By Richard Amerling, MD
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.