Tuesday, June 17, 2008

Physician Access and Loss of Physician Civility

The Medical Payment Advisory Committee (MedPac) has recommended Congress increase pay to primary care physicians. In response, a consortium ciations representing 14 surgical specialty societies fired MedPac a letter protesting the pay increase would come out of their pay.

The physician payment system, you see, is a budget-neutral pie. The bigger one’s specialist’s slice, the smaller the other specialist’s portion of the pie. Surgical specialists are reluctant to give up even a small piece of their share of the pie.

This, to me, is an example of physician angst and loss of civility among physicians. What’s mine is mine, and what’s yours is negotiable, event I make two to three times what you make.

I’ve been observing the rise of physician angst for 30 years. In 1988, I wrote And Who Shall Care for The Sick? The Corporate Transformation in Medicine in Minnesota ( Media Medicus, Minneapolis). In the book I predicted HMOs and managed care, then in rapid ascendancy in Minnesota and elsewhere, would fail. Doctors, I said, would become angry and disillusioned, patients would revolt, physician ties with each other would become strained, and primary care fortunes would decline and fall, and specialists would prosper.

The HMO strategy was to uproot the structure of medical practice by creating a gatekeeper system, whereby referrals to specialists and hospitals would be controlled and limited. This strategy too has failed. Specialists have become richer, generalists poorer, and costs have continued to escalate. Through maneuvers by Medicare, and HMOs, which follow Medicare in lockstep, payers have applied the screws, cutting pay to primary care and specialties alike, while physicians in general have gamed the system in various ways to maintain their life system.

The consequences of this convoluted game has been “angst,” which my dictionary defines as a feeling of dread and anxiety, among primary care physicians and general surgeons who are in short supply and feel they are being shortchanged and potentially being driving out of existence.

I am not alone in my interpretation of events. Timothy Norbeck, who has been associated with organized medicine for 40 years, says physician morale is the lowest he has ever seen. He should know. As executive director of the Connecticut Medical Society, he led the charge amongst 19 state medical societies against HMOs by organizing an anti-racketeering civil action lawsuit against Aetna, and later other HMOs. The suit succeeded and resulted in a federal settlement which culminated in the formation of the Physicians Foundation of Health System Excellence, a 501C3 grantmaking organization dedicated to improving the quality and safety and economic efficiency of care. The Foundation has issued grants totaling $21 million to 41 physician organizations.

The Foundation is now in the midst of conducting a survey of America’s 270,000 primary care physicians and 30,000 specialists to apprise their socioeconomic status and the depth and breadth of their angst. Perhaps this survey will demonstrate to the American public, federal policy makers, and managed care executives that the angst of American physician is rooted in reality, and corrections need to be made lest the primary care shortage loom even larger and we lose the physician foundation of our current health system.

As we go through this corrective process, I hope as physicians and professionals, we will observe the rules of civility among one another. As I was leaving a luncheon the other day, the host handed me a little red book published by Applewood Books entitled George Washington’s Rules of Civility & Decent Behavior. It is a good read, and I recommend it.


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George Anderson said...

This is an excellent article. Not only have your earlier predictions come true, the Joint Commission has been forced to require standards for addressing the "disruptive physician behaviour" which has resulted from Managed Health Care.

George Anderson