Tuesday, March 2, 2010

Should physician anger be directed at denying care to patients?

Congress' failure so far to prevent a Medicare physician payment cut has generated a great deal of anger among physicians. The American Medical Association declares that physicians are "outraged." Alicia Ault blogs that "Doctors are Mad as Hell," citing my post from Friday and its reference to Howard Beale's "I'm mad as hell" rant from 1976"s "Network" movie. Ault also links to a post from the Happy Hospitalist who blogs that "It's time to screw granny and let the government find a way to provide their care for them."

How have we come to the point where a physician would advocate that the medical profession turn away from taking care of elderly patients? Even allowing for the hyperbole that is commonly accepted in the blogosphere, is it right for physicians to allow their righteous indignation at the government's failings to stop a Medicare pay cut (well deserved on this score) descend into threats to deny care to Grandma and Grandpa?

It is one thing to say that continued Medicare pay cuts will force many physicians to limit how many Medicare patients they can see (which I believe to be true), but a very different matter for physicians to advocate that physicians deny care to patients to make a political point. Instead of gaining the support of the public, I believe that the medical profession will lose public support if it seems to be elevating economic self-interest above patient care.

This is that point that "Harrison" made in response to my Friday post: He wrote: "We have to continue to be careful about advocacy. The US economy is precarious. Our patients are increasingly unemployed. It is right for us to advocate for our patients. It is right for us to point out that a 21% cut will lead to an impact on thousands of small businesses and to our employees. But if we start to say that we are going to stop seeing Medicare patients because we are going to get paid $80 per 99214 instead of $100 for a 99214 visit, well ... I don't think that is going to go over so well." Others disagreed.

Last week, an ACP member wrote to me and urged that we organize a "strike" against Medicare patients if the 21% cut goes through, saying he would be "very disappointed" if we did not. I'm not a lawyer, but I know that there are legal reasons why a physician membership organization can't advocate for collective actions by individual members to achieve economic gains for them. But there are ethical reasons as well.

ACP's Ethics, Professionalism and Human Rights Committee published a case study that draws the line between acceptable political advocacy and actions with the intent of denying care to patients to achieve a political purpose. The case study notes that ACP's Ethics Manual, which represents approved ACP policy, states that "... physician efforts to advocate for system change should not include participation in joint actions that adversely affect access to health care or that result in anticompetitive behavior. Physicians should not engage in ... organized actions that are designed implicitly or explicitly to limit or deny services to patients that would otherwise be available." Similarly, in addressing collective actions, the AMA specifically states that "physicians should refrain from strikes because they reduce or delay access to necessary care and interfere with continuity of care, all of which are contrary to professionalism and the physician's ethical obligations."

As I wrote last week, physicians should let their legislators know the continued Medicare pay cuts are unacceptable. They can inform them that they may not be able to afford to continue to see Medicare patients if the cuts continue. But the understandable outrage at government inaction should not turn into calls to organize boycotts or strikes against patients. "Organized actions that are designed implicitly or explicitly to limit or deny services to patients" not only would be bad politics, but according to the ACP and AMA, unethical to boot.

Today's question: Do you think physicians should deny care to their own Medicare patients as means to express their anger at the government?


Harrison said...

We are caught in a political debate. It is not about us. Senator Bunning is upset with his own party.
We are potentially upset about many things.
Some of us are intensely upset with Medicare and with the fact that our fees are price controlled.
Some are upset that the health insurance system creates impediments to care and to our rapport with our patients.
Some are upset that tort reform has not been addressed at a federal level for years and years.
And some are upset that so many of our patients are poorly covered or not covered at all, and we are expected to care for them at a loss too often.

We do not have the best health care system in the world.
Nobody knows that better than our patients.

Should physician anger be directed at efforts to deny care to patients?
Of course not.

Did our patients put Senator Bunning in the powerful position he holds?
They are suffering from his actions too.
He is holding up an extension of COBRA and an extension of unemployment benefits.

Sen Bunning is already hurting our patients.
We don't have to help him.

We are right to be angry.
We are US citizens and we are watching as the most important legislative body we have is being choked by its own broken processes.
A 59% majority should be a landslide. It should give the party in power a mandate.
Instead, it has worked to solidify the opposition so that they do not have to make deals individually and the minority party has assumed control simply by voting as a solid block and saying no.

Senator Bunning is acting on his own.
But he is following in the footsteps of his party.
Behind the scenes he is probably holding out for a deal. A concession.
He may or may not get what he wants if anyone can figure it out.

But our anger should be directed at his office and at this broken process in the U.S. Senate.

