Monday, June 29, 2009

AMNews: June 29, 2009. AMA meeting: Don't shortchange specialists to fund care model ... American Medical News

AMNews: June 29, 2009. AMA meeting: Don't shortchange specialists to fund care model ... American Medical News:

"Chicago -- In the discussion of how to pay for coordinated care under the patient-centered medical home model, the AMA House of Delegates agreed that primary care physicians should not be rewarded at the expense of specialists.

"At its June Annual Meeting, the house voted to advocate that additional pay to physicians for operating a medical home should not come from a reduction to the pay of specialists. Delegates approved language that medical home payments not be subject to requirements for budget neutrality in Medicare, where an extra dollar spent somewhere means a dollar has to be cut elsewhere.

"The house also approved recommendations that private plans and the Centers for Medicare & Medicaid Services develop one standard for a medical home, and that specialty practices as well as primary care practices should be able to serve as that home.

'Primary care needs more help. It just shouldn't come at the expense of specialists,' said Kim Williams, MD, a cardiologist from Chicago and a delegate for the American College of Cardiology."

I am aware that, in the House of Medicine, it is impolite to disagree with this notion that primary care physicians should get more money but there should be no adjustment of specialist reimbursement. It is not just impolite, it is also likely to start fights. I expect that the notion of knocking down the uber-specialists reimbursement lurks in the darkest places of the hearts of many a PCP and psychiatrist, the class-warfare-that-must-not-be-named.

But, consider the incomes of internists starting at $150K or so and neurosurgeons, radiologists (nuclear medicine), thoracic surgeons, invasive cardiologists and orthopedic surgeons starting at between $400K and $600K, it is hard not to wonder whether the economic disincentive of going into primary care can ever be overcome by raising PCP income by 20 or 30 or 40 per cent or more. Value is relative and simply increasing PCP income a bit and still having one's peers making vastly more explicitly marks the value we place on primary care.

Societies generally reward physicians with good incomes, but except for the incomes of specialists in the Netherlands, nowhere near as highly as we do. But, on the other hand, no country saddles their young doctors with the massive debt that we do. Heavily subsidized tuition is the norm, not the exception, and so young doctors around the world do not feel the economic imperative to enter the best paid fields as we do here. Nor do other countries have the massive overhead of physicians beyond debt: malpractice insurance, billing staff to fight with insurers and so on.

I expect that if we graduated medical school with debt similar to those of our non M.D. peers, incomes more comparable to our international peers would be more acceptable.

Sphere: Related Content

AMNews: June 29, 2009. AMA meeting: AMA reaffirms stance in health system reform debate ... American Medical News

AMNews: June 29, 2009. AMA meeting: AMA reaffirms stance in health system reform debate ... American Medical News:

"Chicago -- Addressing what has become the hottest flashpoint in this year's health system reform debate, the American Medical Association House of Delegates at its Annual Meeting in June renewed its existing reform policies rather than declare a position on whether lawmakers should establish a new national federal health insurance plan that would compete with private insurers.

"Delegates agreed that the AMA should 'support health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice and universal access for patients.'

"Both supporters and opponents of the public plan concept wanted the Association to take a definitive stand on the issue. But after AMA Immediate Past President Nancy H. Nielsen, MD, PhD, warned that such a move could handicap the organization as it tries to influence the health reform debate, delegates backed away from those resolutions.

"Dr. Nielsen said the resolution that ultimately passed would allow her and AMA President J. James Rohack, MD, to keep the AMA engaged in the debate without restriction but with a clear directive to advocate for choice for both physicians and patients."

An encouraging sign for progressives at the AMA House of Delegates. I am pleased to be wrong in expecting the conservatives to win the day and the resolution that passed gives wiggle room to the AMA leadership.

It is worth pointing out that there will be much struggle throughout this process. AMA policy language stands largely against any reforms leading to any expanded role for government in health care and specifically declares that an "Unfair concentration of market power of payers is detrimental to patients and physicians," and labels single payer as such and calls for continued opposition by the AMA.

Interestingly enough, however, the AMA has endorsed the principles of Medical Professionalism of the ABIM, ACP-ASIM and European Federation of Medicine. This Charter unequivocally advocates the physicians role in promoting social justice, fair distribution of finite resources and promoting fair access to care.

I am sure my conservative colleagues would argue that this can all be achieved by a more libertarian/Randian approach to health care, but I think, finally, that the number who believe that is growing smaller by the week.

Certainly polls indicate that most physicians now recognize that our system is broken and that the cure is not rearranging the deck chairs on this sinking ship and clinging to a heyday that hasn't offered us or our patients much "hey."

Sphere: Related Content

Thursday, June 25, 2009

In case you're wondering...

why I'm not blogging...

I hope that link works!

I'm on va-ca in the mountains of western North Carolina.

See you next week!

Sphere: Related Content

Friday, June 19, 2009

Median Physicians' Salaries - Health Blog - WSJ

Median Physicians' Salaries - Health Blog - WSJ:

"Good news for med students worried about their debt loads: Physicians coming out of residencies last year reported increases in their starting salaries in many specialties, according to a survey by the Medical Group Management Association, a trade group for medical groups.

