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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17 replies »

  1. 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 Massachusetts, then no, you can’t.

  2. 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 my own ‘opinions’ about containing costs until I worked at a military hospital as a civilian contractor. These organizations compete internally for allocation of ‘fixed dollars’ by ‘proving’ they produce. Departmental budgets are determined by ‘utilization, which is monitored by evaluating RVUs generated by providers. If RVUs diminish so too does their budget. (or overall institution). Coding experts regularly ‘train’ providers to ‘upcode’ their services. The military in particular has their own system of using
    CPT codes. I would be honest in stating that this is not due to greed, but the fear that by not reporting every RVU nickel that department would be penalized. The emphasis is to ‘spend every dollar’ each fiscal year for fear of losing it in the next budget cycle. I was amazed one day to see an emergency patient who came in with a ‘simple migraine headache’ The ER provider note’s treatment plan included a “screening MRI”. Perhaps this is the new paradigm for younger providers who do rely much more heavily upon technology. Providers in this environment also seem to order more lab tests because they don’t think it ‘costs’ the system’ when a patient (or they ) never see a ‘bill’ to whomever supplies the services. Particularly in the military these services are provided by ‘outside contractors’ who must be reimbursed as well.
    Those who observe “our system’ from 40,000 feet really have inadequate knowledge of how the systems work internally. Those who regulate have little involvement in how much it costs to regulate. Regulatin and oversight is contracted out to third parties, whose costs are ‘hidden’ Congressman Pete Stark frequently tell us the overhead for medicare is 2-3%. That is just not true. Medicare costs us much more due to cost shifting to private payors and hospitals, frequent administrative changes in coding, because their rates are miserably low, and other payors pick up the difference. Medicare and Medicaid do not share in the costs of the uninsured. This is passed on to County and State governments. Statistic lie.
    If you are upset about the government running General Motors, just wait….

  3. 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 requirement to use certified EHRs affects only Medicare and Medicaid reimbursements.
    The New Jersey bill would affect all health care providers, even those who do not treat a lot of Medicare or Medicaid beneficiaries.
    If approved, it is unclear how New Jersey would enforce such a law. It also is unclear how the bill would affect health IT products, such as practice management software, that CCHIT does not certify.
    According to FierceEMR, additional questions would arise if HHS decides to recognize multiple certifying bodies.
    Blogosphere Reaction
    The bill has garnered a lot of backlash in the blogosphere, FierceEMR reports.
    Al Borges, a Virginia internist and oncologist, reports that the bill’s sponsor, Assembly member Herb Conaway (D), is active in the New Jersey chapter of the Healthcare Information and Management Systems Society (Versel, FierceEMR, 6/11).

  4. 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. And how far behind is the AHA?
    One disagreement I have with you is that I think bipartisanship is irrelevant. By the time the sausage has passed through the political meatgrinder, the Democrats couldn’t pass the kind of reform you (and I!) want, even if they only aimed for 51 votes.
    That’s why I’ve kept arguing that we need to take a two stage strategy: get universal health care with minimal reforms to improve the value of care now (just enough that that Obama can claim victory on paper). Once that is in place the pain will force, and provide the leverage for, deep reforms within a few years.

  5. 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 hand, less politiciazation (or more bipartisanship) means that not much will get done and the situation wont change. IMHO the patient needs radical surgery, the time for watchful waiting is over. But we’re going to get a biopsy…

  6. 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. We need more thoughtful, informed voices, and less politicization – on all sides – of this very important subject.
    Evan Falchuk

  7. 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 States, which is why the recent Atul Gwande article in the New Yorker about insane practice variations in the U.S. is so important. Keep in mind that Dr. Gwande was citing Dartmouth Atlas data from the Medicare program, precisely the program that Hacker et al. think is a model for a new public plan.

  8. 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?

  9. 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.

  10. 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.

  11. 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 like but, in my best Seth Myers, really?
    The AMA may be off its rocker in a number of ways relating to reform, but at least they can get people’s attention across party lines in ways partisans can’t. I see their (and AHIP, and others) role being to stop the train that’s currently running full-steam away from Reasonville and hurdling off a cliff.
    Dan M.

  12. 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 ..

  13. 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.

  14. 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?

  15. When I was a first year med student in Germany, the anatomy prof said in one lecture: I see now that, since earning and carrer expectations are much lower now, students have changed; they are not in it for the money, and I am happy about that (in Gremany at that time, there was a marked over supply of doctors and it was hard to get into a reasonable residency, as opposed to the 70s, where very doc was getting easily in a busy private practice and the top percentile income wise).
    Why do I mention this senile anecdote (I am actually not that old, that happened in 1990)? I do believe that very many US doctors are overly motivated by money. I repeatedly sat in meetings where boosting certain tests/services were discussed, not based on needs, but based on income considerations. And these meetings happened in regions that, in terms of utilization, are probably considered much more reasonable than McAllen, TX.
    Fact is: in the US, we have a patient entitlement problem, and a physician entitlement problem. I am a physician and certainly do favor good reimbursment for docs doing mostly hard work requiring a lot of training and carrying a lot of responsibility. But maybe we need a cap, like in the case of CEO compensation: a physician should be doing quite alright (incl. repayment of loans) making 300 to 350 K at the most. And yes, I think it’s better to educate docs with the help of a fellowship, docs who later hopefully are less money driven. But please excuse me now, I have to go to a communist party meeting.

  16. It has become a habit to blame the doctors and the lawyers. They are as human as we all are – look at the not so greedy corporate executives.
    If you really dig deeper, the group that tops the list who is mostly responsbilt for healtcare crisis is hospitals. Most of the waste is there. Now, then come the second tier in which insurance and physicians have big role. But if you keep on threateing the doctors for lawsuite, then they have to over treat. Thus, before we complain about them, we need to reform the policies, compliance processes etc and then hold them accountable.
    In my analyis, I think Insurance industries should be given the responsbility to reduce the cost. I think they have not yet figured out except the negotation. What they do not realize is that even though they can negotiate the cost down, providers compensate for it by providing additional services.