By Richard Reece

Talk to the chief executives of American’s prominent health –care institutions, and you might be surprised what you hear:

When it comes to medical care, the United States isn’t getting its money’s worth…A high-performance 21st century health system, they say, must revolve around the central goal of paying for results. That will entail managing chronic diseases better, adopting electronic medical records, coordinating care, researching what treatments work, realigning financial incentives to reward success, encouraging prevention strategies, and, most daunting but perhaps most important, saying no to expensive, unproven therapies. — Ceci Connolly, “U.S. ‘Not Getting What We Pay For.’”

As we approach the Obama administration’s dawn, health care institutional leaders, think tank experts, and politicians recently gathered in Washington, D.C. to pronounce what needs to done to fix the system. The Washington Post reported that leaders from Mayo, Kaiser, Virginia Mason Medical Center, the UnitedHealth Group, and other leading health care organizations were there.

No Complaint
I have no complaint about the executives’ conclusions or opinions issued therein. I note, however, that leaders representing independent physicians were not there to give their point of view. Practitioners presumably were too swamped taking care of patients and trying to meet the bottom line. They rarely have the time or money to spend attending august gatherings.

One Quibble
My only quibble is that those who go to reform meetings rarely represent clinicians in the trenches – those who deliver over 80% of the care. Instead those who go represent the “adminisphere” of institutions, those managing the affairs of large organizations. Not represented are the practicing physicians outside those institutions, who are less well-organized and who speak with multiple voices.

Modest Proposal
I have a modest proposal – that we strive to place practicing physicians at the reform table. As everybody knows, the Clintons’ 1994 reform effort ignominiously collapsed for want of input from those who delivered the care. In retrospect, one reason for that effort’s failure was the absence of practicing physicians and practicing hospital administrators in the Clinton task force of more than 1,000 contributors, composed mostly of Congressional staff, academics, and policy wonks.

The Clinton effort proposed a universal managed competition system that few understood, that was so complex, so unrealistic, and so fraught with managed care jargon that Harry and Louise had an easy time shooting it down. Ira Magiziner, the senior health care advisor to the Clinton task force, unlike Mafia dons, was said to offer a favor that nobody understood.

This Time Around
This time around, we are told, things will be different.  “The reform stars,” says the Post, “will be aligned,” Among physicians, insurers, academics, and corporate executives from across the ideological spectrum, “there is remarkably broad consensus on what ought to be done.”

A Spoilsport Speaks
I don’t want to be a spoilsport, but I’m not so sure. Health plans, private Medicare plans, device manufacturers, pharmaceutical firms, and others in the supply chain who profit from the status quo will have lobbyists willing and ready to challenge reform assumptions and will not be taken by surprise. Independent physicians, weary of harassments and low reimbursements from Medicare and Medicaid and private plan followers, are leery of government efforts that infringe upon their autonomy and sovereignty.

Escalating Physician Shortage
Let us not forget the looming physician shortage at the primary care entry level of patients into the system.  Universal coverage without primary is access is meaningless. Just ask Massachusetts citizens. And if Congress follows its formula for cutting Medicare by 21% in June 2009, we will have a political donnybrook of unimaginable dimensions on our hands. If that cut occurs, it is likely 1/3 of physicians will no longer accept new Medicare or Medicaid patients. The outcry from the disenfranchised but entitlement-minded populace will be thunderous.

No Single Organization Represents Independent Clinicians
As things now stand, no single organization speaks for independent practicing physicians.

• Not the AMA, which now has only 1/5 of physicians as members, which is perceived to be on side of specialists in its coding system, and which has failed in such things as broad20malpractice reform, the bête noir of most doctors.
• Not the MGMA, whose 2800 members are made up mostly of practice managers of groups.
• Not the Medical Group Association, which is comprised of the multispecialty megaclinics of America, who care for about 10% of Americans.
• Not the Association of American Medical Colleges, representing teaching hospitals, academic medical centers, and whose mission is serve and lead the academic medical community.
• Not the New England Journal of Medicine, a liberal publication – the voice of academic medical community and advocates of government mandated universal coverage.
• And certainly not America’s Health Insurance Plans (AHIP), 1,300 strong, which serves as a surrogate for American business, covering 150 million Americans, and whose policies are not necessarily in the best interests of independent physicians.

It is largely practicing physicians’ own fault that no unified voice represents their work on the front lines.  Doctors are fragmented into more than 100 different specialties, each with its own ax to grind. This overspecialization has clouded and diluted the common interests and has produced doctor disarray across the practitioner spectrum. And because most doctors function in democratic autonomous small groups in which each participant has veto power, they are not as well organized or purposeful as hospitals, payers, suppliers or drug firms.