"Here are the specialties with the biggest jumps in 2008 from a year earlier based on data from 3,520 physicians:

Neurology: $200,000 to $230,000 –- up 15%

Non-invasive cardiology: $350,000 to $400,000 – up 14.29%

Anesthesiology: $275,000 to $312,500 – up 13.64%

Emergency medicine: $192,000 to $215,040 – up 12%

Internal medicine: $150,000 to $165,000 – up 10%

"And as if we needed any more reminders about why there’s a shortage of pediatricians and family practitioners, the report also contains data on the extremes: The lowest starting salary in 2008 was for pediatricians — $132,500. The other lowest-paid specialties, in ascending order: family practice, geriatrics, urgent care, internal medicine and infectious disease.

The highest specialty salary was for those starting out in neurological surgery — $605,000. Others at the top of the heap, in descending order: radiology (nuclear medicine), thoracic surgery, cardiology and orthopedic surgery."

I've blogged about this before, but coming out of medical school in massive debt, knowing that you are going to make low wages for your three to seven years of training, and still choosing one of the lower income specialties requires some significant altruism. God bless everyone who does this.

But, this should not be such a stark decision. We really do need to do something about reducing or eliminating the cost of medical school to encourage (or at least make it not an economically crazy thing to do) students to enter primary care and other lower paid specialties.

Sphere: Related Content

Wednesday, June 17, 2009

Attacks on Dartmouth Atlas Rebutted

Health Affairs Blog:

"[HA Blog]Editor’s Note: In the post below, Amitabh Chandra responds to criticisms of the Dartmouth Atlas and offers his vision of the lessons of the Dartmouth findings on variations in health care costs and practice styles. Watch the Blog tomorrow for a roundtable discussion on Atul Gawande’s New Yorker article on McAllen Texas and the policy implications of the Dartmouth work. Roundtable participants will include Robert Berenson, Elliott Fisher, Robert Galvin and Gail Wilensky."

I heard Sen. Judd Gregg this AM on CSPAN pontificating at the Budget Committee meeting on health care, fretting that any kind of health board would result in "control" of health care by "Washington". If it's staffed by people like Dr. Chandra, we'll be OK.

But, more to the point, he still lives in the DC bubble fantasy land where he thinks patients have control of their health care, and not the private health insurers. He worries about a board being formed to guide decision making by clinicians. I think this is absolutely critical to reigning in health care costs, though, as Dr. Chandra so clearly indicates, this is as complex a set of problems as we're ever going to face in our life times, so it will require multiple iterations of progress to get where we ultimately wish to go.

And that was another thing Gregg lamented: the complexity of the bill. If he wants straight-forward, then HR 676 is his bill. But I'm guessing a single payer system is a non starter for him. So, given that we're talking about 20% of the economy, it's gonna be a complex solution!

Sphere: Related Content

What we're up against...

Terry Jeffrey : Obama: "There Are Countries Where a Single-Payer System Works Pretty Well" -

I was going to post over at TownHall on this piece, but after reading the comments, the ignorance is just too staggering to event try to overcome.

This is a hard fight. Many Americans think the opinions expressed at this site (and are articles of faith among many conservatives) are based upon facts instead of the ideologic fantasies that they are based upon


Sphere: Related Content

Monday, June 15, 2009

Bill Mann: Americans Who've Used Canada's Health-Care System Respond to Current Big-Lie Media Campaign

Bill Mann: Americans Who've Used Canada's Health-Care System Respond to Current Big-Lie Media Campaign:

"The scare ads and op-ed pieces featuring Canadians telling us American how terrible their government health-care systems have arrived - predictably.

"There's another, factual view - by those of us Americans who've lived in Canada and used their system.

"My wife and I did for years, and we've been incensed by the lies we've heard back here in the U.S. about Canada's supposedly broken system."

Read on...

Sphere: Related Content

Sunday, June 14, 2009

Health Beat: The AMA Would Make Health Care Unaffordable for Many Americans

Health Beat: The AMA Would Make Health Care Unaffordable for Many Americans:

"The American Medical Association has announced its opposition to a public-sector health plan that would compete with private insurers. Why? Because the AMA fears that Medicare E (for everyone) might not pay some specialists as handsomely as private insurers do now.

"Why do private insurers pay more? Because they can pass the cost along to you and I in the form of higher premiums. Medicare E has no one to pass costs on to—except taxpayers. And taxpayers will already be helping to subsidize those who cannot afford insurance.

"Everyone agrees that primary care physicians are underpaid. Democrats in both the House and the Senate propose raising their fees, as does the Medicare Payment Advisory Commission (MedPac)---the group that might take over setting fees for Medicare. Moreover, the House, the Senate, President Obama and MedPac have made it clear that they do not favor the across-the-board-cuts called for under the sustainable growth rate (SGR) formula. Congress has consistently refused to make those cuts and President Obama did not include them in the 2010 budget that he originally sent to Congress. On that score, the AMA has nothing to worry about.

"Protecting Excessive Fees for Some Specialists’ Services

"So what does the AMA fear? That either MedPac or Medicare will trim fees for certain specialists’ services. Keep in mind that Medicare’s fee schedule has traditionally been set –and adjusted on a regular basis, by the RUC-- a committee dominated by specialists.( Private insurers then follow that fee schedule, usually paying somewhat more for each service.) I have described this group in the past: They meet behind closed doors. No minutes are kept of their meetings. They rarely suggest lowering fees—even though as technology advances, some services become easier to perform. MedPac has pointed out that a less biased group should be involved in determining fees—perhaps physicians who work on salary, and are not affected by Medicare’s fee schedule.

