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.