Matthew Holt

Op-Ed: How I’ve Missed the AMA….

6a00d8341c909d53ef0105371fd47b970b-320wi Over at Dr Val’s Get Better Health site Evan Falchuk from Best Doctors is very grumpy about Steve Pearlstein’s column in the WaPo. Pearlstein rewrites Gawande’s rewrite of Shannon Brownlee’s Overtreated. Not much surprise here—everyone is doing it and despite my cynicism Gawande’s piece in The New Yorker has hit a nerve, not least because Obama told everyone to read it—showing that he’s way more influential than Orszag in the White House despite what we wonks all think. Orszag by the way has been hammering on about the Dartmouth stuff for years and even dragged me into his office at CBO back in 2007 to suggest THCB kept plugging away about practice variation. But obviously no one in the White House was heeding his back reading of THCB, until the boss came and told them all to read Gawande.

But it was Pearlstein’s comments in the subsequent webinar that really teed off Falchuk and veered him towards the side of unreason. Essentially Evan feels that Pearlstein blames individual physicians for what the overall system makes them do. Even though his solutions (socializing medical school debt and making physicians practice where the government suggests) are mass solutions, Evan clearly feels that individual doctors are being accused of greed in the Pearlstein/Gawande/Brownlee/Wennberg world view.

So how are the mass of doctors responding?

The AMA has a long and inglorious history of pig-headedly opposing health reform and universal coverage. But it has now come around and believes in insurance for all. Except of course that it doesn’t want it if that insurance comes from an extension of a public plan—after all physicians have suffered so much since the introduction of Medicare (well other than their real incomes have gone through the roof).

But by jumping in and maintaining their stance of “give us more paying customers, but don’t in any real way limit how or what they pay us”, the AMA is proving Pearlstein right. Lots of doctors, and likely most AMA members, would stand to see reduced incomes under a rational Dartmouth-style universal care plan—if only because we need more generalists and fewer highly paid specialists. And that doesn’t even mention reducing the excesses caused by entrepreneurial doctors sticking it to the taxpayer that Gawande found in Texas. And the most likely way any serious effort to reduce health care costs will happen (under the current reform scenarios) is via a strong public plan.

This of course is the same AMA that just last week laughably said that it was going to help save money by helping reduce inappropriate imaging, hospital re-admissions, and over-prescription of anti-biotics. (Read page 17–19 of this letter to Obama if you want a good chuckle).

Unfortunately the AMA, which to be clear only represents about a third of American doctors and in general over-represents specialists and those in small practices, hasn’t got any credibility when it says it’s for reform, but against any real efforts to sacrifice in the process. Yet as a member organization whose individuals will rebel if they are actually expected to make any sacrifices, it doesn’t have the ability to deliver even on its modest promises.

But as a student of the health reform history, and a cynical observer of interest group behavior, I’m always amused when the AMA decides it’s time to get back in the ring. It’s a pity that as a policy wonk I can’t take them seriously, and its more of a pity that politicians feel that they must.

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Deron S.Gary M. Levin M.D.John Haughton MD, MSjdEvan Falchuk Recent comment authors
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jd
Guest
jd

Deron, it depends on what you believe can change in the system. If we allow greater use of physician-extenders (RNs or less) for routine tasks, have 20% of visits replaced by e-visits (I’ve seen an estimate that at least 30% could be replaced without patient harm), reward quality of care rather than quantity so that physicians stop doing some of the useless stuff, and make a few other changes…then yes, we can have 100% coverage with the current supply of physicians. But, if you don’t change those things and just get everyone covered, like they have done so far in… Read more »

Deron S.
Guest

jd – Do you think we can sustain 100% coverage with the supply of physicians we have?

Gary M. Levin M.D.
Guest

It is be a sad fact that those who propose a government run health care system, are misinformed about containment of health care costs. They argue that ‘non-entrepenurial’ systems elimlinate abuse and misuse of health care resources. The end game of reducing costs to the patient, and payor is offset by the increase in bureaucracy. Institutions, and provider groups will hire watchdogs as overseers to monitor the ‘quality’ of healthcare. The expense of this will be considerable to providers organization. The cost however will be absorbed and shifted to the ‘producers’ of the organization. I was mistaken about this in… Read more »