"There is good reason to suspect that the RUC has over-rated the value of some services.. MedPac has suggested taking a look at particularly lucrative tests or treatments that are being done in large volume. Often, this may mean that patients who don’t need the service are receiving it; if the procedure isn’t necessary, then, by definition, they are being exposed to risks without benefits. And in fact, experience shows that when high fees are trimmed, volume falls, suggesting that rich fees were, in fact, driving overtreatment."

There is more here about using medicare to "bend the curve," or reduce over-utilization, improve use of preventive services, as well as a discussion of how a Public Plan might besubsidezed, etc. well worth reading, particularly about subsidization.

I would only add that the title falls a bit short: The AMA, or rather, conservative physicians, are hardly the only group fighting significant change. The Health Insurance industry, despite conciliatroy noise, will be the big guns or long knives as this goes forward. And behind them will be Pharma, other device and equipment manufacturers, probably home health servicers, ambulatory care centers, and, for purely ideological reasons, all conservatives.

Sphere: Related Content

Friday, June 12, 2009

QUALITY: Waiting for ...the Cardiologist. And the Orthopedist. And the Dermatologist... | New America Blogs

QUALITY: Waiting for ...the Cardiologist. And the Orthopedist. And the Dermatologist... New America Blogs:

"Health care consultants Merritt Hawkins and Associates...looked at waiting times in 15 American cities for nonemergency care.

Overall, the average wait was three weeks—up from 8.6 days since the last survey of this type in 2004 -for a routine heart checkup from a cardiologist, a checkup for skin cancer from a dermatologist, a painful or injured knee from an orthopedic surgeon, a 'well woman' exam from an OB/GYN and a routine physical from a family practitioner. But there was a huge variety in wait times, anything from one day to an entire year."

Going to the actual document is interesting.

Sphere: Related Content

Thursday, June 11, 2009

Dr. Chris McCoy: Dear AMA: I Quit!

Dr. Chris McCoy: Dear AMA: I Quit!:

"Dear American Medical Association,

"I recently had the opportunity to read your response to the Senate Finance Committee proposal [pdf] for health care reform, and it is clear to me that I cannot remain a member in your organization. Please remove my name from your membership rolls, effective immediately.

"In reading the response, I was frustrated and disheartened by the fact that you couldn't get through the second paragraph before bringing up the issue of physician reimbursement. This merely highlights how the AMA represents a physician-centered and self-interested perspective rather than honoring the altruistic nature of my profession. As a physician, I advocate first for what is best for my patients and believe that as a physician, as long as I continue to maintain the trust and integrity of the profession, I will earn the respect of my community. The appropriate financial compensation for my endeavors will follow in kind."

Read on. I agree with everything he says here, and yet, until the AMA House of Delegates meeting this week has concluded, I will withhold judgement and retain my membership.

If the floor fight at the House of Delegates takes shape as I predict, the old (literally) guard will get reaffirmation of every anti-reform policy reaffirmed and get an anti- public option policy added and will force the AMA leadership (progressive as they might be) to act like the AMA of old and start fighting reform.

We'll see. I have friends in leadership in AMA and they say it has changed.

We'll find out very soon.

Sphere: Related Content

A.M.A. Opposes Government-Sponsored Health Plan -

A.M.A. Opposes Government-Sponsored Health Plan -

"As the health care debate heats up, the American Medical Association is letting Congress know that it will oppose creation of a government-sponsored insurance plan, which President Obama and many other Democrats see as an essential element of legislation to remake the health care system."

I am OK with opposition to making participation mandatory if one accepts Medicare for the obvious reason is that it is coercive, but mainly, because the plan should be able to stand on its own and thrive. If it does not, then something is wrong in the way it was set up, and it should fail.

So I believe we MUST have a good public option, but it must be good in all senses: promoting better use of resources, reducing administrative waste, continuing Medicare's freedom to choose providers and so on.

Can't wait for the AMA meeting outcome...

Check out the letters in response which, perhaps led to the AMA press release:

Make no mistake: health reform that covers the uninsured is AMA’s top priority this year. Every American deserves affordable, high-quality health care coverage.
“Today's New York Times story creates a false impression about the AMA's position on a public plan option in health care reform legislation. The AMA opposes any public plan that forces physicians to participate, expands the fiscally-challenged Medicare program or pays Medicare rates, but the AMA is willing to consider other variations of the public plan that are currently under discussion in Congress. This includes a federally chartered co-op health plan or a level playing field option for all plans. The AMA is working to achieve meaningful health reform this year and is ready to stand behind legislation that includes coverage options that work for patients and physicians.”

Thanks to my peeps at Doctors for America for the heads up!

Sphere: Related Content

Saturday, June 6, 2009

Winston Churchill, Comm-Symp

NHS at 60: A vision in which we still believe - Telegraph:

"In 1942, he [Beveridge] proposed the creation of a national health service, as part of a system of compulsory social insurance to slay 'the five giants of want, disease, squalor, ignorance and idleness'.

"Such was the enthusiasm for his ideas that there were queues to buy the report outside His Majesty's Stationery Office.

"The plans were backed a year later by the prime minister, Winston Churchill, but when the Conservatives lost the general election in 1945, Churchill's Labour successor, Clement Attlee, pledged to introduce the changes, with free medical treatment for all by the establishment of the National Health Service in 1948.

"While the plan was popular with the public, not everyone was keen.

