ObamaCare: The Threat to Physician Autonomy
Monday, March 1, 2010 at 7:15PM by aaps by Richard Amerling, M.D.
The debate raging over ObamaCare has been carried on mostly by politicians, pundits, policy wonks and economists, with little input from those most intimately involved with delivery of health care—medical practitioners. Doctors have too often been marginalized as self-interested. If that were true, there would be far fewer practicing physicians. Of course we are concerned with income, as are all taxpayers and businesses faced with rising costs and taxes. Unlike other businesses, however, most doctors are unable to pass higher costs to consumers due to price controls on reimbursement. When costs outpace income, bankruptcy ensues. This renders discussions of autonomy moot.
Autonomy, for physician and patient, is central to the medical profession and dates back to Hippocrates: "I will prescribe regimen for the good of my patients according to my ability and my judgment. I will keep them from harm and injustice."
To be fair, physician autonomy, and the doctor-patient relationship, have been under assault for decades. This was an inevitable result of the acceptance of third party payment by physicians, and was greatly accelerated by Medicare and Medicaid beginning in 1965, and the Health Maintenance Organization in the 1970s.
Medicare and Medicaid sought to control costs by limiting reimbursement to physicians, payment to hospitals based on diagnosis, and by limiting payment to services it deemed “medically necessary.” Practice was and is distorted by these interventions. For example, faced with declining payment for services, doctors increase the volume of services. This means less time per patient, declining quality, and greater reliance on laboratory services, imaging procedures, consultants and hospitalizations. Total costs actually rise when physician fees are cut!
Health Maintenance Organizations promised to improve quality and control costs by assigning each patient to a Primary Care Provider, or PCP. The PCP, who could be a nurse practitioner or physician, serves as a gatekeeper, blocking access to higher level care. They receive direct financial incentives to spend the least amount per patient. This is the opposite of physician autonomy, with the PCP in effect working for the HMO.
Whatever its final form, ObamaCare would perpetuate these failed models. In addition, it will include enhanced measures to control medical care. These will be implemented under the guise of quality assurance and cost containment. Slipped into the so called stimulus bill passed last February is a new federal health care panel that will decide which procedures and drugs are “medically necessary” and “cost effective.” Based on the writings of Ezekiel Emmanuel, brother of Rahm and close Obama health advisor, we can assume rationing of care to the elderly (over 65!) and very young (under 2). Also included is a mandate for adoption of electronic health records (EHR). The clear goal here is to have access to every medical interaction; the only rationale for gathering such detailed information is to exercise control over medical decision-making.
The mechanisms are already in place. For the past couple of decades medical specialty societies, aided and abetted by the government, the American Medical Association, and Big Pharma, have been crafting clinical practice guidelines. These mostly opinion based recommendations will be transformed into mandates, first as “clinical performance measures,” then as “payment for performance.” Treatment algorithms will be built into the EHR to guide decision making at the point of service. Such a “one size fits all” approach will be an unmitigated disaster for patients.
The Senate bill states that qualified health plans may only work with doctors who “implement such mechanisms to improve health-care quality as the secretary (HHS) may by regulation require.” In other words, doctors who refuse to turn over patient information and treat according to guidelines will be barred from participating.
The way to preserve a semblance of physician autonomy is to send this bill to the shredder. Failing this, the medical profession must come together and refuse to sell out their patients and their profession. We must assert our right to treat patients as individuals, to the best of our ability.
Richard Amerling, MD, is a nephrologist practicing in New York City. He is an Associate Professor of Clinical Medicine at Albert Einstein College of Medicine in New York, and the Director of Outpatient Dialysis at the Beth Israel Medical Center. Dr. Amerling studied medicine at the Catholic University of Louvain in Belgium, graduating cum laude in 1981. He completed a medical residency at the New York Hospital Queens and a nephrology fellowship at the Hospital of the University of Pennsylvania. He has written and lectured extensively on health care issues and is a board member of the Association of American Physicians and Surgeons. Dr. Amerling authored and signed the Physicians’ Declaration of Independence.
Reader Comments (12)
Oh yes, I remember the 70s, when managed care really got going, and how angry my physician was - he felt then, and I agreed then and now, that my medical care should be decided between him and me, based on his judgement and expertise, but only after a detailed discussion with me about the ailment, symptoms, options, risks, and potential outcomes. This can't be done by a computer, and not by a bureaucrat in Washington, D.C. who has never met me.
I prefer to put my trust in a doctor who has been thru medical school, and who has personal knowledge of my body! Let's put medicine back in the hands of the professionals who spent years learning how to make these decisions!
There is little doubt that health care in America is expensive and needs some reform. The trick is to reform it without losing quality. The bills currently going through the Senate and the Congress are just a shallow attempt to more government control. I am very happy with my physicians and want it to continue that way.
Dr. Amerling,
You've made some valid points within your essay.
