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Association of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto

Volume 64, No. 1 January 2008


The American College of Physicians (ACP), the second-largest physician group in the U.S., has repackaged its perennial call for socialized medicine as "evidence based." There's an "appalling lack of access to affordable health coverage," an impending crisis caused by a shortage of primary-care physicians, excessive costs, etc. (www.acponline.org).

Despite the headline "Doctors Endorse Single Payer," the ACP stops short of saying that a system like Medicare is the best way to achieve universal coverage. The current "pluralistic mix" might be expanded, but everyone would be required to obtain health insurance (Philadelphia Inquirer 12/4/07).

Elaborate plans offered by the ACP (Position Paper, Ann Intern Med, January 2008), the AMA, or politicians all tend to mix and match variants on several chronic, stupid ideas:

1. If one shop botches the job, keep taking your car (or body or medical system or whatever) there for repairs.

If it looks as though various reform proposals are coming out of the same shop, it s because they probably are. Ideas from the gurus who created the current mess keep getting recycled from one foundation, think tank, university, government agency, or advocacy group to another. A lot of them are in the archives of the Clinton Health Care Task Force.

For example, the ACP wants a "national workforce policy" to ensure "an adequate supply of physicians trained to manage care for the whole patient." If trends continue, as few as 10% of those training in internal medicine will practice as general internists. And there's "The Impending Disappearance of the General Surgeon" (JAMA 2007;298:2191-2192).

The reason: "Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it the resource-based relative value scale." The AMA's RUC (RBRVS Update Committee), which meets behind closed doors, sets the policy (Goodson J, JAMA 2007;298:2308-2310).

The solution: "reformulate" the same flawed process.

2. Give overstretched personnel more work to do.

"The right services appear to be carried out less than half the time," say experts on children's medical care (N Engl J Med 2007;357:1549-1551). Providing all recommended services to a panel of 2,500 patients could require up to 7.5 hours per day of physician time, Goodson writes. So while emergency rooms are overloaded, and specialists are often unavailable to care for the acutely sick or injured, we need to have more primary-care doctors doing "prevention," fixing "disparities," and documenting and checking compliance with "best practices."

Everyone should have a "personal medical home" (the American Academy of Family Physicians descriptor) or an "advanced medical home" (the ACP's "whole-person oriented," "patient-centered" model. There, the patient receives primary, principal, coordinated, integrated, continuous, and comprehensive care with enhanced access, quality, and safety, in a culturally and linguistically appropriate manner, consistently using evidence and decision-support tools. This is made possible by redirected federal health care policy and a voluntary recognition process by an appropriate nongovernment entity.

3. Fix an unsustainable system by forcing everyone into it.

The ACP notes that government pays 46% of all U.S. medical bills. "Despite repeated attempts to rein in federal expenditures for Medicare and Medicaid, federal expenditures have continued to increase much faster than inflation in the entire economy," it says. The two ACP options: single payer, or the current mix plus more guarantees and subsidies.

4. Curb innovation and technology.

The ACP complains that the U.S. lacks a central authority for ruling on the clinical or cost-effectiveness of new technology, or for restraining its spread. Insurers are free to cover, and physicians, patients, and hospitals are free to use it.

5. Require use of prescribed health information technology.

Interoperable data will help patients and physicians make "informed decisions about the appropriate use of health care services" and will "enhance monitoring of patient adherence," ACP states. Thus it will help curb use of diagnostic and healing technology while enforcing use of certain approved preventive and chronic disease monitoring technologies.

6. If people decline to buy a product, force them to; make it "affordable" by making others pay.

This is basically the Massachusetts model. The ACP has not awaited results from the Massachusetts experiment (see p 2). While the ACP eschews the term "individual mandate," that is apparently what a "legal guarantee" of coverage means. As Paul Krugman notes, speaking of universal coverage without a "so- called mandate" is disingenuous and not serious; it would be like making payroll taxes voluntary (NY Times 12/7/07).

