The AMA’s Forgotten Fight Against Physician Greed

Michael MillensonPerhaps the most well-known part of the 1965 Medicare creation tale is the opposition by the American Medical Association (AMA) to “socialized medicine.” Yet with financial incentives assuming a new prominence for provider and patient alike, we shouldn’t overlook the AMA’s equally unsuccessful battle against the excesses of capitalistic medicine. The forgotten story of the professionalism’s failure to contain physician greed provides an important policy perspective.

The Myth Of Medicine’s ‘Golden Age’

Medical practice pre-1965 is often portrayed as a mythical “Golden Age.” The truth, as I found researching my 1997 book, Demanding Medical Excellence: Doctors and Accountability in the Information Age, was that the post-war years were a time when way too many doctors grasped for the gold.

The most common “entrepreneurial” excesses were fee splitting, where a specialist paid a kickback to the referring doctor, and ghost surgery, where a surgeon secretly paid a colleague to operate on an anesthetized patient. The first surgeon paid the “ghost” a small part of the total fee and pocketed the difference. Even worse was rampant surgical overuse, where common excesses included appendectomies for stomachaches and hysterectomies on young women with nothing more than back pain.

Although professional societies wielded far more influence than now, efforts by leaders of the AMA and the American College of Surgeons to stop these abuses repeatedly fell short. Doctors “display a consistent preoccupation with their economic insecurity,” a 1955 report by the AMA concluded with discomfiting bluntness.

They think about money a lot — about how to increase their incomes, about the cost of running their offices, about what their colleagues in other specialties make, about what plumbers make for house calls and what a liquor dealer’s net is compared to their own.

A 1956 AMA poll found that 43 percent of patients thought their doctor charged too much, an opinion reflected in a 1959 cartoon in The New Yorker. A balding physician is pictured making a house call to an elderly matron. As she glares from her bed, the doctor opens his little black bag and wads of paper currency pop out. “Pshaw! I grabbed the wrong bag,” the doctor exclaims.

Despite this public unease, policymakers were unwilling to intrude on professional prerogatives. Economist Kenneth Arrow explained in a landmark 1963 essay that the market for medical care was unique because outsiders could not judge the quantity or quality of services provided. Instead, the “behavior expected of sellers of medical care is different from that of business men in general.…The ethically understood restrictions on the activities of a physician are much more severe than on those of, say, a barber.” Or plumber.

Medicare Takes Effect

This was the environment in which Medicare took effect on July 1, 1966. To appease the AMA, physician payment was based on a local calculation of a “customary, prevailing and reasonable” fee. However, doctors did not have to accept Medicare’s fee as payment in full (i.e., “take assignment”) for any individual patient. With professional self-control the only control, the rate of increase in doctors’ fees doubled. (The net income of nonprofit hospitals shot up 76 percent between 1965 and 1969, but that’s part of a different story.) Establishing a perennial policy staple, the very first National Conference on Medical Costs convened in June 1967.

Speaking at an AMA conference later that year, AMA president Milford O. Rouse noted that physician fees were rising faster than the cost of food and housing, and he urged members to address “efficiency, cost and methods of delivery” of health services in order to preserve freedom from further government intervention. As in years past, that plea did little to ameliorate profit maximization.

In July 1969 the Senate held hearings on Medicare and Medicaid fraud, with senators denouncing “ruthless providers of health services” who routinely charged the government two to four times what was billed commercial insurers. One general practitioner had billed Medicare $58,000 for home visits to 49 patients. Quipped Senate Finance Committee chairman Russell Long (D-La.): “Who says you can’t get a doctor to make a house call anymore?”

Later that month, President Richard Nixon declared the first health care “crisis.” John G. Veneman, undersecretary of what was then the Department of Health, Education, and Welfare, made a prophetic pronouncement whose candor is difficult to imagine today. Veneman declared: “In the past, decisions on health care delivery were largely professional ones. Now, the decisions will be largely political.”

Bipartisan Influences

And so they have been. The 1965 law envisioned voluntary oversight by local physicians of colleagues’ care. When doctors showed no appetite for second-guessing peers, the Social Security Amendments of 1972 authorized Medicare to disallow “any costs unnecessary to the efficient[emphasis added] provision of care” and established Professional Standards Review Organizations (PSROs). That pattern of periodic legislative responses to curb abuses of market power by physicians has continued ever since through Republican and Democratic administrations.

