Are Doctors Dumb Enough to Be Society’s Hitmen?

You have to hand it to the American Medical Association (AMA), it has a real talent for destroying the medical profession.

Over time this aptitude has been turned to a variety of uses.  In the late 1980s and early 1990s it was used to support the development and deployment of the RBRVS system of coding and billing.  The AMA was a direct beneficiary of this development by virtue of the monopoly that it received for developing and maintaining these codes – around $70 to $100 million annually by most estimates.  The AMA is quick to point out that no tax dollars were spent in the process, as if this is a point of honor.  Medicare, Medicaid and other federal government programs may use these codes freely.  So who is paying the AMA all of this money?  Why, physicians and patients are of course!  Doctors and the people who bill for them (as well as hospitals, clinics, acute care centers, physical therapists, podiatrists, insurance companies and anyone else involved in healthcare), are all forced to pay the AMA for their use of the CPT codes embedded in billing software, electronic medical records, books, forms and everything else that they might use to bill or refer to procedures.  The cost to insurers is passed directly to patients in the cost of their premiums.  The cost to hospitals and everyone else may or may not be passed along depending upon whether they have the ability to set their own prices.  Since the vast majority of physicians do not, most of absorb the cost dollar-for-dollar as a loss of income they would have otherwise taken home.

And then, of course, there was the Affordable Care Act (aka “ObamaCare”), a law that really has no benefit to doctors whatsoever other than some temporary increases in Medicaid payments to primary care physicians.  Instead, the law offers to reduce Medicare payments to clinicians by $500 billion over ten years, adds lots of great new bureaucratic requirements, 130-odd new boards, panels, committees and other entities that will almost certainly make life miserable for physicians, does nothing to help fix the dysfunctional medical malpractice system, and did not even bother to fix the annual travesty of Medicare’s “sustainable growth rate” (SGR) formula.

Of course, the AMA supported it.  Presumably it did so because it was afraid otherwise, its lucrative CPT monopoly might be taken away by an Act of Congress or some sort of Executive Branch directive.  And maybe that’s true.  But the AMA’s support was certainly not given because the law is a good thing for physicians or their patients.  Far from it.

But as bad as these past transgressions against the medical profession might have been, they absolutely pale compared to the AMA’s latest endeavor.  For reasons known only to the folks in charge of that august organization, “America’s largest physician group” wants to change the role your doctor from that of your advocate, to a hitman advocating for the greater good of society.  If this is not what you had in mind when you made your clinic appointment, you may want to ask your physician if he or she happens to be a supporting member of the AMA…

Here’s the story as reported by MedPage Today:

CHICAGO — Providing effective medical care includes an “obligation” to prudently manage healthcare resources, according to a report approved by the American Medical Association’s House of Delegates on Monday.

In fact, managing healthcare resources “is compatible with physicians’ primary obligation to serve the interests of individual patients,” the report reads. It further states that considering the welfare of only the patient currently being treated when making recommendations does “not mesh with the reality of clinical practice.”…

Specifically, the report recommends that physicians should:

• Base their medical recommendations on patients’ medical needs using scientifically grounded evidence.
• Help patients and their families form realistic expectations about whether a particular intervention is likely to achieve those goals.
• Choose the course of action that “requires fewer resources when alternative courses of action offer similar likelihood and degree of anticipated benefit compared to anticipated harm” for that particular patient.
• Be transparent about the medical alternatives, including disclosing when a constraint on resources played a role in decision-making.
• Participate in efforts to resolve disagreement if a patient feels a costly intervention is worthwhile. This could include consulting other physicians or an ethics committee.

The report also calls on doctors to advocate for medical liability reform to avoid barriers that impede “responsible stewardship” — for example, the need some physicians feel to order unnecessary tests or procedures so they can avoid being sued for medical malpractice.

During a reference committee debate on the subject, most physicians were in favor of the report, but several were concerned that if physicians were encouraged to consider the cost of care, they would no longer put their patients’ well-being first…

Delegates at the AMA meeting seemed comfortable, however, in supporting the idea that doctors use cost as a consideration in what kind of care they provide, especially when deciding between two equally effective treatment options that carry very different price tags.

Tamaan Osbourn Roberts, MD, a family physician in Colorado, told the House of Delegates Monday that “stewardship is not antithetical to care of a patient.”

“As physicians, we make decisions on resources every day,” he said. “If not us, who?”

This issue is so important, and so critical to the appropriate management of the physician-patient relationship, that it’s worth some serious consideration.  Let’s start with some basic principles of medicine, economics and human behavior.

The first principle is that, in Western democratic cultures, when any of us seek out a physician for care, our primary goal is finding a solution to our own particular medical problems rather than a cure for the ills of society.  In this role and in our minds, a doctor is supposed to be the equivalent of our “medical lawyer”:

• We provide the facts of the case as we know them.
• Our physician is supposed to gather any other relevant evidence and, using his special knowledge, outline all of the possible courses of action we might take and suggest the one that is most compatible with our goals and the resources available to us.
• He is supposed to looking out for our best interests rather than the interests of others.  When a doctor or lawyer takes your case, he is supposed to be working for you: not your opponent, not insurers, not government, not world peace or society as a whole.