These stupid ideas from the standpoint of improving U.S. medicine or lowering costs are not put forth by stupid people. Quality and spending are only pretexts. The ideas are well- designed to further the real agenda. Bankrupt institutions and damaged care create pressure for a government takeover.

The problem is that "expanding government authority over a health care system that accounts for more than $2 trillion and one sixth of the economy in a country that is ambivalent about public power is...controversial."

"No universal coverage plan, no matter how clever, can avoid that ideological debate" (NEJM 2007;357:1677-1679).

The Evidence Base

The ACP pushes for "performance measures" to reduce errors and improve quality. Here's the evidence:

"More than 90% of the variation in reported risk-adjusted 30-day mortality rates for acute myocardial infarction, congestive heart failure, and pneumonia is not explained by the most evidence-based performance measures in use today" (Holloway RG, Quill TE, JAMA 2007;298:802-804).

During the last 20 years, incentivized performance programs have shown, writes Jeff Evans, that "what you measure generally improves and what gets measured is generally what is easiest to measure. But the ease of measurement does not necessarily define the importance of the measurement" (Ob.Gyn.News 10/15/07).


Physician Manpower

The average age of physicians in New York State is 51 (MSSNYe-news 12/1/06). One of three practicing physicians in the U.S. is over the age of 55. Anecdotal evidence suggests that it may take two younger physicians to cover the workload of one retiring physician, writes John Commins. Younger physicians are less likely to work 80 hr/wk; and 24% of women physicians under the age of 50 worked part time, in contrast to only 2% of men (healthleadersmedia.com, October 2007). A Merritt Hawkins survey of physicians aged 50 65 showed that 38% planned to retire from clinical practice as soon as they could, and about half planned to make changes that would at least reduce their patient load within 3 years. Not a single physician indicated that recent graduates were more dedicated and hard-working than physicians their age, and 68% thought they were less so.

While some studies estimate that the U.S. will be short as many as 200,000 physicians by 2020, Shannon Brownlee writes that none of the presidential candidates has addressed the "flood of new doctors coming down the pipeline," which could wipe out all the benefits of their plans by ordering tests and driving up costs. Said Elliott Fisher of Dartmouth Medical School, "If we sent 30% of the doctors in this country to Africa, we might raise the level of health on both continents ("Overdose," Atlantic Monthly, December 2007).

A shortage of the "medical homes" touted by the ACP could surely drive down expenditures, as in Canada, where 15.8% of the population (29% in Quebec) has no primary physician. Without a generalist, no one can get a referral to a specialist. About 25% of Canada's family doctors are foreign trained (www.stopgovernmentmedicine.com).


Per Capita and Out-of-Pocket Costs

According to Figure 3 in the ACP Position Paper (op. cit.), the U.S. had the fifth lowest percentage (13.2%) of medical costs paid out of pocket, compared with 27 other nations, in 2004. France was lowest (7.6%), and Mexico highest (50.6%). The average was 19.8%; Canada, 14.9%; Switzerland, 31.9%. It is noted that U.S. OOP expenditures are highest in absolute terms but so is U.S. income. Health spending increases at a constant rate of about 8% for every $1,000 increase in GDP per capita (Wall St J 11/13/07).

As OOP expenses declined (from 33% of personal health expenditures in 1975), the share of GDP devoted to medical expenses increased (N Engl J Med 2007;357:1793-1795).


The Evidence from Massachusetts

The free or nearly free (taxpayer-funded) health insurance available to people with sufficiently low income is so popular that the program may exceed its budget by $150 million. About 133,000 of 207,000 eligibles have signed up.

