition—know as Stevens-Johnson syndrome—caused by a reaction to a medication. She eventually went blind after the cells in her eye died and left corneal scarring.

While her hair and skin grew back, her eyes remained useless. Her condition devastated her: She thought about suicide, and tried a stem cell procedure, but couldn’t be considered for a cornea transplant. Finally she went on a desperate search for any experimental treatment to cure her blindness.

For the first time in the U.S., surgeons decided to perform a rare procedure called modified osteo-odonto keratoprosthesis, to correct corneal scaring. While the procedure has been done a total of 600 times since the 1980s, it’s still pretty complicated: First the surgeons took Thornton’s tooth and part of her jawbone, and made a hole for the prosthetic lens. Then it got weirder: The surgeons implanted the modified tooth into the woman’s chest and left it there for a few months so the two parts could grow together. And finally, the tooth was implanted into her eye.

CNN reports:

Dr. Ivan Schwab with the American Academy of Ophthalmology told CNN he believes the process is too difficult and the result too disfiguring. There are alternatives that are nearly as good, he added.

“We’ve known about the procedure since the ’80s. It’s been going on for a while,” he said. “We’ve viewed it with some skepticism. It requires a sizable team and several operations. It seems to be reasonably successful on the small numbers that have been done,” though it does bring some disfigurement.

Surgeons doubt the procedure will be common in the U.S. anytime soon. But for Thornton, it gave her a reason to live.

Breaking down the Baucus bill

By: Carrie Budoff Brown and Patrick O'Connor September 17, 2009 05:13 AM EST

Senate Finance Committee Chairman Max Baucus (D-Mont.) worked for months to find common ground with Republicans on health care reform — but when he released his long-anticipated proposal Wednesday, the real problem quickly came into focus. He set the stage for a titanic struggle within his own party. Reaction from congressional Democratic leaders was lukewarm to worse, progressives were downright hostile and Republicans were scornful of what they described as brazen government grab. But Baucus may have provided lawmakers with the only viable blueprint for winning support across Congress, because he sought to find elements that pleased all sides. “There are honest and principled differences on all of us working for reform, and this package may not represent all of our first choices,” Baucus said. “But at the end of the day, we all share a common purpose: that is to make the lives of Americans better tomorrow than they are today and to get health care reform done, which means the time for action is now.” The next challenge for Baucus and the Senate leadership is to get the bill out of the Finance Committee — but after that, Senate Majority Leader Harry Reid (D-Nev.) will need to merge the Finance bill with one approved in July by the Senate Health, Education, Labor and Pensions Committee. Even Reid, who has generally supported Baucus’s efforts, sounded less than pleased, saying he needs to be convinced the bill is right for Nevada on a proposed Medicaid expansion. House Speaker Nancy Pelosi (D-Calif.) dug in on the element dear to her liberal caucus — the public insurance option — and whacked the Baucus bill for shunning it. Baucus has made the challenge clear for Democrats, who now must choose between competing visions of health reform: an employer mandate versus fees on employers, a public insurance option versus nonprofit insurance cooperatives, and taxes on millionaires versus industry and people with expensive health care plans. The proposal capped months of closed-door discussions that, in the end, produced no immediate Republican support — and critical comments from negotiators Chuck Grassley of Iowa and Mike Enzi of Wyoming, both of whom complained about “artificial deadlines” from the White House and Democratic leaders to push through a bill, as Grassley said. Baucus put the cost of his bill at $856 billion. It would require nearly all Americans to carry insurance and employers to help cover the costs of providing government subsidies, while prohibiting insurance companies from dropping or denying coverage for people with pre-existing conditions. The Congressional Budget Office estimated the bill would cost $774 billion over 10 years and cover 94 percent of Americans. It would leave 25 million people uninsured in 2019 — a third of whom are illegal immigrants — compared with 17 million in the House bill. The analysis came in $82 billion lower than Baucus had thought it would, suggesting there could be room for senators to make adjustments. However, any expenses added to the bill must be offset with new revenue, making the task politically difficult. Another looming battle between Baucus and fellow Democrats is over how to pay for the bill — especially since the Finance bill came in at least $100 billion cheaper than the House bill. The House would pay for health reform in part by taxing high earners, families who make at least $1 million, but Baucus proposed an excise tax on insurers for their top-of-the-line plans. And Republicans think both plans cost too much. “Bipartisanship on Capitol Hill is the equivalent of a child looking for the unicorn,” Rep. Anthony Weiner (D-N.Y.) said, referring to the months of negotiations between Baucus and three Republican senators on the committee — none of whom has embraced his bill. Weiner, an outspoken defender of the public option, said the Baucus bill would be “dead on arrival” in the House — a far stronger claim than that of his party’s leaders in that chamber. “It has been said that the Senate is the cooling saucer of our democracy,” Weiner said. “At this point, it is more akin to the meat locker. ... The Senate proposal will not pass muster in the House.” But Baucus aides said there is plenty for progressives to like: tax credits to purchase insurance for families with incomes of $88,200 or less, immediate creation of a high-risk pool to provide coverage to the uninsured and people with pre-existing conditions, an expansion of Medicaid, and Medicare coverage for annual prevention and wellness checkups. “It is common sense. It is a balanced bill. It certainly is a bill that can pass,” Baucus said. “And the choice now is up to those on the other side of the aisle — if they want to vote for it or not.”

