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  1. Matthew:
    I haven’t been able to get this article out of my head since I first read it on September 14th, because it described what I believe to be one of the saddest things to happen to American Medicine.
    No, I am not referring to the fact that doctors’ Medicare reimbursements have been going down. What I am referring to is that over the years, as a profession, doctors seem to have lost their love for (and commitment to) their patients, and have gained an ever-increasing love for money.
    If you told a “real doctor” – and by this I mean one who truly loved his work and his patients – that you were going to lower his (or her) salary and that he (or she), therefore, would only be able to spend five minutes with each patient, a “real doctor” would respond in one of two ways:
    Either the “real doctor” would say, “The heck with this! Go ahead and dock my pay. I won’t practice medicine this way. I’ll just have to earn less money.”
    Another, more political “real doctor” would get together with other doctors – in this case, internists, pediatricians, and family practitioners – to lobby for increased understanding of, and respect for, the need of a “real doctor” to spend more time with patients, and therefore get better reimbursed.
    Now that’s a “cause” that patients would get behind – without being prodded by the AMA.
    What, instead, has been the response of today’s doctors?
    With nary a squeak or a squawk in protest, they either bow to the “demand” to see patients for 5 minutes at a clip, or they choose to enter another, better paying, specialty. Or, they quit the medical profession entirely and go into a field where they can make even more money.
    How do I know what a “real doctor” would do? I know because I grew up with one: my Dad, a general practitioner who practiced medicine in the 1940s until he died in the mid-‘70s. Though he died 30 years ago, my Dad complained even then about the greed of his fellow doctors. (To read more about my Dad and his disappointment in his profession, please see the article about him, “Medicine in the ‘Good Old Days’” on my website, at http://honestmedicine.typepad.com/medical_watch/2006/08/medicine_in_the.html.
    What I didn’t say in that article, and perhaps I should add it, is that my Dad’s colleagues often teased him for charging poor people only what they could afford, and not chasing them down for the rest. I know that, if my Dad were alive today, he would not only be perturbed with his fellow doctors, as he was back then. He would be ashamed.
    The ironic part is that, while my Dad was never rich, he did okay financially. But he did better than okay in life because he was a happy and satisfied doctor who loved serving his patients.
    Recently, Dr. Catherine DeAngelis, editor-in-chief of JAMA, was interviewed on WTTW-television in Chicago about physician/industry ties. At one point, talking about doctors’ feeling of entitlement for the “extras,” she said: “I think it’s part of this culture that was developed and I don’t understand it. Physicians make a very decent living. We certainly are in the top at least 10% of wage earners in this country. And why do you need this extra money?”
    Then, asked about the decline in Medicare reimbursements, she answered: “I don’t know the exact figures for people in private practice. . . you have to work much, much harder to earn the same amount of money. But still, the amount you earn is pretty decent.”
    Julia Schopick
    (To read the entire transcript of Dr. DeAngelis’ interview , go to http://honestmedicine.typepad.com/medical_watch/files/DEANGELIS-MARIN-WTTW-FINAL-TRANSCRIPT.doc

  2. Lynn and Scott,
    Actually, in 1950 or thereabouts, Walter Reuther, then President of the UAW, wanted a multi-employer health insurance plan that would cover not only Big Three workers but parts company employees as well. Charlie Wilson, then CEO of General Motors, was dead set against this idea and wanted each company to provide insurance for its own workers instead. That is the system that ultimately prevailed.
    The essence of compact between the company and union for the next several decades was as follows: the company will provide generous wages and benefits. In return, the union will provide labor peace, stability and not cause trouble, though strikes are, of course, allowed at contract renegotiation time. The company will pass on the steady increase in costs to car buyers by raising prices as necessary. Afterall, with much of the European and Japanese industrial infrastructure destroyed or damaged during World War II, U.S. customers had no place else to go for cars besides the Big Three (plus, at the time, American Motors and Studebaker). They did not pay adequate attention to either quality or, eventually, foreign competition until it was too late. They are now paying the price for that arrogance and mismanagement.

