A study of physicians reactions to health care reform

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Quirk's Marketing Research Review February 1994

A study of physicians' reactions to health care reform
by Dr. Murray Simon and Pat Gick

Editor's note: Dr. Murray Simon is president of D/R/S HealthCare Consultants, Charlotte, N.C. Pat Gick is assistant vice president at Axxiom Research, Glen Rock, Pa.

As you read this article, the American public is anxiously awaiting the fate of President Clinton's health care plan. Few, if any would argue the need for reform. Health care now accounts for approximately 16% of the expenditure of state and local tax revenues. There are 37 million people in the United States who have no health care coverage. Untold numbers of employees are locked into jobs they would leave if it weren't for the accompanying insurance coverage they have to protect and maintain.
     For small businesses, insurance has become just about unaffordable. Despite the protest over costs during the past few years, the projected expenditure of $800 billion dollars on health care in 1993 represents an increase of more than 37% from 1990 (before inflation).
     The fact is that if we have a health care system in this country, it is terminally ill and in need of heroic efforts and sacrifices to save it.
     There are resuscitation efforts taking place on a local and regional basis. Powerful buyers' groups (also known as health maintenance organizations {HMOs}, corporate health coalitions, state government, the federal Medicare program, etc.) are negotiating with medical groups and hospitals to provide quality care at lower cost. "Outcome" programs are being developed and put into place to determine the effectiveness of various providers and therapies, with the goal of more standardized and predicable treatment.
     Similar programs are being used to evaluate the performance of hospitals, HMOs and large group practices so buying coalitions can monitor the quality and effectiveness of the treatment they are paying for. Hospitals are merging, in part to eliminate redundancy and inefficiency in a geographic area. Does a smaller city really need more than one CAT scan machine? Is it efficient to have two or more separate physical therapy units in one town? Isn't it more cost-effective to maintain one boiler room that two?
     If you keep up with all the media reports, you've seen a lot of finger-pointing. Hospitals are accused of "delusions of grandeur"; pharmaceutical companies are depicted as bloated, impersonal corporate entities feeding greedily off the public's prescription needs; insurance companies continue to raise premiums while building bigger and grander buildings; lawyers are castigated for adding to health care costs by pursuing malpractice litigation, as visions of huge settlement fees dance in their heads.

What about the doctors?
     And then, of course, there are the doctors.
     The public tends to think of physicians, for the most part, as bright, well educated, thoroughly trained individuals who are essentially insensitive to the psychological and emotional needs of the patient. They're accused of making their patients feel like faceless, nameless ciphers in their "take-a-number-and-we'll-call-you-when-it's-your-turn" practices.
     Is it any wonder that what the public fears most about health care reform is not being able to choose their doctors? The specter of managed care represents, for many patients, greater anonymity in the patient/doctor relationship - which is not what they want! The physician, on the other hand wants the public to better appreciate the pressures doctors work under and the long hours they spend caring for their patients.
     Much has been written about how changes in the health care system will affect the patient, but little more than abstract conjecture has been devoted to how such changes would affect the health care provider.

Assess physicians' attitudes
To shed some light on how change and anticipation of change are influencing physicians' thinking, D/R/S HealthCare Consultants of Charlotte, N.C., and The Axxiom Research Network of Glen Rock, Pa., jointly developed an independent research study to assess physicians' current attitudes about their profession and the factors that are dramatically affection them. It is hope that these results will add new dimensions to the framework necessary to begin the rebuilding process.
The results were developed from 275 telephone interviews with physicians throughout the United States. The doctors interviewed represent a broad mix of specialties, ages and geographic diversity.

What one change would you make in the way medicine is currently practiced?

     While there were a variety of responses, in essence they boiled down to "eliminate the middleman." They saw the government (represented by Medicare and Medicaid) and the insurance companies as agents of interference between the doctors and their patients. They repeatedly referred to mountains of paperwork that cut into time for treating patients. It was their aggregate opinion that eliminating much of the paperwork - and the people who process it - would contribute significantly to reducing health care costs.
     They also indicted the government and insurance companies for controls and regulations on physicians' diagnostic and treatment decisions. Despite the cry for cost cutting, these doctors felt that current medical coverage is not broad enough and limits their ability to provide appropriate and thorough care. Several said that the Medicare system of predetermined fees for specific procedures acts as a disincentive to the development of higher skill levels among physicians, and encourages mediocrity.
     Many respondents said that managed care and competitive fee schedules represent the future of medicine. Some were for it, many were not. Not surprisingly, there was a strong correlation between years in practice and resistance to managed care. What they object to most are politicians and business people administering these programs. While they did not think physicians should take on this administrative role, none the less they believe that doctors are not adequately involved in the decision making process.

