Tuesday, July 28, 2009

While Doctors Slept

All Americans want health-care reform. Moreover, as the President and others have said, there is a mandate for such reform. However, there is no mandate to get it wrong.

Where is the physician leadership in this health-care debate? Why aren’t the physician members of Congress leading this discussion? Physicians must be positive forces in driving this health-care discussion.

The physician leadership in the United States, I will use the American Medical Association (AMA) as a point of reference, has completely rolled over in this health-care debate. Rather than taking a firm stand in support of the quality of health-care and drawing a line in the sand, leadership has accepted relatively insignificant scraps from the discussion table. The reasons for this I think are twofold. First, there is a fear that too strong a stand by physicians will appear self-serving with resultant backlash of opinion against physicians. This fear is unfounded. If we physicians argue poignantly and firmly about the quality service we continue to provide and the concerns that we have about the negative impact the present health-care reform bill will have on patient care, our point of view will be critical component of the health care reform debate. Our fiduciary responsibilities to our patients include not only practicing good medicine but also, and very importantly, publicly taking a stand ensuring the continued existence of quality health-care. And secondly, there is a sense as in years past that little will change and it is pointless to get all bothered up. This view is wholly incorrect and to ignore the winds of change will be detrimental to Americans.

In the prelude to Presidential Obama’s lecture to the AMA, AMA’s Board of Trustee member Dr. Nancy H. Nielson pointed out four areas on which physicians (read AMA) and the administration agree. Three are rather straightforward and would be considered low-hanging fruit: (1) Support for electronic medical records – the idea here is that medical records could be easily transferred between doctors and hospitals. Every hospital administrator and physician would agree this is a most worthy goal. One issue that hasn't been resolved is getting all the competing software products to intercommunicate. Are we to only have a single product? And why would the AMA wait for government guidance on this? The AMA ought to take the leadership role in this otherwise we may very well be forced to accept a product none of us want (such as DOD’s AHLTA system). (2) Comparative effectiveness research to enhance quality medical care. We already have this: these are called clinical trials and are routinely published on completion. Moreover, each medical specialty and subspecialty already has established rigorous (generally) guidelines published for all physicians and patients to review. We surely don't need to waste money on a government agency or another study by the Institute of Medicine to determine how physicians should practice. (3) An agreement between the AMA and the administration on medical liability (physician malpractice). Really? What auditory filter does the AMA leadership have? The President has clearly stated that he has no desire for tort reform. The fourth area involves Medicare reimbursement. Dr. Nielson indicated there is an agreement to use realistic numbers, i.e. dollars, in determining the true cost of treating Medicare patients and charting a new course to replace Medicare physician payments. Don't you believe it. This is lip service to physician concerns and a political ploy to get physicians on board – the Administration is already touting this achievement. The AMA is being taken for a ride – this is no less than the story of the gingerbread man.

In President Obama's address to the AMA, it is clear he and his administration understand neither physicians nor the practice of medicine. He discusses the needed change from quantity to quality of medicine. All the physicians I know practice quality medicine already and I know of none that practice “defensive medicine” or get extra tests. Physicians don’t benefit from ordering MRI or PET scans. He also addressed the newly popular concept of bundling reimbursement for a particular disease. For example, a patient with diabetes is admitted to the hospital for diabetic complications. With the bundling idea, rather than each physician and the hospital being paid individually for their services, a fixed lump sum will be submitted for the patient’s medical care. This will pit physicians and hospital against each other and make it easier for the government to reduce reimbursements; none of this is good for patient care. The President indicates there will not be an increased burden on the national budget. How so? He will borrow from Peter (Medicare) to pay Paul (public option); this can only hurt those on Medicare. The president demonstrated a paternalistic view toward physicians, at one point essentially instructing physicians not to worry about the business side; just leave it up to the government. [So lawyers who want to practice law shouldn’t be concerned about the business side of their law practice? Give me a break.] Whether in private practice or academic medicine, physicians are by now used to the business aspects of medicine – good medicine is good business. But a far more bothersome comment was when he had the temerity to instruct physicians on our motive for entering medicine. Wow! Tell that to any other professional organization. The AMA leadership ignored this (or maybe they looked to it as a form of penance).

