Physicians

POLICY/PHYSICIANS: More on the AMA

So why did I get so grumpy with the secretary of the AMA and his talk at TEPR. I actually stood up and asked a long question which he interrupted to tell a bunch of lies about Canada, ignoring that there are lots of other countries with universal health care that do it differently and better. When I finally got to ask about why when ePrescribing was originally mandated for Part B in the house version of the 2003 MMA eRx legislation and ask as to why it mysteriously was left out of the final bill, and what was the AMA’s role in that — well as Neil Versel said to me afterwards “no one dodges the question like the AMA.”

Things he featured prominently………………The uninsurance crisis and how tough that is for doctorsThings he didn’t mention……………………The AMA’s long, long history of opposing universal health insurance including 1994

Things he featured prominently………………The AMA’s proposal for tax credits for the uninsuredThings he didn’t mention……………………That those proposals do almost nothing to reduce uninsurance

Things he featured prominently……………….How Pay for Performance was unfair on doctorsThings he didn’t mention……………………The AMA’s long, long history of opposing quality improvement

Things he featured prominently……………….How Medicare pay rates have fallen by half over timeThings he didn’t mention……………………The vast real increase in physician incomes since 1965

Things he featured prominently……………….How physicians will drop Medicare patients if fees go downThings he didn’t mention……………………The research that shows that this is untrue and an empty threat

Things he featured prominently……………….How other countries government’s paid for doctors’ ITThings he didn’t mention……………………How other countries doctors earn much less than him and his colleagues

Things he featured prominently……………….How the government should pay for physician IT but not mandate its useThings he didn’t mention……………………Every other business has been force to get IT to better serve its customers

Things he featured prominently……………….How Canada has rationing and is going to allow some private medicineThings he didn’t mention……………………That low–middle income Canadians don’t go bankrupt from the cost of health care

Yup, apparently it is just everyone else’s fault and physicians have no need to change anything.

I am on record as wanting doctors to run our health care system. I want physician organizations to get the money and decide its rational allocation . But apparently organized medicine’s response is to bury its head in the sand and demand that the rest of us hand them a blank check, and let’s all pretend it’s 1972 again.

Please please someone tell me that this guy is an anachronism and that he really doesn’t represent physician opinion….or else I will get even more depressed…

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11 replies »

  1. Tom L: Agreed and perfectly phrased.
    TomH: Great response. But I promise, it’s not “cheap demagoguery.” It’s actually terribly expensive demagoguery. Tongue-in-cheek, but even so.
    Scott: Thanks, I appreciate the praise and constructive criticism.

  2. Matt S. –
    I agree that I am splitting hairs, but the devil is always in the details. Your rebuttal is good.
    I cringe whenever the AMA is quoted in any fashion because I just don’t accept them as an expert source in anything. They have very little credibility with me because they only represent a minority of practicing physicians.

  3. Much appreciate the references regarding senior wealth. Here are the basic issues.
    1. Seniors have more household wealth than younger Americans. Most of the disparity, though not all, is due to home equity. Here’s the relevant numbers on median net worth from the Census Bureau report that Tom Leith cites:
    75+ 19,025
    70-74 31,400
    65-69 27,588
    55-64 32,304
    45-54 23,525
    35-44 13,100
    -35 3,300
    2. The Census Bureau notes that excluding home equity when comparing net worth is important “for households with retired householders.” That’s because the householder pays property taxes on a sharply reduced income. And the equity cannot be freely used to substitute for lost income. Financial counselors advise seniors to avoid all forms of home equity loans as long as possible, because the equity may be needed to pay for long-term care. That’s not a financial threat faced by any other age group.
    3. Median income drops by almost half after 65, from $49,192 to $25,316. (2004 numbers from AARP) Also, the poverty rate for seniors is about the same as for other age groups – something one would not expect if seniors were rolling in money.
    My point here is not that seniors deserve special treatment. In fact, I agree with Matt S. that it’s terrible public policy to create a universal health coverage program but restrict it to one age group. But we should avoid conflating that valid point with cheap demagoguery about wealthy seniors. Let’s avoid the politics of resentment, shall we?

