Tag Archives: Family Medicine

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House Bill Aims to Curb Employers Ability to Force Doctors to Leave State

I prepared this potential op-ed prior to the death of HB 2931 in the Washington legislature. Non-compete clauses (also known as restrictive covenants) in physician contracts have had a devastating effect on the primary care workforce in Vancouver, Washington and other border regions of the state.

I understand the need to protect employers from the costs of recruiting a physician who then turns around and threatens to compete from across the street (really… who does that?) On the other hand, large groups in the state have thrown their weight around and hospital systems have thrown temper tantrums. I would prefer to eliminate restrictive covenants for family physicians, but there is good evidence from numerous sectors fo the economy that putting sharp limits on the enforceability of restrictive covenants is good for the economy. The best example is Silicon Valley,  where companies treat their employees very well, manage them extraordinarily well and continue to work with the intellectual capital they attract long after it leaves to spin off new entities and foster even more innovation.

Other physicians need the support, but so do baristas, hairdressers, nail spa workers and tattoo artists, who are unfairly unlimited by the legacy companies. I have to believe it makes these companies lazy and less considerate than they would be otherwise.

There were several bills, but I addressed the one widely regarded as the most likely to cross to the senate. In the Senate there was SB 6625 sponsored by Senators Conway, Hasegawa, Keiser, Chase, which restricted non-competes to 6 months for hourly wage workers. HB 2406 was sponsored by Representatives Manweller, Sells, Stanford, Magendanz, Tarleton, Moscoso, Ormsby and S. Hunt and stipulated that non-compete clauses were null and void in the case of a listed number of low hourly wage work such as fast food and dry wall applicators. HB 2931, sponsored by Representatives Stanford and Ormsby was the most sophisticated of the three and tried to outline certain parameters for which it is inappropriate to impose a non-compete. In short, if you are not an executive, non-competes would not be enforceable beyond one year.

None of the bills proposed geographic limits as “reasonable” in a non-compete.

All I can say is “we’ll be back,” even though I am poised to become an employer of physcians and stand to benefit from the applicability of these absurd covenants. There is still this thing called “doing the right thing.” Here is my unpublished opinion piece.

 

House Bill 2931 limits how employers can impose non-compete agreements on prospective employees and will be good for all industries in the state, although it will have an unexpected beneficial effect on health of Washingtonians. The bill received a vote on the House Floor Tuesday and will now go to the Senate for consideration.

 

Non-compete agreements in health care protect hospitals and larger medical groups, ostensibly from the high cost of physician recruitment. However, once a doctor agrees to be employed by a medical group, these agreements become a not-so-subtle means of controlling the doctors. An unhappy doctor could be required to leave the city, county or state because the agreement states that he or she is not allowed to practice their profession under any circumstances within the exclusion area. Since doctors have families and children, the non-compete agreement becomes a leash which can only be broken at substantial personal cost, which many families simply are not willing to accept. In one draconian example, one employer in Southwest Washington defines the geographic exclusion area as three counties. The doctor is often left with a Hobson’s choice of staying at an unhappy job with incompetent and potentially dangerous management or leaving town. No one is left to advocate for you, the patient.

 

Non-compete agreements are outrageous and unethical in healthcare. They disrupt the doctor patient relationship and hurt our workforce. When physicians leave the state, even for a short period of time, they rarely come back. Most medical groups spend a huge amount of money recruiting, but nobody tracks losses when doctors leave. In the end, it is the patients who suffer when they lose a trusted provider. I have never seen an administrator look an elderly woman in the eye and explain how his contract forced her doctor out of town.

 

It should come as no surprise that the Washington Hospital Association is profoundly opposes HB 2931. The Washington State Medical Association debated the issue heatedly, and emerged officially neutral. At least one large group made veiled threats to leave the association if even a watered down proposal were considered. The Washington Academy of Family Physicians is the only group that supports the bill, reflecting the public health orientation of primary care sector. Oddly enough, Republicans tend to like bills like HB 2931, because they foster free markets. Democrats like them because they protect employees. This is a bipartisan issue that aims to clip “Big Corporate,” not “Big Government.”

 

In many industries, non-compete agreements are merely an over-reaching effort to own their workforce. As one misdirected lobbyist asserted at the House Labor Committee, “our people ARE our intellectual property.” One wonders how Silicon Valley has thrived, since California is a place where these covenants are nearly completely unenforceable. Perhaps economic development is constrained when tech companies are allowed to impose draconian non-compete clauses?

 

There are numerous options which would make covenants more fair to communities, patients and doctors, but none of the corporations that run the state’s health care apparatus will even discuss the matter. It is time to reclaim the natural rights of individuals to work where they please without undue interference from anonymous corporations. Now it is up to the Senate to make HB 2931 law.

