Wednesday, May 12, 2010

Sympathy for the "Devil"

Just the other day, I was skimming through the FM dial as I drove my rental car from Hattiesburg to the airport in Jackson, following a combined ACP Mississippi/Louisiana chapter meeting. Along with the Sunday morning preachers and stale classic rock, I came across a broadcast that caught my attention: Someone (I never heard the name) was ranting about the American Medical Association's support for health care reform. His gist was that the AMA "sold out" doctors by supporting enactment of "ObamaCare" in order to protect its "monopoly" on the CPT coding system.

He also accused the AMA of trying to "gag" physicians from telling patients about how they would be harmed by the legislation, echoing a Wall Street Journal op-ed that accuses the AMA of "now trying to silence doctors who oppose it." (In fact, the AMA didn't try to gag anyone, but expressed concern about a Florida urologist who put up a sign telling patients who voted for President Obama to go "elsewhere" for their care.)

This is just one of the many barbs directed at the AMA for its decision to support enactment of the Patient Protection and Affordable Care Act (PPACA). There is no doubt that some doctors are angry, very angry, at the AMA. A blog search comes up with dozens of posts about how the AMA has betrayed doctors. It is almost as if the AMA has become the devil incarnate in some doctors' minds.

There is a remarkable degree of incoherence in the criticisms. Many people who decry Harry Reid's "backroom" deals to get the legislation passed apparently see no contradiction in blasting the AMA for not negotiating its own deal to get tort reform passed or the SGR repealed.

Some say that AMA "sold out" doctors - but then say they got nothing in return. Which is it? Some criticize the AMA for being too cozy with primary care at the expense of other specialists, others for being too close to specialists at the expense of primary care. Which is it? The AMA-financed RUC, which recommends relative values to the CMS and other payers, is a favorite whipping boy, even though the PPACA requires HHS to establish a process, outside of the RUC, to review the accuracy of relative values. (This wasn't one of the provisions in the law that the AMA favored, but AMA ended up supporting the overall legislation, nonetheless.)

It is interesting that some disgruntled internists will cut ACP more slack than the AMA. While in Hattiesburg, an ACP member politely told me he had torn up his AMA membership card in protest, but that he continued to support ACP, even though he disagrees with the ACP’s support for the PPACA.

I am glad, of course, that many internists who disagree with ACP's position on health reform remain loyal to the organization. And although it isn't my job to defend the AMA, I am bothered that the invective directed at the AMA always assigns the worst possible motivations behind the association’s actions. It isn't a case of just disagreeing with the AMA's stances, but of assuming that the AMA was motivated by crass and venal self-interest or by a cynical political agenda that put its own leaders' interests above its physician members.

This does not square with the people I know who are in the leadership of the AMA. People like Cecil Wilson, MD, MACP, the incoming President of the AMA, a private practice internist from Winter Park, Florida (and former chair of the ACP Board of Regents), one of the most principled physicians I know. Or Jim Rohack, MD, FACP, the outgoing AMA President, and Nancy Nielsen, MD, FACP, past-president of the AMA--all doctors of character and principle. Or the AMA staff in Washington, who work tirelessly to represent AMA members' interests in Washington. The AMA didn't get everything it wanted - who did? - but it did its best to represent its members' interests and the policies given to it by its House of Delegates.

The critics of the AMA might entertain this thought: Maybe, just maybe, the AMA supported health care reform because getting 95% of all Americans covered was the right thing to do.

I think it the AMA showed enormous character, courage and leadership by supporting the final bill, even as it knew that physicians and the public were divided and that they would likely lose some members as a result.

Today's question: What do you think about the AMA's actions on health reform?


ray said...

Please answer how cognitive medicine got into this pitiful state that if medical students choose primary care they are considered dumb and had NO choice. AMA driven RUC favored proceduralists for decades, how else can a 45 min of managing complicated history, counselling, and reconciliation of medications be worth a fraction of fancy procedure( which after time becomes easier for the operator in most cases). I do toe nail avulsions, joint injections and these pay more than managing 6 medical conditions though I swear it is harder to do a good job with the latter. Tell me who is responsible? Maybe time to educate your members why they are in this happening.

Arvind said...

Why am I not surprised that you, Bob, support the AMA? Because the ACP has exactly the same ugly truth to hide.
* Why does the AMA project to represent America's physicians when only 17% of practicing physicians are AMA members?
* What was AMA doing when the SGR was signed into law?
* Why does the AMA not come clean declaring how much money it makes by licensing the CPT codes?
* Why are we forced to use CPT codes in order to get paid?
* How do you classify an office visit as a "procedure"?
* If the AMA (and ACP) were defending their members' interest, why did they not stand up for the most critical points - the SGR, tort reform, and allowing free market to determine true cost of care?

I completely agree with the recent Op-Ed in the WSJ. The AMA has to be characterized exactly the way it is - as said in that article. BTW, the nice doctors who lead the AMA are not the real culprits -its those lifetime AMA technocrats that actually run the organization. The sooner America's docs realize this, the better it will be.

Rich Neubauer MD said...