But only 10,000 of the 215,000 uninsured who are not eligible for subsidies have obtained coverage through the Connector. The rest either just remain uninsured or ask to be exempted from the mandate (NY Times 11/25/07). Lawmakers couldn't repeal the reality that insurance is expensive because care is expensive, exceeding the upper limit of 2.7% to 9% of income for those earning between $15,000 and $50,000. And since the government had run out of money for more subsidies, 20% had to be exempted (Pipes SC, "HillaryCare the Preview," Wall St J 10/12/07). So much for universal coverage. And people who have signed up for coverage are having trouble finding a doctor who will see them.

Insurers were expected to increase rates in unsubsidized plans by 10% to 12% next year, twice the national average. But the Connector voted to press insurers to hold premium increases to 5% without shifting the 8% to 10% increases in cost of care to plan members. To enable insurers' to meet their "target" of 5%, "providers are going to have to scale back their demands," said Marylou Buyse, president of the Massachusetts Association of Health Plans (MAHP). Other suggestions by the Connector: steer patients to lower-cost providers; encourage use of generic drugs; and strengthen prevention programs for people with chronic illnesses (Boston Globe 12/5/07).

Boston Medical Center HealthNet Plan is to be punished for trying to "poach" beneficiaries from other plans, probably by having the number of its insureds reduced (Boston Globe 12/4/07). Universal coverage was supposed to end "cherry picking," and choice and competition were to be encouraged, but apparently marketing is not allowed (Consumer Power Report 12/6/07).

The really ugly part of the Massachusetts plan is the out- year costs. Officials projected that the plan would cost about $1.4 billion per year for the first 3 years, and budgeted no funds for subsequent years. According to the Kaiser Commission on Medicaid and the Uninsured, "The state anticipates that no additional funding will be needed beyond three years" (Hyman D, Cato Policy Analysis No. 595, June 28, 2007).


100 Million Uninsured...

The number of Americans lacking disability coverage is about 100 million. And some 68 million lack life insurance, according to the Life Insurance Marketing Association, writes Tim Pitcher. The percentage of Americans without health insurance was at its peak of 100% in 1930, and declined steadily until 1982, notes Greg Scandlen, referencing the Source Book of Health Insurance Data, 1990.

Maryland Court Checks Medical Board on Privacy

After more than 5 years of litigation, the Maryland Court of Special Appeals held that psychiatrist Harold Eist, M.D., had not failed to cooperate with a lawful investigation by demanding that the licensure board justify its request for records of patients who had refused to grant consent. An administrative law judge (twice), two Maryland circuit judges, and now three appellate judges have held that the prosecution of Dr. Eist was not justified.

"At the heart of this case is the Maryland board's assertion that its power is absolute and is not answerable to patients, physicians, legal precedents, or medical ethics," write Janis G. Chester, M.D., and Robert L. Pyles, M.D., (Clinical Psychiatry News, November 2007). "It remained the board's position that issuance of a subpoena was not open to challenge."

The court's decision closely followed the legal arguments in an amicus brief filed by AAPS and a number of other organizations. It held that the medical board, like other American governmental agencies, is subject to checks and balances. If a physician or patient challenges its demand for medical records, the burden rests with the board to prove that its need to invade privacy outweighs the patient's right to privacy. The board must seek an independent court ruling.

The reaffirmation of a right to privacy is especially important, given the rush to embrace electronic medical records without adequate privacy protection.


AHA Claims Right to Defame with Impunity

In an amicus curiae brief filed before the Fifth Circuit Court in the appeal of the jury verdict in Poliner v. Texas Health Systems, the Health Care Indemnity Corporation, the American Hospital Association (AHA), and others argue that the Health Care Quality Improvement Act (HCQIA) bars damages based on either tort or contract. Thus, it bars damages based on violations of medical staff bylaws.

The AHA argues that bad-faith motives of peer reviewers are irrelevant even outright fabrications are apparently acceptable. In its brief, the AHA asserts that "Dr. Poliner has at all times admitted his mistake." Dr. Poliner insists that he did not make a mistake, nor say that he did. All that is necessary to confer immunity, the AHA says, is that reviewers' statements meet some sort of standard of "objective reasonableness" not a "subjective" standard of good faith.

