The AMA: Pushing Patients Around

[Guest guest]

The AMA: Pushing Patients Around

 

It is time to dip into some murky waters here at Spot-on. Like it or not, it's

time to see what the American Medical Association (AMA) is up to. Why so murky?

Well, the AMA is the group most responsible of any for ensuring that America

does not have universal health insurance for every citizen, and also for the

fact that the quality and even type of health care patients receive varies

dramatically.

 

It lobbies for a number of causes - reduced salt in our diets, for instance,

in addition to the work it does on behalf of individual doctors so it's hard to

really get a handle on the type of real work the AMA does. But, well, that's why

I'm here: To put it all in perspective.

 

Recently the association conducted a public opinion poll, one designed to

strengthen its arguments on Capitol Hill against cutting phycians fees. Guess

what it said? Most Americans are alarmed by impending Medicare cuts that will

harm seniors' access to care!

 

Well actually most Americans had never heard of the cuts, and most Americans

believe that health care is way too expensive and would presumably like to pay

less for it. But leave that aside. After the pollsters told them that Medicare

fees would be cut, the next question was obvious. It was something like " Doctors

say that if you pay them less they won't take Medicare patients, who will be

left on the street to die. Then their bodies will be eaten by wolves. Are you

worried that this will impact access for grandma to her doctor? " And you can

guess what the answer will be.

 

This is the typical semi-fraudulent poll you'd expect from a self-interested

lobbying group. And the AMA, of course, is able to say that it's not fighting to

maintain its members' incomes, it's fighting to preserve access to care for

grandma. The real problem physicians are complaining about is that in real terms

their incomes have gone down over the past decade, although most of the fall was

in the 1990s, and they're starting to pick up again now. But when you're talking

about an average income of about $200,000 a year it's pretty hard to get public

sympathy for your cause. And on top of that, the poll's assertions are supported

by real life. Doctors may say they're not going to take anymore Medicare

patients if fees go down, but the real data shows that they continue to treat

Medicare patients. Earlier fee reductions made essentially no difference in the

number of physicians taking Medicare patients. And that's only logical: Elderly

Medicare patients are, by far, the

biggest users of health care and therefore doctors' biggest customers. But

those seniors are being scared into protesting by the physician lobby, and that

will likely get those fee cuts put off for yet another year.

 

How did the AMA end up using patients to lobby for policies which are not

really in their best interests, let alone the interests of taxpayers, employees

and consumers paying for health care? It's a long and sordid story. By far the

best analysis of the development of physicians as a distinct and highly

privileged trade guild was written by Paul Starr whose seminal work, The Social

Transformation of American Medicine, tells the story of how allopathic

physicians distinguished themselves from various other types of medical

practitioners and quacks in the latter years of the 19th century.

 

They managed to use their growing social status and the political influence of

their major membership organization, the AMA and its state chapters, to resist

the ability of corporations to overrun their status as independent small

businessman (as happened to most craftsmen and many other professionals). They

also prevented the government from closely regulating how they actually

practiced medicine and from creating a social insurance scheme, which presumably

they'd be forced to work under. That's why attempts to introduce universal

health care reform failed in 1917, 1934, 1948, 1965, 1974 and 1994 (although by

1994 the AMA had help).

 

Suffice it to say this was a remarkable triumph both socially and politically.

And when the government did finally get a halfway-house social insurance scheme

in place - the introduction of Medicare for the elderly in 1965 - the power of

the AMA was sufficient to make sure that for the next 20 years, physicians were

able to bill the government essentially as much as they liked, and received no

interference in what they were billing for.

 

Eventually though these good times couldn't last.

 

A couple of things started to happen. Although corporations are banned from

" practicing medicine " in many states including California, the ability of the

physicians' guild - the AMA - to restrain the growth of large-scale practice

groups began to wane over the years. It has become harder and harder for

physicians to start new solo practices, even though more than 60% of doctors

still work in very, very small groups. Partly because of this, only some 30% of

physicians are now AMA members, and they tend to be those in small and solo

practices who regard themselves as independent businessmen.

 

And after about 20 years of seeing the rate of health care costs increase

dramatically the government and private payers have looked for ways to slow

their health care costs. The government tends to lead the charge on this because

the government pays for Medicare which is by far the biggest and most important

health care program in the U.S. Inevitably reducing physician fees is a prime

candidate. Reducing the fees is only half the equation, however. Physicians also

tend to get paid for each service they deliver. So typically any attempt to

reduce fees results in physicians increasing services - not only those they

provide themselves but also the attendant tests, hospital admissions and other

things that go along with that. So a cut in fees doesn't convert to a straight

cut in income, or a reduction in health care costs overall. But it's not, of

course, something physicians are going to be keen on.

 

Now, Medicare has an incredibly complicated fee schedule, and spends its time

trying to adjust it so that its constituencies of physicians, hospitals, health

industry players and taxpayers all have their irreconcilable demands met, or

not. As many private plans mirror Medicare in how they pay out on their fee

schedules, the fight around who gets what is crucial.

 

This year, Medicare is trying to re-jigger an attempt it made in the late

1980s to straighten out one of the worst aspects of its fee schedule. Right now,

procedures (e.g.surgery) get reimbursed at a significantly higher hourly rate

then consultative services (e.g office visits). So most doctors coming out of

medical school want to be surgeons and investigational radiologists because they

get paid one hell of a lot more than primary care doctors and pediatricians.

Take a look:

 

Incomes of different medical specialists

 

(Source is American Medical Group Association surveys; chart from NEJM)

Meanwhile, the primary-care docs have been trying to make it up on volume -

driving themselves insane in the process. So the various specialty societies are

at each other's throats as Medicare tries to divvy up a budget neutral

reallocation of income.

 

But while that's the backdrop to the internecine struggle among doctors,

there's a more immediate problem--hence the polling and protests. Back in 1997

when it allegedly cared about balancing the budget, Congress mandated large

across the board cuts in physician fees - for all doctors. And every year the

AMA gets its friends on Capitol Hill to override the mandated cuts. This year

things might be coming down to the wire. Which is why the AMA's polling and

threatening - in passing - to leave grandma in the waiting room.

 

Now realistically, and practically, we're not going to get a decent health

care system until the doctors are brought into the reform tent, but it's

possible that the baggage that the AMA brings to the table means this may not

happen until there's a revolution in organized medicine. The good news is that

as more and more doctors are not in the solo-practice fee-for-service model that

the AMA has historically represented. So there is some hope that the association

will fade in relevance, reform itself, or be replaced by a new physician

organization which takes a reasonable approach to reforming the health care

system. The bad news is that there's no sign of that happening anytime soon.

 

Posted by Matthew Holt at 8:21 AM

 

http://www.spot-on.com/archives/holt/2006/09/the_amas_push_poll_gets_the_an.html

 

 

" A trail blazed by an elephant becomes a roadway. " Burmese proverb

 

" The care of the Earth is our most ancient and most worthy, and after

all our most pleasing responsibility. To cherish what remains of it and to

foster its renewal is our only hope. " Wendell Berry

 

 

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