Our patients are blameless.


PCP said...

We for damn certain need to do a better job of educating the public about this travesty being foisted upon them by their elected representatives. As to whether part of that is to put curbs on the numbers of Medicare patients seen, well that is up to each individual physician I would think. When each and every time it is my ethics and high moral standing that the Congress counts on to balance the ignorance of their spending policies, this will eventually only end up one way. Our nation is not getting younger, our middle class is not getting richer, our special interests are not getting any quieter, and our politicians are not getting any less corruptible. The only conclusion to be drawn from this therefore is that the current trajectory is set to continue.
The Hospitalist movement is atleast in part borne out of the miserable/intolerable work environment created by Gov't policy against primary care medicine in the past decade. When I interact with my Hospitalist colleagues, many of whom are younger than I am, it seems their choice to do that is less of a proactive decision as much as it is a reactive one to the miserable work environment scenario perceived in the traditional model, one of increasingly detached short term relationships with patients, decreased practice autonomy, increased bureaucracy, declining rewards, increasing hours and the rest of it which is generally well chronicled.
Sadly this fracture in the Doctor patient relationship has left Doctors more upset with patients and vice versa. The results of which are not going to be pretty neither for patients nor for the profession.
The real anger and ire ought to be directed at the allocators of resources. When patients pay roughly double in premiums today than they do in 2001, and Doctors reimbursements are lower in real as well as inflation adjusted terms. There is a legitimate point about cost inflation. There are a lot of places 2.4 trillion dollars are going. Some of it is going to more legitimate, tangible value adding goods and services than others. If the solution to this is to cut more where there is value then, I am afraid we are not going to go anywhere good with this. We as a nation ought t be able to answer hard questions. Looking at insurance overhead, I find it reprehensible that there needs to be any discussion about whether 15% of premium dollars as administrative overhead/profit is adequate. We ought to just move on to the next topic. Likewise, drug price negotiations with Big Pharma. When Medicare does it to Physicians, why the double standard? Or is it the lobbying power?
Likewise the Home health fiasco, the Hospital oligopolies, the DME suppliers, the PBM etc etc. The list is so long that it is exhausting.
My view is simple. Doctors have given about as much as we are willing to give. We may yet give more if/when our nations situation warrants it. However before we can even get to that point in the discussions, we have a lot more fat that needs cutting in the rest of the 2.4 trillion dollars. Lets have a discussion about what value we each bring to the table. While we are at it, lets include the RBRVU system in that discussion as well.
So, as our leaders always do, they will appeal to our responsibility gene, now that is in conflict with another gene, our survival gene.

The Happy Hospitalist said...

By your reasoning physicians who choose nit to accept Medicare should be demonized. Physicians who choose to stop accepting Medicare patients and to excuse all Medicare patients from their practice are not abandoning anyone. They are stating, as clear as day, that the governament hS failed the patients. Any patient who wishes to pay cash for a physician's service has every right to do so. A government that places physicians into a position of having to choose between remaining solvent and remaining availabe is a government that had failed it's people. It's time to stop deamonizing physicians from making necessary business decisions that sacrifice Medicare patients to prevent from going bankrupt. I'm disappointed you chose to blame physicians for doing what they must do, even at the risk of patients losing access. It's not the physicians fault nor the patient's fault. It's the government's fault. And the longer physicians play their role as the sacrificial lamb, the longer the government inaction will continue.

One question. At what economic point would you consider it acceptable for doctors to drop Medicare? Many diva have determined that point is now. I wrote a post several years back that extrapolated current SGR cuts into the future. I calculated that a primary car doc would earn $6.60 an hour. That's less than a burger flipper at Burger King. Would you consider it OK for a doctor to exit Medicare under these circumstances.

Arvind said...

Dear Bob: I am surprised to see you ranting against the idea of collective action, since you and your leftist friends seem to support such actions by your friends in the trade unions!

Now, let me try to unmask the hypocrisy of your current post. First, those of us that have decided not accept any new Medicare patients, have not abandoned our patients. We simply say that we cannot provide service at Medicare rates. People can still see us - I have even offered to see them for free, but I not on my office time (when I have to pay my staff, etc.). Or they can pay for my service at a reasonable rate just like they pay for their electricity or gas. So by linking access to not accepting Medicare, you are making a very big mistake.

Second, we have written, emailed, called our Senators and Congressmen about the same nonsense (SGR) since 2002; just like our beloved organizations like the ACP has asked us to do. All we have gotten in return is a 0.5 % increase since 2002. The AMA and the ACP would like to project this as a great victory.