"The British Medical Association famously opposed the creation of the NHS, with the health minister, Aneurin Bevan, later admitting that he had 'stuffed their mouths with gold' via a generous contract which allowed them to carry on doing private work, and provided lucrative bonuses."

Also, from Churchill, March 2, 1944

“The discoveries of healing science must be the inheritance of all. That is clear. Disease must be attacked, whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the same way as the fire brigade will give its full assistance to the humblest cottage as readily as to the most important mansion… Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

And, in contrast, from the former British Medical Association Chairman, Alfred Cox, "I have examined the Bill and it looks to me uncommonly like the first step, and a big one, to national socialism as practised in Germany. The medical service there was early put under the dictatorship of a "medical fuhrer" The Bill will establish the minister for health in that capacity."

Conservatives, always so prescient.

Sphere: Related Content

From our friends at the South Carolina Medical Association

Dear Colleague, [This was sent to the members of the SCMA - my comments are in italics below.]

The momentum that has been building in support of a nationalized health care system appears to be overwhelming. With health care overhaul bills on the fast-track in Congress, and with a new and powerful administration determined to pass legislation this year, the deck is stacked against us. We’ve been told to sit in the corner and watch while the “experts” figure out how to fix health care. The problem is that the “experts” who are fixing health care are the same people who have run Medicare into insolvency and created a Medicaid system that is inefficient and ineffective.

The federal government is kicking us down the road toward indentured servitude. Envision a world where each decision you make for every patient has to be approved through the laborious channels of government bureaucracy. Imagine the federal government dictating to you which patients yo can and cannot see and which treatments you can and cannot provide—not just for Medicare patients but for all of your patients. Consider what it will be like to be reimbursed for all of your patients at levels significantly less than current Medicare.

Physicians have been offered a seat at the table so long as we sit still with our hands folded in our laps and keep our mouths shut. Dutiful compliance and inaction are no longer options. The muzzle that the Feds placed on us must be removed and the decibel level of our voices must be raised so that we are unmistakably heard. We’re not suggesting a strike, but anything short of that is the kind of bold and thunderous statement we need to be making right now.

The leadership of the South Carolina Medical Association senses the anger and the building resentment and confusion that physicians are currently experiencing. Our commitment to channeling these strong feelings into action is strong and will not lessen. W will not stand silent and watch while the federal government destroys our health care system. In the next few weeks, we will be laying out a course of action to ensure that our voice is heard. Be ready to act quickly, speak loudly, and fight for your career and the health care freedoms your patients deserve.

[Signed by the President and Chair of the Board of the SCMA]

Wow. They must be practicing in paradise down there in South Carolina. No problems, everybody's insured, getting great preventive and chronic care, nobody goes bankrupt from health care expenses, etc. Maybe we all should move there. Because, you know, in the rest of the country we have ridiculous bureaucracies, rules, and non-physicians telling us what we can do and who we can see and what we can charge already, only they are our private health insurance companies.

But here is the money quote, "Consider what it will be like to be reimbursed for all of your patients at levels significantly less than current Medicare. " And that' really what it boils down to for so many, doesn't it? And besides, the answer to this question is that, if I don't have to hire a team of staff to fight with PRIVATE insurers to get reimbursed, to get prior approval, to jump through all of their hoops, maybe that reimbursement would result in a higher net reimbursement. And at least Medicare doesn't tell my patients whether they can see a physician because he's not on the right panel.

SCMA, what is the solution? Or aren't there any problems with the health care system in South Carolina.

Maybe they're still all practicing in Mayberry in the 1950's, but for the rest of us, we need to fix this broken system!

I ranted further over at dailykos...

Wow. This is not about healthcare reform with these people. These are like the Japanese soldiers found on islands 20 years after WW II, still fighting against the Yankees. They are opposing a Soviet medical gulag, entirely a figment of their imaginations and deep paranoia. Lively debate, eh?

But, to the letter's substance, and frankly, its' ignorance.

Nationalized, or singe payer, if that's what they mean, is pretty much off the table according to the guys in charge of the process like Baucus. It would be nice to have the momentum for that, but although there are vocal supporters at the grass roots level, the powers that be will not hear of it. But sadly, I doubt they even know what they mean when they say "nationalized." I am sure they have some conceptual bogey man system hybrid of the UK, Canada, and the old Soviet Union in their heads, but I am equally certain they have not spent more than 10 minutes actually learning any comparative health care, even bothered to investigate the systems in Germany, France, Australia and elsewhere.

"The deck is stacked against us." Is that against patients, physicians, insurance companies, who? Who is the deck stacked against?

"We've been told to sit in the corner..." Really? The message I've heard from Congress and the White House is that they value and want physician input. Maybe they don't want bat-shit crazy input, but they want input.

"The same people who have run Medicare into insolvency..." Um, that would fall quite largely on the shoulders of physicians. We have abdicated our role in shaping health care policy and controlling spending and reducing unwarranted and dangereous practice variation and having realistic end-of-life discussions with our patients and so on. We have also not called BS on the private insurers who steal health care dollars in the name of private enterprise and we have taken the money of Pharma for ou meetings and lunches and pretended they were spending all that money on R & D and not on recruiting cheerleaders. Literally recruiting cheerleaders.
But I'm with them on the Medicaid thing.

"The federal government is kicking us down the road toward indentured servitude." Seriously? Don't you guys have private health insurance companies in South Carolina? But really, this letter is not about health care, this is a stale ideology in its last throes.

