Category: AMA

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.

A.M.A. Opposes Government-Sponsored Health Plan – NYTimes.com

A.M.A. Opposes Government-Sponsored Health Plan – NYTimes.com:

“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…

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

AMA COMMITTED TO HEALTH REFORM THIS YEAR
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!

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) : http://www.archives.gov/exhibits/charters/bill_of_rights_transcript.html
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:http://www.kipling.org.uk/poems_if.htm and http://www.theodore-roosevelt.com/trsorbonnespeech.html

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: http://www.ama-assn.org/ama/no-index/about-ama/11760.shtml 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:http://www.hbo.com/films/intothestorm/ 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.
*sigh*

—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.

Medical News: AMA: Membership Bounces Back Slightly – in Meeting Coverage, AMA from MedPage Today

Medical News: AMA: Membership Bounces Back Slightly – in Meeting Coverage, AMA from MedPage Today:
“According to Dr. Maves, the AMA signed up 3,300 more physicians in 2005 than it did in 2004, which is a 2.5% increase. The increase, he said, came in regular members plus physicians in their first or second year of practice and military physicians—all membership categories that reflect ‘real, practicing physicians.’

“There are more than 850,000 MDs in the United States and 56,000 osteopathic physicians. About a quarter of this total, including interns, residents, and retirees, who pay sharply reduced dues, are members.

“The increase in members added $500,000 to AMA coffers, but represented only a small fraction of the $28.1 million operating profit that Dr. Maves reported for 2005.

“Regular members pay $420 a year. Physicians in the second year of practice pay $315, military physicians pay $280, and first-year physicians pay $210.
“Overall, AMA membership in 2005 was 244,005, a number that includes medical students, who pay $20 a year to join the AMA and residents who pay $45 year.

“The AMA will not, however, release the number of practicing physicians who are members, but using the 3,300 figure to calculate the total membership the math works to where 132,000 members in the ‘real, practicing physicians’ were in this category in 2004 and 135,300 in 2005.

“‘The first year I was here, we lost 17,000 members, so this is definitely a victory,’ Dr. Maves said in an interview. But he added that the AMA has still not increased its market share which was 26% in 2004.

“That stands in stark contrast to the 80% membership market share claimed by national medical specialty societies.”

AMNews: April 27, 2009. AMA letter backs Obama’s broad principles for health system reform … American Medical News

AMNews: April 27, 2009. AMA letter backs Obama’s broad principles for health system reform … American Medical News:

“But embracing the eight principles does not mean the AMA necessarily backs every idea on health reform that Obama has revealed so far. For instance, the president has called for creating a public health plan option linked with a national health insurance exchange to serve as competition for private plans. In its letter to the White House, the AMA says it supports a health insurance exchange to ensure coverage choice and portability, but it does not weigh in on the public plan option. To move toward universal coverage, Congress should build on the employer-based system and strengthen the safety net provided by publicly financed programs such as Medicare, Medicaid and the Children’s Health Insurance Program, Dr. Nielsen and Dr. Rohack wrote.

“Dr. Nielsen stressed that the organization is mindful of the need to watch the dollar signs as policymakers work toward the goal of universal coverage. ‘It’s very important for us that all Americans have health care coverage that’s affordable. But we do understand that we can’t afford everything for everybody, so we need to have fiscally responsible conversations.’

“The letter proposes expanding on Obama’s principles in a number of ways, including:

  • Reforming and improving the insurance market through the use of modified community rating, guaranteed renewability and fewer benefit mandates.
  • Assisting low-income individuals through premium subsidies and cost-sharing assistance.
  • Promoting medical home models to reduce system fragmentation and improve care coordination.
  • Establishing antitrust reforms that would allow groups of physicians to contract jointly with payers as long as the doctors certify they are collaborating on health information technology and quality improvement initiatives.
  • Easing the effect of liability pressure on the practice of defensive medicine through innovative approaches, such as health courts, early disclosure and compensation programs, and expert witness qualification standards”

The “8 Principles” of Obama are at the end of the article.

