Know your worth: A few last words from AMA chair

For my last column, I want to revisit the growing problem of inadequate physician reimbursement. In past columns, I have briefly outlined the genesis and progression of this problem, and I have stressed the importance of addressing it. To that end, I suggested that individual physicians undertake the simple exercise of determining their own worth.

My suggestion was not particularly well received by some physicians, who find no reason for such an evaluation. Let me explain why I feel that this process is an absolute necessity as an initial step.

A review of the past 15 to 20 years of physician reimbursement in the United States quickly reveals that public and private third-party payers are intent on imposing rock-bottom reimbursement levels.

What's more, we are inundated daily about the need to reduce the cost of health care even further. The most consistently used method of cost control has been the repeated lowering of physician reimbursement by government and private insurers. This will continue until physicians say "No!"

In past columns, I have advised physicians to look carefully at the value of their own work, and I have done so for two reasons.

First, this exercise will make clear the growing inequity between what you estimate your work is worth compared with how your work is valued by others.

Second, this exercise will force all physicians to get the hard facts about their practices -- and to decide where they draw the line.

I often speak to physicians who have signed contracts to provide services to insured patients for progressively decreasing reimbursement rates. I continually ask myself, how can anyone be successful in improving overall reimbursement when physicians sign such contracts?

Our detractors gleefully (and unfortunately, correctly) point out that signatures on such contracts prove that physicians agree that such levels of pay are adequate. I would only add that payment will continue to decrease until so many physicians say "No" that there is a problem with access.

It is very difficult to decide to stop working at a job you love because it no longer makes fiscal sense. But at a certain point, this decision becomes inevitable. We must each decide -- with the help of our own families and loved ones -- what that point is.

I have spent too much time with too many conscientious physicians whose savings, retirement plans and even homes have been decimated in vain attempts to prop up a failing practice. These practices failed because of inadequate reimbursement, coupled with outrageously escalating expenses, such as medical liability costs. The only way to be certain to prevent this unacceptable outcome is to be prepared to say "No!"

The AMA is fully committed to re-establishing contracts between the physician and the patient. Patients then can contract with a third-party intermediary if they so desire.

But the reimbursement disaster we now face resulted from the insertion of a third-party payer between the physician and the patient. This contract between the individual physician and a huge third-party payer also has led to multimillion-dollar -- even billion-dollar -- profits that such intermediaries proudly report. These millions upon millions of dollars get pulled out of physician practices -- and the actual care of patients. It's an obscenity of staggering proportions.

I recently met with some physicians who told me how low -- or even no -- reimbursements, along with escalating costs, had driven almost all of their fellow specialists from practice. This exodus meant that their hospital had only two doctors in their specialty to provide 24-hour emergency department coverage. These physicians were about ready to throw in the towel.

Yet these physicians have never been in a stronger position. At the very least, they can certainly find out their true worth to their hospital and community.

I suggested that they explore some sort of a legal affiliation for the provision of ED services that would allow coordinated action. It has been suggested that "virtual" affiliations could be formed that would meet the requirements necessary to allow unified action. But these types of options must not be undertaken without thorough legal review and advice because of antitrust concerns.

Other arrangements, such as retainer practices, are working well for some physicians. This is an interesting and telling trend that reinstitutes the contract between physician and patient -- and removes third-party payers from the patient-physician relationship.

Not surprisingly, these practices have been the subject of vicious attack from government and private insurers. Again, retainer practices must be especially careful to abide by the law and follow the rules.

As I have said before, the battle for fair reimbursement will be a bitter one. Government, HMOs, private insurers, investors and others have benefited hugely from fixing the wages of physicians. They will stop at nothing to keep the golden goose laying. The first line of attack will be personal vilification and charges of ethical violations. If we are not cowed by those tactics, our profession will be threatened with the expansion of privileges for a wide variety of nonphysician practitioners -- all by legislative or bureaucratic fiat.

If the issue is not important enough for physicians to be prepared to leave their practices, we will not prevail and probably will receive some type of punishment to boot. So again, every physician must decide the value of his own time and efforts. No one else can do this for us.

I know that this might seem a grim way for me to end this series of columns. In fact, I remain enthusiastic about the future of medicine and of the AMA. I sincerely feel that our profession is worth fighting for, and I am ready to join the necessary battles that we face.

Finally, I want to say that I have thoroughly enjoyed the opportunity to share some of my thoughts about our profession each month.

I also wish to thank all who have been prompted by something I wrote to share your feelings and opinions with me. Whether you agreed with me or not, I appreciate that you took your time to respond. I have learned from every one of you.