Get the lawyers off our backs
     It should come as no surprise that there was a widespread hostility toward the legal profession. (As we analyzed the survey results and read their suggestions on "what to do with lawyers," we had to wonder: What happens when lawyers need medical care?) Many doctors said that lawyers are responsible for a significant portion of the high cost of health care, by forcing doctors to practice defensive medicine and giving patients the idea that if a treatment outcome is not successful, a lawsuit is the next logical step.
     This has had an obvious impact on their collective psyches. Many expressed the belief that a managed care system could be workable if it included strict regulation of medical malpractice litigation. The implication was clear: "Get the lawyers off our backs and we'll make managed care work."
      Several respondents commented on medicine's loss of prestige. There were numerous statements about "not being appreciated, not being understood." A few claimed that medicine has its "bad apples," who are giving the profession a bad image. There were vague references to "getting rid of the greedy ones," so the profession could once again regain its former high standing.

If you had it to do over again, would you go into medicine?

Despite all the strongly worded complaints, 82% of the respondents said they would choose the same profession again. The most frequent reasons were that medicine provides a good income and a level of personal satisfaction that's hard to find in any other field.
Respondents were asked what they would be if they were not a physician. Among those who said they would not choose medicine again, 42% said they would be a business person, 10% indicated they would choose a teaching career and, surprisingly, 10% said they would be a musician.

What changes would you make in medical school curriculums?

     There were two primary areas of medical education that most doctors thought needed changing:

     1. A shift from academic subjects to more clinically oriented, "real-life" teaching.
     2. Education in the business aspects of medicine.

     Almost without exception, the doctors interviewed said that med school fails to prepare the student for the realities of actual practice, a problem they considered more urgent than ever. As one physician put it, "We tend to come out of school with our heads buried in medicine, we get burned and then we become cynical." One of the most common suggestions was to have medical students do a rotation in private practices and clinics.

What changes would you make in internship and residency programs?

     The overwhelming concern among these practitioners was the long hours that are an integral part of internship and residency programs. Many were concerned about the attendant fatigue and resultant potential for mistakes. On the other hand, some expressed the attitude that "We did it, why shouldn't the next generation of med students?"
     Another frequent complaint was too much emphasis on specialization, with a resultant narrowing of the physician's perspective. Some said that more interns must be encouraged to go into primary care medicine as their area of practice.
     A number of respondents said that treating patients exclusively within a hospital setting tends to create a strong bias in treatment protocol. Interns and residents have to deal with an ever-changing group of patients with little or no follow-up after the patient is discharged. The respondents felt that most of the patient management issues in medicine are not learned until the doctor is in private practice. As one internist said of his internship/residency, "They taught me how to treat sick people, not how to keep them well."

Is medicine a job or a way of life for you? Do you think young physicians coming into medicine consider it a job or a way of life?

     These questions produced an interesting dichotomy. Eighty-one percent of the respondents classified medicine as a way of life for them, yet 59% thought that young physicians consider medicine a job. When asked to comment on whether the latter is bad or good, 82% said it was bad.
     And whether they considered it bad or good, the reasons given were often similar: Medicine practiced on a nine-to-five basis leads to a loss of patient empathy; or "nine-to-five" medicine leaves time for a life outside the office and a healthier mental attitude.
      Much has been written about fragmenting the medical community into competing specialties, with primary care physicians scrambling for their piece of the pie. This survey indicates that there is also a pronounced generation gap within the profession.

What can be done to reduce health care costs?

     For the most part, this question produced the same responses as the first question: reduce the time spent on paperwork, and limit medical litigation. There were two additional suggestions:
     1. End-stage patients should not be kept on life support for indefinite periods. There should be a previously agreed-upon time when treatment is discontinued.
     2. Patients should not be allowed to abuse the system. There are too many for whom frequent medical visits are a way of life.

Doctors aren't part of the problem
Some noteworthy take-aways from this study:

There were very few comments from these doctors about cost reduction or containment. Their attitude was if you control the paperwork and the lawyers, everything else will take care of itself.
Controls and regulations were viewed as essentially negative, mainly because they are created by non-providers.
Although it is obvious that there will be limits imposed on the amount of treatment and types of treatment performed, these physicians felt a need for broader medical coverage because anything less will limit their ability to provide adequate care.
Most respondents felt med schools do a poor job of training graduates for the realities of medicine.
When asked what they would be in they weren't physicians, 62% mentioned non-scientific vocations, with business mentioned most frequently. The American public should be encouraged that, despite all the complaints registered, 82% said they would go into medicine again.
Practicing physicians see the "recently minted physician" as less altruistic in their reasons for practicing medicine; they believe these young doctors view their profession as a job rather than a way of life. They think the experienced physician, on the the other hand, practices medicine as a way of life.
As specialists in health care marketing research, we find the most interesting factor from this study to be that physicians essentially do not seem to see themselves as part of the problem. Most doctors believe that if they are allowed to practice the way they see fit, then health care costs will no longer be a concern.
One of the strongest recommendations for change is the medical school curriculum was to introduce business related subjects - and the need is obviously even greater than they realize. The road to health care reform is going to be a long and bumpy one. ¤