I do wonder why the AMA is pushing back on the public option. It seems to me the only chance physicians have of keeping reimbursement rates reasonable because private insurers will do their darndest to NOT wring savings out of the system (except on the provider side!), and so all that money is money not available to providers. One man’s waste is another man’s revenue.

AMNews: March 16, 2009. White House summit takes 1st step in health system reform discussion … American Medical News

AMNews: March 16, 2009. White House summit takes 1st step in health system reform discussion … American Medical News:

AMNews had a more complete list of physicians in attendance than I did in an earlier post about the Summit:

“President Obama invited more than 100 people to a White House summit on health system reform on March 5, including the following physicians.
Rep. Michael Burgess, MD (R, Texas)
Ted Epperly, MD, American Academy of Family Physicians president
Oliver Fein, MD, Physicians for a National Health Plan director
Jeffrey P. Harris, MD, American College of Physicians president
Risa Lavizzo-Mourey, MD, Robert Wood Johnson Foundation president and CEO
Nancy H. Nielsen, MD, PhD, American Medical Association president
Irwin E. Redlener, MD, Columbia University Mailman School of Public Health professor
Elena V. Rios, MD, MSPH, Hispanic Medical Assn. president
Michael Salem, MD, National Jewish Health hospital system president
Henry E. Simmons, MD, MPH, National Coalition on Health Care president
David T. Tayloe Jr., MD, American Academy of Pediatrics president
Ho Luong Tran, MD, MPH, Asian and Pacific Islander American Health Forum president and CEO
W. Douglas Weaver, MD, American College of Cardiology president”

For my own edification, I did some research on membership numbers:
First, total number of ohysicians in US about 800K.

American College of Physicians (Internists and Medical Specialists) 126,000 members
American Academy of Family Physicians 94,000 members
American Academy of Pediatrics 60,000 members

Amercian College of Cardiology 36,000 members

AMA 240,000 including students and residents (free membership) and retired.
— maybe 140,000 practicing physicians (Approximately 20 % or less of all physicians)

Hispanic Medical Association 36,000 members

Others:

American College of Surgeons 76,000 members

American College of Obstetricians and Gynecologists 52,000 members

American Society of Anesthesiology 43,000 members

American Psychiatric Association 38,000 members

American College of Radiology 32,000 members

American College of Emergency Physicians 27,000 members

American Academy of Dermatology 16,000 members

American Academy of Ophthalmology 7,000 members

American Orthopaedic Association (AOA) 1,500 members

These numbers are from the organizations own websites, except for the AMA data which is from Wikipedia – I actually have the actual data from the membership committee buried in my office somewhere, and if I can find it, I’ll post it.

In any case, some of the numbers include medical students, residents and fellows, and international members. But at least a rough guide, suggesting that there really is no single big gorilla, but I know some small groups put their money where their mouths are and have outsized political clout…

Some State Membership numbers, from their web sites:

California Medical Association 35,000

Texas Medical Society 43,000

Medical Society of New York 30,000

Florida Medical Association 19,000

Illinois State Medical Society _____

Pennsylvania Medical Society 20,000

Eight principles of Health Care Reform – from Obama Budget

• Guarantee Choice. The plan should provide Americans a choice of health plans and physicians. People will be allowed to keep their own doctor and their employer-based health plan.

• Make Health Coverage Affordable. The plan must reduce waste and fraud, high administrative costs, unnecessary tests and services, and other inefficiencies that drive up costs with no added health benefits.

• Protect Families’ Financial Health. The plan must reduce the growing premiums and other costs American citizens and businesses pay for health care. People must be protected from bankruptcy due to catastrophic illness.

• Invest in Prevention and Wellness. The plan must invest in public health measures proven to reduce cost drivers in our system—such as obesity, sedentary lifestyles, and smoking—as well as guarantee access to proven preventive treatments.