The AHA asserts that the court should not substitute its judgment for that of the supreme hospital, notes Dr. Huntoon.

The AHA posted its brief at www.aha.org. The AAPS amicus brief is posted at www.aapsonline.org.


P4P and Kickbacks

One way for physicians to get more money from a contract is to meet performance measures in one of four categories: clinical quality and patient safety, patient experience, business operations, and utilization management. Under the last category, physicians could be rewarded for switching to generic drugs. The payments might be rationalized as compensation for the extra work involved in making the shift. However, the AMA warns that such payments could be construed as kickbacks. In 37 states, antikickback laws also apply to private patients (BNA's HCFR 12/5/07).


On the National Provider Identifier

From the Healthcare IT Transition Group blog: Darrell Pruitt, D.D.S., responds to IT professional Martin Jensen (http://blog.hittransition.com):

"[T]he NPI benefits nobody more than insurers and healthcare IT stakeholders like you, whose careers depend on unraveling expensive and dangerous artificial messes....

"By choice, I am not a HIPAA-covered entity....

"[T]he reason doctors have trouble getting paid in a timely manner has nothing to do with identifiers. Delay-deny-lose is just the way insurers traditionally operate. The NPI just makes it cheaper for them because they save postage on denial letters.

"Do you mean to say that as desperately as our nation needs doctors, they are going to be put out of business if they do not get an NPI number?

"[T]he NPI...is integral to Pay-for-Performance an artifi- cial...market force in the form of a doctor's report card, created and published by stakeholders.... The report card is designed to replace a traditional free market, where consumers determine who gets paid and how much. Like HIPAA, NPI is about control of doctor-patient relationships."


Peer Review Limbo

Suspended by a hospital in 2004, Dr. Jimmie R. Crow, a surgical oncologist in Colorado, is still waiting for his initial "fair hearing" in the hospital. In 2006, he sued the hospital. In a unanimous opinion, the Colorado Supreme Court held that: "a reviewing court cannot capably make that determination until the administrative remedies have been exhausted and a complete record has been developed to accomplish `meaningful' review." Dr. Crow claimed that the hospital had repeatedly denied him access to medical records that he needed to defend himself. Other states that require exhaustion of all administrative remedies before allowing access to the courts include Alaska, California, New Jersey, and the District of Columbia (Amy Lynn Sorrell, AM News 11/19/07).


Quota for Doctor Discipline

In 2004, the Texas legislature in its appropriations bill expressed its expectation that 18% of complaints against physicians should result in disciplinary action in 2006 and 2007, an increase from the prior 10% (www.texmed.org). Only by turning trivial and irrelevant complaints into "results" can an agency comply with such an arbitrary request, notes a Texas physician. One source of complaints is insurers who manufacture a sham standard of care to support denial of benefits, and attack physicians who provide denied care.


Deleting "Toxic" Doctors

Colorado Permanente Medical Group pulled itself out of the red and reached all-time highs for physician and patient satisfaction, using a process described in Business 2.0, May 2007, by Jeffrey Pfeffer. Using a new evaluation process, president Jack Cochran and medical director Patty Fahy began removing 10 to 20 doctors per year, 2% of the total. The doctors' "toxic behavior" infected the organization, they said. Since attitudes were more important than skills, Fahy discovered, anonymous surveys became an important part of the turnaround.


Managed Democracy. Parliamentary elections that delivered a landslide (98%) victory to Vladimir Putin's United Russia party, were denounced by European officials. "Steered democracy," said the Swedish foreign minister. "Not a level playing field," said the European observer mission. "If Russia is a managed democracy, these were managed elections," said Luc van den Brande, head of the Council of Europe delegation.

Putin's party now has a large enough majority to amend the constitution without the support of others. The victory at the polls was a "sign of trust," Putin said. "Russians will never allow the nation to take a destructive path, as happened in some other ex-Soviet nations" (Buffalo News 12/4/07).

