Medicine at a crossroads

Disregarding the majority’s wants, Congress passed and the president signed into law the Patient Protection and Affordable Care Act. The bill was supported, but not totally endorsed, by the American Medical Association (AMA). This support has created tension between the Florida Medical Association (FMA) and the AMA.

The AMA found itself in a difficult position at the start of the reform debate. It had fought and won many political battles to prevent partial or complete national healthcare models from being instituted. From President Franklin Roosevelt on, the AMA had been able to negotiate effectively for its membership while still maintaining its core mission of improving healthcare for Americans.

During this most recent debate, the AMA found itself in a disadvantaged position. Having seen a sister medical organization completely excluded from the negotiations for taking a hard stand against this reform package, the AMA leadership realized that it had to be “at the table.” The leadership worked towards meaningful input into the legislation despite the competitive, complicated, and multi-interested nature of the negotiations.

The AMA’s participation allowed it to negotiate against an experienced group of reform advocates including Rahm Emanuel and Nancy-Ann Min DeParle — both Clinton-era healthcare veterans. In addition, both houses of Congress were in the grips of reform-minded Democrats with little sympathy for doctors. As news of each major reform was released, doctors and state medical societies vociferously resisted the changes. The laws would forever alter the practice and even content of medicine. It was then that AMA membership levels began dropping, and doctors’ outcries of no confidence began.

Many doctors believe that the AMA was giving up doctors’ rights to independent medical practice for cosmetic gains. Doctors were banned from owning hospitals or other healthcare facilities, which is exactly what they had historically done: the Mayo Clinic, the Cleveland Clinic and the Ochsner Clinic are three prime examples. In addition, doctors were being forced into “Accountable Healthcare Organizations,” meaning they would become paid employees.

The Sustainable Growth Rate (SGR) formula was not fixed, so doctors still face a substantial 21 to 35 percent fee reduction in the next several months. More cuts will follow in order to meet budget projections, as noted on page fourteen of the Congressional Budget Office report to Speaker Nancy Pelosi. Even though the AMA was successful in preventing the newly established Comparative Effectiveness Committee’s findings from being used to dictate practice decisions, deny treatments, or set payments, the committee still establishes the effectiveness of treatments. It is hard to imagine that this data will not be drawn upon to make policy.

From within this assault on medicine, dissatisfaction with the AMA’s ability to represent Florida physicians grew, and the Florida Medical Association met to discuss the AMA’s actions. The odium towards the AMA was only inflamed when the leadership gave support to Obama’s pick to lead Centers for Medicare and Medicaid Services (CMS) — Dr. Donald Berwick. His beliefs about redistribution, socialist healthcare delivery systems, and healthcare rationing are well documented.
During the FMA’s Orlando meeting, Jeff Goldsmith, Ph.D., from the University of Virginia and a recognized expert on healthcare legislation, validated every fear that organized medicine had about the bill. Medicine in the future will be delivered by large multi-specialty hospitals, with capitated coverage and risk-sharing systems; doctors will be employed by these systems, many in shift work. This change has already started, as noted by a survey taken at a FMA meeting revealing only 30 percent of doctors are still in solo private practice. Private medical and academic practitioners are concerned about their future as independent professionals.

At the meeting, civil and sometimes stinging arguments for and against secession from the AMA were debated. Ultimately in a 52 percent to 48 percent vote, the decision to put the AMA on notice and remain a collective body passed. The members of Congress have long recognized the AMA as the single most important voice for medicine, invariably asking the AMA’s position on any issue. The FMA and the 49 other state medical societies know that without a single voice the opposition to the free practice of medicine will be empowered.

The AMA tried and succeeded in this round of reform to preserve some sanctity to the doctor-patient relationship by keeping the government from coming completely between it, but future changes could still undo this relationship. Granted there are marked regional variations in doctors’ vision of healthcare reform.

Understanding this, the FMA House of Delegates came to the right decision to sanction but not secede from the AMA. Without a single respected and experienced voice at future negotiations, no administration is going to listen to the blather of dozens of separate organizations. The AMA accomplished much in this reform battle but the war is not over, since so many believe only a single-payer national healthcare system is the answer.

If for nothing but the sake of America’s constitutional liberties and the freedom to practice as one chooses, this must be prevented and it is the voice of the AMA that will lead that fight. But it has been placed on notice and may find itself alone if it continues to lose the big battles in this war.

Dr. Smith is a historical novelist and has written extensively on medical economics. He is an adjunct faculty member at Santa Fe College, a Fellow in the American College of Surgeons, and delegate to the FMA House of Delegates.