Stuart A. Cohen, MD, MPH
San Diego Physician: Why did you choose to become a doctor?
Dr. Cohen: I was attracted to the profession since I was a young child because it seemed like a very honorable vocation. As I got older and narrowed down my career choices, I decided that I wanted to do something that would be mentally challenging, would allow me to actively engage with people, and would be different all the time. I think I ended up going into the right profession for the right reasons.
SDP: You graduated from medical school in Canada. What brought you to the United States?
Dr. Cohen: During my residency, I was able to travel numerous times to outposts in very small communities in the Arctic Circle and near Hudson Bay where I helped to run medical clinics for native Indians and Eskimos. Through that experience I became interested in public health and decided to augment my pediatric training with a master’s degree in that field. Being from Winnipeg, where there are only two seasons (hockey season and summer), I decided to come to sunny San Diego to earn my master’s degree in public health. After a brief return to Canada to fulfill a university teaching commitment, I returned to San Diego in late 1987.
SDP: Did you practice medicine in Canada? If so, what would you say are the differences between the Canadian and U.S. healthcare systems?
Dr. Cohen: Yes, I did. There are numerous differences between the two systems. In Canada, all medical training is publicly funded and supported, so if you don’t pass your residency training, you just keep going until you can make the grades or accomplish what you need to do to finish your exams and become board certified. This is not the case in the United States where medical training is more of a mix between public and private funding. The training in the United States, while exemplary, is more work oriented. Also, the training in Canada, as in the rest of the Commonwealth, is more patient oriented, where here it’s more focused on appropriate diagnostic testing.
A second issue is obviously access to care. The Canadian system is a more egalitarian system; medical care is rationed and everybody gets treated the same. Access to care in the United States, on the other hand, is mostly based on the patient’s ability to pay. Of course there are tradeoffs. For example, Canadians have longer waiting lists for surgeries and other procedures, and newer technologies are not as readily available or widely adopted as they are in the United States. Regionalization of services and diagnostic equipment is standard, and there are very limited options there for privately offered services.
SDP: Discuss your present group, Children’s Primary Care Medical Group.
Dr. Cohen: I joined Children’s Primary Care Medical Group in 1996 and have been on the board since that time. With over 80 pediatricians, it is the largest group of its kind in the United States. It is a physician-hospital organization, affiliated with Rady Children’s Hospital, and we are integrated into our own IPA, Children’s Physicians Medical Group (CPMG), which includes the majority of non-CPCMG pediatricians in private practice in the county, as well as the Rady Children’s Specialists of San Diego Medical Group (CSSD). We also have our own MSO (medical services organization) that does the contracting for our group, CPMS, Children’s Physicians Medical Services. But what I am most proud of is our group’s mission to serve all comers. We serve patients that have private insurance, a very large percentage of the Medicaid (or Medi-Cal in California) population in our community, and about 70–75 percent of all the foster kids in the San Diego County system. It’s been a very positive experience watching the group grow and develop into a major entity in our community.
SDP: How is the under funding of Medicare and Medicaid affecting you and your group?
Dr. Cohen: There are many issues to discuss with Medicare and Medicaid; both programs are flawed and have a lot of difficulties inherent in each of them. Historically, there has been poor oversight from Congress and the Centers for Medicare and Medicaid Services over how the funds for theses programs are spent.
People assume that we, as pediatricians, don’t have to worry about Medicare. But, since most of our private insurance payments are based on Medicare RBRVS with a conversion factor that’s proprietary, a decrease in Medicare means a decrease in our commercial health insurance payments. So it’s vitally important to preserve appropriate reimbursement from Medicare so that our commercial population can reimburse us in appropriate terms.
Medicaid is a federal-state entitlement program that, unlike Medicare, has not had cost-of-living adjustments over many years. Although equal access provisions in federal law mandate that physician payment should be sufficient to ensure access to care as is found in the commercial population beneficiaries, this has never been enforced, and states are free to set their own rates, pretty much without regard to outside factors.
The average Medicaid rates overall are only 60 percent of Medicare. Because reimbursement rates haven’t kept up with the increasing cost of healthcare, the sustainability and viability of primary care practices that look after the Medicaid population are in jeopardy. Access to specialty care, primarily for adults but in some cases for children, is also in peril.
SDP: When did you join SDCMS and why?
Dr. Cohen: I’ve always been involved with organized medicine. In fact, I held prominent positions as a resident and fellow at my institution in Canada. Being involved helped me realize that I did have a say in how things were run and could make significant changes to the problems that I noticed. One of the first things I did when I came to San Diego, aside form getting my medical license and board certifications in order, was to join SDCMS.
SDP: Why do you think doctors should become involved with organized medicine?
Dr. Cohen: It’s very important to be involved for a multiplicity of reasons. We physicians need to take a stake in our own profession and guide its destiny. If we don’t set and take charge of our own standards, if we don’t take charge of how we are treated by third parties, then other institutions will do that for us.
We also need to look after the means of sustainability of our practice. There are a lot of scope-of-practice issues, third-party payors who are monopolizing the insurance industry and trying to increase profits by undervaluing and underpaying for physicians services, issues with access to care in our country for people that are uninsured or underinsured, and increasing governmental and quasi-governmental regulatory issues. If we don’t have a say on how these things are developed and regulated, we will not be able to maintain the viable and sustainable profession as we know it today.
So we need to be involved, we need to have our voices heard, we need to be part of a fair and active process that includes the public (our patients), the government (as our regulators and overseers), and ourselves working together to make sure we serve the public in the noble way in which we first entered into our profession.
SDP: What do you want to accomplish as president of SDCMS?
Dr. Cohen: Well, first and foremost, I want to maintain the momentum that started in the last few years with the leadership of Drs. Hertzka, Hay, Young, Mazer, and Ray, who have really established us as the strongest county medical society in all of California. I feel a strong sense of obligation to carry on in their tradition in keeping our medical society active and viable.
We have a very strong mission and a number of local projects, and I want to make sure the leadership on the bench coming forward is in tune with what we’re doing with regard to access to care. I would also like to partner with the SDCMS Foundation, County Medical Services (CMS), and the Hospital Association of San Diego and Imperial Counties (HASDIC) to discuss and implement projects that will aid in access to care in our county. I want to look incrementally at what we can do, and use SDCMS resources to make more physicians aware of and involved in the different opportunities to help locally and countywide with providing medical services to needy uninsured and underinsured patients.
Second, I would like to use San Diego Physician magazine, and other SDCMS communication vehicles to highlight ongoing volunteerism that many of our members engage in within the local, regional, national, and international communities.
SDP: What thoughts would you like to leave us with?
Dr. Cohen: It’s been an honor to be chosen and approved by my peers to have the bully pulpit as SDCMS president for 2008–09. I’m going to do the best I can to honor the position and my peers, and I look forward to a challenging year.