"Physicians have been offered a seat at the table so long as we sit still with our hands folded in our laps and keep our mouths shut. "
Again, one has to have reasonable views to expect to be listened to seriously Foaming at the mouth like Zell Miller and Sean Hannity does not invite reasoned discussion. But listen, all of the physician supporters of single payer have much more to gripe about than the SCMA. At least organized medicine is participating in discussions, while PNHP has to have a major grass roots insurrection just to get invited to the White House photo-op. If anybody has the right to gripe about exclusion, it's the progressives, not the conservatives.

"The leadership of the South Carolina Medical Association senses the anger and the building resentment and confusion that physicians are currently experiencing." I expect this is true. SC represents a far more conservative population than most states (it's in the top 10 most red states), and so their phsyicains likely are more conservative as well. So, fine, make your case, but we will not sit quietly by and let you screw up the best chance for health care reform we've had in this country's history.

The final line about fighting "for your career and the health care freedoms your patients deserve." Again, maybe I'm practicing in a dark dystopic bit of America, but around here, that ship has sailed. Our patients, even the insured ones, have little choice in doctors or hospitals. They only go to whom and where their plan allows. No "freedom" there. And our careers? Whose careers? Your primary care physicians careers? Really? I'll let my colleagues decide who you're really looking out for. My bet is that you're looking out for your failed ideology, not for physicians or patients.

Sphere: Related Content

Friday, June 5, 2009

Study Links Medical Costs and Personal Bankruptcy - BusinessWeek

Study Links Medical Costs and Personal Bankruptcy - BusinessWeek:

"Medical problems caused 62% of all personal bankruptcies filed in the U.S. in 2007, according to a study by Harvard researchers. And in a finding that surprised even the researchers, 78% of those filers had medical insurance at the start of their illness, including 60.3% who had private coverage, not Medicare or Medicaid.

"Medically related bankruptcies have been rising steadily for decades. In 1981, only 8% of families filing for bankruptcy cited a serious medical problem as the reason, while a 2001 study of bankruptcies in five states by the same researchers found that illness or medical bills contributed to 50% of all filings. This newest, nationwide study, conducted before the start of the current recession by Drs. David Himmelstein and Steffie Woolhandler of Harvard Medical School, Elizabeth Warren of Harvard Law School, and Deborah Thorne, a sociology professor at Ohio University, found that the filers were for the most part solidly middle class before medical disaster hit. Two-thirds owned their home and three-fifths had gone to college."

The abstract is here, I cannot access the full text, unfortunately.

Sphere: Related Content

Wednesday, June 3, 2009

McCarthyism and health reform - Joe Paduta

Managed Care Matters:

"Ya gotta do your research.

"That's a basic lesson in the business world, but one that some seem to forget. The latest example - actually there are two - comes courtesy of Grace-Marie Turner of the Galen Institute. Ms Turner sent me an email, copied below."

Read on and then say it with me, "Oh, snap!"

Sphere: Related Content

Health Care Reform - Old School!

Donald J Palmisano was President of the AMA for the 2003-2004 term. You can jump to his bio at his company's website. Apparently he also sends out his opinions via an email newsletter which a friend forwards to me on occasion. Here is the newest one, and since I haven't responded line by line to the conservative arguments on health care reform in a while, I thought now would be a good time to do so. I'm in italics.

DJP Update 6-1-2009: Health System Reform & AMA - Additional Reflections; comments on recent AMA writings.

The advantages of being an American and living in the USA are many. One of the great liberties we enjoy is the First Amendment to the US Constitution (part of the Bill of Rights) :
AMENDMENT I: Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.

I always find it ironic when conservatives quote the Constitution given the penchant for the authoritarian-submissive personality among them. If that seems gratuitous, sorry, but I am always irritated when conservatives quote the Constitution as if it's news to the rest of us.

Also, one of the advantages of being an AMA member and getting elected to be a delegate (or have the privilege, as I have, as a former AMA president) and to sit in the AMA House of Delegates is the right to discuss, debate, and yes, offer alternative views if one perceives the ship of state is heading in the wrong direction. That is part of leadership. Without the courage to enter the debate, one cannot earn the title of leader. Of course, one's view may be defeated but then you have the comfort of the wisdom of Kipling's poem "IF" and President Teddy Roosevelt's words in his famous speech at the Sorbonne in 1910. See page 56 of my book, "On Leadership..." or go to: and

Interesting bit from the TR speech: "It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein."

This would, unfortunately, require us to look past the end of our noses for potential solutions and, as Churchill might say, "This is something up with which I will not put!"

Another bit, "The poorest way to face life is to face it with a sneer. There are many men who feel a kind of twister pride in cynicism; there are many who confine themselves to criticism of the way others do what they themselves dare not even attempt. There is no more unhealthy being, no man less worthy of respect, than he who either really holds, or feigns to hold, an attitude of sneering disbelief toward all that is great and lofty, whether in achievement or in that noble effort which, even if it fails, comes to second achievement."

This is always how I see the conservatives sneering at the idea of universal health care. To quote JFK, "We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too."