Remember how advocates of managed care used to warn that care previously provided by physicians was "unmanaged," and by implication reckless, inefficient, perhaps even dangerous? Is the same true of an unmanaged what we might call "free" society?
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY


The Ultimate Cost-Saver. It is quite true that costs will be reduced if everyone accepts death. It is far cheaper to kill people than to treat them, and that is why nationalized systems are heading in that direction as fast as they can. This is why we heard all the nonsense from experts of this and that who claimed that Terri Schiavo's death by starvation and dehydration was peaceful, dignified, and painless. Apparently they were unacquainted with Robert Conquest's bone-chilling descriptions of starving to death during Stalin's Ukrainian famine.

It is not true that the biggest portion of money is spent on dying people. Recent Medicare figures show that the largest spending occurs between age 65 and 75, not over 75.
Linda Gorman, Independence Institute, Golden, CO


Overhead. When I was born, my mother stayed in a private room for two full weeks. At $5/day, I cost $75.

As HMOs try to tease out the part of deliveries that is crucial and really expensive, they will eventually learn that the true source of the heavy cost is overhead which will float around and land on whatever is being paid for at the moment, and typically will be something you don't dare cut.

What is the justification? Perhaps some clue comes from learning that my hospital sets aside 10% of revenues for new buildings and equipment. It takes a very large team of managers to do the planning, shift everything around during construction, manage the confusion, hire new people, arrange early retirement for obsolescent job descriptions, discover and respond to flaws in the new development as they surface....
George Fisher, M.D., Philadelphia, PA


Beware of Medicare Advantage Plans. We had to refund the better part of a year's Medicare payments for a patient who thought she was in standard Medicare but was actually in a Medicare Advantage Fee-for-Service plan. We then had to bill the FFS plan, and by so doing, agree to their rules. Since we're the ones who have to straighten out this mess, we contribute to Medicare's "low administrative overhead."
Russell W. Faria, D.O., Newport, OR


Economic Fascism. I have been hooted down for describing individual mandates as "fascism." But an essay by Thomas DiLorenzo 15 years ago explained how "corporatism" or "industrial policy" an essential ingredient of the economic totalitarianism practiced by Mussolini and Hitler had permeated the Clinton Administration (Freeman, June 1994, www.fee.org). It is still very much alive today .
Greg Scandlen, Consumers for Health Care Choices


Where Does the SCHIP Money Go? In Ohio, a lot goes to CareSource, a highly profitable Medicaid HMO that is erecting a $55 million building in downtown Dayton. The chairman of the board is also CEO of Dayton's largest hospital group. Many CareSource enrollees are cancelling their commercial insurance. Doctors can't make a living on the 5% to 8% paid by CareSource. So what is hailed as "coverage" means that services are no longer available.
Kenneth D. Christman, M.D., Dayton, OH


Second-class Citizens. Medical professionals are no longer full citizens with equal rights in what the late Milton Friedman called the "socialist communist system of health care" that exists now in the U.S. Almost all proposed plans will increase medical communism. All physicians should refuse to serve in any of the "plans," as I will.
Samuel Nigro, M.D., Cleveland Heights, OH


Liberals Love Guns, Hate 2nd Amendment. Nationalized medical care would be involuntary; thus it would depend on government force, and ultimately on agents with guns. Without a gun pointed at my head, I wouldn't let the government take 15% of my earnings for fraudulent Ponzi schemes. Who would?
Craig Cantoni, Scottsdale, AZ


All You Need to Know about Universal Healthcare. From report GAO-08-17: "CMS and states do not prevent healthcare providers who have federal tax debts [evaders] from enrolling in Medicaid. CMS officials stated such a requirement for screening providers could adversely impact the states' ability to provide healthcare to low income people."
Frank Timmins, Dallas, TX