Physician Patient

MPPA Meeting Tuesday March 8, 2016 at 7 PM in Central Medical Building, St. Paul

Those present: President Lee Beecher, Bob Geist, Doug Smith, Dave Racer, Lyle Swenson, Peter Nelson, Gabriel Komjathy, Hannelore Brucker, Lee Kurisko, Adam Lokeh (plastic surgeon), and special guest, Dr. Susan Bailey, Speaker of the AMA House of Delegates.

1) The sole order of business was a conversation with Dr. Bailey:

• Dr. Morris first outlined the issues—Professional Factors (“reform” effects on ethics, quality of care, patient-physician relationship) and Economic Factors (cartel formation, centralization of power, costs to patients, patient choice, insurance costs).
• He noted a sharp decline in independent practice.
• Dr. Bailey said that the doctor-patient relationship was of primary importance and her focus.
o She briefly described her career—she practices in a two person group in Fort Worth TX [her distinguished CV was noted in the meeting announcement].
o She noted that external forces impact our care. Therefore, she feels that we all have a moral imperative to be involved in public policy, as an obligation to patients and their protection from such forces.
o The AMA is a democratic organization run by its HOD (550 physicians); the Board (21) executes HOD policy.
• The current president is age 44.
• The AMA CEO and JAMA editor were recently fired—“big changes”.
• Payment system is subject to much pressure.
• The health insurance ‘right’ ought to include issues created by the employer-based system and AMA policy to promote UHI—she noted that before ACA was passed (2010 Obamacare) AMA approval was based on AMA policy favoring UHI—the adoption of this policy and subsequent ACA approval took place while she was president of the TMA. The HOD vote on including an individual mandate was in favor 51%-49%. In 2009 the AMA then urged members to support ACA passage.
• Once ACA passed in 2010, AMA membership dropped precipitously.
• Audience had ObamaCare comments:
o Access is important; not synonymous with ‘coverage’.
o Cost problem is due to lack of price sensitivity.
o Government can’t solve all problems of medicine.
• Dr. Bailey noted that ACA can’t be repealed or changed with Obama in office.
o Good aspects ought to be continued: guaranteed issue and parent insurance to age 26.
o AMA wants CMS to decrease regulations (problems with “meaningful use”). Even CMS (Andrew Slavitt) admits “we’re losing doctors”.
o Insurance deductibles keep people from care.
o Insurance companies losing millions in exchanges.
o The SGR (“doc fix”) battle took “air out of the room”.
o Hopeful that MACRA (“doc fix) law) will help give choice for alternative payments.
o Cost problem due to change in medical market basket.
• Dr. RWG two comments:
o “Doc fix” beneficence is an illusion. SGR “reform” (MACRA ‘doc fix’ law) simply replaced pay cuts for allegedly doing “too many” services with pay cuts for ordering “too many” services.
• This was no minor change—a change to corporate profit-driven bedside gatekeeping. The law induces a bedside conflict of interest with patients, because franchising care can legally be limited to mini-insurance corporations (the CMS ACO/APM “value purchasing” edict) , corporations profit driven to restrict access and to do “gain share” profiteering with “joint venture” mega HMO corporations.
• The mini-ACO/APM insurance corporation “arrangements” with HMO “payers” are a necessity, since they have no state insurance license (therefore no untaxed reserves), no sales force, no patients (until bidding at auctions of “payer” clientele for servicing), no money, no actuaries, no lobbyists, and no back-office insurance capabilities.
• The AMA has recently lacked insight into the ethics of pay for decreasing “resource use” profitable to 3rd parties paying kickbacks for bedside gatekeeping and “gain sharing” the profits with “joint ventured” HMO corporations. The AMA fought in the late 19701s but then had to cave to the FTC in court by changing its Code in 1981.
o Cost Inflation is not due to a change in the medical market basket (a relative minor factor). Technology has reduced the cost of illness and morbidity, e.g., vaccinations, antibiotics (for pneumonia), many devices (mini-invasive surgery), etc.
• Inflation is due to tax-subsidized inexpensive insurance making medical goods and services appear “free” [references on request]. “The boss/government pays for it” created demand inflation abruptly after 1965 when 85% of the populace suddenly had tax-free insurance—it made sense to “cover” even expected affordable services with cheap insurance.
• Subsequent unrelenting demand inflation is induced by government economic malpractice and is not due to “poor-care greedy” physicians or a beer guzzling smoking populace. Political diagnostic malpractice was compounded by choosing to ration supply rather than repeal poplar “free” care subsidies driving demand. Rationing of supply has proved futile: price fixing after 1971; CON after 1974; DRGs after 1984; and after 1973 corporations (HMOs) profit driven to ration access to care supply (called by some corporate socialism under the façade of “privatization”).
• The AMA shares a lack of economic insight into the futility of government profit driven cost control panaceas; it hasn’t ask when or why the panaceas failed and supports a more powerful ObamaCare managed care panacea.
• Dr. AL—can’t get hospital privileges without being able to bill Medicare, although he has opted out to never bill Medicare or any insurer [a catch 22].
• Dr. Bailey noted that the AMA is a hybrid organization consisting of “individual elements” [I think she meant independent practitioners] and of “organization elements” [I think she meant managed care organization (MCO) proponents].
o Dr. DS inferred where the balance of power resided at this time by saying that this is what makes the AMA of little value.
o Dr. Bailey countered that the monthly dues were only $35/month—a real value, and that change cannot be made by opting out of membership.
o Peter N. commented on the restrictions placed on individual practice—Dr. Bailey noted the TX prohibits corporate practice of medicine. Dr, RWG noted that absence of corporate practice of medicine law in MN was by-passed with a 1955 MN AG ruling for Group Health Corporation to practice medicine [MN Op. Att’y Gen. No. 92-B-11, Oct. 5, 1955)].
o Dr. Bailey noted that the AMA has a litigation division dedicated to helping doctors, where external forces hamper medical practice.
• There were many random comments:
o Dropping out of the dominant managed care/government insurance system is “the only option”.
o Public doesn’t know that doctors are paid to restrict care.
o Corporate (not patient) employed doctors are the new dominant model.
o Dr. LB noted that global corporate budgets result in delays—Dr. LK’s problem before leaving Canada was delay for elective care rising to 13 months and that it was illegal to jump the queue by paying for care oneself. [Not mentioned was that the majority of doctors aided friends and family to jump the cue, that basket ball and hockey players are favored, that those rich can go south for care (the Cleveland clinic was dubbed the ‘orthopedic center’ of Ontario), and that two prime ministers went to the US for care (one Ca and one cardiac)].
o Dr. RWG pointed out that in no other economic sector was FFS deemed a cause of inflation [the specious conventional wisdom of pundits and politicians promoted by insurance industry moguls.]
o Dr. DS said he practiced patient care—doctors cannot practice population care without becoming insurance corporation underwriters in financial conflict of interest with their patients and constrained by population-guidelines, which may be of little use or even harmful to a patient.
o Dr. Bailey agreed that there was a trade-off, when population care is the system model, that the AMA agrees with folks having individual insurance policies, and that the AMA agreed with the Berwick’s Triple Aim (improved patient experience, improved population health, and reduced capitation costs).
• Dr. RWG countered that the triple aim was only a hacked up version of the real HMO dilemma: “cost, quality, access—pick any two” [Bodenheimer T. N Engl J Med. 1997;337:651-655, 720-723.]
o Dr. Bailey said that the AMA was concerned about the patient-physician bond where population care dominates. [At this point there was no time left to further analyze this important issue or any AMA policy directions to deal with population care reality and often spurious rhetoric]