• Provide Portability of Coverage. People should not be locked into their job just to secure health coverage, and no American should be denied coverage because of preexisting conditions.

• Aim for Universality. The plan must put the United States on a clear path to cover all Americans.

• Improve Patient Safety and Quality Care. The plan must ensure the implementation of proven patient safety measures and provide incentives for changes in the delivery system to reduce unnecessary variability in patient care. It must support the widespread use of health information technology with rigorous privacy protections and the development of data on the effectiveness of medical interventions to improve the quality of care delivered.

• Maintain Long-Term Fiscal Sustainability. The plan must pay for itself by reducing the level of cost growth, improving productivity, and dedicating additional sources of revenue.

Nothing over the top in here. The principles, I think, are not very assailable.

The Politico offers their “translation” and I think zeroes in on what may become the critical throw down issue: Will we have a public insurance option to compete with private insurers in a system where all are required to have insurance?

Henry Waxman told AMA members in DC that a public option was in his plans, and Obama and Sen. Baucus have also indicated support for a public option.

Here is a link to the AMA National Advocacy Council news site. I have to say, the list of speakers is impressive. No Cato, Fraser, Heritage to be found (at least on the fist day – Tuesday) speaker list. Mostly progressive speakers.

Some AMA Policies Pertinent to Healthcare Reform Debate

H-165.856 Health Insurance Market Regulation
Our AMA supports the following principles for health insurance market regulation:(1) There should be greater national uniformity of market regulation across health insurance markets, regardless of type of sub-market (e.g., large group, small group, individual), geographic location, or type of health plan;(2) State variation in market regulation is permissible so long as states demonstrate that departures from national regulations would not drive up the number of uninsured, and so long as variations do not unduly hamper the development of multi-state group purchasing alliances, or create adverse selection;(3) Risk-related subsidies such as subsidies for high-risk pools, reinsurance, and risk adjustment should be financed through general tax revenues rather than through strict community rating or premium surcharges;(4) Strict community rating should be replaced with modified community rating, risk bands, or risk corridors. Although some degree of age rating is acceptable, an individual’s genetic information should not be used to determine his or her premium;(5) Insured individuals should be protected by guaranteed renewability;(6) Guaranteed renewability regulations and multi-year contracts may include provisions allowing insurers to single out individuals for rate changes or other incentives related to changes in controllable lifestyle choices;(7) Guaranteed issue regulations should be rescinded;(8) Insured individuals wishing to switch plans should be subject to a lesser degree of risk rating and pre-existing conditions limitations than individuals who are newly seeking coverage; and(9) The regulatory environment should enable rather than impede private market innovation in product development and purchasing arrangements. Specifically:(a) Legislative and regulatory barriers to the formation and operation of group purchasing alliances should, in general, be removed;(b) Benefit mandates should be minimized to allow markets to determine benefit packages and permit a wide choice of coverage options; and(c) Any legislative and regulatory barriers to the development of multi-year insurance contracts should be identified and removed.

H-165.866 All Americans Must Have Health Insurance
Our AMA strongly affirms and calls upon all of the state medical societies and all other national physician specialty organizations to strongly affirm the joint statement, “All Americans Must Have Health Insurance.” (The Statement was developed in 1999 by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Emergency Physicians, the American College of Obstetricians and Gynocologists, the American College of Physicians-American Society of Internal Medicine, the American College of Surgeons, and the American Medical Association. The Statement was further endorsed by other physician specialty organizations.)