Third, I don't believe we as physicians are expressing anger by refusing to accept Medicare rates. We are making a point that we will cease to exist as viable practices if we continue to accept these payments as fair reimbursement. Even if I took home no profit (i.e. pay) and saw only Medicare patients in my practice, I would still go bankrupt in a year. Of course my family would divorce me and look for another source of income! So this is a last gasp effort to save our profession, dear Bob, not anger. Now, if I have to explain this basic concept to you, I think you should be looking for another job, because I have very serious reservations in your ability and willingness to represent my professional interests to the government.

Fourth, and most critical point, is that the AMA does not represent me, and I have never signed on to any document that obliges me to worry about their "code of ethics". Sometimes I feel the same way about the ACP. But for the AMA to talk about ethics is worse than a mass-murderer preaching morality. So, please do not bring this topic for discussion again Bob.

Finally, it is time for the public (including Medicare recipients) to learn and experience what government-run health care really looks like, and for them to understand what the future potentially holds for them. It is time for us to stand up and hold a mirror in their faces and ask them to reflect. If they don't like what they see, they should not blame the person holding the mirror. Just like the MJ song...man in the mirror...

JimS said...

I agree with you completely that physicians should not refuse care to Medicare patients they have seen for years. However, many physicians are unable to accept any new Medicare patients. I am in a more rural area and the cuts in reimbursement in conjunction with rising costs mean that Medicare reimbursement will barely cover the cost of a visit, which is why so many rural practitioners whose practices are funded by Medicare, Medicaid and charity care have closed their offices. We must remember that our patients deserve nothing less than our commitment to their best interests, regardless of political/governmental actions. That being said, I do not think it is in my patients best interest to have a payment system that causes the collapse of primary care and especially primary care internal medicine.

Robert J. Sobel, M.D. said...

Of course not. We have always done our best to behave distinct from typical businesses. The nature of the patient-physician relationship is hardly defined by the financial realm only.

What will have to happen, short of anger, is considered decision making by independent physicians on how to go forward. Participation in insurance companies, public or private, that deny fair payment will be less tenable. Careful transitions will be weathered.

Unfortunately, the immersion of managed care principles into the psyche of modern medicine will continue to hasten hegemony. Participation in all these accountability entities will dilute effort, thereby obviating its original intention to improve quality.

The absence of price reform of new pharmaceuticals and technologies will doom any reform effort. Neither private nor public can control costs otherwise. Physicians, especially primary care, can be the friend of the bean counter and the enemy of profiteering. Prorate the cost of the new and don't squeeze any further the reimbursement of independent, outpatient practices.

Rich Neubauer MD said...

My simple answer to your question: "should (physicians) deny care to their own Medicare patients as means to express their anger at the government?" is "NO".

There is a much more complex dynamic at work however, and it is nefarious and multifactorial. First, there is the mass exodus from primary care. If the 21% cut holds, this will become a stampede since such cuts selectively hurt non-procedural physicians. Second, passive aggressive moves of this sort by government erode trust in ways that outlast their actual impact. Some physicians will say "never again" to Medicare, opt out, etc. Some who are hanging on for dear life will just retire and say the heck with it. Those who crave that government take on comprehensive planning and evaluation of workforce can only be bitterly disappointed. In a era where we are discussing something at least resembling comprehensive reform, we end up instead with the equivalent of an obscene gesture from the congress.

I've heard some welcome a real meltdown of the system, such as would be brought on by survival of the 21% SGR cut. Their point is that only a full blown crisis will lead to reform. But the tragedy that would be wrought in such a scenario is a horrible price to pay.

ACP has fought the good fight regarding the SGR for many years. We need to keep it up and advocate for the benefit of the patients and the public at large that we serve.

Steve Lucas said...

I would hope doctors would not deny care to existing patients due to the proposed Medicare cuts. The other reality is everyone knows the cuts will not be enacted and legislation to backdate funding has already been introduced.

What this points out is a bigger problem. Last week I caught a small portion of a CNN interview with six retiring Congressmen. I liked these guys. They made a couple of very good points.

One: The discussion is being driven by the extremes of both parties. The result is the level of partisan politics is stopping the system from working.

Two: Both parties are not dealing with the financial realities of their proposed legislation. Democrats, at the extreme, want a socialist system and they feel all they need to do is tax the rich. Republicans, at the extreme, want programs and no taxes at all.

The reality is there are not enough “rich” to pay for everything, and it does take a certain amount of money to run government.

My reality is that we have enough money in the system to cover health care; the problem is distribution and asset allocation. We cannot continue the Cadillac care we receive, cover all of the population, and not expect rising cost.

