by Richard Amerling, M.D.
The debate raging over ObamaCare has been carried on mostly by politicians, pundits, policy wonks and economists, with little input from those most intimately involved with delivery of health care—medical practitioners. Doctors have too often been marginalized as self-interested. If that were true, there would be far fewer practicing physicians. Of course we are concerned with income, as are all taxpayers and businesses faced with rising costs and taxes. Unlike other businesses, however, most doctors are unable to pass higher costs to consumers due to price controls on reimbursement. When costs outpace income, bankruptcy ensues. This renders discussions of autonomy moot.
Autonomy, for physician and patient, is central to the medical profession and dates back to Hippocrates: “I will prescribe regimen for the good of my patients according to my ability and my judgment. I will keep them from harm and injustice.”
To be fair, physician autonomy, and the doctor-patient relationship, have been under assault for decades. This was an inevitable result of the acceptance of third party payment by physicians, and was greatly accelerated by Medicare and Medicaid beginning in 1965, and the Health Maintenance Organization in the 1970s.
Medicare and Medicaid sought to control costs by limiting reimbursement to physicians, payment to hospitals based on diagnosis, and by limiting payment to services it deemed “medically necessary.” Practice was and is distorted by these interventions. For example, faced with declining payment for services, doctors increase the volume of services. This means less time per patient, declining quality, and greater reliance on laboratory services, imaging procedures, consultants and hospitalizations. Total costs actually rise when physician fees are cut!
Health Maintenance Organizations promised to improve quality and control costs by assigning each patient to a Primary Care Provider, or PCP. The PCP, who could be a nurse practitioner or physician, serves as a gatekeeper, blocking access to higher level care. They receive direct financial incentives to spend the least amount per patient. This is the opposite of physician autonomy, with the PCP in effect working for the HMO.
Whatever its final form, ObamaCare would perpetuate these failed models. In addition, it will include enhanced measures to control medical care. These will be implemented under the guise of quality assurance and cost containment. Slipped into the so called stimulus bill passed last February is a new federal health care panel that will decide which procedures and drugs are “medically necessary” and “cost effective.” Based on the writings of Ezekiel Emmanuel, brother of Rahm and close Obama health advisor, we can assume rationing of care to the elderly (over 65!) and very young (under 2). Also included is a mandate for adoption of electronic health records (EHR). The clear goal here is to have access to every medical interaction; the only rationale for gathering such detailed information is to exercise control over medical decision-making.
The mechanisms are already in place. For the past couple of decades medical specialty societies, aided and abetted by the government, the American Medical Association, and Big Pharma, have been crafting clinical practice guidelines. These mostly opinion based recommendations will be transformed into mandates, first as “clinical performance measures,” then as “payment for performance.” Treatment algorithms will be built into the EHR to guide decision making at the point of service. Such a “one size fits all” approach will be an unmitigated disaster for patients.
The Senate bill states that qualified health plans may only work with doctors who “implement such mechanisms to improve health-care quality as the secretary (HHS) may by regulation require.” In other words, doctors who refuse to turn over patient information and treat according to guidelines will be barred from participating.
The way to preserve a semblance of physician autonomy is to send this bill to the shredder. Failing this, the medical profession must come together and refuse to sell out their patients and their profession. We must assert our right to treat patients as individuals, to the best of our ability.
Richard Amerling, MD, is a nephrologist practicing in New York City. He is an Associate Professor of Clinical Medicine at Albert Einstein College of Medicine in New York, and the Director of Outpatient Dialysis at the Beth Israel Medical Center. Dr. Amerling studied medicine at the Catholic University of Louvain in Belgium, graduating cum laude in 1981. He completed a medical residency at the New York Hospital Queens and a nephrology fellowship at the Hospital of the University of Pennsylvania. He has written and lectured extensively on health care issues and is a board member of the Association of American Physicians and Surgeons. Dr. Amerling authored and signed the Physicians’ Declaration of Independence.
Hello-
I have been an AAPS member since medical school, and in general agree with the majority of positions taken by AAPS. However, the article above contains a philosophical and ethical error which will only strengthen our enemies weaken our position- this error is the implicit condemnation of “self-interest” as a reason for physicians to practice medicine.
In brief, I am self-interested and proud of it. I love my job as a neurosurgeon- that love is very self-interested. I take pride in trying to do my best as a surgeon primarily for myself- that sense of pride is very self-interested (this is also, secondarily, the best protection and insurance for my patients).
