Guest Editorial

Insecurity Breeds Hysteria; Health Care Needs Evidence-Based Activism

Nancy S. Reau

Today, we as physicians confront the political nature of medicine on a daily basis and, for me, the number one issue with the politics-medicine intersection is essentially insecurity.

Whether it’s the repeal of the Affordable Care Act without a solid understanding of what options will be once it’s repealed or the thought of our immigrant colleagues not returning to the United States, our insecurity drives a fair amount of hysteria. Medicine is already something where the people within medicine and the individuals affected by it lack a sense of control.

Lack of Control

When discussing drug pricing or choices of medications, like those for hepatitis C, universally, you hear that physicians do not feel that they have control over what they can prescribe. They use what insurance allows them. When ordering evaluations and diagnostic tests, we are often limited by the approval process. Painful peer-review deters physicians from deviating from a preset algorithm often defined by a payer, not prescribers.

Nearly every aspect of medicine is dictated by an outside influence. Documentation requirements, looming litigation, EMRs and reimbursement lend to daily anxiety. Medicine is one of the few fields where neither consumer nor provider can control cost. We can’t negotiate how much we are paid. We don’t control how much a service is reimbursed.

New grads face significant debt and the knowledge that medical salaries have been decreasing every year — as opposed to most jobs where salary increases with inflation. This adds to the unpredictability of a job in medicine.

When you add additional levels of insecurity to something we have so little control over, it naturally breeds hysteria.

ACA, Pricing, Immigration

In the past, there were many people who were under insured or uninsured and the ACA was an attempt to eliminate some of that. Regardless of political view, now most patients have an insurance option. Many physicians that care for large populations enriched with socioeconomically marginalized patients worry patients will lose the ability to be insured or a change in status will disrupt the medical relationship because the transition to a new system won’t allow for continuation of care.

Drug pricing is especially hazy. Most medications are completely unaffordable to our patients despite paying just a portion of what their insurance company negotiates. A drug’s price angers many parties, especially if price is used to limit access to lifesaving therapies. However, given the lack of transparency in drug pricing, it’s hard to find the truth in the details.

Do we need to have control over medical costs? Absolutely. Is drug price part of this? Absolutely. Is it all drug pricing? No.

A commercial, open economy, allows for competition. Other competitive products bring the price down, and the promise of revenue drives scientific discovery. Yet, it does have to be reasonable.

The immigration policy is also hugely important to medicine because if you look at our physicians, physicians-in-training, and physician extenders, we have a lot of non-U.S. citizens providing care, especially primary care, in our country. Foreign post-grads conduct much of our medical research and we are importing nurses from other countries. In the Association of American Medical Colleges’ statement, it was estimated that 25% of our medical workforce is comprised of international graduates.

The immigration prohibitions could be impractical and the medical societies such as the American Medical Association have begun to release statements suggesting that these travel bans can impact medical care both for physicians and their patients.

Recognition Requires Activism

A lot of what we need now is recognition. There is no class in medical school that discusses the political aspects of medicine. Most physicians don’t imagine advocacy or policy as part of their job. Yet, if we don’t offer some unified opinion as to the impact of policy on our lives, then we lose even more control.

Every aspect of a private GI or hepatologist’s life is relatively out of their hands. Recognizing that and supporting or participating in the political advocacy groups in our societies is of utmost importance. Every single one of the big societies has a public policy committee. That very committee may provide impactful information to the delegates, however it’s often dismissed. When there’s such insecurity, it’s overwhelming to find information and even more challenging to put it to use.

Like any one of us that takes on an aspect of learning where we have very little basis, it will come. You just need motivation to learn.

The dialogue must be open and it must be neutral. We need to prioritize what is most important and get out of the political rhetoric of the two-party system. This dialogue cannot be polarizing. Rather, it must be evidence-based and focused on the issues we need to recapture. Bring the scientific analysis to politics. It will be difficult, but you’re going to have to take a step backward to progress forward.

To offer your perspective, please email Gastroenterology@Healio.com.

Nancy S. Reau, MD, FAASLD, AGAF
Healio Gastroenterology
Co-Chief Medical Editor

Disclosure: Reau reports no relevant financial disclosures.

