Reprinted From The Hill; September 29, 2010

http://thehill.com/blogs/congress-blog/healthcare/121575-medicine-at-a-crossroads

Medicine at a Cross Roads

By

Larry N. Smith, M.D., F.A.C.S.

The battle-lines have formed and skirmishes are breaking out as doctors across the nation, particularly in Florida, struggle to regain relevance in today’s healthcare environment. Prior to passage of President Obama’s massive healthcare system overhaul, polls across America revealed that a large majority of non-medical voters and an even larger majority of doctors disapproved of the extent of the proposed legislation. Disregarding the majority’s wants, Congress passed and the President signed into law the Patient Protection and Affordable Care Act. The bill was supported, but not totally endorsed, by the American Medical Association (AMA). This support has created tension between the Florida Medical Association (FMA) and the AMA.

The AMA found itself in a difficult position at the start of the reform debate. It had fought and won many political battles to prevent partial or complete national healthcare models from being instituted. From President Franklin Roosevelt on, the AMA had been able to negotiate effectively for its membership while still maintaining its core mission of improving healthcare for Americans. During this most recent debate, the AMA found itself in a disadvantaged position. Having seen a sister medical organization completely excluded from the negotiations for taking a hard stand against this reform package, the AMA leadership realized that it had to be “at the table.” The leadership worked towards meaningful input into the legislation despite the competitive, complicated, and multi-interested nature of the negotiations.

 The AMA’s participation allowed it to negotiate against an experienced group of reform advocates including Rahm Emanuel and Nancy-Ann Min DeParle — both Clinton-era healthcare veterans. In addition, both houses of Congress were in the grips of reform-minded Democrats with little sympathy for doctors. As news of each major reform was released, doctors and state medical societies vociferously resisted the changes. The laws would forever alter the practice and even content of medicine. It was then that AMA membership levels began dropping, and doctors’ outcries of no confidence began.

Many doctors believe that the AMA was giving up doctors’ rights to independent medical practice for cosmetic gains. Doctors were banned from owning hospitals or other healthcare facilities, which is exactly what they had historically done: the Mayo Clinic, the Cleveland Clinic and the Ochsner Clinic are three prime examples. In addition, doctors were being forced into “Accountable Healthcare Organizations,” meaning they would become paid employees. The SGR formula was not fixed, so doctors still face a substantial 21 to 35 percent fee reduction in the next several months. More cuts will follow in order to meet budget projections, as noted on page fourteen of the Congressional Budget Office report to Speaker Nancy Pelosi. Even though the AMA was successful in preventing the newly established Comparative Effectiveness Committee’s findings from being used to dictate practice decisions, deny treatments, or set payments, the committee still establishes the effectiveness of treatments. It is hard to imagine that this data will not be drawn upon to make policy.

From within this assault on medicine, dissatisfaction with the AMA’s ability to represent Florida physicians grew, and the Florida Medical Association met to discuss the AMA’s actions. The odium towards the AMA was only inflamed when the leadership gave support to Obama’s pick to lead CMS — Dr. Donald Berwick. His beliefs about redistribution, socialist healthcare delivery systems, and healthcare rationing are well documented. During the FMA’s Orlando meeting, Jeff Goldsmith, a PhD from the University of Virginia and a recognized expert on healthcare legislation, validated every fear that organized medicine had about the bill. Medicine in the future will be delivered by large multi-specialty hospitals, with capitated coverage and risk-sharing systems; doctors will be employed by these systems, many in shift work. This change has already started, as noted by a survey taken at a FMA meeting revealing only 30 percent of doctors are still in solo private practice. Private medical and academic practitioners are concerned about their future as independent professionals.

At the meeting, civil and sometimes stinging arguments for and against secession from the AMA were debated. Ultimately in a 52% to 48% vote, the decision to put the AMA on notice and remain a collective body passed. The members of Congress have long recognized the AMA as the single most important voice for medicine, invariably asking the AMA’s position on any issue. The FMA and the 49 other state medical societies know that without a single voice the opposition to the free practice of medicine will be empowered. The AMA tried and succeeded in this round of reform to preserve some sanctity to the doctor-patient relationship by keeping the government from coming completely between it, but future changes could still undo this relationship. Granted there are marked regional variations in doctors’ vision of healthcare reform. Understanding this, the FMA House of Delegates came to the right decision to sanction but not secede from the AMA. Without a single respected and experienced voice at future negotiations, no administration is going to listen to the blather of dozens of separate organizations. The AMA accomplished much in this reform battle but the war is not over, since so many believe only a single-payer national healthcare system is the answer. If for nothing but the sake of America’s constitutional liberties and the freedom to practice as one chooses, this must be prevented and it is the voice of the AMA that will lead that fight. But it has been placed on notice and may find itself alone if it continues to lose the big battles in this war.