I am good at rhetoric and puffery, I am a businessman. I would hope doctors would take a more realistic view of the issues at hand and propose solutions that result in real fixes to the medical system, not solutions that only result in financial gain for a select few.

Steve Lucas

BDoherty said...

I expected my post from yesterday to result in a spirited debate—but I don’t think the discussion is well served when a comment crosses into personal attacks. Yesterday’s post reflects and cites the policies and codes of ethics developed by the ACP members on our Ethics, Professionalism and Human Rights Committee, with input by the elected Board of Governors and ACP council members, and approved by our elected Board of Regents. If any ACP member disagrees with policies adopted by the organization, fine—I have always encouraged spirited discussion and respect a diversity of opinion, and I would never attack the qualifications, sincerity, or motivations of those of you who post comments. I believe all of you are devoted to the best interests of patients. The same is true of ACP, and the staff who do our best to represent the diverse views of interests, myself included.

On substance, the critics miss the point. I was not suggesting that it is inappropriate for ACP members to make a decision that they no longer can see Medicare patients. In fact, I called upon them to make this point clearly with Congress. But collective action to organize a boycott or strike that has the explicit or implicit intent of denying care to patients has been determined by the ACP, AMA, and others to be inconsistent with physicians’ professional and ethical obligations to patients. This distinction is an important one, as the ethics case study shows, and one that our members need to be aware of.

Rich Neubauer MD said...

You are right to emphasize the work of the Ethics, Professionalism and Human Rights Committee of the ACP and the carefully laid policy groundwork of the college governance. When emotions run high, it is extremely important to take a deep breath and consider basic principles.

A question I've heard asked more than once in recent years from prospective members is: why should I be a member of ACP? I believe you've laid out one strong reason in this discussion: because ACP is a guiding light in difficult times - a beacon of professionalism.

The Happy Hospitalist said...

Do you consider concierge physicians who accept no insurance to be unethical? If so I disagree with your core principles and values. If you do believe that concierge doctors are unethical, then you are making a senseless distinction between patients losing insurance access and patients never having insurance access. The end point is the same. Physicians who decide not to accept insurance will cause patients to lose insurance access, whether they had it to begin with or lost it after the fact.

That's a problem with the insurance contracts being offered to physicians by government. That's not a problem for physicians to fix. The patient is the collateral damage of an inactive government, not an inactive physician.

Jay Larson MD said...

To deny care to established patients to make a political statement is not ethical. With that said, it should be a physician’s choice to determine the best way they can practice medicine with their patients. Every physician has a different practice circumstance.

Concierge medicine is a way to avoid the intrusion of insurance companies into the patient-physician relationship. By improving the time and quality of patient interactions, better treatment decisions can be made. It is not the fault of physicians that the health care insurance companies have become so invasive into the patient-physician relationship that physicians must seek a different style of practice to improve professional and patient satisfaction.

If Medicare reimbursement rates drop (or stay flat for that matter), there comes a point in which the physician just can’t run that fast and they may have to consider reducing the number of Medicare patients they can manage to stay in practice. That is the simple reality. It is not a political statement.

The statement that politicians are making to senior citizens is concerning. It is as if to say “You may have been the Greatest Generation, but now you are the Disposable Generation”. If Medicare reimbursement rates are decreased, Medicare patients will have increased outpatient medical care access issues. The access issues will arise from lack of physician participation in Medicare. For physicians bordering on the fence to participate in Medicare, a 21% reimbursement drop will be an easy push to non-participation.

In regards to Senator Bunning blocking the SGR fix, I really don’t know what he is thinking. It is almost like watching someone in Yellowstone Park walk up to a bison to pet it.

Arvind said...

Bob, in my earlier comment, I did not mean you per se, but the position you hold, as the legal representative of the ACP, of which I am a dues-paying member and Fellow. If I cannot be assured that my representative is conveying my message to the Congress, but rather undermining my position via-a-vis my patients, I must object to it,even if it mean sounding rash. I certainly did not mean it on a personal level. For those who do not fully understand that the medical profession is on the verge of extinction if current "reforms" are actually enacted, this is a call to decide how they would like to react. The government has already destroyed the physician-patient relationship, eviscerated the clinical independence of the physician, degraded the profession by making us "providers", decided that we are all frauds unless proven otherwise and now will complete the process by "redistributing our incomes" and converting us into salaried clerks in the rank and files of the Walmarts of health care.

Unfortunately, professionalism must work bi-directionally. Let the government start treating us as professionals and then we can reciprocate. As the Hospitalist says, we ar all collateral damage in this process. I would have hoped that you would have stood by the practicing physicians rather than pull the rug from under them.

