Wednesday, June 17, 2009

Why I trust my doctor but not the American Medical Association

Businessweek has an article on the American Medical Association's response to President Obama's talk. An excerpt:

Obama's speech came just days after the AMA said it opposed the creation of a public insurance plan fashioned after Medicare to cover the uninsured. That's an option favored by Obama and many Democratic legislators. But Obama did not back down—a sign that the AMA may no longer have the clout it once had to control the health-care agenda.


fee-for-service inefficient and wasteful

Obama wants to change that math. He has made it clear that he expects doctors to sacrifice along with insurers and drug companies. Although the President made no significant new proposals in his speech, he strongly reiterated his position that the current payment system, in which doctors are reimbursed for every service and office visit, leads to waste and inefficiencies and must be changed.

"It is a model that has taken the pursuit of medicine from a profession— - a calling -—to a business," said Obama. "And a lot of people in this room know what I'm talking about."

If they did, they didn't show it. The 500 delegates in the room met this portion of his speech with a deafening silence. Only his call to reform malpractice laws met with sustained applause, though Obama quickly followed up that statement—quieting the room—by saying he would not impose caps on malpractice awards, something doctors have long fought for. Nor was there much enthusiasm for his call to use Medicare reimbursements to reduce the number of patients readmitted to a hospital within 30 days of release, which would almost certainly lower hospital revenues. Likewise for the President's call to adjust Medicare payments to reflect medical advances and productivity gains, which would almost certainly lower payments to doctors.
only 25% of U.S. doctors are in the AMA.

In the past, such statements would almost certainly have set the AMA on a collision course with any reform attempts. The group has been able to block significant health-care reform efforts dating back to President Theodore Roosevelt's Administration. In 1948, when President Harry S Truman tried to enact universal health insurance, the AMA urged its members to "resist the enslavement of the medical profession." The group tried to stop the creation of Medicare until it was outmaneuvered by President Lyndon B. Johnson. And in 1986, President Ronald Reagan failed to persuade the AMA to support a Medicare freeze. Reagan was the last President prior to Obama to plead his case directly to the group.

Malpractice laws are a symptom, but in themselves they are not the main problem. They can and should be reformed, but malpractice premiums account for maybe 1% of total medical spending. The Congressional Budget Office says defensive medicine accounts for perhaps another 1%.

The main problem is the astronomically increasing cost of new medical technology and its inappropriate use. Too many doctors and hospitals are performing inefficient, excessive care.

In contrast, while insured through Kaiser Permanente, an integrated HMO, my doctors have prescribed cheap, effective generic drugs. Physicians who are on a salary, and employed directly by a hospital or healthcare system, perform fewer unnecessary tests. The problem is, most doctors practice independently. Under present payment systems, they have incentive to perform more tests and services.

Someone's waste is someone else's profit. The AMA, unfortunately, seems to be more concerned about its own profits than society's waste.

But medicine has splintered into dozens of specialties in recent decades, many of them with opposing interests. The AMA now represents 245,000 doctors, about one-fourth of the nation's total. The second-largest group, the American College of Physicians—or ACP, with 126,000 internists as members—looks much more favorably on a public plan and a payment model that rewards different specialists working together as a team to provide care for an individual patient rather than the piecemeal approach that now typifies American medicine. "We think changing the system that simply rewards volume rather than value is very important," says Dr. Joseph W. Stubbs, president of the ACP. In fact, a survey of U.S. doctors last year found that 59% support federal legislation to establish national health insurance.

Moreover, doctors are no longer seen by the public as infallible or untouchable. An influential article in the New Yorker last month by Harvard-trained surgeon Dr. Atul Gawande laid out the huge regional disparities in U.S. health-care spending and pinpointed the main cause as overtreatment by doctors who seek to boost their earnings. The article has become a rallying cry for health-care reformers. Obama made it required reading in the White House, and it is regularly referred to by legislators on Capital Hill.

I trust my doctors, but I do not trust the American Medical Association. America's Health Insurance Plans realize that they've lost the public's trust - they've said so in public and basically asked to be regulated. I hope the AMA comes to the same realization. Meanwhile, their lack of concern over the need to practice medicine more efficiently shows that right now, they are part of the problem.

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