H-165.888 Evaluating Health System Reform Proposals
Our AMA will continue its efforts to ensure that health system reform proposals adhere to the following principles:(1) Physicians maintain primary ethical responsibility to advocate for their patients’ interests and needs.(2) Unfair concentration of market power of payers is detrimental to patients and physicians, if patient freedom of choice or physician ability to select mode of practice is limited or denied. Single-payer systems clearly fall within such a definition and, consequently, should continue to be opposed by the AMA. Reform proposals should balance fairly the market power between payers and physicians or be opposed.(3) All health system reform proposals should include a valid estimate of implementation cost, based on all health care expenditures to be included in the reform; and supports the concept that all health system reform proposals should identify specifically what means of funding (including employer-mandated funding, general taxation, payroll or value-added taxation) will be used to pay for the reform proposal and what the impact will be.(4) All physicians participating in managed care plans and medical delivery systems must be able without threat of punitive action to comment on and present their positions on the plan’s policies and procedures for medical review, quality assurance, grievance procedures, credentialing criteria, and other financial and administrative matters, including physician representation on the governing board and key committees of the plan.(5) Any national legislation for health system reform should include sufficient and continuing financial support for inner-city and rural hospitals, community health centers, clinics, special programs for special populations and other essential public health facilities that serve underserved populations that otherwise lack the financial means to pay for their health care.(6) Health system reform proposals and ultimate legislation should result in adequate resources to enable medical schools and residency programs to produce an adequate supply and appropriate generalist/specialist mix of physicians to deliver patient care in a reformed health care system.(7) All civilian federal government employees, including Congress and the Administration, should be covered by any health care delivery system passed by Congress and signed by the President.(8) True health reform is impossible without true tort reform.

H-165.904 Universal Health Coverage
Our AMA: (1) seeks to ensure that federal health system reform include payment for the urgent and emergent treatment of illnesses and injuries of indigent, non-U.S. citizens in the U.S. or its territories; (2) seeks federal legislation that would require the federal government to provide financial support to any individuals, organizations, and institutions providing legally-mandated health care services to foreign nationals and other persons not covered under health system reform; and (3) continues to assign a high priority to the problem of the medically uninsured and underinsured and continues to work toward national consensus on providing access to adequate health care coverage for all Americans

H-165.916 Government Controlled Medicine
Our AMA strongly reaffirms its unwavering opposition against the encroachment of government in the practice of medicine as well as any attempts to covertly change the American health care system to a government program with the subsequent loss of precious personal freedoms, including the right of physicians and patients to contract privately for health care without government interference.

H-165.920 Individual Health Insurance
Our AMA:(1) affirms its support for pluralism of health care delivery systems and financing mechanisms in obtaining universal coverage and access to health care services;(2) recognizes incremental levels of coverage for different groups of the uninsured, consistent with finite resources, as a necessary interim step toward universal access;(3) actively supports the principle of the individual’s right to select his/her health insurance plan and actively support ways in which the concept of individually selected and individually owned health insurance can be appropriately integrated, in a complementary position, into the Association’s position on achieving universal coverage and access to health care services. To do this, our AMA will:(a) Continue to support equal tax treatment for payment of health insurane coverage whether the employer provides the coverage for the employee or whether the employer provides a financial contribution to the employee to purchase individually selected and individually owned health insurance coverage, including the exemption of both employer and employee contributions toward the individually owned insurance from FICA (Social Security and Medicare) and federal and state unemployment taxes;(b) Support the concept that the tax treatment would be the same as long as the employer’s contribution toward the cost of the employee’s health insurance is at least equivalent to the same dollar amount that the employer would pay when purchasing the employee’s insurance directly;(c) Study the viability of provisions that would allow individual employees to opt out of group plans without jeopardizing the ability of the group to continue their employer sponsored group coverage; and(d) Work toward establishment of safeguards, such as a health care voucher system, to ensure that to the extent that employer direct contributions made to the employee for the purchase of individually selected and individually owned health insurance coverage continue, such contributions are used only for that purpose when the employer direct contributions are less than the cost of the specified minimum level of coverage. Any excess of the direct contribution over the cost of such coverage could be used by the individual for other purposes;(4) will identify any further means through which universal coverage and access can be achieved;(5) supports individually selected and individually-owned health insurance as the preferred method for people to obtain health insurance coverage; and supports and advocates a system where individually-purchased and owned health insurance coverage is the preferred option, but employer-provided coverage is still available to the extent the market demands it;(6) supports the individual’s right to select his/her health insurance plan and to receive the same tax treatment for individually purchased coverage, for contributions toward employer-provided coverage, and for completely employer provided coverage;(7) supports immediate tax equity for health insurance costs of self-employed and unemployed persons;(8) supports legislation to remove paragraph (4) of Section 162(l) of the US tax code, which discriminates against the self-employed by requiring them to pay federal payroll (FICA) tax on health insurance premium expenditures;(9) supports legislation requiring a “maintenance of effort” period, such as one or two years, during which employers would be required to add to the employee’s salary the cash value of any health insurance coverage they directly provide if they discontinue that coverage or if the employee opts out of the employer-provided plan;(10) encourages through all appropriate channels the development of educational programs to assist consumers in making informed choices as to sources of individual health insurance coverage;(11) encourages employers, unions, and other employee groups to consider the merits of risk-adjusting the amount of the employer direct contributions toward individually purchased coverage. Under such an approach, useful risk adjustment measures such as age, sex, and family status would be used to provide higher-risk employees with a larger contribution and lower-risk employees with a lesser one;(12) supports a replacement of the present federal income tax exclusion from employees’ taxable income of employer-provided health insurance coverage with tax credits for individuals and families, while allowing all health insurance expenditures to be exempt from federal and state payroll taxes, including FICA (Social Security and Medicare) payroll tax, FUTA (federal unemployment tax act) payroll tax, and SUTA (state unemployment tax act) payroll tax;(13) advocates that, upon replacement, with tax credits, of the exclusion of employer-sponsored health insurance from employees’ federal income tax, any states and municipalities conforming to this federal tax change be required to use the resulting increase in state and local tax revenues to finance health insurance tax credits, vouchers or other coverage subsidies; and(14) believes that refundable, advanceable tax credits inversely related to income are preferred over public sector expansions as a means of providing coverage to the uninsured.