Baucas Press Conference

Greater Louisville Medical Society President's eVoice September 2009

The future's so bright, I gotta wear shades... This article was written during a tennis tournament "road trip" with my daughter. I sent Mackenzie ahead with another lucky family, and drove the 6 plus hour trip to North Carolina by myself. This allowed me the opportunity to think but also to listen to whatever I wanted on the radio. I ended up with the 70's and 80's channels (and hence the title to this article). Almost each and every song brought a smile to my face and brought back the memory of a moment from high school, college or some aspect of medical training. I was clearly in my "happy place." This tournament is also a little different than others. Most tennis tournaments include mainly singles events, where it's all about you. You either win or lose, and if it's the latter, you head home a lot sooner than everyone else. In this tournament, the "zonals," the kids are placed on teams representing different regions (Southern, Caribbean, Mid-Atlantic, etc), 6 girls, and 6 boys, and each day they play doubles, mixed doubles and singles, for a total of 18 possible points per day. The teams with the most points after several days, play each other at the end of the tournament, but in general, everyone plays every day, win or lose. And the best part, team members can clap and yell and cheer for each other, which is mostly forbidden in all other tournaments. This tournament takes what can be a very solitary, individual sport and turns it into a team sport. It's a lot of fun. If she's played well enough through the year to be selected, it is clearly my daughter's favorite tournament. Could this be where medicine is going? Most of us perform as individuals, working directly with patients to diagnose, plan and implement treatments. Will health care reform transform us into something like tennis "zonals?" Will we be put on teams with other physicians? Michael Porter wrote a book on reforming healthcare even before all this recent talk of reform, and he predicted that care in the future would be delivered around a patient's main type of disease (diabetes, cardiovascular disease, etc), and that physicians would be organized in groups in order to manage chronic illnesses. Will primary care be delivered through a "medical home," a team of physicians, nurses and other professionals? Will physicians need to form larger group practices in order to be successful? Will physicians be on teams with hospitals or health systems in order to receive bundled payments? As the debates go on in Washington, the GLMS, KMA and AMA continue to try to participate and influence the discussions. I think we all realize that the status quo will likely not continue, and that patient care is improved by more collaboration and continuity. Figuring out how we can make the practice of medicine more of a team sport instead of an individual one is likely a good idea, and maybe it will be even more fun than practicing alone, just like the "zonals." Sincerely, Lynn T. Simon, MD GLMS President Louisville Medicine wants your proposals on health care reform: By now you've read and heard many pundits' views of how to provide access to working health insurance for all, or at least more, Americans. Louisville Medicine wants to know what your proposals are. What kinds of solutions do you favor, and how would you design and finance them? Please join in and enlighten us - we who provide the care have a valuable perspective. Send your responses to bert.guinn@glms.org or by mail to the GLMS Communications Dept., 101 W. Chestnut, Louisville, KY 40202. Thanks from all of us - Mary G.Barry, MD and the Editorial Board

GLMS Mission - Promote the science, art and profession of medicine - Protect the integrity of the physician-patient relationship - Advocate for the health and well-being of the community - Unite physicians to achieve these ends