Reform and Loss of Physician Freedoms: Consequences, Trends, and Alternatives*
before Physicians Insurance Association of America, Leadership Camp, May 9, 2012, J.W, Marriot Center, Washington,
May 10, 2012
– What follows is a presentation I gave yesterday before physician leaders of the
leadership camp of the Physician Insurance Association of America.
I have edited the talk to accommodate changes I made while on the podium and to
fit this print version.
PIAA leadership camp. Given the unsettled state
of tort reform and the looming uncertainties of health reform law, I am assuming you are not all happy campers.
I would like
to thank Dr. Donald Palmisano, one of your distinguished leaders and former
president of the American Medical Association(2003-2004) for that generous
introduction, which I so richly deserve but so seldom get. Before you know it, I will be a legend in my
own mind. Not to worry. As my
wife of 50 years explained to me, “Be humble.
You have a lot to be humble about.”
today is preservation of physician and patient liberties and your future. I deeply care about these liberties and what
lies ahead. Otherwise I would not have
written 2300 blogs, 1300 tweets, and 11 books on the subject.
Everything I say today will revolve around the
freedom theme, preserving individual liberties, improving the system, and lowering costs through
WSJ Journal Editorial
Let me begin
with a quote from a Wall Street Journal
editorial, “Liberty and Obamacare,”
dated March 23, 2012, Obamacare's second birthday.
are much larger than one law or one president.
It is not an exaggeration to say that the Supreme Court’s answers may
constitute a hinge in the history of American liberty and limited and enumerated
government. The Justices must decide if
those principles still mean something.”
When he invited me to give this presentation, Dr.
Palmisano instructed, “Give an unbiased picture of the future of physicians during and after reform and leave plenty of
time for questions.”
I will leave
time for questions, but I can’t give an unbiased view.
I am biased in favor of
physicians. I want clinicians to retain
freedom to make decisions independently of bureaucrats and managers.
event, here we are in Washington, D.C.
Among critics of Obamacare, “D.C.”
stands for “Darkness and Confusion.”
Among advocates, “D.C” is known as
“Destination - Control.” My job today is
to describe the darkness, clear up the
confusion, and warn of excessive control.
orders from your meeting planner are to speak for 45 minutes, leave 15 minutes
for questions, and use less than 36 slides, It is now
1:55 PM. That gives my 35 minutes to
make my case. I shall wrap up by 2:30
P.M.. As a pediatrician friend of mine
once remarked, “You may now circumsize your watches.”’
Blunt Message – Raw Deal
I shall be
blunt. Your future stinks under
current reform law. You are getting a
raw deal If Obamacare goes forward as planned,
you will lose clinical freedoms and
This is a
watershed period for your future. Either
we go the way the U.S. or the way of Europe.
Your future depends on the Supreme Court decision in late June or the
election in early November.
I am not
here to curse the darkness or to confound the confusion. I am here to say we must offer
alternatives. We must lead, and we must
light candles of innovation to find our way out of the bureaucratic swamp.
you are feeling hemmed in by a law that promises to decrease your income; regulate your decisions through protocols
on evidence-based practices as dictated by “clinical effectiveness research”; trap you into a coding straight jacket ; stifle your innovative spirit; and reduce our choices and options.
matters, you are feeling loss or lack of
leadership. The AMA endorsed Medicare,
and partly as a result of physician discontent with that decision, it lost members. Today only 15% to
17% of physicians belong to the AMA.
In a speech before the AMA in Chicago on June 15, 2009, President Obama declared, “ If you like your physician, you can keep your
physician. Period. If you like your health plan, you can keep
your health plan. Period. Nobody can
take that away from you. No matter what.”
"No Matter What" Has Arrived
matter what” has arrived. Employers
are in the process of dropping as many 20 million employees from health plans, and
the doctors who go with those plans
other Obama promises - lower premiums costs by $2500 by 2016 for a
family of four, greater access to
doctors, and higher quality – are looking more and more like a fantasy.
punctuation marks, I am reminded of the story of the grammarian who developed
colon cancer. He thought his life was
coming to a period. But a surgeon resected his cancer, and it came only to a
semi-colon. President Obama’s dream is
now a semi-colon. We have yet to see if
it will end in a period, and it may, come June or November.
Back to Darkness and Raw Deal
As I see it,
there will be:
permanent SGR fix, barring a GOP sweep.