H-165.969 Federation and Physician Unity on Health System Reform
The AMA renews its call to the Federation, including state and specialty societies, to work together in a professional and collegial fashion to forge consensus in health system reform.

H-165.985 Opposition to Nationalized Health Care
Our AMA reaffirms the following statement of principles as a positive articulation of the Association’s opposition to socialized or nationalized health care:(1) Free market competition among all modes of health care delivery and financing, with the growth of any one system determined by the number of people who prefer that mode of delivery, and not determined by preferential federal subsidy, regulations or promotion.(2) Freedom of patients to select and to change their physician or medical care plan, including those patients whose care is financed through Medicaid or other tax-supported programs, recognizing that in the choice of some plans the patient is accepting limitations in the free choice of medical services. (3) Full and clear information to consumers on the provisions and benefits offered by alternative medical care and health benefit plans, so that the choice of a source of medical care delivery is an informed one.(4) Freedom of physicians to choose whom they will serve, to establish their fees at a level which they believe fairly reflect the value of their services, to participate or not participate in a particular insurance plan or method of payment, and to accept or decline a third party allowance as payment in full for a service.(5) Inclusion in all methods of medical care payment of mechanisms to foster increased cost awareness by both providers and recipients of service, which could include patient cost sharing in an amount which does not preclude access to needed care, deferral by physicians of a specified portion of fee income, and voluntary professionally directed peer review.(6) The use of tax incentives to encourage provision of specified adequate benefits, including catastrophic expense protection, in health benefit plans.(7) The expansion of adequate health insurance coverage to the presently uninsured, through formation of insurance risk pools in each state, sliding-scale vouchers to help those with marginal incomes purchase pool coverage, development of state funds for reimbursing providers of uncompensated care, and reform of the Medicaid program to provide uniform adequate benefits to all persons with incomes below the poverty level.(8) Replacing the present Medicare program with a system developed by the AMA of pre-funded vouchers to older persons to purchase health insurance with comprehensive benefits, including catastrophic coverage.(9) Development of improved methods of financing long-term care expense through a combination of private and public resources, including encouragement of privately prefunded long-term care financing to the extent that personal income permits, assurance of access to needed services when personal resources are inadequate to finance needed care, and promotion of family caregiving.