John Haughton MD, MS
Guest

From iHealthbeat… Thoughts / Reactions? John Haughton ————————– New Jersey Bill Would Outlaw Health IT Not Certified by CCHIT New Jersey lawmakers are considering a bill that would prohibit the use of health IT products that are not certified by the Certification Commission for Healthcare IT, FierceEMR reports. Under the bill, anyone caught selling or distributing such a product could be fined up to $5,000 per violation. The federal stimulus package includes financial incentives for health care providers who use certified electronic health records and eventually penalizes health providers who do not make the transition to certified EHRs. However, the… Read more »

jd
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jd

Matthew, as cynical as you can be, didn’t you always think that the politics was going to prevent deep reforms to the delivery of, and payment for, care at this time? It was inevitable that whatever was proposed to reduce costs, if it appeared to have any teeth, would be resisted by the providers and suppliers in direct proportion to the perceived effectiveness of the reform. Note that the AMA didn’t wait for Baucus’s version of a public payer, but are instead looking to shape it so that either it doesn’t do much to control costs or it disappears altogether.… Read more »

Matthew Holt
Guest

Evan, actually the “unreason” remark is just me being sloppy. I read the piece very fast from Val’s tweet and thought that she wrote it–and I needle her all the time about being the “voice of reason”. On realizing that you wrote it, I changed all the references but sloppily left that one in. 🙂 But it is possible to be dismayed at what collectively physicians have done to American health care while recognizing that the vast majority on an individual level are disappointed with both their and our situations and want us all to do better. On the other… Read more »

Evan Falchuk
Guest

Matt, Thank you for the post. Pearlstein’s work didn’t cause me to veer into unreason. I did that a long, long time ago. I don’t have strong views on the AMA’s position on reform, except to say if a reform idea is good it ought to be able to withstand some criticism. And in a debate between Obama and the AMA, I think Obama wins. But this is beside the point. Pearlstein is entitled to his views and is of course an accomplished journalist. But a lot of what he said in his web chat was really off the wall.… Read more »

Skeptic
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Skeptic

Matt, if I thought the architects of the public plan currently being considered by Congress were serious about changing the provider payment system to improve care coordination, promote evidence-based medicine, and drive lousy physicians and hospitals out of the market I would be storming Washington DC with you. My problem with the public plan is that the stated rationale (for example, see Jacob Hacker’s paper) relies too much on the belief that administered pricing and lower administrative overhead is the path to a better health care system. Much more needs to be done to improve health care in the United… Read more »

Matthew Holt
Guest

I think Skeptic has a fair point….but only substantial reform of the payment system can change how health care is delivered and that will by definition mean changes to doctors incomes (and others’ incomes too like hospitals). Now even if we say we’re going to do that (as we did with DRGs and RBRVS) with a new public plan, it doesn’t mean that the new plan won’t be subverted as were they.
But if we DON’T get a new public plan, can you see any chance of these changes happening?

Skeptic
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Skeptic

Dear R. Watkins:
I am all for marginalizing the AMA, but you miss my point. If Congress and CMS lack the political will to reform the Medicare physician payment system, why would a new public plan be able to do any better? Based on what I’ve read in the NY Times, it appears that the new public plan being crafted by Ted Kennedy et al. will perpetuate all of the perverse incentives embedded in the current Medicare payment system (although at reimbursement rates that are perhaps 10% higher). This doesn’t sound like “reform” to me.
Skeptic

R Watkins
Guest
R Watkins

Skeptic:
The current payment system is completely the product of the AMA’s RVU committee, whose recommendations are rubber-stamped by Medicare. The AMA deserves to be marginalized.

Dan M.
Guest

I just am continually saddened by the rush to screw this up. On election night I said, “We got what we wanted, now let’s see if we get what we hoped for.” While I certainly understand that bold initiatives are risky, often seem wrong-headed and arouse the humors of their detractors (see also: “putting a man on the moon in this decade”) I remain puzzled as to why reform has been set up as an “all or nothing” gambit that has to be tackled in the first 200 days. I understand the mechanics of political capital, perceived mandates and the… Read more »

David F.
Guest

We hope that now all want to be involved in the medical system is improved, but not because they think the medical system is very much less come to trust that these events will reduce the cost and benefit millions of people throughout the country, and they say that things in findrxonline improved from 60% in recent weeks, hopefully this is the case ..

Health Plan Veteran
Guest
Health Plan Veteran

Perhaps Obama needs to get the AMA’s attention by suggesting that a government public plan is a better option for AMA membership than a single-payer government program where they would become salaried employees. The latter option, unfortunately, may be clearest path to controlling health care costs and addressing unnecessary utilization of health care services. Time for the AMA to embrace the Obama administration’s theme of personal responsibility.

Skeptic
Guest
Skeptic

Matt:
If the Medicare program (or Congress) hasn’t figured out a way to restructure its physician payment system to reduce payments to overpaid specialists and increase payments to underpaid primary care MDs, what makes you think a new public plan would do any better?
Skeptic