Politicians simply don’t have the guts to fix it because it would add $300
billion to the current $16 trillion national deficit.
physician income rise. Instead Obamacare proposes systematic cuts in Medicare fees for specialists over the
next 10 years, with token increases for primary care, with Medicare fees less than Medicaid fees by
2019 for all physicians.
national tort reform, which is unlikely as long a the Trial Lawyers remain heavy
market-driven incentives - shopping
across state lines, HSAs, HRAs, and variants with high deductibles, individual plan ownership, tax credits for all, individual plan ownership.
dependency on government – with 110 million on Medicare and Medicaid- now 1/3
of population, growing to ½ by 2020 – with more of GDP going to government. In France, 54% of spending is by government. The
French, by voting in a socialist government, want even more government
spending, whether or not government has the money.
mandates - for individuals, physicians, hospitals, employers, and
expanding bureaucratic alphabet soup – CMS,
HHS, IRS, PCORI, CER. PHM, EBN, IPAB, ACOs, EHRs, HIT, and, of course, with 159 new agencies,
commissions, boards, and of course, POTUS (President of the U.S.)
C. directed and dominated health exchanges at state level.
coding straight-jacket, which will not allow physicains to innovate or reprice
and repackage their services.
health care income game – If doctors go up, hospitals go down, and vice-versa.
Now, if I
may, I will sum up what I have just said, in rhyme, I do so in honor of my son, Spencer, who is
an internationally acclaimed poet and because using prose is simply too painful
There will be no SGR fix, at least
not with the current political mix.
Medicare fees will fall over the next
decade, bundled, capitated, or prepaid.
Market-based incentives, like HSAs
will not occur, those on the left concur.
Don’t count on national tort reform,
barring a perfect political storm
Swing states could swing the right way,
but as of now, the polls don’t look that way.
Let us hope the Justices will do ther right thing, and voters will remember, come
talk, I shall:
with a touch of levity.
In short, I shall be terse,
for nothing is worse,
than verbal longevity.
A friend of
mine once told me, “Dick, I always knew you were full of pith.” Which
gives me a title for my next book, which
will be mercifully brief,
Obamacare: Pith and Vinegar.
So that you
will now who is telling you this, here is my background
(A specialist who knows everything but it is too llate), editor, blogger,
experience (Connecticut, Minneosta, North Carolina, Oklahoma)
practice time n Minnesota (25 years, 1967-1990)
Editor, Minnesota Medicine (1975-1990)
books, 2300 blogs, 1300 tweets
book – Health Reform Maze (Greenbranch Publishings, 2011)
and Tweets now internationally syndicated by Newstex, com
Box on Cover of My New Book – The Health Reform Maze
There's a picture of the bureaucratic box on the cover
on my book, It'a condensed version of the 2801
page health reform law. The law stretches for 2801 pages,
longer than War and Peace, and of
its length, then House-Speaker Nancy Pelosi famously said, “We’ll have to pass it to see what’s in it.”
Depending on your point of view, you could call this box a progresscive blast-off platform. a conservative bureaucratic burial ground, a consultant's bonanza, or physician's burden to bear.
Whatever you call it, what's in
the box is a massive new bureaucracy, with 159 new boards, agencies,
commissions, at parade ground for at least 5000 new
bureaucrats and technocrats, and 16,500
new IRS agents to enforce mandates and to collect new taxes.
The bureacratic box has an entry but no exit. This law, in one way another, will be with us through eternity
even if the Supreme Court or the Election
rules most of it null and void, or Republicans repeal it.
Whatever happens, the law's effects will linger,
and health plans and other buyers will
adopt some of its provisions. Your practice will never be the same again. In one fashion or another, by a public or private entity, your performance will be digitized, audited, and measured.
physicians, do you disentangle yourself from
this byzantine bureaucracy or even understand it? My advice is for you to follow the lead and
read the works of the Physicians Foundation.
This non-profit organization, which was founded in 2003 as the result of
legal settlement with major managed care companies , represents 17 state and 3 county medical societies, and the majority of U.S. physicians. It has issued over $25 million in grants to
physician organizations to improve quaIity and has done groundbreaking surveys
to see what doctors think and how they are likely to react to health reform. I
commend for your reading its 2010 survey Health Reform and Decline of Private
Practices, and I recommend you look out
for the results of its 2012 e-survey of
650,000 doctors, now being conducted, which will be released before the November elections. Its website is physiciansfoundation.org
Before I get
into the consequences, trends, and
alternatives to Obamacare, Its important
that you understand where I am coming from.