BDoherty said...

I think this post may have set a record for the most responses back and forth!

Again, I think the comments by "The Happy Hospitalist" miss the point. Nowhere did I (or ACP policy) suggest that it is unethical for physicians to contract privately with patients, or for them to discontinue seeing patients if they can no longer afford to subsidize their care under the government's inadequate payment rates. If the government's pay cuts and price controls make it impossible for you to continue to see Medicare patients, or will cause you to move towards a concierge-type practice, you should let your elected lawmakers know. But saying, as the Happy Hospitalist did, that the answer is to "screw" granny. . .is that the message that physicians really want to send to the public and their patients?

The problem, according to ACP's ethics policies, is when anger at the government leads to advocacy for actions that are implicitly and explicitly are intended to deny care to patients for the purposes of making a political point. This, the policy says, is unethical. Intent matters in determining when an individual action by a physician, or collective action by physicians, crosses the line from making prudent business decisions, allowing a physician to engage in necessary political advocacy (like going to a rally), and limiting care to patients as a means of exerting pressure on government or payers. The latter is when it becomes problematic. I believe it will ultimately be counterproductive for physicians in the political arena if they are perceived as engaging in actions that are intended to deny care to patients in order to achieve a political objective. Scare tactics at senior citizens, in particular, have been used been used over and over by politicians (Democrats when they charged that the GOP wanted to take away their Social Security, Republicans when they charge that health reform will lead to death panels), but society expects better of their physicians.

There also is a fundamental distinction between unions and trade associations, which are created to advocate for the economic interests of their members, and the learned professions, which are held to a different (and yes) higher standard of professionalism.

I have spent every day of my 31 plus years doing everything I can to advocate for the best interests of practicing internists. This sometimes means speaking out when I think that some voices within the profession are advocating a course of action that will backfire politically, and especially when such actions create ethical tensions with physicians’ professional obligations to their patients and society, as determined by ACP members on the ACP's own Committee on Ethics, Professionalism and Human Rights. I don't believe that ACP members are well served by my telling them only what some want to hear, and I will continue to share with you my best judgment on how you can best achieve the best outcome for your patients, and for internal medicine. My employer, ACP, expects nothing less from me. I will also continue to respectfully invite your comments when you dissent from my advice.

The Happy Hospitalist said...

My "screw granny" comment had no political meaning at all. In fact I know of only one physician in the seven short professional years of my hospitalist career. The comment however is politically incorrect. But that is beside the point sice the intent of my politically incorrect position has nothing to do with politics and everything to do with the laws of economics.

I don't know any physician who would drop Medicare purely for political reasons. Physicians as a group are politically disengaged and rarely have the time to get involved because the are too busy taking care of Medicare patients. Screw granny is an economic statement and nothing more. A statement of necessity.

Unknown said...

Re Doherty's blog "Should physician anger be directed at denying care to patients?":

When you set the terms of the debate by the statement above, what's the point in talking?

I'm a Fort Myers, Florida general internist with a 95% Medicare practice. On March 1st, I called every single one of my Medicare patients and told them that, because of SGR, I wouldn't see them unless they had an urgent problem, as defined by the patient, not by me. I told them why, and I told them who they should call in Congress.

Guess what? The patients understood. I wasn't directing my anger at them. It's real simple: our practice has an 80% overhead, and 100% - 21.5%=... Wow!

So why does AMA and ACP keep setting the debate in terms of patient abandonment? As long as (dis)organized medicine uses the terms "deny care to Grandma", "unethical", etc. nothing will ever change. We've only had 13 years to fix this, but yeah, let's write some more letters to our Senators, that'll work, especially if we say we're "outraged".

How about you "leaders" at ACP actually lead something?

Robert J. Sobel, M.D. said...

I believe I posted the above supplanting hegemony for homogeneity. As I was further enlightened on the concept of hegemony (patients are a great source of learning), I thought I would look back at my comment and correct it. In the interim, I see that Rob has let off a little steam.

Maybe I was inadvertently on to something. The "best practices" concept being bandied about appears benign enough. Maybe someone will come by and sample our approaches and offer up some hints to others (who, how, and why is my auto-retort).

What is more than a little scary is a top-down standard of care hatched in an administrative, academic incubator. Let us not believe that an authoritative, quality police, is really a goal for medicine (especially on the outpatient side). Let us call it a thousand points of light, instead. Enforced hegemony (like the idea of not being tort liable if you follow the guideline) should not be condoned.