  4. > Medicare recipients have twice the
    > net wealth of people under 65? Source please.
    US Census Bureau.
    The statement is true enough even if we exclude home equity, which there is no reason on earth to do. We have such friction-free capital markets here that the equity in one’s home may be converted to cash, in full or in part, with a few simple strokes of a pen. To say that home equity is not “liquid” is just silly.
    > the elderly are far less poor[…] thanks to
    > social security and medicare
    Just because somebody gives you something doesn’t mean you’re not poor.
    > Please please someone tell me that this guy is
    > an anachronism […] or else I will get even more
    > depressed
    He is an anachronism, but I think he does represent physician opinion pretty well. They do not want to face a knowledgable buyer, period. Here is some electronic Zoloft.
    t

  5. [Ah, Jack Daniels. We meet again. And I see you’ve brought your trusty sidekick, Random Capitalization. Gentlemen: a pleasure. As for you, Random Caps, I’m just going to call you Rocks n’ Coke from now on, since you and Jack seem to go together so naturally. Seriously, Jack, I kid. But next time, hold the Rocks n’ Coke.]

    Jack, I didn’t say that every doctor was in the AMA. I said that the views of the AMA were more representative than most people think. I know this from experience in my job. In addition, simply because 70% of doctors don’t belong to the AMA doesn’t mean that they don’t agree with what the AMA says.
    Simply because a lobbying group is not in the top ten doesn’t mean that group is not powerful.
    A lobbying trade organization? Really so much different than a union? I didn’t even say the AMA was a labor union (but even if I did, that wouldn’t be a stretch usage, either), I said they approximate a union. It’s hard to believe you are actually splitting hairs with me on definitions. Trade unions can lobby. In fact, I would say that unions are political by nature. Seems like the AMA similarly engages in things that organized labor does, such as providing benefits to members, fostering political activity, spurring industry action…almost like a union, no?
    As Scott points out, they do not collectively bargain. So yeah, that’s a valid point. But they do signal potential strategies to those that bargain. So I guess they’re 3/4 of a union. To re-state, the AMA approximates a labor union…oh, wait…that’s what I said before.
    Wealth increases with age. There’s a million sources for this, I’ve listed two below. In the post WWII historical period, the elderly have gone from being one of the poorest groups to being one of the wealthiest.
    1. For style, here’s some stats from the AARP. Don’t forget that the younger cohorts are somewhat larger than the older ones (for now…). Note how the numbers change as you move left.
    http://assets.aarp.org/rgcenter/econ/graphics/dd44_2.gif
    2. Scroll down to “Increase in Wealth by Age” and read the last sentence. Again from the AARP. I mean, really.
    http://www.aarp.org/research/economy/incomedist/aresearch-import-322-DD44.html
    As for excluding home value, I’d argue we shouldn’t do that. If we did so for the elderly, we’d have to take all the money that the younger, non-home-owning community pay into their mortgages and subtract that out from their income, since that money is spent on attaining a home (to cancel out for the cost of wealth accumulation). Homes are actually pretty liquid these days: it’s (eerily) easy to take a home equity loan.
    Anyway, the elderly (who vote) have been voting themselves entitlement benefits since button shoes were stylish, Social Security and Medicare leading the pack.
    The point: the elderly are wealthy. And we continue to subsidize their wealth all the time…perhaps some national guilty conscience for our grandparents’ grandparents being poor? Maybe. And it’s not just that we subsidize, either…we subsidize into programs so much that by the time we get into those programs, they’ll be little money left, if any.
    Scott, again, from my experience on the negotiation side (especially with large physician groups), what the AMA secretary had to say rang true with what many, many docs believe. Dollars to donuts, it’s much more than you’d think. Especially for specialists, who are by far the highest paid docs in the land.

  6. Hmm. Medicare recipients have twice the net wealth of people under 65? Source please. And let’s exclude home value, since that’s not a liquid asset.
    I wouldn’t mind seeing a comparison of non-public income between the elderly and the non-elderly. My recollection is that the elderly are far less poor than they once were, thanks to social security and medicare, but still poorer than the American population as a whole.
    It’s not as if the U.S. passed Medicare because the AARP asked for it. It’s just as close as the AMA would let us get to universal health coverage in 1965.

  7. I do not belong to the AMA – never have, never will.
    Matt S. – you may think (loud and clear) that the AMA is a labor union, but you may need to re-educate yourself on labor relations, collective bargaining, mandated membership rules, etc. There cannot be a “union” if the members cannot collectively bargin with payors.
    The AMA is a trade organization/political action committee – no more, no less – that represents fewer than 1/3 of physicians in the U.S. – very few clinicians care or support anything that the AMA has to say.

  8. Just to clarify: Medicare for all is something I’m not for. But getting us all into one risk pool is something I do entertain.

