Richard Armstrong, M.D., Interview

Question: Share with me your background and why you became so intensely interested in health reform and what you think physicians can do to make a difference.

Answer:I am a general surgeon currently working in a multi-specialty group based at a critical access hospital in the upper peninsula of Michigan. I have been in my current position for 13 years.
I graduated from The Ohio State University College of Medicine in 1976. Medical school was paid for by a United States Navy Scholarship. As a condition of the scholarship, I did a 5 year general surgery residency at the Naval Regional Medical Center in Portsmouth, VA

Following completion of this program in 1981 I received orders to the USS Nimitz and served one year as the Ship’s Surgeon on deployment in the Mediterranean Sea.

In 1982 I was assigned to the United States Naval Hospital, Great Lakes, Illinois and became the acting Chief of Surgery. I could not assume the full title as I was still a junior officer…LCDR. I spent two years at Great Lakes during which time I also had the title of Assistant Professor of Surgery at The Chicago Medical School. We trained students and residents at the Naval Hospital in conjunction with the North Chicago Veterans Administration Hospital.

I received the Navy Achievement Medal for my service at Great Lakes and was promoted to Commander, but I would have been required to spend two more years in the Navy to accept the promotion and I had decided that I wanted to become a “real” general surgeon in rural private practice. I moved to the upper peninsula of Michigan in 1984 and formed “Superior Surgical P.C.” with a partner.
During 18 years in private practice my partner and I built a new $1.6 million office building and as a hospital board member for 17 years I assisted with doubling the size of the hospital and increasing the volume of our practice so that it was possible to hire a third full time general surgeon. I represented my hospital on the Michigan Hospital Association and the American Hospital Association.

I became a Fellow of the American College of Surgeons in 1987 and eventually chaired the regional Committee on Fellowship for the Upper Peninsula for the College. I also became an ATLS instructor and actively taught trauma care for over a decade in upper Michigan and northern Minnesota.

In 2002 at the request of my family I sold my interest in my private practice and designed a new practice at my current location in conjunction with the hospital’s CEO who had been a friend of mine since 1984.
I am also a Clinical Assistant Professor of Surgery with the Michigan State University College of Medicine and teach medical students from both Michigan and the University of Minnesota.

Question: When did your interest in health care policy intensify?

I have had an intense interest in United States health care policy since I began medical school but was able to follow things much more closely after I left private practice for my position at Helen Newberry Joy Hospital.
In September of 2009 I listened to President Obama speak to a joint session of Congress about health care, and I was horrified. He was describing building a larger federal health care bureaucracy which from the point of view of a practicing physician was the last thing we needed.

This was the continuation of an ideologically driven agenda which began early in the 20th century. I felt that practicing doctors needed to act. I couldn’t sleep, so at 4 am the following morning I wrote to the President and explained that he needed to speak with the working physicians in America, those who care for patients day and night, rather than relying on “policy experts” within the beltway and academia.

Question: What is your connection to SERMO?

I posted my letter on SERMO, which is now the world’s largest social media site for physicians. I immediately began to get calls and was invited to read my letter as well as explain my views at a rally in Washington, DC on October 1st, 2009. I had to go because I was very tired of hearing doctors complain while doing nothing positive about it.

In Washington I met Dr. Hal Scherz who had formed the 527 political action group, Docs 4 Patient Care in Atlanta, Georgia earlier that year. Hal and I become friends.
We began communicating with each other and Dr. Lee Gross through SERMO. At the request of many physicians nationwide Docs 4 Patient Care was transitioned to a 501c6 membership organization in January of 2010 with the intent to stop the passage of the Affordable Care Act and to give American doctors a voice in the debate.

This was a daunting task . We managed to increase our national membership to over 1000 physicians and develop chapters in 17 states, the ACA passed in March of 2010. Subsequently, we spent a tremendous amount of time working on the political front. We actively helped elect a general surgeon to Michigan District 1, Bart Stupak’s former seat in the fall elections of 2010, We supported many other candidates nationwide who agreed that the ACA was not the solution for American health care.