To give two prominent examples, the Omnibus Budget Reconciliation Act (OBRA) of 1989, signed into law by President George H.W. Bush, referred to increasing the “effectiveness, efficiency and quality of health services” and changed Medicare physician reimbursement from “usual” charges to fees based on the resources needed to provide those services. In that same vein, the Obama administration’s passage of the Patient Protection and Affordable Care Act of 2010 detailed a host of changes to physician and hospital payment under Title III, “Improving the Quality and Efficiency of Health Care.”

Buyers Become Less Timid

Back in the 1930s, the AMA opposed all health insurance on the grounds that “no third party must be permitted to come between the patient and his physician in any medical relation.” That set a pattern that implicitly intertwined the financial and clinical, whether in opposition to Medicare in the mid-1960s or in the mid-1980s, when the AMA’s top executive told The New York Times that Medicare’s use of diagnosis-related groups for hospital payment had doctors “worried that they’re not going to be allowed to practice medicine…based on their own judgment.” Medicare’s new payment policy was said to invade the doctor-patient relationship, and the AMA warned darkly of “rationing.”

Similar charges are regularly hurled at Medicare today. A more accurate characterization is that a program that began as a timid buyer of medical care has become a much smarter shopper. Rather than being “socialized medicine,” Medicare has been consistently molded by Republican and Democratic policymakers alike into a tougher and more demanding purchaser on behalf of the American public. That’s not rationing, but the rational economic behavior capitalism celebrates. Unsurprisingly, physicians, hospitals, pharmaceutical companies, and others who’ve lost market control aren’t eager to acknowledge this reality.

A 1993 poll by the AMA, at a time when the Clinton administration reform proposals seemed on the verge of becoming law, found that an all-time high of 70 percent of the public was beginning to lose faith in their doctors. Sixty-nine percent thought doctors were too interested in making money. The forgotten story of Medicare payment policy suggests there were times when the leaders of American medicine might privately have agreed.

Lessons Learned

Policymakers can learn several lessons from this history. To begin with, accountability and paying prudently strengthen the doctor-patient bond rather than weaken it. Unrestricted fee-for-service payment has often undermined public trust. It is telling that a recent cartoon in The New Yorkerechoed the exact same suspicion of misaligned incentives reflected in the 1959 cartoon mentioned above (and, for that matter, much earlier by Mark Twain and George Bernard Shaw). A physician looks at a clipboard with test results while speaking to an anxious patient sitting on the exam room table (no more house calls). The doctor says, “Of course, this could also be confirmation bias from me wanting you to get sick.”

At the same time, every method of physician payment has drawbacks and dangers, and value-based payment is no exception. “Better, smarter, healthier” is a worthy goal, but any incentive can lead to unanticipated and undesired consequences. Consolidation of commercial insurers combined with new payment strategies by Medicare could also push the pendulum too far in the opposite direction. Whatever the failings of fee-for-service physicians, health insurers, and large hospital systems, including those nominally organized as nonprofits, are hardly immune from abuse of economic power.

Consumers’ costs of care can be pushed up by the consolidation of local providers, raising prices, or by consolidation of insurers, raising premiums, or simply because certain “must-have” hospitals charge top dollar for their services. Some physicians could also be excluded from coverage by a health system that includes only its employed doctors in a plan or by a health insurer whose take-it-or-leave-it payment scale leaves some doctors out in the cold.

The more fundamental question is what “fair” physician payment really means in an era very different from when Medicare was signed into law. While physicians complain vociferously about income, a recent survey of median wages based on Bureau of Labor Statistics data found that six of the top 10 jobs were held by health care professionals, with surgeons leading the way.

Meanwhile, an article in the August issue of the AMA Journal of Ethics examining the history of “money and medicine” refers to the “ethical challenges” posed by “overconsumption” of medical services by patients with good health insurance, “aided and abetted by fee-for-service payment policies.” Doctors, in this reframing, simply “did their very best to accommodate the growing demand.”