I believe, Because
of the nature of the bureucratic beast, government
is poor at innovation. Because of its
special interest constituencies, its
ability to print money to keep going, and its reliance on good intentions rather
than results, it can never admit failure and shut anything down.
believe in market-driven competition and innovation as the best means of
raising quality, achieving excellence, and lowering costs.
believe in physician entrepreneurship and innovation.
believe constructive reform is not possible without engaging physicians and
health consumers as the driving forces - 90% of factors determining health and longevity - patient behavior, genetic predisposition, the environment, social deprivation, homicides and accidients - are beyond the physician's control and occur outside the office. Therefore, patient must be engaged if health reform is to succeed).
believe the future depends, not solely on the Supreme Court and the American electorate,
but on external events like the economy, the price of gas, a possible Israeli air strike, terrorist attacks, and you. Without you, there is no health
believe in what previous leaders have said: Reagan “The government is the
problem, not the solution,” Churchill
"The inheret vice of capitalism is the unequal sharing of blessings; the
inherent virtue of socialism the equal
sharing of miseries,” and Thatcher “The only problem with socialism is that
sooner or later you run out of other peoples’ money.”
Finally, I give two cheers for capitalism and one
cheer for government. An enlightened
partnership is necessary to reform care, but, as a practical matter, one cannot never do away with dependency induced
by entitlement programs, Once this dependency is established, its tends to grow and metastasize.
themes of this talk are the loss of clinical and individual freedoms due to an
overreaching government. The subthemes are the consequences, trends,
and alternatives secondary to this overreach.
are the consequences? According to the
Congressional Budget Offiice and the Office of Management and Budget, costs will run $1.76 trillion by 2022 and $2.5 trillion
by 2024, two to three times more than original 2010
estimate of $940 billion by 2020.
rules, regulations, protocols, mandates, taxes,
and IRS and government electronic surveillance, all of which stifle
political discontent with roughly 15% more favoring repeal than acceptance, and
a startling 76% to 19% saying individual mandate is unconstitutional.
civil war between the majority of states and the federal government, which lead
to the necessity of the present Supreme Court deliberations.
evolving consensus that personal, religious, and clinical liberties are at stake and that
the American people do not like being told what to do.
physicians acceptance of new Medicare
and Medicaid patients, in the 30% to 60% range, with more to follow if
shortages, 50,000 now and up to 150,000 by 2020.
abandonment of 3rd party arrangement with private and public plans,
with the rise of direct cash arrangement in urgicenters, Simple Care networks, retail clinics, and concierge practices.
cutbacks for physicians, especially high tech specialists.
of the SGR formula, which will drive more physicians out of practice.
consequence of these consequences, I foresee a nightmarish political crisis of
unprecedented magnitude three or four years out, as 78 million baby boomers enter the
Medicare rolls at the rate of 10,000 to 12, 000 a day, as 32 million more
Medicare, and more likely 50 million citizens, qualify for Medicaid in 2014, and as the physician shortage escalates.
strongest trend is hospital employment and health system employment. Hospitals already own more than half of
practices. Physicians are streaming
into hospital employment because an administrative infrastructure is needed to
deal with government and health plan payers if one is to negotiate from a position
second strongest trend, related to the first, is accelerated consolidation at
all levels of the system, followed
quickly by waves of decentralization as large organization seek marketing power
through greater patient convenience.
third strongest, also related, is brisk care migrations out of hospitals to minimall
invasive diagnostic and treatment centers and to the home itself, in turn accelerated by the information
fourth strongest is the push for bundled bills, dropping of fee-for-service to rationalize
and coordinate care.
fifth strongest will be the search for some
business model that favors evidence-based quality and outcome efficiency.
In addition to
these trends and intermingled with them,
you will experience profound changes in practice patterns secondary to IT and mobile
devices such atIPhone, IPod, and IPad; accelerated adoption of EHRs by
physicians secondary to newer and cheaper
and better business models, computing in "the cloud", widespread use of speech recognition
software, more waviers from Obamacare by organizations seeking refuge from Obamacare
alternatives, as I see them, are:
from people like Dr. Palmisano and the Physicians Foundation.
innovations, many of which I imention in my blog and in my books
activism and your part and the 19
physicians now serving in Congress.