H-165.841 Comprehensive Health System Reform
Our AMA supports the overall goal of ensuring that every American has access to affordable high quality health care coverage and will work with interested members of Congress to seek legislation consistent with AMA policy.

H-165.847 Comprehensive Health System Reform
1. Comprehensive health system reform, which achieves access to quality health care for all Americans while improving the physician practice environment, is of the highest priority for our AMA.2. Our AMA recognizes that as our health care delivery system evolves, direct and meaningful physician input is essential and must be present at every level of debate. (Res. 613, A-06; Reaffirmation I-07; Res. 107, A-08)

AMA It’s not just about us

AMA It’s not just about us:

Some excerpts from the address of AMA President Nancy Nielsen:

“We need fundamental change in our health care system for ourselves, for our patients, for our nation. Right now annual health care costs exceed $2 trillion. That’s 16 percent of our nation’s GDP. Costs are estimated to reach $4 trillion and 20 percent of GDP in 10 years.

Right now, annual health care costs are the number one reason for bankruptcy. Right now, Americans get about half the preventive services that are recommended. Right now, we rank 19th among 19 developed countries in mortality that could be helped by health care. That means deaths that might have been prevented by health care. Nineteenth out of 19.

Forty-six million Americans have no health insurance, and another 29 million are underinsured. Those 75 million Americans are delaying or failing to obtain preventive care.

In our nation’s sick economy, job losses mean the loss of health insurance. Just yesterday, the government reported that employers cut 240,000 jobs in October alone. And so far in 2008, some 1.2 million jobs have been lost.

We as a nation have to do some serious soul searching. We are the most innovative, resilient, determined, self-reliant and creative nation in the world. Our health care system ought to be the best in the world but currently it is not.

Today we pay twice what other countries with better health outcomes pay. But we rank last or next to last in many health indices. And, that’s compared with Australia, Canada, Germany, New Zealand and the United Kingdom.

Now, we can try to protect the status quo. But the status quo is not serving patients well, and doctors are angry and unhappy. It is high time we do something about it and I’m not talking about single-payer. I am, however, talking about comprehensive change. I’m talking about responsible change that builds on the strengths of the current system. Isn’t it time to build a bridge to a new and better health system? A system where patients are better served and physicians are happier and more fulfilled in their work?”

…

“Do you remember this pivotal question during one of the presidential debates? “Is health care a right, a privilege or a responsibility?” Whatever our personal convictions on the answer to this question, the broader population seems to be moving fairly rapidly to the view that health care is a right.

But who will pay for this right, if that’s the country’s decision? Who will define the parameters of this right to health care? Because everyone cannot have everything, and society should not have to provide everything, nor can it afford to do so.

Take education as an example of setting parameters. Our society has decided that K-12 education is a right, but post-secondary education is a privilege and a responsibility.

Defining parameters for health care “rights” and “responsibilities” will require society’s honest deliberation and some difficult decisions. For sure we have to define the expectations of personal responsibility. What is fair to expect the individual to do? What should be up to the individual, and what should be society’s concerns?”

…

“As we participate with the rest of society in this debate, we cannot allow the discussion to descend into ideology and inflammatory labels. If we do, if we allow reason to be trumped by rhetoric, then we will have lost our chance to shape the change, to build the bridge to a better health system.

So I ask you, are we prepared to participate in that societal debate? Because the debate is going to happen. This is not just about doctors. It is not just about us. But physicians and patients will have to live with the outcomes. That’s why we have a central role to play.

We all use the commons and that is why we all have to do our part to protect it. Make no mistake, I am not in favor of a single-payer system. I am in favor of a health care system that works better for all of us, patients and physicians.

We’re in a time when our country is demanding change. We need change. Let’s harness that energy for our patients and ourselves. For sure, this is for us – we have to remove the sand from our shoes. But it is for so much more than us.”