Enough time spent laying the foundation for the following. Consider this note a part of a "disconfirming opinion" as taught by Dean Donald Jacobs at Northwestern. Plus some praise too! Why has our AMA not put forth in writing to the world, and to those in government we negotiate with, our AMA policy of "unwavering opposition against the encroachment of government in the practice of medicine..." "including the right of physicians and patients to contract privately for health care without government interference." Or "It is the policy of the AMA: (1) that any patient, regardless of age or health care insurance coverage, has both the right to privately contract with a physician for wanted or needed health services and to personally pay for those services; (2) to pursue appropriate legislative and legal means to permanently preserve the patient's basic right to privately contract with physicians for wanted or needed health care services; ..." See multiple AMA policies below and if you want more on the same topic, go to the PolicyFinder at the AMA Website: Is there something that is not clear about the wording in our policy? I conclude no. Hasn't it been repeated enough times in various policies? Certainly.

He is absolutely right here, and I have posted about these AMA policies and the one about single payer in the past, just to serve as a warning that, when it comes down to brass tacks (in the AMA's case, when it comes down to its' (our) House of Delegates), the AMA policy remains staunchly conservative.

Here is the problem. Our government controls our fees. That is a violation of our liberty.

Really? I see conservative physicians posting all the time about opting out of Medicare and other insurance plans precisely so that the government and insurers cannot control our fees. Virtually every nation (Canada a partial exception) allows physicians to practice outside or alongside the national system.

Property rights are an important component of our liberty. We have to recognize that government has the right to decide how much money to spend on some benefit, BUT government doesn't have the right to determine what we charge for a service. AMA leaders for years have advocated defined contribution approach by government with ownership by the patient, and an array of choice of insurance options. Read some of the speeches of Dr. Stormy Johnson, Dr. Nancy Dickey, and mine. And of course, read anything you can find from another AMA president, Dr. Ed Annis, the gold standard for liberty in medicine. Not a price-control system that ends up creating loss of access to care for patients because the fixed payment is below the cost of delivering the service. Throughout history, price-fixing equals loss of availability of the product or service.

Isn't it just hilarious that in a nation of nearly 50 million uninsured and another similar number underinsured, in a nation where we are all at risk of financial ruin due to health care catastrophes, that he expresses concern over "loss of access?" "Throughout history," etc. Again, one does have to look past the end of one's nose to see that this is wrong, wrong, wrong.

AMA has been "at the table" and we are told our policy is being advocated. Great. But has this policy been advocated? Certainly not in our AMA writings. The quest to end the SGR payment formula is good and AMA has advocated that. Unfortunately, we still granted the government the premise that it has the right to control our fees.

First, as noted, you can opt out. You can opt out of the Private Health Insurance market too, except, oh, yeah, unfettered markets have led to dominance by one or two insurers in virtually every large market in the country.

Secondly, this reminds me of President Eisenhower's comments to his brother, "Should any political party attempt to abolish social security, unemployment insurance and eliminate labor laws and farm programs, you would not hear of that party again in our political history. There is a tiny splinter group, of course, that believes that you can do these things. Among them are a few Texas oil millionaires, and an occasional politician or businessman from other areas. Their number is negligible and they are stupid ." This is true of Medicare as well.

In a recent message from AMA, we are advocating a MEI index approach in the negotiations. If one negotiates and allows the other side to set the framework of the debate, you will lose every time (See "On Leadership...). Why do we let government continue to set the paradigm that we don't have a right to set our fees? Note the RECURRENT policies that direct action about privately contracting. AND reaffirmed many times! This is not optional. This is the command of the AMA House of Delegates, the policy setting body of the AMA. AND note the policy about government medicine. Why are we not speaking out against the "public option"? Medicare is going bankrupt, restricting our liberty, and we are not opposing expansion of government medicine? Why not? This is not optional based on our clear AMA policy. Thus you can see I do not share the enthusiasm of my friend Dr. Joe Heyman, AMA Board Chair, in his AMA opinion column dated June 1, 2009, entitled "Health system reform is coming -- and you all helped". I hope AMA's help has not sanctioned a public system enlargement.

He is right about this. In spite of some of the AMA leadership's conciliatory remarks, speeches, etc., AMA policy stands directly opposed to significant reform. The AMA Annual meeting is coming up June 13-17. It'll be interesting to see how that goes.

However, what I do strongly agree with is the praise he gives to the Litigation Center of the AMA and State Medical Societies. I served on that committee when I was on the AMA Board and it does outstanding work. It fights the abuses of managed care, medical liability injustice, and much more. I wish every doctor in America knew of the great work it does. I also applaud our AMA putting in earlier writings that we need medical liability reform and antitrust relief for negotiating against the monopsony power some health insurers have. However, all of this will be wasted if physicians end up as captives of a government takeover of medicine. Hard to compete against government when it has unlimited taxpayer dollars and the power to punish by mandates and tax treatments. Before agreeing to a "better system" read the fine print carefully. One person's version (or the government's) of "better" may be entirely different than ours. Just like some caps on "non-economic" damages are great and others are worthless. Fine print!

Medical liability is still a hot issue for many physicians. In a recent survey by the California Medical Association, 40% still thought it was their number one concern. I do not know the political make up of the responders to that poll [though 67% were in practice more than 20 years - MY cohort!], nor of physicians in general [95% were CMA members], but my guess is that the 40% who still list that as their top concern are the older, whiter, male-r, and more conservative members of the profession.

We have to ask why membership continues to drop and what needs to be done to end the internecine battles among the various specialties. Why join AMA if my specialty does everything for me, including lobbying? Of course we know why everyone should be an AMA member and the Litigation Center is just one of many reasons. If everyone could balance-bill for the additional amount needed, there would be no need for different specialties to run to Congress and say, "Give me more of the Golden Apple as I am the fairest." Remember Paris, the golden apple, and the three goddesses, Hera, Athena and Aphrodite? To the fairest goes the golden apple. The story ended badly and so will the present course our medical ship is on.