We traveled to Washington at our own expense over 14 times and held many sessions with legislators directly which we called “House Calls on Congress”. We worked closely with The Heritage Foundation, The Galen Institute and the Pacific Research Institute in these efforts.
In 2012 we filed an Amicus Brief to the United States Supreme Court in support of the 26 states and NFIB lawsuit against the Secretary of HHS, Kathleen Sebelius. You know the outcome. I also testified about the effects of the ACA that year before the House of Representatives Committee on Oversight and Government Reform.

We supported Governor Mitt Romney in 2012 and worked diligently for his campaign. You are aware of how that worked out. As a candidate, reforms which had been passed in Massachusetts hampered his campaign.

These setbacks, as well as a mood of hopelessness among physicians caused the efforts of the 501c6 organization to wane. We were also finding it increasingly difficult to manage the organization as we are all practicing medicine and surgery full time.

In 2013, Dr. Scherz was approached by a major philanthropist who recommended that we form a non-partisan 501c3 educational project specifically to educate the American public, our physician colleagues, leaders of business and legislators about health care from the point of view of practicing physicians with experience in policy and media. We took the advice and founded the Docs 4 Patient Care Foundation in 2014 which we are actively building now…

https://d4pcfoundation.org

We feel strongly physicians can make a difference by becoming educated about the complex policy issues which affect our ability to practice daily and by working with us to preserve the sanctity of the physician-patient relationship.

Question:

You recently spoke before the Physicians Board, a non-profit organization dedicated to advanced the cause of private practice. What was your message?

Answer:
Yes, I am currently the Treasurer of the Docs 4 Patient Care Foundation, which as mentioned above is the outgrowth of efforts to unite physicians over the past 6 years.

SERMO is the world’s largest physician only social media site. I have been a member since 2007 and have been an active medical advisor for the site for the past 3 years.
Our recent interaction with the Physicians Foundation addressed two main issues. The first was a proposal to collaborate to become actively engaged with the physician community by sponsoring national conferences designed to educate physicians about positive reform efforts, These efforts are possible even under the current laws.

We also wanted to become agents of innovation and change by removing barriers to physician entrepreneurship to strengthen the ability of private practice to remain viable.

To grow this effort, increased funding from many sources will be required. We have approached the Physicians Foundation for financial support as well as many other sources through our association with the professional organization, American Philanthropic.

Question: How large an audience do these and similar organizations, like United Physicians and Surgeons Association, have? I have heard the figure of 460,000 bandied about.

UPSA is an interesting project launched in 2014 by Drs. Michael Strickland, Gina Melink, Dan Craviotto and Judy Thompson. Dr. Strickland is the driving force behind this 501c3 project. The purpose of the group was to organize a national meeting which would bring together like minded groups of physicians to begin a conversation called “Let My Doctor Practice”. This statement summarizes in a short phrase the frustrations many American physicians feel deeply as third parties, mostly related to payment, have intruded on our autonomy and ability to practice what we trained long years to do…medicine and surgery. The meeting was held in July in Keystone, Colorado. The Docs 4 Patient Care Foundation played an integral part in the conversations leading up to the meeting and in the meeting proper. This is summarized on their website…

http://letmydoctorpractice.org/

Dr. Mike Koriwchak, Dr. Hal Scherz and I participated in the web and in the live events in Keystone.
I cannot say how many followers the Let My Doctor Practice site has to this day, but that information should be available from Dr. Strickland.

SERMO currently has over 460,000 members internationally. I communicate daily on the SERMO site.
4: What is the role of the AMA in organizing doctors? As you may know only 15% of practicing doctors belong to the AMA,. Why the high non-participation rate?