…

“In many countries, when people are scared, they turn to government for protection. Even though many do not trust Washington politics, they may see it as their only option. There is great concern in our country. We need to help calm those fears. We need to embrace our role as healers in a time of need. We need to help craft a solution that is based on our professional ethics–one that is equitable and just, one that builds on the strengths of our system, addresses current weaknesses, and allows us to regain the joy and simple dignity of caring for our patients. “

Please go check out the whole thing. Credit where credit is due. It is a remarkable statement from the the AMA President.

I am concerned by the last paragraph I quoted, however. My goal is to turn to my government for fairness, and it is not our of fear, it is out of anger at the mismanagement of our system and at the giant sucking sound, to quote Ross Perot, that emanates from our insurers, Pharma, and ourselves that makes our system so inefficient. So, I hope this is not the line in the sand that the AMA is drawing, that a solution based upon strong government regulation is off the table.

AMNews: April 21, 2008. More physicians backing national coverage — study … American Medical News

AMNews: April 21, 2008. More physicians backing national coverage:

“Physicians who support ‘government legislation to establish national health insurance’
————————-2002————-2007
All specialties————49%————–59%
Psychiatry—————64%————–83%
Pediatric subspecialties—71%————–71%
Emergency medicine—–53%————–69%
Pediatrics—————-64%————–65%
Internal medicine——–56%————–64%
Medical subspecialties—-50%————–63%
Pathology—————-n/a—————60%
Family medicine———-44%————–60%
Ob-gyn——————-48%————–58%
General surgery———-52%————–55%
Surgical subspecialties—-37%————–45%
Anesthesiology———–35%————–39%
Radiology—————-n/a—————30%

I will try to get more of the details to the original article from the April 1 Annals of Internal Medicine tomorrow, as I can’t access it here at home tonight.

Update: here is the link to the Annals page. Actually not much more info there but here is the full results summary:

Results: Of 5000 mailed surveys, 509 were returned as undeliverable and 197 were returned by physicians who were no longer practicing. We received 2193 surveys from the 4294 eligible participants, for a response rate of 51%. Respondents did not differ significantly from nonrespondents in sex, age, doctoral degree type, or specialty. A total of 59% supported legislation to establish national health insurance (28% “strongly” and 31% “generally” supported), 9% were neutral on the topic, and 32% opposed it (17% “strongly” and 15% “generally” opposed). A total of 55% supported achieving universal coverage through more incremental reform (14% “strongly” and 41% “generally” supported), 21% were neutral on the topic, and 25% opposed incremental reform (14% “strongly” and 10% “generally” opposed). A total of 14% of physicians were opposed to national health insurance but supported more incremental reforms. More than one half of the respondents from every medical specialty supported national health insurance legislation, with the exception of respondents in surgical subspecialties, anesthesiologists, and radiologists. Current overall support (59%) increased by 10 percentage points since 2002 (49%). Support increased in every subspecialty since 2002, with the exception of pediatric subspecialists, who were highly supportive in both surveys.

The spin in the AMA News article is predictable (poorly worded survey questions), and, OK, fine, maybe some didn’t mean exactly as they answered. We’ve all taken surveys, and it is true, you can only answer the question that is asked.

But look at some of these numbers because they are astounding. When 45% of physicians in surgical subspecialties (we’re talking orthopods, urologists, and neurosurgeons here!) and 55% (!!!!) of general surgeons answer this way, there is a problem.

AMA Policy is against single payer. But AMA policy is determined by it’s House of Delegates. This is a very democratically structured body, but frankly, delegates are far older and more conservative than all other AMA members and AMA members are older and more conservative than physicians as a whole, so this is a problem that will take a leader from within the AMA leadership to take up and champion. Which, knowing the culture a bit, would be courageous, but history making.

Putting this together with the Minnesota and Jackson and Coker surveys, we may finally be acheiving critical mass.