Opinion

Physicians need one voice to fight for payment reform

A message to all physicians from Joseph M. Heyman, MD, chair of the AMA Board of Trustees.

By Joseph M. Heyman, MDis an obstetrician-gynecologist in private practice in Amesbury, Mass. He served as chair of the AMA Board of Trustees during 2008-09. Posted Jan. 26, 2009.

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Was there ever a more important time for unity in medicine? Here we are at a special place in history with amazing opportunities and challenges, and with broad interest in reform to address flaws in an often-dysfunctional health care system.

Medicine must now deliver united and consistent messages to achieve the desired results. In such a highly competitive environment as the 21st century, medicine cannot afford to be a house divided.

At the same time we approach general health system reform, we face a 21% cut in physician payments, pressure to move from a system where we get paid for enumerated services to a value-based incentive system, demands for performance measurement and reporting, improvements in safety and quality, and efforts to avoid paying for any unintended consequences from our care. Talk about challenges! Has there ever been a time when it was more critical for medicine to speak with one voice? I don't think so.

One issue on which nearly everybody agrees is that something needs to be done about the decreasing number of physicians who are going into primary care, decreasing satisfaction of primary care physicians, and the resulting problems that are on the rise: lack of access to primary care physicians and pressure to substitute with advanced practice nurses and other professionals without medical degrees.

This issue, on which we all agree, threatens to break professional unity, cause rancor, divide us and result in everybody -- including our patients -- losing. We all want to do something to improve the state of primary care. So we need to be certain we are all on the same page when it comes to investing in primary care in this country. We must present a unified front. We must approach Congress and the administration with a single goal about how important an investment it is -- and our country must bite the bullet to find additional money to pay for this investment. But the money cannot come from other physicians who, like primary care physicians, have been subject to Medicare payments that for the last seven years have failed to reflect increases in medical practice costs.

I want to emphasize three key points:

  • The American Medical Association absolutely supports this important investment in primary care. Payments to primary care physicians must increase.
  • The American Medical Association absolutely opposes applying budget-neutrality rules that confine offsets to the physician payment pool. Congress should not rob Dr. Peter, the surgeon, to pay Dr. Paul, the primary care physician.
  • The American Medical Association absolutely is committed to working with Congress and the administration to find alternate pathways to offset the required increases in primary care payments.

This is an important national investment, and our nation must step up to the plate and take aggressive action to solve this problem. But physicians are not the only stakeholders in this industry, and it may be time to look at others. There are continual complaints about waste and inefficiency in the health care system, and some of that might be used. The Government Accountability Office, the Health and Human Services Office of Inspector General and others already have identified sources of additional funds to offset this investment's cost.

The AMA already has delivered this message to Sen. Max Baucus' (D, Mont.) senior health adviser. We will be delivering it more broadly to the new Congress and the Obama administration, in advance of legislative action on Medicare payment policies.

At a time when there is finally bipartisan support for ridding us of our expensive annual "dance" with Congress over the cuts from the flawed sustainable growth rate formula, we don't need to introduce the same problem in another form -- enacting across-the-board blunt budget-neutrality rules. That unwelcome introduction would undermine our shared goals about improving patient access to care. For far too long, policymakers have tried to achieve budgetary objectives by reducing physician payments. But the current marketplace clearly would not allow physicians to "make up" the difference by cost-shifting to private payers when government programs fail to fund adequate payment rates.

Further complicating the situation is the trend of many general surgeons now being forced by shrinking payments into becoming "itinerant" surgeons, even traveling to various states. With the need to quit their own private practices, they are then lost to their local community hospitals for the many emergency department services they once provided, while traveling to other areas at increased costs (including not being present for follow-up care). And to compound the problem, over the last quarter century, the number of general surgeons has declined by 25%.

Each of us deserves the ability to afford to provide good care to our patients. In recent years, physicians have had to shoulder a disproportionate cost-containment burden while hospitals, Medicare Advantage Plans, home health and many others who provide health care have not been saddled with a similar load.

So we at the AMA urge policymakers to make greater investments in primary care and to finance these investments without cutting other physician payments. The key to success is a single, unified voice from all physicians delivering this single, unified message to Congress and the Obama administration.

At a time that we are facing shared goals on coverage, quality, cost and affordability, and broad payment reform issues, the last thing we need is division within our ranks.

Let's work together to fix all of these problems and show the proof that when we are united, nothing can stand in our way.

Joseph M. Heyman, MD is an obstetrician-gynecologist in private practice in Amesbury, Mass. He served as chair of the AMA Board of Trustees during 2008-09.

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