2) Dr. Bailey was thanked for her openness to discussion of problems bothering clinicians and their patients due powerful and growing external political-corporate forces. We asked if MPPA could help. She replied that we ought to continue involvement in policy discussions and to make public comments in letters to newspaper editors, etc.

Meeting Summary–RWG

I, Issues discussed.
The concepts expressed by the meeting’s audience were that the role of doctors is to take care of patients, not populations of corporate or government clientele. Doctors are not public health officers and ought not to be population insurance-underwriters gatekeeping “resource use” profitable to 3rd party corporations or government agencies.

Doctors cannot solve the problems that political panaceas have wrought: tax-subsidized demand inflation and decades of utilitarian rationing of care-supply schemes gone awry. Too many politicians, pundits, and professional associations have little or no insight into the simple philosophic fact that a good end, cost control, never justifies corrupt means, a scandalous system of legalized giant mergers , of ACO-HMO gatekeeper corporations profiteering at the nation’s bedside. ,

III. Issues Not Discussed.
We did not have time to discuss solutions to the problems of unrelenting cost inflation, the possibility of crony public-corporate cartels (CMS in the hands of an HMO trade association executive), the demonization of doctors, the corruption of a profession paid to profit 3rd party corporations, and the lengthening queues in ever-narrowing insurance corporation provider networks.

We did not discuss a possible lapse into more powerful NHS-like single payer corporate-public cartel “partnership” system, or the alternative of seeking re-empowerment of patients controlling their own family medical budget and consumer acting as kings in a medical free marketplace—a free market where prices matter and consumers (not powerful centralize “managers”) can accurately value the quantity and quality of insurance and service, something true in every other microeconomic market sectors where millions of transactions take place daily between millions of people with millions of individual goals.

We did not have time to discuss the AMA’s policies, which seem to enhance financial incentives for bedside gatekeepers to restrict patient care of “value” to corporate and government agency “payers” under the guise of “stewardship”.

3) Next meeting is scheduled for 6 PM April 21, 2016 at the Central Medical Building

Respectfully submitted, Robert W. Geist MD, Secretary pro-tem
651-484-6968
rgeistmd@comcast.net

——-

1. Burwell SM. Setting value payment goals—HHS efforts to improve U.S. health care. N Engl J Med 2015;372:897-899.
2. AMA Council on Ethical and Judicial Affairs Code of Medical Ethics. AMA Chicago IL :1981: Principles of Medical Ethics .Section III, p.xiv
3. Brill J. Competition in health care markets. Keynote Address, Federal Trade Commission Hal White Antitrust Conference, Washington, D.C., Jun 9, 2014. Available at: https://www.ftc.gov/system/files/documents/public_statements/314861/140609halwhite.pdf
4. Federal Trade Commission. Statement of antitrust enforcement policy regarding accountable care organizations participating in the Medicare Shared Savings Program. Federal Register 2011;76(209):67026-67032. Available at: www.gpo.gov/fdsys/pkg/FR-2011-10-28/pdf/2011-27944.pdf
5. Centers for Medicare and Medicaid Services. Medicare program; final waivers in connection with the Shared Savings Program. Federal Register 2011;76(212):67992-68010. Available at: www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27460.pdf
6. Geist RW. Profiteering at the Nation’s Bedside: a corrupt system legalized. In press.
7. AMA code of Medical Ethics. Opinion 9.0652 – Physician Stewardship of Health Care Resources.
AMA Journal of Ethics November 2015;17(11):1044-1045. Available at: http://journalofethics.ama-assn.org/2015/11/coet1-1511.html. Accessed Dec 6, 2015.

Leave a Reply