Privacy is important to preserve as well as quality care resulting from an appropriate doctor patient relationship. Patient and doctor rights are in peril, true.
However, you've exonerated doctors from having anything to do with directly raising the cost of health care - take responsibility Sir. The level of income physicians receive and the power over the management of their practice(s) won't be overlooked.
Do you really think people will believe you don't want to make more and more money, Sir?
At least be honest. Sacrifices must be made.
Dr. Amerling makes some very good points here. I think it is especially important to recognize that physician autonomy has been under assault for decades. The current health reform proposals should not come as a surprise to anyone; we have been marching down the road of government intervention since at least the 1960s (and since the 1900s and earlier in other industries).
The only way to stop this is for today's doctors to realize that they have a moral right to their lives and to their profession. This is what I am trying to teach to med students at The Lucidicus Project. Visit Lucidicus.org to learn more.
DON'T USE A WRECKING BALL TO REPAIR HEALTH CARE. GO AFTER FRAUD, TORT REFORM, INS ACROSS STATE LIINES, AND STREAMLINE MEDICARE FORMS
I have always been amazed in peoples standards, its OK for people in the entertainment business to make millions. On the other hand people who choose to spends years in a field to take care of our health are asked or told they should provide theire services at very low profit...
As far as Medicare goes I hate it, I was on a very good medical plan with SWBT, when I reached 65 I was told I have to go on Medicare or lose my healthcare. Of course I will take Medicare rather than lose my benifits. My United Health care is my secondary insurance and rarely pays any of the plan because you have to go to Doctors that take Medicare, Medicare being my Primary Insurance (now) has a set fee the doctor can charge, which means United Healthcare pays nothing for my care.
The 70% of Indiana 's 30,000 employees with HSAs now enjoy ~$2,000/yr cash in pocket and Indiana saves $10,000,000/yr,writes Gov Mitch Daniels in WSJ 3/1/10!
Consumer directed care, patient power, escapes the tyranny described above.
My cash practice ($50/15 min. concentrating on the patient) has also liberated me from
trying to please third parties Try it. You will like it.
Howard Long
Correct the waste of medicare/medicaid fraud. Implement Tort reform. Have portability of health care, especially now with job relocations. Stop the immmigration use of coming to the US for birth of children to gain citizenship, no prenatal care, both being put on programs under medicare entitlement. Look at US citizens using the system fraudalently, Medicare and medicare.
Find 4 or 5 key components, focus on those and start reform with input of both parties, what they can agree on. Implement on a small scale for trial and adjust as necessary until it works and checks and balances are in place. Look at costs associated with the implementation, not just calculations based on some formula. The formulas being used were apparently wrong before and are probalby not correct now. With small scale and limited components it would be much easier to see where the problems are and to assign & trace accountablity.
I want to thank you for such a valuable site. I have gained such a wealth of honest truths about our healthcare system and what the new one will do to me and my relationship with my doctor. I want to stop the Obamacare and I am calling many senators and governors. I will continue to tthink about our valuable doctors and will stand behind what they say and not the AMA.
Dr. Amerling's essay is superb. Too bad Obama, Pelosi, and Reid won't read it. Most physicians would rather avoid "politics" and just practice medicine, but as we've learned this year, politics has deeply (and permanenty) invaded medicine. There are now many Republican physicians in Congress, including Drs. Coburn, Barasso, Boustany, and Price. We need more of them to run for office. Beyond that, physicians need to give greater support, including financial contributions, to House and Senate members who know about the importance of preserving the doctor/patient relationship and keeping health care from being regulated and cost-controlled into oblivion. All of us are going to have to make sacrifices to overcome the negative image of physicians being propagated by Obama and others. Good doctors have a right, in a free society, to make a good living. But it's a right we can't take for granted.
Healthcare must start at the beginning. The Government must first correct the Medicare/Medicaid they created, We need torte reform and portability to go where we wish to go for insurance as our Constitutional right . Stopping illegal immigration alone will cut bilions of dollars which will in turn erase a lot of the current problems. This government instead of doing their job is wasting precious time messing in Healthcare & should be creating jobs which allows people to pay for care. These idiots won't face fact that jobs and helping small business takes care of a multitude of problems. Instead of hitting the people with costs for medical why don't they cut their own spending in half. I am behind my doctors 100% and thank them for keepiong me alert to what is going on.
I certainly agree with Dr. Amerling's observations. All that said the only way doctors are going to make an impact on the process going on in D.C. is to organize. If we don't come together and act in a firm, uniform effort, we have no hope of derailing the upcoming reform. It may be to late already! We should look at a day out of the office or a week of not accepting medicare patients or, at the best, dropping out of medicare. These look to be the only way we will be heard. Have any physicians, or groups of physicians, been called into the
health care debate? No, and we are at the mercy of the bureaucrats and we will never be heard if we don't do something that will get their attention.