I applaud the AMA and the AMA leadership for their stance on PPACA and health care reform. I agree with you that they took a stand for getting coverage for the majority of Americans.

I've devoted my energies to the ACP over many years now. I have never been a member of AMA although most of my career I've supported my State Medical Association. The AMA's stance on PPACA has drawn me closer to the idea of joining the AMA than I've ever been. Regardless of whether I actually choose to join the AMA, I applaud the courageous stance the organization took in supporting health care reform despite some vocal (and I think misguided) opposition from within their organization.

Harrison said...

The AMA will lose members and gain members, just like the ACP.
They made the right decision and supported a good compromise for the right reasons.

June 1 is approaching.
Any news?


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

I recall that Bill Maher skewered the AMA the week the President spoke to the Delegates in Chicago. They represent an easy target and there is a lot of history there. Incoherent attacks, however, do distract. While the full extent of the role that was played is likely not fully revealed in the current law, I believe we were well served by the both the AMA and the ACP standing in favor of reform. The interval principles that the AMA put forth during the year of evolution of the legislation were usually right on and covered a wide range of issues. I tended to agree with most of those points.

I believe there is sympathy for the plight of independent practice at both the AMA and ACP. Whether there is the political will to stand up to the quality and administrative reporting bureaucracies that are in development remains to be seen.

As the health care industry adapts, it will remain to be seen whether resource re-allocation is truly helpful. I have yet to see data convincing me that the extra efforts put forth in pilots created true outcome benefits that surpass the standard in many communities. I believe the urban and rural distinction has been addressed (I am the opposite pole from the latter, so cannot comment there). From my perspective, I have always worried about reforms that demand exclusivity, feel little reason to be optimistic that Medicare will adjust anything favorably for those who wish to not change their approach, and still see the insurance industry as looking to tie us up any way they can.

I have contemplated some pretty aggressive approaches to reining in the pharmacy-benefit harassment extant in the United States currently. It is a travesty that our prescribing judgements are directly attacked in the name of bottom-line blind manipulations. I believe the AMA, the ACP, and all of the societies that support physicians who prescribe, could get together and defend our autonomy. The change in ancillary costs from reforming the drug industry would truly bring cost savings into health care and would not stymy innovation.

Clifford Dacso, MD said...

Both the ACP and the AMA took principled stands, although, I would argue that the principles were different. I am a general internist who has seen dramatic declines in his paycheck over the past few years as a consequence of case-mix and my practice style. Yet I continue to support reform and the ACP position because equity has to be a guiding principle of our medical practice. My son and daughter in law are general internists and have all the idealism and passion that my now elderly and cranky cohort professed in the past. Desperation and despair are not options.

PCP said...

All I know is that my profession of General IM is on the ropes because of the current policies of the Gov't and the ACP and AMA are endorsing it further.
Where was the AMA and the ACP when SGR was applied to medicare B in 1997? Why are we perrenially playing defence, I'll tell you why, because our so called advocates still have not figured out how it works in DC.
Why no SGR on Medicare A, where is it on Medicare D, the VA, or the CHC networks? Or any of the other health care spending programs for that matter.
Now we are in a pickle, precisely because of the myopic policies of our advocates and my generation of Physicians have been sold down the river by them.
I understand that in large part the AMA sponsored RUC is behind the assignment of RVUs to virtually everything we do and therefore what our financial bottom line is.
Additionally the regulations, paperwork, the overheads, etc are moving in such a way that younger doctors are not looking at this as a good career alternative.
I do not need hearsay to tell me this. I have the yearly NRMP data to prove it.
I give a lot f weightage to the career choices of our medical students. Their choices are the measure by which we determine the career viability of our profession. Full stop.
I would urge Bob to disclose what percentage of younger practicing internists (not including medical students,interns,residents etc) are ACP members. I suspect we are developing a missing generation there. That is because the ACP policies do not represent them.
I see it when I go to the Meetings. Missing 30-45 yr olds.
When you are in a setting of like minded individuals, it is easy to get caught up in the certitude of your actions.
Gov't policy far from fostering an environment where we want to practice seems geared up to creating a workforce of if necessary disillusioned practitioners. Our Organisations like ACP and AMA are accomplices in this and appear to feel that will somehow drive their memberships.They are wrong.
They grow if they represent practicing physicians first, but at this time their actions suggest otherwise.
There may be any number of explanations for this.
The hardcore zealots of this policy can postulate on the various causes for this, they can say, every year some will join and some will leave, however the end result is that the ACP is rapidly becoming an echo chamber for the National health Plan, Physicians on salary crowd.

I have seen how that worked in other countries, one can never count on politicians to treat us fairly. Our current medicare SGR debacle is proof enough.

Just look at Greece today, targeting its doctors to quell public angst.

I have said it all along and I will say it again. The ACPs policy will lead us to the average internist working in a CHC setting with a set of unaccountable mid level providers for whom he/she is responsible, where you are an employee like them , and where they could care less what you think.
The FTCA protects them from the litigation risk. The administrator takes full advantage of the perch given him/her, and we Internists finally lose all vestiges of our professional independence.
This will be the legacy of current health care policy and the ACP/AMAs cheerleading advocacy.