Dr. Smith is a historical novelist and has written extensively on medical economics. He is an adjunct faculty member at Santa Fe College, a Fellow in the American College of Surgeons, and delegate to the FMA House of Delegates

www.darwinswar.com

Other Voices

Views From Beyond the Barron’s staff by Larry Smith, MD

Health Care Over There Needs U.S.-Style Fix

Privatization

stalks the

British

National

Health Service

Creating the British National Health Service (NHS) opened the door to health care for many who could not afford it, even though a great war had just drained Britain’s national resources and treasury. Now that Britain is a much wealthier country than it was in 1948, many new health-care issues are abroad in the land. A big concern is patients’ lack of choice. Others include hospital overcrowding, worsening budget overruns and the rise of resistant staph infections in hospitals. In addition, some British officials are trying to address another problem: They believe the system has an excess of doctors. A forth-coming reorganization of the NHS may reduce opportunities for new graduates. Yet there are problems with the timeliness of patient appointments, dissatisfaction with the hospital care provided in open wards and a rising awareness that poorer areas of the country have relatively few doctors. So the NHS is offering incentives to general practitioners to work in these poorer areas, and is experimenting with a private-public model of competition.

All this is stuff of Fleet Street sensationalism. In at least one newspaper’s interpretation, the Labour government has strayed so far from its socialist roots that it’s been accused of stealthy privatization of the very system the party put in place in 1948. What if Britain turned its medical system over to the health-care organizations that could manage budgets of hundreds of millions of pounds, such as the HMOs United Healthcare, Kaiser Permanente or Blue Cross and Blue Shield? Would that be so bad? Private ownership can bring efficiency and accountability to health care by changing it from a bureaucracy to an industry-and to an efficient marketplace. While health-maintenance organizations’ administrative costs aren’t small, what these private companies do well is control of utilization, and verification of benefits.

Currently, patients have no point-of-service charge for their National Health Service; the real cost is hidden in the tax system and in general practitioners strictly per capita payments (they get the same amount for each patient on their rolls). This is a system that encourages high utilization by patients, while discouraging productivity from the providers. The bandied figure of 40,000 doctors in general practice-serving the United Kingdom’s population of more than 60 million-misses the fact that some doctors work part-time, or less. The Royal College of General Practitioners estimates that there are actually 35,000 full-time-equivalent physicians. With privatization, this number may actually be adequate: Doctors with incentives to work harder produce more. The NHS recently has allowed general practitioners to receive extra payments above the capitation rate (the rate at which a GP is paid per patient) if the GP meets certain targets for health improvement among their patients. In fact, it turns out that many GPs have met their targets or enhanced their services so well that there’ve been adverse consequences for the NHS budget.

The NHS would benefit greatly from competition. Giving patients a choice of health-care providers, allowing competition among providers, instituting quality oversight by private accrediting agencies and having more than one such agency will allow for creation of a competitive marketplace that will better serve patients. Currently, 200 British doctors practice in a completely private setting, receiving all their income from outside the National Health Service. That leaves the remaining 34,800 fulltime-equivalent GPs in Britain receiving at least part of their income from the NHS. If a patient has both NHS coverage and a private-insurance plan from an employer, he probably will use the “free” NHS for routine non-urgent needs. But, as one patient confessed: “If I’m really sick, I just go straight to the private doctors, so I can get taken care of quickly and have a private room.”

It’s not clear how many private MDs the market would bear in Britain, but this sort of cherry-picking illustrates the need to change the NHS to a near-total private system. There will still be a social safety net for the truly needy, but those who can provide for themselves should do so. The private health-care industry in the U.S. grew out of private health-care delivery systems designed, run and administered by doctors, not governments. Private health plans are products of the freedom historically afforded to American health-care providers (today, some U.S. doctors might argue, HMOs “bureaucratize” them too much, but HMOs are learning their lessons and consulting with doctors more). U.K. medical providers need the freedom to build a British version of the U.S. health system.

As Benjamin Rush, an English-trained physician, American revolutionary and signer of the Declaration of Independence wrote: “Unless we put medical freedom into the Constitution, the time will come when medicine will organize into an undercover dictatorship and force people who wish doctors and treatment of their own choice to submit to only what the dictating outfit offers.”

Britain should free her physicians, nurses, midwives and other health-care providers so they can practice independently. If British medical professionals had more opportunity to work for themselves, they could make Britain, now saddled with an antiquated system, a destination for state-of the art European health care. For competition, accountability and incentives encourage excellence.

Copyright Dow Jones & Company Inc.

Tim Foley for Barron’s