Opinion

A president's review of critical issues facing medicine

A message to all physicians from AMA President William G. Plested III, MD.

By William G. Plested III, MDis a thoracic and cardiovascular surgeon from Brentwood, Calif. He served as AMA board chair during 2003-04, and as AMA president during 2006-07. Posted June 11, 2007.

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It is hard for me to believe that the past year has gone and that this is my last opportunity to share some of my concerns and opinions with you in this column. I therefore want to review some of the issues that I feel to be of major importance to physicians and to highlight what I feel to be the most important single issue facing us.

I have not spent much time discussing medical liability reform, primarily because most physicians are extremely well informed about this issue. It remains the No. 1 legislative priority for the AMA. Our experience in the past several years has been that we have more success at the state level than at the federal. This is because of the cloture rule in the Senate that allows for senators who favor the status quo to block a floor vote by filibustering our MICRA-type bills.

We have thoroughly studied the concept of medical courts and are ready to support any state that is prepared to do a demonstration of this attractive alternative to the current tort system. If nothing else, the outrageous cost of the tort system makes change a critical component of any overall health system reform proposal.

Fair reimbursement, especially at the federal level, where Medicare physician payment is subject to the sustainable growth rate formula, remains of critical importance. Physician payment by Medicare today is the same as it was in 2001. This is in spite of Medicare Payment Advisory Commission recommendations to Congress that there be yearly increases that now should total at least 15% since 2001. Since other insurers now set contractual fees that discount from Medicare rates, the SGR travesty becomes even more pernicious.

The latest popular excuse for not fairly reimbursing physicians for their services is "poor quality." It is widely touted that the quality of American medicine is so low that physician payment can be increased only for those who agree to treat patients exactly as decreed by insurers. Elaborate schemes to accomplish these ends are growing like topsy. The bottom line of all is control. Once physicians can be conditioned to perform as dictated by third parties, cost control (or at least the channeling of any profits to those who set the rules) will become a reality.

I have continually reminded all of us that each of these issues represents an erosion of the prerogatives of our profession. The most important and difficult realty we face is that because of strict legal constraints, reversal of these trends can be accomplished by individual action. No organization nor association can do this for us.

The most potent weapon we have is individual action. True, it involves individual risk, but personal risk is exaggerated in the minds of most physicians. The level of sacrifice inherent in achieving a medical degree, and ultimately a practice, renders physicians surprisingly risk-adverse. That reality is exploited by those who would control us.

We sign contracts that others never would consider out of fear of losing the practices that have cost us so dearly to establish. This paralyzing fear allows others to control training, standards, disciplinary actions and valuation of services -- in other words, the prerogatives of a profession.

These are things I have discussed in the past year. Their genesis is easily understood, and solutions remain unchanged. When individual physicians are ready and willing to stand up and say, "Enough!" we will see real change. If we remain the most risk-adverse generation in history, our profession will be drastically changed.

Now for the issue that has consumed most of my time since the first of the year. This is second only to the preservation of our profession in importance. It is becoming increasingly clear that we are on the verge of a great debate about the future of health care delivery in our nation.

The increasing number of uninsured is a prominent driver of the push for reform. But this is only one facet of the problem. Millions of Americans live with the fear that they might lose their insurance, or be devastated by the costs of a serious illness or injury. This means that almost everyone has a reason to demand overall system reform.

The result is that we now have an opportunity to design a health care delivery system. Our current employer-based system is the accidental result of wage and price controls instituted by the federal government during World War II, a time when the armamentarium of a physician was meager. Similarly, Medicare was enacted at a time when the average American had a relatively short life expectancy because of limited technology.

Since those foundational "systems" were instituted, medicine has been totally transformed by explosive growth in technology and by changes in demography. The result is that the status quo in health care delivery is simply no longer a viable or an affordable option.

The juxtaposition of a pending national presidential election completes the climate that will lead to change. This is the golden opportunity that physicians must seize to lead this national debate. The AMA has prepared for this opportunity for years, and we have answers based upon science and long experience.

Unfortunately, many already are touting utopian schemes such as mammoth government single-payer systems that today are being abandoned in other countries throughout the world. The siren's song of free and equal care for all is heady stuff and has strong emotional appeal. But government control has led to neither increased quality, increased efficiency nor decreased cost.

The model that most countries are moving toward is a combination of public and private systems, a combination that works together to ensure that those who can afford care are required to provide for themselves. Those who cannot, receive assistance, an elegantly simple foundation that captures the strength of the American spirit.

Americans will never accept a system that prohibits individuals from spending their hard-earned money as they choose. The corollary is that, as a nation, we help those in need.

Current events and realities present physicians with a combination of opportunities without parallel. We can reclaim our profession and design the future of health care delivery in our country.

Both present opportunity and risk.

We must embrace both.

Let us join to take full advantage of this wonderful opportunity, for truly, TOGETHER WE ARE STRONGER.

Carpe diem.

William G. Plested III, MD is a thoracic and cardiovascular surgeon from Brentwood, Calif. He served as AMA board chair during 2003-04, and as AMA president during 2006-07.

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