Nancy S. Reau

Today, we as physicians confront the political nature of medicine on a daily basis and, for me, the number one issue with the politics-medicine intersection is essentially insecurity.

Whether it’s the repeal of the Affordable Care Act without a solid understanding of what options will be once it’s repealed or the thought of our immigrant colleagues not returning to the United States, our insecurity drives a fair amount of hysteria. Medicine is already something where the people within medicine and the individuals affected by it lack a sense of control.

Lack of Control

When discussing drug pricing or choices of medications, like those for hepatitis C, universally, you hear that physicians do not feel that they have control over what they can prescribe. They use what insurance allows them. When ordering evaluations and diagnostic tests, we are often limited by the approval process. Painful peer-review deters physicians from deviating from a preset algorithm often defined by a payer, not prescribers.

Nearly every aspect of medicine is dictated by an outside influence. Documentation requirements, looming litigation, EMRs and reimbursement lend to daily anxiety. Medicine is one of the few fields where neither consumer nor provider can control cost. We can’t negotiate how much we are paid. We don’t control how much a service is reimbursed.

New grads face significant debt and the knowledge that medical salaries have been decreasing every year — as opposed to most jobs where salary increases with inflation. This adds to the unpredictability of a job in medicine.

When you add additional levels of insecurity to something we have so little control over, it naturally breeds hysteria.

ACA, Pricing, Immigration

In the past, there were many people who were under insured or uninsured and the ACA was an attempt to eliminate some of that. Regardless of political view, now most patients have an insurance option. Many physicians that care for large populations enriched with socioeconomically marginalized patients worry patients will lose the ability to be insured or a change in status will disrupt the medical relationship because the transition to a new system won’t allow for continuation of care.

Drug pricing is especially hazy. Most medications are completely unaffordable to our patients despite paying just a portion of what their insurance company negotiates. A drug’s price angers many parties, especially if price is used to limit access to lifesaving therapies. However, given the lack of transparency in drug pricing, it’s hard to find the truth in the details.

Do we need to have control over medical costs? Absolutely. Is drug price part of this? Absolutely. Is it all drug pricing? No.

A commercial, open economy, allows for competition. Other competitive products bring the price down, and the promise of revenue drives scientific discovery. Yet, it does have to be reasonable.

The immigration policy is also hugely important to medicine because if you look at our physicians, physicians-in-training, and physician extenders, we have a lot of non-U.S. citizens providing care, especially primary care, in our country. Foreign post-grads conduct much of our medical research and we are importing nurses from other countries. In the Association of American Medical Colleges’ statement, it was estimated that 25% of our medical workforce is comprised of international graduates.

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The immigration prohibitions could be impractical and the medical societies such as the American Medical Association have begun to release statements suggesting that these travel bans can impact medical care both for physicians and their patients.

Recognition Requires Activism

A lot of what we need now is recognition. There is no class in medical school that discusses the political aspects of medicine. Most physicians don’t imagine advocacy or policy as part of their job. Yet, if we don’t offer some unified opinion as to the impact of policy on our lives, then we lose even more control.

Every aspect of a private GI or hepatologist’s life is relatively out of their hands. Recognizing that and supporting or participating in the political advocacy groups in our societies is of utmost importance. Every single one of the big societies has a public policy committee. That very committee may provide impactful information to the delegates, however it’s often dismissed. When there’s such insecurity, it’s overwhelming to find information and even more challenging to put it to use.

Like any one of us that takes on an aspect of learning where we have very little basis, it will come. You just need motivation to learn.

The dialogue must be open and it must be neutral. We need to prioritize what is most important and get out of the political rhetoric of the two-party system. This dialogue cannot be polarizing. Rather, it must be evidence-based and focused on the issues we need to recapture. Bring the scientific analysis to politics. It will be difficult, but you’re going to have to take a step backward to progress forward.

To offer your perspective, please email Gastroenterology@Healio.com.

Nancy S. Reau, MD, FAASLD, AGAF
Healio Gastroenterology
Co-Chief Medical Editor

Disclosure: Reau reports no relevant financial disclosures.

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