  3. “the insurance industry will go out of business OVERNIGHT if socialized medicine passes congress.”
    Highly doubtful.
    In fact the same companies that administer Medicare and Medicaid today under contract to the government would take on a proportionally greater role in any national single payer plan. Their private business would decline, their public-sector business would expand enormously. The composition of their business might even continue to include a mix of risk-based contracting (as in Medicare B, C, and D) or administration only (as in Medicare A).
    Even individual health insurance would not disappear, because there will likely continue to be demand for it – people will want to buy individual policies that fill in the deductibles, copays, and coinsurance that are likely to be a part of any affordable federal plan. Of course, Congress could attempt to prohibit private health insurance of any kind. That idea did not get very far the last time it was seriously proposed about 12 years ago.
    Further, it is highly doubtful that the Congress will be interested in legislating any insurance companies out of business – not because they like insurance companies, but because employees are voters.
    So I dont expect that a national single-payer health insurance plan would result in the demise of the likes of United, Blue Cross, Aetna, etc, Even smaller companies would survive.

  4. I agree Lynn, the UAW has done more for private insurance benefits than any other special interest group (other than the insurers themselves).

  5. Matthew: You forgot the critical role unions played in fighting to prevent universal health coverage. (Look where collective bargaining is getting 75,000 UAW members at Ford, now.) The AMA couldn’t do it alone.
    Don’t forget to give credit to Southern politicians who fought against Medicare because God forbid hospitals would have to integrate!
    I see BIG PHARMA and BIG BLUE and the lobby managing the doctors these days the way hospital administrator have always done it–keeping them fighting among themselves then sending them off to fight malpractice reform. It must be successful because public decision makers have been able to avoid true reform.

  6. It’s ironic that during the same 20 years of seeing the rate of health care costs increase dramatically, and the government and private payers have looked for ways to slow their health care costs, was when the shift from the institution-based, inpatient setting to community-based, ambulatory sites for treating the majority of the nation’s cancer patients happened. The Chemotherapy Concession gave oncologists the financial incentive to select certain forms of chemotherapy over others because they receive higher reimbursement, and this has prompted in large part, additional costs to the government and Medicare beneficiaries.

  7. Hmm… anonymity on the Internet? Must be me! err. Jason D. I give my full name and web site to everything I write about health care. My phone number is a google away. Even my nickname on non-health sites is well known (boltyboy). Which is more than you appear to do!
    Why would I be harrassing Kevin?
    Finally the passing of Medicare was a great irony–yes they opposed it, but it also ushered in a great era of increase in incomes.
    And if you think the AMA had no power in 1994 you were simply not paying attention. Their power is relatively less compared to the insurers and pharma cos than it was in the 1960s, but that’s not to say that they havent got any!
    Scott. You may well be right. My overall take is that rational docs like you will need to figure out what the sustainable deal is that can be created so that we can have a health system going forward. That deal is not going to be created by the AMA’s current leaders.

  8. BTW, AMA fought tooth and nail against Medicare in the 60s, which Holt claims resulted in doctors hoarding money and receiving huge income increases from teh federal treasury. Ironic that the AMA would oppose something that would eventually result in doctors getting paid MORE not less.
    Yet despite the AMA’s vocal objections, Medicare passed anyways. But yet you didnt mention that.
    The AMA is not nearly as powerful as you are making them out to be.

  9. Holt you seem to have a delusion on how powerful the AMA is. Pharma and insurance industry lobbying is literally 10 times more powerful than the AMA. Count hte number of lobbyists on capitol hill if you dont believe me. AMA reps are outnumbered 10 to 1.
    In a socialized medical system, doctors will still be employed, although they might make less money. However, the insurance industry will go out of business OVERNIGHT if socialized medicine passes congress.
    The people blocking universal med is the insurance industry. The AMA doesnt support it, but their objections are vastly overshadowed by the insurance industry lobbying.
    BTW, I have you pegged as a certain “anonymous” poster who goes trolling around on Kevin MD as well as this site, screaming about doctor “monopoly.” If any of hte rest of you frequent that site, you know who I’m talking about. YOur rant in “spot on” is virtually identical to the posts on that site as well as periodic rantings by another poster on this blog.

  10. Good article Matt. I’m glad you pointed out that less than a third of docs belong to the AMA. I am not a member, although I am in the small group/independent category of physicians.
    One thing to watch out for: don’t assume that because physicians haven’t left Medicare in the past that they won’t in the future. Eventually there is a breaking point and in San Luis Obispo County we are very close to it. Nearly half of the primary care docs and some specialists are either not accepting new Medicare patients or have switched to “non-participating” status. Access to care here is a big issue for seniors and it may get worse before it gets better.
    Just an anecdote from my neck of the woods.