Friday, April 2, 2010

But what's in it for me???!!!!

One of the critiques directed at ACP (but also at other physician membership organizations, like the AMA) is that organized medicine didn't get "enough" out of health reform for the doctors. By "enough," they usually mean permanent repeal of the Medicare SGR cuts and caps on non-economic damages in malpractice awards.

To be clear, ACP fought (and will continue to battle) for more effective medical liability reforms, including caps, and a permanent end to the cycle of Medicare SGR payment cuts. There are good reasons why neither ended up in the final legislation, which I will come back to in a future blog.

Today, though, I want to address the broader issue being raised by asking what physicians "got" out of health reform. The implication is that ACP should have approached health care reform more like a labor union or trade association, entities that exist principally to protect and promote the economic interests of their members. They engage in "transactional politics" - that is, they approach legislation - from the standpoint of "what's in it for me?" And if they can't get a deal that gives "enough" to their members, they oppose it.

Five years ago, political strategist Joe Trippi blogged on how transactional politics is diminishing our democracy:

"Transactional politics. I'll give you a tax cut for your vote. Health care for everyone for your vote. I'll keep you safe for your vote. Everything is a transaction with the citizen in a transactional democracy - and both of our nation's political parties fell to transactional politics long ago. It happened so slowly. It's like your eyes adjusting so well to the dark and living in the dark for so long - that you don't realize that the bright light of our democracy has been diminished. Transactional politics breeds the politics of 'what's in it for me?' 'What do I get?' At the expense of the common good - something almost never mentioned by our nation's leaders - in both parties - over the past few decades."

Transactional politics may be the raison d'etre for unions and trade associations, but physician membership organizations like ACP are bound by a higher purpose, which is to pursue public policies to serve the broad interest of the public, not just the economic interest of their members. ACP's mission is "To enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine" and a principal goal is "To advocate responsible positions on individual health and on public policy relating to health care for the benefit of the public, our patients, the medical profession, and our members."

ACP also has endorsed the Charter on Professionalism, which was published in the Annals of Internal Medicine, APC's flagship journal. The Charter states that "the medical profession must promote justice in the health care system, including the fair distribution of health care resources" and "A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession." [emphasis added]

By this standard, then, ACP was bound to look at health care reform not exclusively out of "concern for the self-interest of the physician or the profession" but by how it would improve access for patients and the public.

This doesn't mean that ACP didn't pursue (and achieve) policies that had direct benefit to members, including increased Medicare and Medicaid payments to primary care internists (which, it believes, will also have benefit to the public). But ACP's advocacy put a premium on how the legislation would improve access to affordable health insurance coverage. Some recent comments on this blog have taken issue with this, with one writing "it is time for the ACP to change its name to American College of Patients - this suits its mission better than the current name."

I understand and respect the principled reasons why some ACP members believe that the legislation will not be to the benefit of the public. But I would hope that most ACP members wouldn't want ACP to act like a union or trade association that exists only to engage in the transactional politics of "what's in it for me?" The question that ACP asked itself throughout the legislative process was "Will health reform result in 'public policy relating to health care for the benefit of the public, our patients, the medical profession, and our members?'" In the end, it decided that it would, even though the final law didn't include everything it (and its members) wanted.

Today's questions: Do you think ACP should approach legislative advocacy like unions and trade associations that make decisions on legislation based on "what's in it for me?"


Harrison said...

I think that the ACP's choice of advocacy is just right. I think the priorities are correct.

But economists from Hayak to Friedman would argue that everyone should look out for their own interest, and the market will find the balance.
They would argue in fact that tyranny is just around the corner when people start to think that they know what is best for society and start trying to push that into rules and laws.
They of course point to such regimes as the Communists in Russia or the Nazi's.
They would consider them far left leaning social organizations that took the ideas of central control and 'we know best' to an extreme and instead of being a social good they inflicted pain and death on millions.

So maybe it is okay for the ACP to be a membership controlled organization that puts advocacy for the public good as a high priority.
But if the ACP becomes the controlling party of a one party state in charge of America -- well maybe we should stop short of that.



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


I generally don't find this formal of a delineation helpful. Everyone has self-interest and to dismiss this would be folly. To the extent organized medicine is an attempt to provide a shared voice for the independent practitioners that comprise a great percentage of our system, fighting for fair valuation for the internists you represent is a part of your duty. Whether relationships with hospitals, larger provider entities, the government, academia, and industry require adjustment in that duty is a legitimate question. As resources are limited, your sector is likely most in position for an upward correction; therefore, advocating for a downward correction of the non-physician sectors with bureaucratic excess, is part of your global duty.

Ethical principles and the uniqueness of medical professionalism are not in anyway compromised when we recognize the setting of a dynamic American and global market. To provide access to Health Care for Americans, we need to work to have the rewards in health care be proportionate to value provided. The wide swath of needs that primary care clinicians try to provide is being perpetually undervalued. Dr. Larson reminds us how efficient a good internist can be in keeping patients away from hospital catastrophes. Medicare does not provide fair compensation for some of the necessities of that care that the physician orders and provides (why exclude us from giving Zostavax with a fair margin; why bypass us and give retail to Labcorp, Quest, and the like?). I am holding my own for now with private insurance. I can't have the double standard of involvement in a Medicare program that fails to consider the true situation of small practices.

