Sunday, July 19, 2009

CONFLICTED: One Word to Explain How Doctors Feel about Reform

Failure is easy to deal with, but what about success?


Never let a crisis go to waste

Rahm Emanuel, Obama Chief of Staff

In the current debate over health care reform, "rationing" has been a dirty word. Meeting last month with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintonsattempt to achieve reform.

Peter Singer, "Why We Must Ration Health Care," New York Times Magazine, July 19, 2009

These days one word book titles about health reform issues are the rage. There is CRITICAL, Senator Tom Dashle’s tome about the need for a single payer system – written in anticipation of his becoming Obama’s man as Director of Health and Human Services. Then there is CATASTOPHE, which expresses Dick Morris' outrage about Obamacare. Finally, there is FREE, a book about free digital services, and CHEAP, a book devoted to discount services.

Soaking the Rich and Not So Rich

Free or cheap health care services financed on the back of the rich seem to be the wish of House Democrats. Soaking the rich also has an irresistable political cachet among Obamanites. Proposed tax increases now approach 52% of income for the very rich, those making $1 million or more, higher than in any European country.

History will judge if punishing the "rich," many of them athletes, entertainers, CEOs and physicians, others entrepreneurs who create new products, employ new people, and serve as the main source of innovation simultaneously rescues the economy and covers the uninsured, or if surtaxes on the rich, i.e. those making more than $250,000, is simply two cheers for socialism.

Prospects for Naming A New Book

In any event, I’ve been mulling what to call a new book on what doctor’s really think about the prospects of Obamacare. OBAMACARE is over-used. Besides I’ve already written a book OBAMA, DOCTORS, AND HEALTH REFORM (IUniverse, 2009).


I’ve even thought of VICTIMS. After all, since World War II, doctors have been the victims of our own success. No social-technologic enterprise exceeds the demand for modern medicine and its success in prolonging life, restoring function, delaying the inevitable, and in America at least, draining the federal and business coffers.

Politically, how does one cut off the money-consuming and money-generating spigot of life-saving and life-prolonging half-way technologies? Obama thinks he has the answers - prevention, electronic management tools, and coordinated care- but the director of the Congressional Office of Management and Budget disagrees and says these tools will not fundamentally change costs of care or "bend the cost curve".

Other One-Word Titles

Because of President Obama’s tactics of rushing a huge, hastily written, sweeping health care bill through Congress without time to debate the consequences, indeed without even time to read and ponder 1018 page bill, physicians are hesitate to endorse it. He has propelled this bill forward in the names of,

- saving the American economy,

- preserving American global competitiveness,

- lowering health costs through savings by investing trillions,

- imposing individual, business, and health plan mandates,

- turning 1/6 of the American economy upside-down to remove a perceived moral blight by not covering the uninsured,

To highlight the Obama views and physician reactions to them, I have come up with these one-word titles for my new book.

• STAMPEDE, STEAMROLLER, BULLDOZER - These titles speak for themselves, but they strike me as too negative.

NOW, RUSH, MOMENTUM - These stem from the Obama strategy to grab the economic crisis by the ears to further his political advantage.

BROKEN – This is the liberal’s favorite pejorative about the health system, even though 80% of covered Americans say they like their coverage.

• BOOM – This appeals because it stresses the boost health care gives to domestic employment – The July 19 New York Times reports these gains in employment at a time of overall 10% decline in employment – hospitals +3.4%. outpatient care centers +3.6%, health care +3.7%. physician offices +4.1%. ambulatory health care services +4.9%, home health care services +8.6%.

SPEEDTRAP - This is about political hype meeting economic realities – rising unemployment, mounting debts, health industry resistance, the common sense of the American public, Blue Dog Democrats, Intransient Republican opposition, and the OMB director’s announcement Obamacare will.cost, not save, money.

MANDATE- This is appropriate because of federal grabs for power through individual, business, and health plan mandates to assure universal coverage no matter what the price.

UNREAD- I like this because it captures the crisis mentality, namely that this damn thing is so urgent , compelling, and overwhelming that one need not read the small print or consider the implications of what one is doing.

DIVIDED- The nation’s physicians and the American public remains divided on what to do and how to handle the costs of health care. They do not trust the heavy hand of government, yet do not know how a reasonable alternative, e.g.,market-based competition with federal oversight, might work.

RATIONING - This is too abhorrent a word for Americans, although it already exists as economic filter.


I’ve decided upon CONFLICTED. Why? Because we doctors feel genuinely conflicted about President Obama’s plans. Frankly, most of us welcome the ideas of universal coverage and of patients not going bankrupt,and of providing affordable care for all. We like the thought of adding 50 more million paying customers to our panels of care. We like the idea of patients not having to worry about what care costs.

But we're concerned about the strings attached.

We’re conflicted between good intentions and bad consequences. We are in a clash with our own consciences and our own forebodings . We know from the past that,

• adding 50 million more to the federal rolls will cost the system trillions more and will not save money;

• the Golden Rule of Government – he who taxes and uses OPM (other people’s money) has the Gold- will rule;

• you can’t manage care in the office or in the hospital from the Top-Down without distorting and contorting patient-doctor relationships ;

• the current bill being proposed by the House will drive practicing doctors away from seeing new Medicare and Medicaid patients;

• the doctor shortage is real and the next big crisis will be lack of access to doctors with long waiting lines, and overcrowded emergency rooms;

• CMS (Centers of Medicare and Medicaid) is a bad business partner, and is prone to making arbitrary and ill-conceived cuts in reimbursement – as they did this week in cardiology and imaging services in the 20 to 30% range;

• Government pays 20% to 40% less than private plans.

We’re conflicted too because, we don’t trust our own supposed leadership – the AMA and their endorsement of the latest House Plan.

Here, for example, is what 4700 Sermo members are saying about the AMA in a July 19 poll of Sermo’s 100,000 members,

1. Do you endorse the current House Healthcare bill as written?
No, 94%
Yes, 6%

2. Does the AMA speak for you in endorsing the House bill?
No, 95%
Yes, 5%

3. What are the most important issues that must be addressed?
Limiting 3rd party and administrators compromising doctor-patient relationships 36%
Malpractice reform, 32%
Other, 31%.

Small Sample

This is a small sample and may not represent the views of American doctors as a whole, but it deserves our attention. Significant numbers of us think playing ball with the Obama administration and Congressional Democrats is a dangerous game. Many America’s physicians are revolting against the AMA, to which less than 20% now belong. We are doubtful about the motives of America’s political leadership, as manifested by Democratic Congressional majorities. We want to influence the policies that emerge, but feel powerless and conflicted on how to do so.


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