For more realistic guidance to the future, policymakers would do better to consider a recent editorial in the Journal of General Internal Medicine that proposed a new social contract, one that secures appropriate income and autonomy for physicians in return for a professional embrace of genuine accountability. Whether or not this prescription is exactly the right one, the bipartisan history of Medicare payment reform should encourage policymakers to put aside polarizing rhetoric and thoughtfully engage in efforts to provide better care with smarter spending.


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8 replies »

  1. Try practicing “efficient” and “evidence-based” medicine, and see how fast (and how often) you get sued.

    We ALL know that a 3 y/o who bumped his head on the carpet doesn’t need a CT scan.
    We ALL know that 27 y/o women don’t need screening mammography.
    We ALL know that every 52 year old with low back pain doesn’t need an MRI.

    Just try telling that to the plaintiff lawyers when that 1:1,000,000 case has a head bleed, a breast cancer, or spinal hematoma. They do not care about ACP’s “Choosing Wisely” or Ottawa Ankle rules, or any other algorithm.

    The cost of providing medical care will continue to skyrocket in this country, as long as there are technological innovations (CT scans, MRI’s, genetic testing) and people who demand/expect these to be available to everyone everywhere.

  2. Michael, thank you for the perspective. As the son of a physician, and the father of a medical student, each generation often gets a bit myopic about their own experience. Every society tends to overly their culture norms on healthcare delivery. For Americans, capitalism is the default setting, even for markets like healthcare that don’t necessarily follow the rules. You get what you pay for. If the government and the citizenry what a different form of care delivery, there needs to be different rules for reimbursement- the ACA is the start of these new models. Ultimately healthcare is provided for patients, not for providers.

    However, in my experience there are a few physicians who live big. Most seem to be getting by. Starting late in life (my first job after training came at 35), mid life is often not as lucrative as expected. The current % of physicians who would not recommend a career in medicine for the children or others is a harbinger of a changing culture, one where many of the best, brightest and most committed may look elsewhere. As I look out on my daughter’s future, I see less control for physicians and more employment. I hope with these changing conditions there will be a recognition that the commitment and financial burden (most seem to graduate with something like $250,000 in educational debt) for our future care providers needs to be taken into account.

  3. First, thank you for the thoughtful comments. To be clear, I do not want to paint a “black and white picture” but to counteract a sepia-toned one of a “Golden Age.” Doctors should be paid fairly. Indeed, the irony is that Medicare raised doctors’ incomes as a whole to closer to what was fair than the “good old days” ever did.

    But at the same time, there needs to be oversight to be sure that societal goals (better care, appropriate costs) are achieved. The point of the article is that the drumbeat of support for “professionalism,” reignited by the AMA in a JAMA commentary earlier this year, ignores the fact that peer pressure alone is insufficient and always has been to counter overuse. Witness, by the way, the fact that the Choosing Wisely procedures, submitted voluntarily by specialty societies, have not included big-ticket items.

    The conflict is between appropriate autonomy and appropriate accountability. Those who think the individual patient can provide that accountability are well-meaning, but ignore the evidence that, when confronted by YOUR doctor when you are the one who is sick, this is not a “shopping” experience. For instance, even highly educated, upper middle-class patients in the Palo Alto area hesitated in one study to challenge their doctor because of being thought a bad patient.

    There are no bad guys here and no simple solutions.

  4. Very nice piece, Michael. As always, thoughtfully provocative. Payment reform is underway on all fronts, and the replacement system for SGR that will go into effect under Medicare in 2017-18 should put us on a new path, unless it gets politically neutered between now and then. There can no longer be any question that straight FFS must largely be discarded. It will take years, though, to build its replacement: payment on value, quality metrics, resource input, etc. In the meantime, docs who are able to — and especially those nearing retirement – will probably do everything possible to maximize their income. I personably think that by 2025 or so, the vast majority of practicing docs in the U.S. should be on salary, like most other working people. “Retired MD” below makes many good points. Practicing medicine is hard physically, emotionally and intellectually and has a special niche; doctors in the main deserve to be paid well, but with motivation (incentives) for doing well, too. We’ll get there, likely over organized medicine’s (AMA, etc) wishes and nattering complaints.