Answer:

Prior to the passage of Medicare in 1965, the AMA represented over 70% of practicing physicians. In fact, in 1962 Dr. Ed Annis, a general surgeon from Florida who would become the President of the AMA, spoke to the empty Madison Square Garden in protest, the night after President Kennedy went to the stage to promote the King-Anderson Bill which was the original Medicare legislation. His speech is prophetic…]

https://www.youtube.com/watch?v=hqVkOlhbsEM

As we all know, after JFK was assassinated and LBJ won a landslide in 1964, Medicare passed, The AMA attempted to limit federal influence in health care by including language in the original bill which said that the government would never interfere in the practice of medicine. How has that worked out for all of us?
Most critically, the AMA was instrumental in developing the Current Procedural Terminology(CPT) system for coding and billing third parties. This copyright has been lucrative for the AMA. In 1983 the AMA signed a contract with HCFA(now HHS) to be the monopoly provider of the coding system for the government. This was rapidly adopted by virtually all third party payers. The AMA also essentially controls the Relative Value Update Committee.

https://en.wikipedia.org/wiki/Specialty_Society_Relative_Value_Scale_Update_Committee

This committee assigns relative values under the RBRVS to CPT codes and is essentially the government’s price fixing committee under Medicare. The AMA is estimated to generate between 80 and 100 million dollars per year from licensing fees and the sale of CPT coding manuals.
What was once a membership organization for physicians and an advocacy group for independent private practice has become a partner with the federal government. It is this conflict of interest and support for government programs that has resulted in the significant drop in membership for the AMA. While they will debate this, the facts are apparent and are troubling to a majority of American physicians.

Question: What common problems and complaints do physicians share? From my point of view, these problems center around loss of autonomy, interference in the doctor-patient relationship, pay based strictly on data, on outcomes and performance, credentialing hurdles, and the time squandered on electronic health records and documentation. The latest documentation nightmare is how to comply precisely with 70,000 ICD-10 codes to get paid or risk being audited.

Answer:The short answer is all of the above and more. Physician autonomy has been gradually eroding for decades, however the acceleration in metric reporting, RAC audits and much more is directly related to the fact that our federal medical programs are running out of money…rapidly.

Medicare was never a fiscally sound program from the outset. President Johnson knew this and intentionally hid the facts from his own party. Medicare was projected to cost the nation $10 billion by 1990; however the actual figure was $110 billion. Since the passage of Medicare the program has run up a total of $3.2 trillion in deficit spending…. $305 billion in 2014 alone. Currently Medicare is running an estimated $35 trillion in future unfunded obligations…care promised which cannot be paid for.

About 10,000 people become eligible for Medicare daily and on average each one of those recipients will consume $3 of spending for every $1 they deposited in the program during their working years. This is unsustainable. The Medicare Actuary estimates that Part A(the hospital portion) will be depleted in about 2028.

Still, program reforms have had no significant effect on slowing spending. Everyone in Washington knows this, but few politicians have had the courage to address it.
The HITECH Act of 2009 is a classic example of the disaster that can be created when the federal government mandates something which should have been allowed to develop organically in a free market.

In 2007 a small study of early IT adopters, about 3500 tech geek doctors, were interviewed by the RAND Corporation. When asked if they like their systems, 95% of them answered “yes” which should be no surprise as they designed and built custom systems for their own use. However, the NEJM published this as an editorial which stated “95% of doctors like their electronic medical record systems”.

Viola! The politicians and the IT industry pounced. It was stated to the general public, with no evidence, that EMR systems would reduce the cost of medical care, reduce medical errors, make doctors more efficient, and allow more seamless communication among health care providers.
None of this has occurred to any extent. This is not because EMRs are a poor idea; rather it is because the EMR vendors are not working for the users.

The “customer” is the government and the private insurance industry who have forced medical documentation into the CPT coding and billing system. Thank you once again AMA! Is this becoming a bit clearer?

ICD-10 is yet another nightmare story, especially for doctors in private practice. The United States is one of only a few countries using this system for medical coding and billing. In Canada and Europe the ICD-10 system is utilized for research, frankly…where it belongs.