Now, just a word and a list of what I see as
viable practice models.
centers with decentralized free-standing centers performing cataracts, endoscopies, hernia and other minor surgeries, bariatric procedures, cosmetic
procedures, and any minimally invasive procedure.
centers, common in orthopedic world, offering one-stop shopping, - minor surgeries, consultation,
physical therapy, lab work, x-rays, and imaging.
care medical homes wurg coordinated, continuous, and integrated case.
group practices uniting doctors in regions.
clinics (already 30% of corporations offer these clinics on site, run by
on-site primary care physicians and wellness
in retail settings.
mega-clinics like Mayo, Geisinger, Carillion, and academic centers, which now care for about 10% - 12% of Americans.
featuring telehealth, e-visits, and home and work visits.
featuring patient-generated histories and other forms of telecommunciations not
necessarily requiring face-t-face visits.
have done enough bleeding, now is the time to do some leading.
What I Have
I have told
future is bad under the current health reform law
future depends to a great extent on Supreme Court and the elections in November
can brighten your future through leadership, practice innovatiohn, new practice
models, and political actio
inquired , "What do you really think of
Obamacare? What image does it conjure up
in your mind?"
Here, tongue-in-cheek, is my answer.
I think of
Obamacare as an octopus – an amphibious (actually triphibious because it can fly),
ambidextrous (actually octodextrous because it has 8 tentacles), omnivorous
( capable of offering everyone a free lunch and then eating them for
lunch), and omnipotent (at least in its
own mind ) – creature . It is highly
mobile and aggressive. It glides across the floor of society,
sucking up everything in sight on the bottom or then rising to the top, confiscating assets and wealth.
Obamacare Octopus has a huge head – monstrous and swollen and tilting
to the left. It has a brain with two large lobes - Medicare and Medicaid. The corpus collosum is the department of Health
and Human Services. The midbrain is Kathleen Sibelius. The hindbrain is
Congress. The spinal cord is the White
has a blinking, flashing large Cyclops quarely in the middle of its
forehead. The monster's eye eeriely resembles a large TV
screen. Instead of esyelids, however,
teleprompters ring the eye. It has an
ample mouth, the mainstream media. It has a four chambered ink sac on its
under belly- containing black, red, green, and purple ink. The black sac is the smallest and is rarely
used, except in the name of “savings.” The red sac continually gushes huge gobs of red
ink. The green sac squirts ink at anything
that moves – a windmill, rotating solar panels, and electric cars. The purple sac continuously blasts out purple , sometimes subtle prose, mostly
to obscure the other inks.
Obamcare has 8 tentacles
with powerful suction cups on the undersurface. These suctions money and
liberties from Americans.
first tentacle extracts a projected $2.5 trillion from taxpayers over the next
second tentacle takes $575 billion out of Medicare for 10 years.
third tentacle pulls $300 billion to $400 billion out of pockets of physicians
fourth tentacle vacuums $60 billion to
$70 billion in taxes out of the drug firms, device makers, health plans, and
other members of the medical industrial complex.
fifth tentacle takes $100 billion or so from the young and healthy.
sixth tentacle sucks up $400 to $500 billion out of the coffers and profits of large
and small businesses.
seventh tentacle suctions $400 billion to $500 billion out of State Medicaid
budgts, and awy from social services, transportation, and education.
eighth tentacle is required to hire 5000
new CMS employees, including $16,500 IRS agents to enforce the individual
mandate and to collect the new taxes.
So much for
my image of Obamacare. It is a distortion of reality. You may think it grotesque. Still, as Mike Pence
(R-Ind) observed , "Only in Washington, D.C . could you say you’re going to spend a
trillion dollars and save the taxpayers money.” And only in D.C. could you say
you’re going to add 32 million to Medicaid rolls, subsidize every family of
four up to $88,000 , save money, make everything more efficient, and elevate quality.
believe these things, I have a bridge I
would like to sell to you.
Conclusion - Bumpy Road
your hats and wallets, fasten your seatbelts, strap on your lifejackets, jock
straps, and chastity belts, and pray the Supreme Court and the electorate makes
the right decisions.
Above all, hold onto your
freedoms. It’s going to be abumpy road.
me, go to email@example.com, or call
1-860-395-1501 in Connecticut. To read
me, procede to amazon to buy my books, call Greenbranch publishing (1-800-933-3711) to
order my latest book The Health Reform Maze, or Google me at Medinnvoation to
insert a comment or ask a question.
been a gloom-filled talk. Do notdespair.
There’s always gloom for improvement.
Tweet: Physicians’ futures depend on Supreme Court , the
elections, and what physician do to defend
themselves and to innovate to improve the system.
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