  9. Guys get a grip.
    The AMA recently “boasted” that just UNDER 30% OF ALL DOCTORS WERE MEMBERS, thats after a massive membership drive.
    70% of all doctors have NOTHING to do with the AMA. Lets quit pretending that the AMA is some vast mighty force with a lot of clout on capitol hill.
    If you ranked the dominant lobby groups in Washington DC, the AMA would not even make the top 50. If you ranked the AMA among healthcare lobbying organizations, they would not be in the top 10. Medical malpractice TRIAL LAWYERS have more lobbyists and funding in DC than the AMA does.
    Matt S you obviously dont understand what a labor union is. The AMA is a lobbying trade organization, not a union.

  10. Mr. Holt,
    Sadly, your analysis hits the nail on the head. Just to say it again, loud and clear: the AMA is can be approximated as a skilled labor union, using any and all influence to achieve better outcomes for members at the expense of non-members.
    I can tell you that from my experience on the negotiation/insurance side, everything the AMA secretary said is much more representative than most people believe. Not all doctors are like this (and thank goodness for them), but many physician’s views are just as simple and polarized, show a shameful resistance to all attempts at critical thought, and represent the purest form of short-term, naked self interest. In my mind, we can thank some truly awful historical precedents in this country for the deeply entrenched and shameful entitlement that we see from the secretary of the AMA.
    As for Eric, while I don’t agree with everything he says, his statements about the inefficiency of Medicare are spot-on.
    AN ASIDE TO THIS DISCUSSION:
    Ethically speaking, Medicare is flawed from a simple equity standpoint: Medicare rewards a person based on age. However, the average Medicare beneficiary has roughly twice the net wealth as the average person paying for Medicare. As such, Medicare is, for a large percentage of the population, a classic “regressive tax” in that it takes from those with less wealth and gives to those with more wealth…and it incentivizes those with more wealth to over-consume, making the tax even more regressive over time for many of those taxed. Is it, in net, a regressive tax across all of those who pay and all of those you benefit? I do not know. But it certainly is for many, and this could be fixed by simply eliminating the reliance on age. Income (and, I would argue, _only_ income) should be the measure of whether or not to assist a person with paying for medical care. Age is the wrong metric.

  11. Let’s focus on the medicare issue. It is a presumed ‘given’ that the solution for universal coverage for many means medicare for all.
    I am on record, and maintain, that the passage of the medicare legislation CREATED the current health care crisis. Also, as I have written here before, medicare is not a monolithic system, but rather THREE different systems (Part A, B, and D). This has to do with funding streams and rules.
    The magic of LBJ in 1965 was to pass legislation to please everyone. If you must focus on doctors, the charge whatever and get paid for it behavior of the 1970s led eventually to the SGR fiasco of the 1997 balanced budget act. To lump in the behavior and income of those who were in practice 35 years ago, 20 years ago, 10 years ago, and today– is like looking at the New York Yankees success over 4 decades and forgetting that for 15 years straight, they won nothing.
    The failings of medicare are legion– out of control costs, ridiculously inaccurate cost predictions at the program’s outset, artificial price controls on medical products (like orthopedic implants and durable medical equipment), the creation of the arcane billing system subsequently adopted by the private sector, and a prohibition of physician ability to allow market forces to set rates.
    You are absolutely right in that the AMA (whose prominence and prestige is much less than 40 years ago) shamelessly plugged for its members during the medicare debates. You are correct in saying that it did nothing to prevent the reimbursement explosion of the 1970s. They even supported the SGR formula in 1997!
    But you reserve much criticism for the AMA that could, and should be equally directed toward other trade organizations who have so much at stake financially in our system– technology companies have enormous sums to make if IT is mandated, other organizations have billions to make to administer any P4P system, trial attorneys- well, enough said.
    You are also correct in saying that doctors do not act in their own best interests— we continue to participate in the medicare system. The cuts to date have had almost no direct impact on participation rates overall. A close to 45-50% inflation adjusted cut in reimbursement over the next 5-6 years, I believe, would change this, but I do not know where the breaking point is.
    But access has declined ((and very difficutlt to measure): for example, try finding a new orthopedist to take on your case if you need your hip or knee replacement revised; try finding a spine surgeon to take on your case if you have had a previous procedure on your back— this is a huge problem. With the government setting the rates, why should docs spend 3-4x the work with much increased liability for only 15-20% more reimbursement. Matthew, it is unlikely you would bid a job that took 4 days of work only 15% more than a job that took only 1 day.

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