Your solution of a medical home, and the new programs to have me get a boost for proving who I am. will not correct these financial realities. Urgent adjustment in the Medicare fee schedule is needed. The SGR cut is just an ultimate slap in the face. Independent physicians need some urgent attention from Congress and CMS.

Can Medicare quickly correct these inequities? We will se if Dr. Berwick can realize what is truly needed.

ray said...

whenever you post provocative topics like this, there are less comments. Doctors are held to very high standards and for the most part they manage to achieve them. The fact of the matter is one needs to be happy and satisfied in the job they are doing and since doctors are only human, they will ask "what is in it for me". Many fear they will lose autonomy, many others fear income loss. Although these are individual needs, they are real. My sense is that Medical schools are failing miserably in training students for real world and educate them about evidence in health care policy. Most learn the hard way to run a practice and how many doctors actually know how much we spend on health care in U.S? Most don't care because they think it is not their business. Our system is fee for service so I expect doctors to pay attention to their bottom line.

Arvind said...

Bob, you obviously ask this question because you are not a physician, let alone be a practicing one. Any way, in response to a question, I would like to say "yes and no". In many ways one could argue that organizations that primarily exist based on membership dues (I suppose the ACP is one such organization) should indeed behave in the interest of its membership, i.e. like a trade association. Since physicians have been reduced to 'providers' and the ACP has made no effort to rectify this characterization, I am not sure why we should have any "holier than thou" attitude.

On the other hand, I could say No, the ACP should indeed keep the objective that patient access to quality care should be a part of its agenda in supporting a federal policy. Unfortunately, the ACP simply does not achieve this noble objective by supporting this foolish notion that somehow by providing more uninsured people with Medicaid and Medicare cards, it is actually increasing access to quality care.

If you were an uninsured patient in my neck of the woods, Bob, you would have a better chance of getting high quality care at my office than if you carried a Medicare or Medicaid card, because that is exactly what has been happening for the past 4 months. In fact, every day I see at least one uninsured new patient, but zero Medicare/Medicaid new patient. These uninsured patients get the exact same care from us; we even arrange for discounted rates for lab and radiology services and even for testing supplies, insulin, etc. Each one of these patients is extremely grateful for our service and help and do not miss not having a Medicaid or Medicare card.

In other words, your whole presumption is based on a false sense of right and wrong, Bob. Therefore it pays to take a walk down the trenches of real medicine. Your esteemed decision-makers in the ACP would do themselves and the profession a big favor if they could climb down their ivory towers and see what is actually effective in the real world of medical practice.

And, it is time for all the academics in the ACP to come out and tell the medical students that it is OK to expect to be paid fairly if you are physician; economic health of a medical practice should be equally important to a physician as the health of his/her patient; because if the medical practice practice dies, it is only a matter of time that the patients follow suit.

PCP said...

About 6 yrs ago I sat through an ACP chapter meeting when we were told by the ACP chapter president that ACP advocacy was based on the premise that we advocate for our patients and that in the end what is good for our patients will in the end be good for us.
Though I though that to be a bit naive given our political environment, I thought medical leadership sufficiently balanced in their views to be able to look out for Physician interests also.

Six years on, with the health care bill passed and looking back. I feel certain that the naivete of our leadership will prove disastrous for the profession.
Financially many practices are in dire shape. We have surrendered much and got nothing in return. We are effectively no longer allowed to set our fees, we are in many ways told how to practice, we are persistently told that auxiliary providers are our peers, that we are merely another provider, we are consistently told that this is the era of consumerism(conveniently ignoring that this does not work within a 3rd party payer system).
THen we are blamed for any bad outcome, for the escalating costs, for volume driven care, for .cutting out kids tonsils.
In general there is a Blame the Doc. culture being fostered by our leaders. That is undeniable.
What is ghastly, is that much of this vitriol comes from within our medical profession. Very few of those rendering the criticism understand the issues driving Doctors away from private practice of Medicine. Perhaps this is intentional and ideological. Maybe the left leaning all doctors must be employed in an NHS type system ala the VA system, or community health centers.
The irony is that they clearly deny that but push policy in that direction. Hypocrisy at its best.

The private practitioner is ailing right now. The proposed policies will do nothing to improve this. The stampede out will continue. If this is the intention, you are winning.
It is simply shocking that medical organisations are the giddy cheerleaders of this bill, sans any tort reform, SGR fix or shoring up of our professional roles.

I find that the ACP is less and less representative of my professional and practice needs in their advocacy efforts. They are clearly more ideologically. They see their ideology as more important than representing the interests of their membership.
As such, that annual membership expense is increasingly expendable to me in the emerging reimbursement environment.
I doubt I will renew this summer.

Jay Larson MD said...

The ACP has diverse membership. The range of physician practices span from mostly cognitive based to mostly procedurally based. For the ACP to step into a roll of advocacy like unions and trade associations would be an impossible task. Kind of along the lines of an infinite force meets an immovable object.

Besides, that model would further support the “getting as much as possible” mentality that is shared by many aspects of the health care system. Those of us in direct patient care (especially longitudinal care verses intermittent care) still are reminded daily that the health and welfare of the person in the exam room is our charge.

DrScott said...

In my experience, if we take care of the patients (professionally), the patients will take care of us (politically). Thanks to ACP for striking the right balance between membership advocacy and patients'/society's benefit.