The reason we look at things this way is our second principle: experience has taught us that one simply cannot serve two masters whose interests may conflict, and still be true to both of them.  Your best interests and those of society may not be the same when it comes to the distribution of resources.  This is especially true when “value” of the alternative uses of those resources is largely subjective.

Here’s a simple example.  In the real world, the “best interests of society” are routinely determined by politicians or employees of the executive branch of government.  In California, politicians have recently decided that it is in the best interests of society to pay large pensions to employees of the state rather than keeping state parks open for the benefit of all Californians.  These politicians are essentially responding to the needs of two masters: the voters on one hand and organized labor on the other.  Both interests are competing for scarce resources; they cannot both “win”.

Now let’s take an example of you and having your health care expenses covered by these same government entities.  Your doctor has been asked to look after the best interests of “society”, as well as you.  The same politicians then decide that it is better to give government employees generous pension benefits than to fully fund the public health insurance program.  Based upon the AMA guidelines, your physician tells you that there are two drugs that can be used to treat your condition that have comparable cure rates.  One is more expensive, but it is associated with better compliance and fewer side effects.  The cheaper one will address your problem, but you’ll probably feel sicker from the side effects and have a harder time taking it consistently.  Your doctor tells you about both of them, including the fact that it’s more socially responsible to use the cheaper one.  He explains that taking the cheaper one will allow more patients to be treated with the available insurance budget that the government insurer has decided upon.  Having barely finished high school, the amount you know about medicines would fit into a thimble.  You ask for his advice, and he recommends the cheaper one because it helps to promote equity and social justice.

How do you feel about your doctor now that he’s gone through this exercise?  Do you still trust him?  Is he looking out for what’s best for you, or what’s best for state employee pensions?  How would you know?

We don’t believe that anyone could disagree with the notion that explaining all of the facts of the case to patient – both medical and economic – is a fair and reasonable thing to for any clinician to do.  But the moment the slightest question arises about exactly who that clinician is working for, the entire basis of the physician-patient relationship collapses.  At that moment your doctor is magically transformed from an advocate into something entirely different.  A lobbyist.  A vendor.  A social activist.  Someone who is not just on your side, but someone else’s side as well.

So how do we reconcile the needs of society with the needs of individuals?  There are several possible approaches:

1. Subordinate the needs of individuals to the needs of society.  This is the approach taken in places like North Korea or other communist countries.  “From each according to his abilities, to each according to his needs.”  Of course, the “needs” that get satisfied are only the needs that society sees fit to bestow.
2. Subordinate the needs of the society to the needs of the individual.  This is essentially the approach that Congress and successive administrations have taken to thus far in granting benefits to individuals without regard to how these benefits will be paid for.  Seniors want free drugs without bothering with a donut hole?  What the heck, here you go!  Too many people are unemployed?  Give them nine weeks of unemployment benefits rather than using that same money to create job growth.  In the absence of a clear way to pay for them, both of these measures clearly place the interests of individuals above those of society, since those same funds could have been invested for the benefit of all members of society.
3. Finally, one can accept that there is a high likelihood that the needs and wants of individuals and the needs and wants of society will never coincide.  Indeed, at times they may well be in direct conflict.  Since society cannot be expected to subordinate its needs to those of any given individual, the best that we can do is to give each individual the freedom to pursue her own interests with whatever resources she may have at her disposal.  “Society” is always going to looking out for itself.  Individuals need to have the same right as long as those actions do not directly harm others.

What does this mean in practical terms?  It’s simple.  Doctors have no business advising or pressuring their patients with respect to the best use of society’s resources.  Resource decisions need to be made by whoever is paying for this stuff.  Period.  In medical terms, once society has decided what it will cover and what it won’t, the patient must have the freedom to purchase whatever might be missing with her own money.  The job of each doctor then becomes counseling us on how to get the best possible deal (i.e., the one that best meets our needs), with the total resources each of us happens to have available to us.

How does this look from the perspective of each of the parties involved?

From “society’s” perspective, our elected and appointed representatives are free to make whatever coverage decisions they wish with respect to the resources that they are making available for the use of individuals.  The is never going to be anything predictable or rational about many of those decisions; they will ebb and flow like the tides in the face of different elected majorities, different presidents, and the sausage-making process of legislation.

From the patient’s perspective, there is no use in worrying about coverage that our insurers have elected to provide unless you are in a position to do something about it.  The real question is, “what’s best for you, and can you obtain it through either your insurance or by simply paying for it yourself?”  At least you can trust your doctor to give you all of the options, and enlist his aid in getting whatever might best meet your personal needs.

From the physician’s perspective, there is good news.  You are not a god.  You are not supposed to weigh the benefits to society versus the benefits to individuals.  You do not have to decide who shall live and who shall die.  Why should you take the bullet on behalf of the rationing decisions made by politicians, appointees or insurance executives?  Why should you bear the malpractice risk of recommending treatments that may not be the very best for a given patient?  You are supposed to do your job as an honest broker of information and professional services.  That’s what the patient is paying you to do either directly or indirectly.  Achieve the best outcomes for each individual with the resources that happen to be available.

Anything else is hogwash, no matter what the AMA says.

You’ll notice that the AMA isn’t called “The American Doctors’ Association”.  Once you know that it doesn’t really represent doctors so much as its own financial and political interests, the logic of this begins to make sense.