Who Speaks for Independent Practitioners
As I see it, three organizations are rising to represent the voice of frustrated independent practicing physicians who want a voice at the health reform table and who seek to change the shape of American medicine.

Sermo – This social networking website formed two years ago. It is open only to physicians and has about 100.000 participating doctors. Its purpose is to let doctors openly present cases to each other, learn from each other, give early evidence of adverse drug reactions or positive drug effects, voice their complaints, suggestions, and observations about the current health system, and to unite on issues relating to reform. Sermo physicians are not happy with with system, tend to favor consumer-driven care, harbor a deep angst against health plans, and do not believe EMRs represent the Holy Grail that will lead the system onto higher ground. Sermo’s participants are in the late stages of issuing an Open Letter to the American Public signed by 10,000 physicians about their grievances.

The Patient-Centered Primary Care Collaborative (PCPCC)– Paul Grundy, MD, an IBM physician executive, deserved credit for being the moving force behind this collaborative. As a buyer of care worldwide for IBM, he had observed that countries with a broad primary care base have higher satisfaction, higher quality, and better outcomes than the U.S.

The organization, now about two  years old, is coalition of primary care organizations (America Academy of Family Physicians, American College of Physicians, American Academy of Pediatricians, and American Osteopathic Association), major employers, consumer groups, quality organizations, and health plans.  Its main purpose is to advance primary care and increase its numbers to improve care, sustain the system, and change the mode of compensating physicians. Irrefutable evidence shows a broad primary care base cuts costs, improves care, and enhances outcomes.  Though multiple initiatives at the state and federal levels, the PCPCC is pushing the concept of the Medical Home, led by primary care physicians and their teams, to offer coordinated comprehensive care at one location.  These initiatives are running into political resistance from some quarters and are at the lift-off stage. Given the tyranny of the status quo and profitability of entrenched special interests, progress may be fitful and slow, but is nevertheless underway.

The Physicians’ Foundation – Created in 2003 with assets of $98 million as the result of a successful claims action suit against major insurers, the Foundation represents state and local medical societies, which have a much larger membership than the AMA, perhaps because they are closer to the ground and know intimately the concerns of their members.

The Foundation seeks to improve care delivered by its members through grants and through surveys highlighting their problems. It has issued grants worth $22 million to 41 member organizations, often relating to EMRs, but found members were ill-equipped to implement these systems and to use them in a productive way with adequate return on investment or improvement in practice quality.   On November 18, the Foundation released results of a national survey mailed to 270,000 primary care physicians and 50,000 specialists.

The survey, released to national news media, received wide exposure. It indicated a deep loss of morale among primary care physicians, with 78% of respondents saying a shortage of physicians existed, 49% saying in the next three years they planned to reduce the number of patient seen or to retire, and 60% indicating they would not recommend medicine as a career to young people. More and more physicians are seeking a way out. Growing numbers are seeking hospital employment and non-clinical positions.  Through this survey and other efforts, the Foundation hopes to persuade policymakers that something has to be done to address the concerns of primary care doctors and to ward off an impending and escalating physician shortage.

Such a shortage no doubt will create a political crisis. The Foundation believes compensation methods for rewarding primary care doctor’s needs to be overhauled, and the 21% cut in Medicare fees, scheduled for June 21, 2009, must be averted.

Conclusions
Unhappy doctors are groping to find a unified voice, expressing their frustrations with the existing health system.  Certain organizations – Sermo, Patient-Centered Primary Care Collaborative, and The Physicians’ Foundation – are emerging as vehicles to influence policymakers, to express physician unhappiness, to warn pervasive loss of morale will produce further physician shortages, and to predict these shortages may lead to an access and a political crisis.

Political reforms that expand coverage are certain to exacerbate the physician shortage and magnify defects of the system. The solutions may lie in more equitable payment reforms, more formal and larger physician organizations, in more hierarchical organizational structures and in salaried employment.  Primary care physicians and specialists will need to find common ground to end doctor disarray and to serve patients better in a more coordinated and comprehensive fashion, or the greater physician community will continued to whipsawed between more organized entities seeking a larger part of the health care pie.

**********@*ol.com“>Richard L. Reece MD is a retired pathologist who believes in the abilities of practicing doctors and their patients to control and improve their health destinies through innovation. He is author of ten books. The latest is Innovation-Driven Health Care: 34 Key Concepts for Transformation.