Thursday, July 16, 2009

The battle for physicians' hearts and minds (part two)

The natural tendency for most people, is to put off a difficult choice as long as possible. So instead of taking definitive positions on controversial issues, we sit on the fence.

Before too long, though, fence-sitting can be pretty darn uncomfortable. When the fence separates two warring parties, getting off requires that we make a decision on which side to join. Staying on the fence, though, guarantees that we'll get caught in the crossfire.

Release of the House's health care reform bill is forcing physicians to get off the fence. They are deciding if they want to be on the side that wants President Obama and Congress to succeed in getting health care reform enacted this year. Or, to join forces with those who want to stop them.

(Opponents of the current bills will say that they aren't against health care reform, just against how the Democratic majority and President Obama plan to go about it. Fair enough. But as a practical matter, the opponents don't have the votes to pass their alternatives - whether it is small government, market-based reform from the right, or a single payer system from the left. So if they are successful in getting Congress to defeat health care reform for this year, they likely will have killed health care reform for the remainder of Obama's presidency. Which, I suspect, is what most of the opponents really want, when all is said and done.)

Choosing sides is particularly hard when you represent a diverse membership like ACP's - or the American Medical Association's. We have liberals and conservatives and everything in between. We have generalists and subspecialists, city dwellers and country doctors, red-staters and blue-staters, solo doctors and doctors in mega-group practices. We have the glass-half-empty pessimists and the glass-half-full optimists. We have starry-eyed idealists and rock-ribbed cynics. I hear from them all.

It is also hard when you are a non-partisan organization, like ACP, knowing that any decision you make on supporting a bill that is being championed by one political party (in this case the Democrats) will be opposed by most members of the other political party (in this care, Republicans). We had the reverse a few years ago when ACP took its lumps from Democrats for supporting the Republican-championed Medicare Part D drug bill.

I think it is significant then, that the largest medical organizations in the United States, representing the most diverse memberships, have all decided to be supportive of the House bill. Letters of support have been sent by the American Medical Association, ACP, the American Academy of Family Physicians, American Academy of Pediatrics and the American Osteopathic Association. The American College of Surgeons is also expected to support the bill.

Why did these organizations, which collectively represent the vast majority of physicians in the United States, decide to get off the fence and take a stand in favor of the House bill? One explanation is that we all are suffering from mass insanity, as one commenter said about ACP in response to my post yesterday. If one assumes though that we haven't all lost our collective minds, then I would hope that the critics of our positions would consider our reasons for support, and offer a considered rejoinder if they disagree.

For ACP, the reasons for our support are pretty clear: the bill does much of what we asked Congress to do in terms of coverage, support for the primary care workforce, payment and delivery system reform, based on long-standing policies that have been adopted by this organization. We would support any bill that accomplishes our goals in a way that is consistent with ACP policy, whether championed by Republicans or Democrats, but prefer when they are supported by both. (This, regrettably, is rarely the case these days.) Most importantly, we believe that the status quo is not in the best interests of doctors or patients, and that the risk of staying with the status quo is greater than the risk of change.

This doesn't mean we are fully satisfied with the bill. We will, for instance, continue to seek more meaningful improvements in pay for primary care and push our ideas on how a public plan should operate. But we have to stay at the table if we want to make such improvements, because the game will go with or without us.

Today's questions: Do you think it is possible for large and diverse physician membership organizations, like ACP and AMA, to keep their membership (mostly) together on issues as controversial as health reform? If so, how?


PCP said...

I disagree with the assertion that the game will go with or without us.
That may be true of other parties in these discussions but not Doctors.
One of the people most trusted to guide reform is Doctors, and sadly we have been the most quiet ones at the table. Ironically the least trusted are the Insurers, and they have been the most vocal in this debate.
I feel that, you are right that we are at the point where we have to choose, however, it is the process of getting us to this point that I feel saddened about. Anyone could have seen the issues of paltry improvements in PCP pay, the issue of NP led Medical Homes, the neglect of Tort reform etc. The lack of curbs on DTC advertising, emerging as negatives for organized medicine. We ought to have been firmer in our demands on these issues in exchange for our very influential(and quite possibly decisive)support. Politicians cannot underestimate the influence of doctors en mass, discussing this issue with their patients combined with directed advertisements. If most doctors did this for a week, the impact would be insurmountable. Everyone knows that, for the doubters think back to last summer/fall and the way some republican senators fearing for their seats reversed their decisions on the 10% cut in Medicare fees to Docs.
Some of these are not even fiscal problems, they are constituency ones(like tort reform and the trial lawyers), and sadly it is because we have been so mild mannered in our ways that we have not got a framework for regeneration of Primary Care Generalism. I have long said that the reason for the acceleration in some of the negative trends in our health care system has been the systematic destruction/dismantling of Primary Care Medicine. The value of the General Internist of yesteryear, when carved out into all its constituent parts, will lead to fiscal disaster. No amount of autonomous NPs or other paraprofessionals will change that.
Quite simply we have not been as assertive as we should have been.
As a result of this we lose twice. We lose as a Generalists yes, but we also lose as Americans desirous of a globally competitive health care system.