And this would not be complete without mentioning the American Board of Medical Specialties Recertification and Maintenance of Certification conundrum which is driving physicians nationwide to retire early or opt out of all areas where these onerous requirements must be met.

Kurt Eichenwald of Newsweek has published three recent articles about that which are linked here

http://www.newsweek.com/2015/03/27/ugly-civil-war-american-medicine-312662.html
http://www.newsweek.com/certified-medical-controversy-320495
http://www.newsweek.com/abim-american-board-internal-medicine-doctors-revolt-372723

So, the bottom line is that doctors are being crushed from all sides…even by the leadership of their own profession and they have become sick and tired of it, which is why the Summit at the Summit was organized and why the Docs 4 Patient Care Foundation feels so passionately about reclaiming the leadership position once held by American practicing physicians.

Question: As I see it, one of two central problems that need to be addressed is the relationship between physicians and hospitals and how to get paid across the “continuum of care.” I am dubious about the proposition that can use EHRs to document every patient across the full continuum of care.

Answer:There are many layers of this issue to explore, but among the most critical related to the erosion of physician autonomy is the move toward the employed physician models…the corporatization of the profession. In subtle and not so subtle ways the authority of the independent medical staff in the hierarchy of hospital management is disappearing, and this is dangerous.
In most hospitals the Medical Staff is an independent body responsible through its bylaws to set policies, do peer review, do credentialing and appoint committees among other duties. It is a separate entity which reports to administration and ultimately to the Board of Trustees of the hospital.

As more and more physicians become employed by for-profit hospital corporations the Medical Staff is losing independence and is often unduly influenced not by the medical needs of the patients, rather by the bottom line of the corporation.

Sometimes the changes are subtle and gradual and at other times they are obvious and disturbing. This was a recent topic of serious discussion at a meeting convened by the President and the Executive Director of the American College of Surgeons in Chicago which I attended personally.

The bundling of payments issue is, in my view, an outgrowth of the demonization of fee-for-service which has been the result of poor federal policies, not the fact that payment for medical services by any “fee” is bad. Incentives in federal systems have been misaligned for decades where reduced reimbursement has stimulated physicians to make up for this with greater volume.
In family practice this has reduced the average office visit in America to 8 minutes. How can you have a relationship with a patient in an eight minute visit? I would be pleased to discuss this in much more depth, but this is why Direct Primary Care is on the rise and is also why places like The Surgery Center of Oklahoma are succeeding and growing.

I believe there is great potential for digital technology to improve patient care, but we need to let the market work. Doctors and patients should adopt systems which help them become better at what they do, not have a one-size fits all solution forced upon them.

Question : What is your attitude towards Accountable Care Organizations, Obamacare’s answer for assembling doctors and hospitals into common organizations responsive to government regulation and saving Medicare money.

The short answer is that, like the HMOs of the 90s, they will fail. The longer answer is that they are inherently unethical for the medical profession.

Essentially the federal government is telling the doctor…”here is a pot of money to care for these 5000 Medicare “covered lives”. If you manage the care in such a way that you come in under budget…you get a bonus. If you don’t…no bonus.

Now, aside from the obvious fact that these “assigned lives” all have behaviors which the physician cannot control…including using up some ACO money outside of the ACO, what the physician becomes is a “covert rationer” of care at the patient’s expense.

This may be subtle at first, but it could come down to a question…expensive MRI vs. more money in my pocket. This is an unethical choice which no physician should agree to participate in…my strong opinion.

Question: Recently the Sustainable Growth Rate formula was replaced by a new payment model, transitioning away from fee-for-service and towards “value” of outcomes and quality for 30% of care by 2018.
Do you think this new model is feasible?

Aanswer: My short answer is no. John Graham, my friend and a health care economist with the National Center for Policy Analysis describes it well here

http://www.ncpa.org/pdfs/st364.pdf

What I was personally outraged about was the way Congress and our major medical societies handled this “SGR fix”. In a word…it was a scam.