The proposed public option will negatively impact health care in the United States, not immediately but definitely in the long-term. There are many reasons Americans must not support the public option:
1) There already exists two government programs (Medicare and TRICARE) with major unresolved issues. Why would we want a third such program? REP Joe Courtney (D-CT) has publicly stated that Medicare is efficient and therefore a model for the public option. If Medicare is so efficient, explain the more than $1 billion in fraudulent claims in the past few years.
2) Patients already receiving Medicare will have less choice in selecting a physician. This is a result of decreasing Medicare reimbursement to pay for the public option. More physicians in small private practices close to the patient’s home will see fewer patients with Medicare as their sole source of healthcare insurance. These patients will go to emergency departments for healthcare, travel long distances which many cannot afford, or will forgo medical care altogether.
3) With decreasing Medicare reimbursement to hospitals and imaging centers to pay for the public option, physicians in teaching and research hospitals will not be immune. They will be forced to see more patients in clinic and more patients will be admitted to these hospitals thereby reducing (a) clinical and basic science research, the fuel that propels medicine forward and makes US medicine sine pari, and (b) the time committed to training of the next generation of physicians.
4) More physicians in private practice will be forced to cap the number of Medicare patients the see in clinic, as many already do. As discussed above, this will be a hardship for these patients. Alternatively, the physicians will cram more Medicare patients into the clinic day with shorter visits and an overall reduction in the quality of care.
5) The cost savings to support the public option are to come from taxes (which I will not discuss), reduction in Medicare reimbursements (see above) and something completely new: government oversight of physicians practice habits. SEN Chuck Grassley (R-IA) indicated we could reduce costs by preventing patients from seeing a physician for several days on a daily basis. On numerous occasions I have followed a patient for several days as an outpatient so as to reduce costs by preventing a more expensive hospital admission. Physicians will not accept Federal oversight in their daily medical practice. [We may be willing to accept federal oversight if every other profession in the country would accept such oversight in their daily work: attorneys, plumbers, bakers, scientists, etc].
6) The law of unintended consequences and the myth of keeping your doctor are consequences of three key developments: (a) Premiums for the public option are predicted to be less than those of private insurers; (b) Hospital and physician reimbursements from the public options will not be any better than those of Medicare; (c) It is predicted that over time, individuals and families will convert to the public option. These developments will result in the following: (a) reduction in benefits as the government reigns in growing costs (Medicare and the public option combined); (b) inability of participating Americans to keep their favorite physician as practices cap the number of patients with government insurance; (c) physicians effectively become government employees as larger portions of reimbursements are federally managed and accompanied by mandated oversight; and (d) rationing of healthcare and worsening of a two-tiered healthcare system as experienced by citizens of countries with government run healthcare programs.

A government run public option is actually the easy solution, but also a more dangerous one for the long term health of US healthcare. We run the serious risk of damaging the quality of healthcare in this country. A more creative answer would take far longer to achieve and would require input from and participation of the private sector.

If the administration and supporters are indeed serious about the public option, they will demonstrate their leadership by example. The following amendment to the health-care reform bill is proposed: “For as long as a public option exists, all members of the executive branch and Congress must enroll in the public option and furthermore are not eligible for care at any military treatment facility”. Only in this way will Americans be assured of the feasibility and success of such an enterprise.

It’s worth specifically discussing health-care rationing and treatment delays as serious consequences of the eventuality of a government run program. On a recent news program, Secretary Sebelius has indicated that rationing goes on all the time. Yes and no. Rationing must not be confused with good medicine. A physician’s decision not to order a test or perform a procedure not indicated for a patient’s symptoms or disease is not rationing; rather, it’s just good medicine. There are three types of rationing: natural, self and financial. Natural rationing is a consequence of a limited biologic resource; an example would be limitations in the number of hearts available for heart transplants. Self rationing is when a patient’s clinical situation precludes interventional therapies. For example, an individual with a broken hip and advanced cancer of the pancreas with less than two months to live would not receive a hip replacement. Physicians make these decisions all the time. Financial rationing is the limiting of healthcare because of arbitrary fiscal constraints; e.g. where an indicated treatment (surgery, chemotherapy etc) that will improve survival and/or quality of life is not provided because of arbitrary measures and/or inherent delays. It is this type of rationing that scares Americans.

Why will Americans not accept financial rationing of health-care as mandated by a national run health program? This gets to our national psychology. Americans are of the mindset that anything is possible; after all we established a new nation and became the most productive nation on Earth with much hard work. We are an independent lot and believe the individual can accomplish whatever they set out to achieve. This psychology rolls over to what we expect from our medical care. We want everything reasonable to be done that will prolong survival and the quality of life. Countries that accept government health-care and rationing have a different history; a history of feudalism with largesse handed down at the discretion of a power elite (and little chance for advancement) as well as centuries of death from pestilence/disease/chronic wars with the result that dying before everything possible can be done is, though not acceptable, less unacceptable.

We hear over and over again that the cost of US health-care exceeds that of other countries and with poorer outcomes. This is far too broad a statement because it mixes apples and oranges (as well as and every other fruit). Sure the costs are higher here in the US. A major part of this is the cost of prescription medicines. It is eminently clear that the US is virtually the sole worldwide developer of new drugs that continuously make progress toward cures and improving the quality of life for the rest of world. Other countries don’t have the high costs because many drugs are just not allowed to be given (for example, some anti-cancer agents). It is very hard to think of any new drug development in other countries recently. Why? There is no incentive to develop a new drug if the government run health-care system won’t pay for its clinical use. Essentially, the US healthcare system subsidizes the world’s health-care! With regard to outcomes, let’s look at a cancer treatment example. Individuals with advanced breast cancer have, unfortunately, an incurable disease. Many countries with government run health-care programs limit treatment options. In the US, we give as many chemotherapy regimens as possible to prolong the patient’s life for years while maintaining the quality of that life. Sure the eventual outcome is the same, but the timing is different. I want to give that 38 year old mother of three with advanced breast cancer more time with her family.

Some (policymakers and non-practicing physicians) have argued that the US doesn’t have the best medical care in the world. Then why is it that people come from all over the world seek medical here? Conversely, why do Americans not seek health-care outside the US?

Physicians in the trenches taking care of patients have not been heard from. What we have are opinions of policymakers and talking heads who know little to nothing of the practice of medicine. Health-care professionals must speak up because this is not the time to hold back, our patients depend on us. We all know the potentialities when a driver falls asleep at the wheel.

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