Now Is the Time: Physician Involvement in Health Care Reform

Physician involvement in health care reform must go beyond the roles of organized medicine, and must occur on a local as well as national level. We outline a variety of ways for practicing physicians to become involved in health care reform and in redefining the fundamental purposes of the health care system. Our actions as physicians during the next few years can help shape reform. The choice now is to lead or be left behind.

Health care reform is necessary. The public recognizes that the United States stands alone among developed nations in failing to ensure access to health care for all its citizens, in the high cost of its health care, and in the large and growing disparities between the health of its advantaged and its disadvantaged citizens [1]. Political leaders and advocates for business and human services recognize that uncontrolled health care costs are consuming resources needed for other social programs and for economic growth. The results of the 1992 election were a clear message about the public desire for change, including reform of the health care system. The issue now is not whether there will be reform but what configuration the reform will take. Our actions as physicians during the next few years can help shape reform, shape our future role in the health care system, and shape public esteem for the profession. We can either lead or be left behind.

Many physicians' organizations—The American Academy of Family Physicians, the American Academy of Pediatrics, the American Medical Association, the American Society of Internal Medicine, the Society for General Internal Medicine, and others—have entered the reform debate. Physicians for a National Health Program was specifically formed to advocate single-payer reform. The American College of Physicians is a model for the kind of leadership that is necessary from professional organizations. It has conducted research, developed proposals, invited members' views, and published its opinions [2, 3].

Individual physicians must play a role in reform as well. We cannot let only national organizations speak for us.

Most physicians have pressing responsibilities and feel they lack the time or expertise to enter the reform process. However, the changes in health care will not wait until physicians have more time. Reform is occurring all around us: in clinics and hospitals, in our communities, in relationships with payers, and by state and federal legislation. Physicians can choose to take advantage of the many opportunities to become involved in their own communities or relinquish their role in health care reform and turn the solutions over to others.

Individual physicians can become involved in many ways. First, each physician can become a knowledgeable participant in the debate about health care reform—with the understanding that the public wants physicians to collaborate in, but not dictate, the terms of reform [4]. There are many opportunities to learn about the range of reform proposals being advocated by physicians' organizations and by business, labor, citizens groups, the insurance industry, as well as by state and federal government. Local newspapers, public radio stations, and television stations regularly feature programs on health care reform. Major medical journals, as well as new publications like the American Journal of Health Policy, offer a range of comprehensible articles. The American College of Physicians analyzes health policy in the ACP Observer. At the very least, we can try to understand the access and cost problems of our patients who are trapped in their jobs and forced to pay ever larger out-of-pocket costs for drugs, medical services, and insurance. Those physicians who do not treat patients with access problems can extend their contacts in the community to learn more about the problems individuals have obtaining care.

Second, physicians can help change unrealistic public expectations of the health care system, which drive up medical costs. We can promote reasonable expectations for care at the end of life and for referrals to other specialists. We can promote the rational deployment of expensive technologies to meet the needs of our communities and forgo those aspects of competition that lead to redundancy and oversupply. We can invite officials from state, county, and national government to clinics and hospitals so that they can see for themselves the actual problems and needs of medical practice. Finally, we can reach out to our communities by writing for local newspapers or participating in public discussions about the health care system.

Third, health system reform cannot succeed in the long run unless the training of physicians is restructured. Many of the nation's internists are already clinical teachers. They can design new curricula to ensure that medical students and residents learn about cost effectiveness, medical interviewing, and community-based approaches to common problems—to balance what is already done so well for hospital-based care. Physicians can open their practices, serving as mentors and role models to students and residents. More clinical education should occur in health maintenance organizations and other managed care settings, because these sites are ideal places to teach responsible cost-containment skills and population-based clinical thinking. Those of us practicing in teaching clinics must work to assure that shifting medical education to the outpatient setting does not destabilize their already marginal financial support.

Fourth, physicians can redefine the fundamental purposes of the health care system. They must accept that the success of the health care system is measured by the well being of society as a whole and not just by individual patients' outcomes. The success of therapies with indisputably great individual benefit, such as heart transplants, will not improve national health indicators such as life expectancy or neonatal mortality. Services should be advocated not only because of their benefits to individual patients but also because of their effects on the overall health of our nation's entire population. For example, physicians should advocate redirecting health care resources to counseling and follow up on smoking cessation and diet with the same vigor that they promote cardiac catheterization for people with coronary artery disease. Physicians and the public must discuss together the outcomes by which to measure the health of their communities. The fundamental question of how to assess the progress of the health care system must be the foundation for rational reform.

Some physicians may feel that personal involvement in the political process is not ethical. After all, the doctor-patient relationship gives them unusual influence over their patients. However, a distinction exists between informing patients or motivating them to become involved and suggesting that there is a “correct” point of view. For example, in the recent election, we may have suggested that our patients register and vote, but it would have been inappropriate to tell them whom to vote for.

As physicians directly engage the most difficult problem of health care cost containment, they must recognize that there are conflicts between what is best for their patients, for society, and for their professional or personal interests. The public is concerned about present and rising health care costs and also believes physicians' self-interest is a major barrier to reform [5, 6]. As we attempt to preserve what is good about U.S. medicine, we must realize that the credibility of the profession is on the line. In Vermont and Florida, physicians successfully collaborated with health care reform leaders to develop and support cost containment. In Minnesota, health care providers focused on obtaining more funds for health care; this position was widely viewed as self-interested, and it alienated them from the public and from policy makers [7]. Confidence in the role of physicians in health care reform and in managing the troubling ethical issues that reform itself poses will only improve with good collaborative reform policies.

There has never been a better time for physician involvement in health system reform. The reform debate will be uncomfortable, and in the short run it may be divisive, but it can and must lead to a more inclusive, sustainable health care system.

• Copyright ©2004 by the American College of Physicians