I think the answer about AMA membership is clear, but it is not at all the same answer arrived at by Dr. P. There are a large number of physicians who focus primarily on income or revenue and see medical liability premiums as a scourge to their take-home pay, but for most, this is not the focus of their lives, professional or otherwise. I would like to see us continue to make inroads into medical liability reform, but not through caps, but through honesty, alternative dispute resolution, and taking responsibility, as a profession, for our colleagues who have fallen behind.

On D-Day all allied forces agreed to land on the same coast of France and worked together for a common goal. Perhaps all physicians and every American citizen should watch the HBO special on Winston Churchill that played last night entitled "Into the Storm". Read about it at: Outstanding and a gold standard how to rally the nation against what appeared to be overwhelming force directed against Europe. No appeasement; no giving up; no "You don't understand". Instead, a fight to the end for important principles.

I am prone to hyperbole as well, so will let this pass...

But on the larger point, D-Day was about solidarity, exactly what we who are advocating for serious, comprehensive healthcare reform are promoting. We are in this community, this society, this national life, together. There is no religion, no school of thought (I always have to add, "except Ayn Rand's") whose central message is "every man for himself."

As Uwe Reinhardt says, "Go explain to God why you cannot do this. He will laugh at you."

Review the following AMA policies on privately contracting and unwavering opposition to government medicine. Trust but verify. Here is your chance to verify. [DJP here sites the policies I linked to earlier.]

In 1976 (yes, 1976) I testified before the U.S. House of Representatives' Ways & Means Committee opposing the government takeover of medicine and opposing a single-payer system. Representative Rostenkowski was the chair of the committee. Since that time, I have not found any evidence to change that view and I now have had the opportunity, thanks to AMA, to visit the Canadian Medical Association and the British Medical Association's annual meetings and learn directly from the doctors there about government promises and the failure to keep them. Check out one of my writings about this at: JAMA -- Proposals for US National Health Insurance, December 3, 2003, Palmisano 290 (21): 2797. It contains the following:-----In June 2003, the Chairman of the British Medical Association characterized his nation's single-payer health care system as "the stifling of innovation by excessive, intrusive audit . . . the shackling of doctors by prescribing guidelines, referral guidelines and protocols . . . the suffocation of professional responsibility by target-setting and production line values that leave little room for the professional judgment of individual doctors or the needs of individual patients."4 His strong words come from long experience with a single-payer health system.------I also witnessed how the government breached the promise in Section 1801 of the Medicare law, ("Prohibition Against Any Federal Interference"), not to interfere with the practice of medicine. See Notes section of my book, "On Leadership..." at pages 255-258.

Yes, if you ignore everything wrong in our system, every other system looks awful. If you ignore every good thing in every other system around the world, our system looks great. If you focus on Canada and Britain, the two countries that perform near the bottom in the world for health care system performance (you know, down there close to as poorly as we do), our system looks pretty good. On the other hand, if you look at the high performing systems with great outcomes, satisfied patients and physicians, great high tech medicine and great primary care and low cost, we don't look so hot.

This is the same ignorant line of reasoning promulgated by the Right Wing Noise Machine, Health Care Edition.

Most importantly, I have seen the sacrifice of the brave men and women who fight for our USA to preserve our liberty. I had the privilege during my tour of duty at the time of the Vietnam War to treat them at our airbase when they rotated back to the USA for 6 months. And I write about other military heroes in my book. Surely we cannot dishonor them by giving up our liberty. Sounds too strong? Have at it.

Oh, yeah, conservatives loves them some soldiers. That's why they're in our US Socialized Medicine system, the VA. You know this one. [In the interest of full disclosure, I have a friend whose son has PTSD, from Iraq, and the VA is failing him. We need to put pressure on our Congress to step up and make this right.]

Let me end this discussion by again recommending that everyone read "The Road to Serfdom".The author is F.A. Hayek, the co-winner of the Nobel Memorial Prize in Economics in 1974 and recipient of the Presidential Medal of Freedom in 1991.Here is what the back cover of the paperback edition (ISBN-13: 978-0-226-32055-7) of "The Road to Serfdom - The Definitive Edition", edited by Bruce Caldwell, says:"For F.A. Hayek, the collectivist idea of empowering government with increasing economic control would lead not to a utopia but to the horrors of Nazi Germany and fascist Italy."The original text was in the book was written in 1944. Think about it. At the start of Chapter Nine, he has two quotes: Here is one: In a country where the sole employer is the State, opposition means death by slow starvation. The old principle: who does not work shall not eat, has been replaced by a new one: who does not obey shall not eat. ---Leon Trotsky (1937) Think about how that applies to medicine. Would it not be better to bring about change in medicine by testing rather than just getting an idea and implementing it for the whole nation? Imagine if we gave patients new drugs without proper testing. I believe there would be many disasters. As Louis Pasteur said,"Imagination should give wings to our thoughts, but we always need decisive experimental proof. "The debate in our Land of Liberty is upon us. We may hear things that are not true. As scientist, it is our duty to insist on due diligence. As George Orwell said, "In a time of universal deceit, telling the truth becomes a revolutionary act." It doesn't have to be universal deceit, it can be universal failure to do the homework and testing and a rush to pass bills. It can be erroneous statistics with sampling errors and failure to compare apples vs apples. You get the idea. The quest for truth can be a lonely path. Leaders must courageously pursue it. Let's be a revolutionary for truth!--

One would think this is a satirical critique on the modern conservative-authoritarian movement, the failure of regulation of the marketplace, and the interjection of commercial interests into medical research, but sadly, no.