I could go on, but, in brief, the position too often taken by AAPS (and the AMA) is that we do our job out of a sense of self-sacrifice. This position will not help us in our fight to save medicine, and will ultimately be our downfall if it continues.
Sincerely,
Michael A. Sandquist, MD
Physician autonomy? The mere existence of the boards of medicine changes the nominally voluntary adherence to medical practice guidelines to mandatory (Goldfarb v. Virginia State Bar). Studies have found the average medical guideline is a failure. In an alleged trivial niche of a subspecialty, there is a 13% treatment failure rate and perhaps a 50% diagnostic failure rate because ethical physicians fear for their careers. So in the world of self-regulation to failed guidelines and sham peer reviews, just how is ethical autonomy to survive?
What has government ever run well? Government is about self-interest, by those who govern. It is about them having power, money, status, and control. Government can do nothing without first taking away from someone else. For government to take half of what I earn without my permission, under threat of force or imprisonment, is theft, even if government calls it legal. The current federal government in America is not Constitutional, even if it is called legal by our current courts. All of our elected officials take oaths to uphold the Constitution, yet none of them are. We need to restore our Republic. Stand up! Vote! Take to the streets. Join in a Taxed Enough Already (TEA) Party!
An understanding of the so-called healthcare reform legislation under consideration in Washington can be enlightened by the study of parasitology. This legislation would simply be another massive wealth transfer from the pockets of American citizens into the pockets of the political and financial sectors of the economy. The parasitic self-serving political sector (government) and the parasitic self-serving financial sector (insurance companies) have been sucking value out of morally legitimate private financial transactions between doctors and patients for the past fifty years. Unwittingly, doctors themselves helped nurture their growth by entering into a Faustian pact to accept payment from them in the first place. That was a huge mistake.
Once the parasites were allowed to insert themselves into the doctor/patient relationship and begin extracting their toll of economic blood in the form of taxes and insurance premiums, both doctors and patients lost their autonomy and right to self-determination. Once they got control of the money they were quickly able to gain control over all terms of the relationship, even the technical professional aspects. They now dictate what care will be provided, how it will be provided, and what payment will be made.
We have reached a crisis point where the host doctor/patient relationship, having been bled nearly dry, can no longer sustain the parasite load. ObamaCare would simply increase the volume and velocity of the flow of our economic blood to transfuse the third party leeches who created the current crisis in the first place.
I provide services to patients because it gives me personal satisfaction and economically sustains my life as well. And yes, I do it out of healthy self-interest. And because I value my right to self-determination, I will have no dealings whatsoever with third party parasites. I may lose some business as a result, but I retain control of my own life.
Well, this is fine mess we have gotten ourselves into. We go through years of rigorous education and residency training at great personal and financial expense all to become servants of the State! What a deal! The problem is that we are trapped by altruism which trumps the individual “self-interest” of the doctor. Because the consumers of our services (patients) are needy, they automatically become “morally superior” to us, i.e., the “greedy” doctors. Politicians latch onto the concept of altruism like leeches to gain and maintain their power structure under the veil of “social justice.” They then invent a “right” to health care which translates into a “right” to the labor of doctors, but nobody cares about our loss of professional freedom. No one would think they have a “right” to have a plumber fix their water heater or the “right” to have an auto mechanic fix their car. But people have been indoctrinated into thinking they have a “right” to health care no matter what the cost, no matter who pays for it or who actually has to provide it. Thus, there is discrimination against the medical profession where doctors are not allowed their pursuit of happiness and not allowed their professional autonomy in what was supposed to be a free society. Exit…the good doctors.
Excellent comments all! I completely agree.
Thanks for taking the time to read my article and for your great posts.
Dear Doctors: If I was in Congress or in State government I would want to remove all regulations on medical establishment, doctors, hospitals. All drugs to be handled like package stores. I feel that people will know what to do or will learn in a hurry how to deal with problems. Of course, nothing will be corrected unless we get “real money”. backed by gold and silver. Kick the Federal Reserve out and charge them as the thieves that they are and represent. The government wants TOTAL CONTROL of all of its’ slaves. YOU INCLUDED. Are you ready to take out a bullet or delivery a baby for a sandwich? I think it may happen as early as next year.I suggest that you listen to: http://www.republicbroadcasting.org or archives for $1.88 a month for Monday and Tuesday programs. It is a good place to learn the truth of want is happening.
Using the logic of Goldfarb v Va State Bar, physicians engage in commerce. Therefore, much like accountants’ service, the provision of healthcare is a service, not a right.