The AMA wanted this very badly. They had compromised with the administration during the debate over the ACA to keep the “cost” over the first decade below $900 billion. A “Doc Fix” then would have run up the tab to about $1.2 trillion which would have killed the ACA(eerily reminiscent of 1965). So, Congress was anxious to get this done and so was organized Medicine. Our medical organizations sent out mass e-mails telling members to “Call your Congressman and tell her/him to vote yes on the SGR repeal”….stop! The SGR was repealed in the first 11 pages of a 263 page document.
The following pages set up the Alternative Payment Models and the Merit Based Incentive Payment System which officially begin in 2019. These are bureaucratic nightmares for doctors. They lock in the Meaningful Use program for EHRs and also the MOC system of the ABMS. Most doctors don’t understand this yet, but they should be uniformly outraged as they were once again sold out by the AMA and the majority of organized medicine. Yes, this one makes my blood boil.

Question: : As you know, the Physicians Foundation, founded in 2003, in response to a court settlement with HMOs, has conducted a number of large scale national physician surveys. These surveys show demoralization among physicians, dissatisfaction with ObamaCare, and a widespread unhappiness with time spent on paperwork. I believe these surveys are fundamental importance and contribute to doctor shortages and the massive wave of hospitals hiring doctors, seeking to escape the rigors and headaches of modern practice.

Answer:I agree that the surveys are extremely valuable and assist all of us in presenting data which backs up our general assertions.

Question: Do you believe direct cash practices, including concierge medicine and direct pay for ambulatory care patients, has a future?

Answer: The short answer is yes. This is one of the bright future prospects for primary care in America and is what our Foundation President, Dr. Lee Gross, is personally doing in Florida with his practice…Epiphany Direct Care

http://benjaminrushinstitute.org/lee-gross-epiphany-health-concierge-care-for-the-little-guy/

Question: I’m aware you call yourself an independent, neither Republican nor Democrat.

Given that state of mind what do you think about the GOP proposals out there? Among these proposals are universal tax credits, lids on catastrophic care, expansion of health savings accounts with high deductibles, patients shopping for routine care and paying for that care, shopping for care across state lines, and more affordable health plans with narrower choice of benefits, and retention of guaranteed access to care for chronic illnesses and coverage of care for young adults under 26 under their parents plans.

Answer:There are elements of our Physician’s Prescription For Health Care Reform in most of the announced candidates plans. Ben Carson talks about Health Savings Accounts wherever he speaks and we have placed the document in his hands personally. Marco Rubio has our document which was given to him by one of our colleagues who is close to him in Florida. Scott Walker embraced many of our ideas. Jeb Bush just released some detail today which I have not had a chance to read. However, all agree that the ACA needs to be repealed, but I think it would be a huge error to replace it with another centrally planned and administered legislative product.

America needs more market driven reforms while understanding that we can afford to provide a safety net for those who need it and in fact it is our moral obligation to do so, however, it is not compassionate to drive the federal government into fiscal insolvency over political promises which obviously cannot be kept.
I would also add that we are in the process of rewriting the linked document and would appreciate any commentary from you, Walker and Tim in that regard.

Question: Why do you think heretofore, physicians were not part of the reform conversation? How do we insert ourselves into that conversation?

Answer:Our experience is that the majority of doctors are too busy practicing or are employees and feel generally “safe”. Of course for those of us that have been studying the ACA and the financial pressures ahead, we know that employment is not safe. I would anticipate that in the coming years as new practice models spring up spontaneously there will be a shift back to private groups of physicians. What we hope and desire is that doctors will have a soft landing as the government programs begin to wane.

I think we get them into this conversation by positive engagement in meetings, conferences, media and much more. SERMO has been an excellent tool for that and we intend to continue to nurture that relationship.

Question - In general, patients and consumers have not been consulted about what they would like as the ideal solution to health reform. The Physicians Foundation is in the process of conducting such a survey? Why is this survey so overdue? After all, patients are what health care is all about.

Answer: I believe that such a survey will be quite valuable and look forward to seeing it.