  5. Dear Mr. Millenson,

    I read your book a number of years ago. I agree that there is greed amongst some physicians, but there is greed in every profession. Most physicians I have known have been honest, and most have been involved in charity care at some time in their career. Lawyers, bankers, and businessmen are no different. Even consultants look to see how their competitors are doing, and what their billing rates are.
    But bashing all doctors will not solve the problem. While there needs to be better mechanisms to recognize offending physicians, there also need to be better mechanisms to recognize offending healthcare systems.
    The doctors are not always to blame. Hospital systems should share a good part of the criticism. Most physicians are affiliated with hospitals. Most hospitals have committees which review the care given by physicians. However, these committees’ actions are often thwarted by the hospital administration. The hospital looks the other way if a surgeon performs too many surgeries or has too many complications. The hospital does not protest if a medical physician admits too many patients needlessly. The hospitals are in it for the money, and they make it clear to these rogue doctors that this behavior is fine in their facility, but just to keep it hush, hush, and to use defensible documentation. The sanctions by Medicare for readmissions is a first step towards making the hospitals more accountable for their actions. Too bad it is the type of action that is needed to promote good behavior.
    ACO’s are an attempt to solve this problem as well, but putting the hospitals in charge will result in smaller physician panels for the patients, and more hospital interference to maximize the hospital’s income. Physicians and hospitals need separate organizations for ACO’s to be effective.
    Doctors need to make quality treatment decisions based on good research studies. However, there are not as many good studies as one might think. There are a lot of statistical studies, and many meta-analyses, but one has to remember that the results do not apply to everyone. There is a need for discussion between the physician and the patient as to which option is best for the patient. I believe a good part of the role of the future physician who does not do procedures will be to interpret studies for the patient so a rational treatment decision can be made. Most patients are not ready to make their own diagnoses and treatment decisions without help. All one needs to do is to read the answers in the “Think Like a Doctor” column in the NY Times to understand that.
    There are other reasons for cost increases beyond physician fees. In the 1960’s there were no ultrasounds, CT scans, or MRI’s. Medications and treatments were less complex and cheaper. Patients now demand these services. In many cases they are helpful, but they are expensive. Often they can be avoided with a good history, physical exam, and discussion. However, physicians are not reimbursed for the extra time this takes.
    Reading your piece makes one think that you live in a black or white world. You are either good or bad, a saint or a sinner. This is not the case, and medicine is a profession firmly in the gray. Diagnoses are not always clear, and neither are treatments. Medications that are felt to be miracles are taken off the market for side effects, but usually not until after a difficult battle with the pharmaceutical company. Vioxx is one, but Rezulin, Avandia, and Actos are others that were acceptable drugs for years. Treatment goals also change. One example is determining the optimal HgbA1c in diabetics, which has undergone a number of iterations in the past few years. Diagnostic criteria also change, such as whether or not to perform a PSA on an asymptomatic male.
    I really don’t think that relying on cartoons from the New Yorker, or opinion pieces are the best way to make informed decisions. One needs to go into the field, and see things for oneself. You really need to spend a month with a physician in practice to understand all of the gray areas that are faced on a daily basis.
    Remember the AMA does not speak for most physicians, and if you don’t think the ACA, and the mandated Medicare fees are not a turn towards socialized medicine, I would have you reread the ACA and I would like to have the government fix your fees.
    While there is much more to say, this is enough for now, and good luck in changing basic human behavior.

  6. …posted too soon…continued:
    In fact, the third party doesn’t much care either as it wants to grow larger. Insurance companies want more and more money to go through them.

    One of the ways to slightly assuage this dilemma is to go back to indemnity style insurance wherein the claim money is paid to the patient and he pays the provider/doctor. At least this causes some awareness in everyone as to what costs are and the patient finds himself with a little more. power as he can refuse to pay his providers if he is not satisfied.

  7. I think the biggest single problem is that our services and other provider services have such a yearly coefficient of variation–i.e. some years people need us and some years they dont–that insurance is necessary as a funding mechanism. The insurance causes a third party to be considered as the actual payer (always a delusion). This causes the provider and the patient not to care how much something costs. In fact, the third party insurer dpesn’t