Leonidas300MD said...

The ACP and the AMA have sold out physicians. I predict MDs will drop out of Medicare in droves as NP and PAs become "equal" to MDs in the governments eyes.

A new organization will arise of the best MDs who will be motivated to provide FFS outside the government plan. Primary care will thrive there but will disappear under the government plan.

ACP , AMA goodbye and goodluck!

BTW , like my previous comment , I do not expect you to publish this . You will not be able to surpress the truth about the duplicity of the ACP by only publishing favorable comments. I dont really care . AMA and ACP are doomed , no one in their right minds will pay dues for this detestable treachery.

Leonidas300MD FACP

Anonymous said...

I agree that as internists we are a diverse group with varied backgrounds. I don't think that is the issue here. The issue is the very survival of Internal Medicine. I agree that it is time for action, and not to sit on the fence. Unless meaningful changes are made to how we practice and how we are reimbursed, alot of internists will be retiring or going out of business. I know many who are just hanging on now. Young physicians will continue to shun primary care given the hours, low pay, threat of malpractic, etc.

It seems that the other parts of the medical system will do fine under the new plan-for profit insurance companies will make even more money while exerting a strangle hold on how we practice and how we are paid. Pharma, medical device manufacturers, hospitals will all do fine. I dont understand how internists will be better off under this new system then we were before.

I agree that we need universal coverage as well as all the laudible goals that Bob Doherty talks about. I just don't think that internists should be the ones to insure that everone else is taken care of first.

It is time for organized medicine to say NO, just once, until previously made promises are realized. Our jobs can't be outsourced to another country or eliminated-the system doesn't function very well without us. Why are we so eager to capitulate once again? We all need is to say NO, and demand our leaders say NO until we get a reasonable deal!!! I am having a hard trying to figure out who our leaders are representing, but I know it is not me.

Internal Medicine is at a crossroads, the question is do we go quietly into the night and disappear, or do we demand better?

Unknown said...

No. The house bill as presently formulated is a disaster, and if supported by ACP then I can no longer in good conscious support this organization. The fundamental cause of severe misallocation of health care resources presently is that there is too little accountability by both patients and providers for the health care decisions being made (inappropriate antibiotics, needless surgery, tens of thousands of dollars spent on patients in the last few months of life resulting in nothing but increased suffering, etc). The house bill basically funds "improved" access to the present dysfunctional, out of control system for 98% of the population by placing a surcharge or increased tax on 2% of the population. This is SPECTACULARLY bad public policy. It does nothing to improve health care quality, nothing to address overutilization, nothing to improve accountability or personal responsibility, and adds millions of patients to a system in which a majority of physicians are doing everything they can to limit or completely avoid taking care of medicare patients as it is. I agree completely that we need health care reform. But adding more patients to the current dysfunctional, expensive system delivering subpar results is a serious public policy error. If ACP as an organization cannot see this then I will reluctantly resign my membership.

JimS said...

You said it better than I. If we as physicians take only an oppositional view, we will not have a voice in the coming health care reform and I applaud the ACP stance and involvement in the debate. I am a general internist in Longview, Texas and am witnessing the collapse of primary care in rural areas of East Texas and the severe strain uninsured individuals put on our hospitals, and the lack of necessary preventive care they are able to get in our area. I agree with the House bill and the ACP on this issue. I am part of a 100+ provider group and we are in the process of implementing EMR across our clinic and I understand the necessity of helping physicians who have made this step.
James W Sawyer MD FACP

Dantes said...
This comment has been removed by a blog administrator.
Steve Lucas said...

I feel it is important to remember the very real and negative way in which physicians view the practice of medicine in today's environment as highlighted by Roy Posses in this Health Care Renewal post: Thursday, July 09, 2009 A Window on the Unworkable Settings in Which Physicians Practice

Even as a non-physician the numbers are shattering, but reflective of the physicians I see professionally and socially. Further, if action is not taken, then we can expect the practice of primary care to only decline.

Steve Lucas

rashid baghai said...

liability reform must be part of health reform .we do not need that much intervention by lawyers to treat our patients in primary care setting.I do not see anybody talking about it.

Unknown said...

Jims -- good luck with the EMR. Before we had one, I was able to do direct patient care 90% of the time. Now, I see my patients 60% of the time, 20% of my time is served as a clerk typist, and 20% as a medical records technician. Walk into a nurses station, please -- where are the nurses? At the keyboard, not the bedside. EMR is not a panacea.

JimS said...

Your point is well taken. The EMR is a valuable tool for large practices at different sites so that MD can communicate efficiently with each other. But HIT is not an end by itself which I think is what is portrayed in the press and that nationwide implementation will solve our healthcare issues. Like a stethoscope, it is only as good a tool as the user makes it.