Liberals are anti-authoritarian, for goodness sake. You think Thomas Jefferson was a conservative authoritarian?!?

It's just not worth wasting the time on.

---I look forward to the debate at the June AMA House of Delegates in Chicago. Watch for "Resolution 203 - Right to Privately Contract" at AMA June Meeting in Reference Committee B. Resolve two of that resolution deals with the right to restore fairness to negotiations with the private health insurers and the government. There are at least 19 state and specialty co-sponsors. This resolution elevates the issue to highest priority. The people of America need to know what is at risk with their medical care. If we don't sound the alarm, I believe other grassroots groups will take the leadership for a clarion call to action and the world will wonder what happened to our AMA.

Well, I hope the HOD has the chutzpa to smack these people down once and for all, but I'm not counting on it.

Sphere: Related Content

Tuesday, June 2, 2009

Baucus Watch, Public Option issues: Columbia Journalsm Review

Baucus Watch, Part X : CJR:

Columbia Journalism review tries to get reporters to focus on the substance of the Public Option debate, rather than on the horse-race, who's up, who's down BS they generally like to cover 'cause it's easier and more fun. As a reminder of the thinking in general, you can read more about the "weak" vs. "strong" public plan options here.

"To move this story—and it’s an important one—beyond the process of reform to the substance of reform, we offer a few questions for reporters:
• Who will really be able to join a public plan—everyone, or just those who don’t have other coverage or are too ill for insurers to take them on as customers?
• Can workers with coverage from their employers go to a public plan if it’s cheaper? In other words, is there a real choice for everyone?
• How will coverage be financed—by taxpayer dollars, or by premiums from people needing insurance?
• Will the government provide the coverage, as it does for Medicare’s hospital and doctor benefits, or will private insurers provide it, as they do for Medicare’s prescription drug benefit? There’s a big difference here.
• What will the benefit package look like? Which special interests are working to make sure that their latest gee-whiz technology gets covered?
• Will doctors and hospitals be paid the Medicare rates, or something higher?
• If they get the higher rates, then where will the cost-savings come from?
• If private carriers provide the benefits with more of the same inefficient billing costs, where will the administrative savings come from?"

Sphere: Related Content

Monday, June 1, 2009

The High Concentration of U.S. Health Care Expenditures

The High Concentration of U.S. Health Care Expenditures:

"Half of the population spends little or nothing on health care, while 5 percent of the population spends almost half of the total amount. Examining the distribution of health care expenses among the U.S. population sheds light on areas where changes in policy might bring about the greatest savings.

"Select to download print version (PDF File, 785 KB). "

Indeed, well run micro-systems that exist at Mayo, Cleveland, Geisinger, Virginia-Mason and others show us it's possible.

Sphere: Related Content

Snapshots: Health Care Spending in the United States and OECD Countries - Kaiser Family Foundation

Snapshots: Health Care Spending in the United States and OECD Countries - Kaiser Family Foundation:

"Health spending is rising faster than incomes in most developed countries, which raises questions about how these countries will pay for future health care needs. The issue may be particularly acute in the United States, which not only spends much more per capita on health care than any other country, but which also has had one of the fastest growth rates in health spending among developed countries. Despite this higher level of spending, the United States does not achieve better outcomes on many important health measures. This paper uses information from the Organisation for Economic Co-operation and Development (OECD)1 to compare the level and growth rate of health care spending in the United States with other OECD countries. In an increasingly competitive international economy, policymakers in the United States will need to be aware of how the health spending and spending growth in the United States compares to that of other nations."

Sphere: Related Content

George Lakoff: Empathy, Sotomayor, and Democracy: The Conservative Stealth Strategy

George Lakoff: Empathy, Sotomayor, and Democracy: The Conservative Stealth Strategy:

"Let's start with the attack on empathy. Why empathy? Isn't empathy a good thing?
Empathy is at the heart of progressive thought. It is the capacity to put oneself in the shoes of others -- not just individuals, but whole categories of people: one's countrymen, those in other countries, other living beings, especially those who are in some way oppressed, threatened, or harmed. Empathy is the capacity to care, to feel what others feel, to understand what others are facing and what their lives are like. Empathy extends well beyond feeling to understanding, and it extends beyond individuals to groups, communities, peoples, even species. Empathy is at the heart of real rationality, because it goes to the heart of our values, which are the basis of our sense of justice.

"Progressives care about others as well as themselves. They have a moral obligation to act on their empathy -- a social responsibility in addition to personal responsibility, a responsibility to make the world better by making themselves better. This leads to a view of a government that cares about its citizens and has a moral obligation to protect and empower them. Protection includes worker, consumer, and environmental protection as well as safety nets and health care. Empowerment includes what is in the president's stimulus plan: infrastructure, education, communication, energy, the availability of credit from banks, a stock market that works. No one can earn anything at all in this country without protection and empowerment by the government. All progressive legislation is made on this basis. "

Very well written post in defense of empathy. It is amazing to have to defend empathy to people who claim to be moral Christians.

Sphere: Related Content