 

Uncategorized, Video

Is it Tax Deductible?

Video

DPC fees are not tax deductible or applicable to health savings accounts (HSA’s) due to an IRS regulation that views DPC as insurance, although it is clearly not. Several state legislatures ahve passed enabling legislation that specifically states DPC is not insurance, nor is to be treated as such. Currently, Senate Bill 1989 at the Capitol will make this the law of the land and open the possibility of allowing Medicare money to be directed by patients to primary care physicians who are willing to accept such payments.

 

 

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Primary care is key piece to U.S. healthcare puzzle

Another article, this one published in the Vancouver Business Journal on June 19, 2015, found here.

 

Healthcare in the U.S. is sick, bloated and ineffective. In some circles, investment in primary care infrastructure is prescribed as one of the important components in an effort to fix the U.S. healthcare system. My personal opinion is that primary care infrastructure is the single most important piece of the puzzle.

Healthcare is a $4 trillion industry that represents more than 1/6th of GDP. It is also growing at a rate that threatens to exceed the 20 percent threshold in the next few years. The Soviet Union’s economy collapsed when non-productive spending on defense exceeded 25 percent, and it has been argued that this level in healthcare expenditures would cause enormous misery for U.S. businesses. However, it is a mistake to examine healthcare as a monolith. The system is made up of various parts, each of which has varying interests to assure their survival within the system.

Hospitals, for instance, rely on flow-through of as many procedures as possible. Orthopedic, heart and urological procedures traditionally lead the way. Physicians in these specialties are especially prized by hospitals since they tend to refer the most valuable patients. Other physicians have professional and financial interests that are diametrically opposed. If primary care was enabled to do its job, it would keep interventions in community offices, where charges are at lower rates and the care, while some would argue is technically less precise, is often more personalized and therefore more prized by individual patients.

Even the insurance industry is not monolithic in the market conditions that maximize their bottom lines. Some insurers manage care very little, limiting the review of utilization and making their money from processing transactions. In some ways, these companies are aligned with the hospitals and specialty physicians. The managed care plans assume risk for their subscribers’ healthcare costs. They stand to make money if patients use fewer services and as such, are more closely aligned to the average primary physician rather than the average specialist.

Of course, this varies tremendously from person to person. A provider at Kaiser tends to think of fewer procedures, tests and consults as better care, whereas a for-profit primary care practice may gravitate to concierge care, and developing niche service lines like Botox, varicose vein treatments and selling nutraceuticals. Some of the more abusive niche products are narcotic pill mills, medical marijuana clinics and some of the new testosterone-centered men’s clinics.

Primary care has been marginalized in an overtly specializing society. The main driver of this phenomenon is that the financial incentives for a significant portion of the industry are aligned with generating more procedures, more testing and more specialty consultations. After all, that is where the best margins are.

On the other hand, managed care and primary care tend to have aligned interests in saving money for people and the health system in general. Primary care cannot stand on its own; there is no point to having preventive services and first line care if curative care and specialized care is not available. But not every person with high blood pressure or heart failure needs a cardiologist. In fact, specialists would spend more time treating and caring for conditions more suited to their degree of specialization if front line medicine was better built up than it is today.

The trend toward healthcare purchasers utilizing narrow networks of high value providers is related to effective primary care and an appropriate specialty network. Trouble is that the infrastructure for primary care has been neglected for so long that competition for primary care services is likely to raise prices to the extent that, in the near future, it will compete with current health plan offerings. For now however, high-value primary care holds the promise of reducing employer costs and putting enough money into primary care to attract medical students and resident graduates into areas of healthcare that have been spurned for so long.

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Direct Primary Care and the Working Poor

This post was written for PanZoe‘s blog on May 21, 2015, here.

 

One of the easiest vulnerabilities to spot in healthcare after the Accountable care Act are those individuals who simply cannot afford their deductibles. The insurance mandate in Obamacare leads those who work low wage jobs without benefits to buy the cheapest policies.

These policies have huge deductibles, so even with great subsidies, these individuals simply can’t afford to see a doctor. In fact, they are often exposed to the full “rack rate” for health services and have inflated out of pocket costs 2 to 3 times as high as insurance companies pay providers.

A 40 year old man sat at home with a cold, or so he thought. When his fever did not get better after three weeks and he started getting so short of breath that he couldn’t work, he finally came to see me. His cold was really a pneumonia and could have been treated weeks earlier by someone who recognized the red flags early enough. Instead, he ended up in hospital and his $8000 deductible got charged pretty fast.

Low wage workers are the productive members of society trying to transition out of multi-generational cycle of poverty, and succeeding to some extent. Such shocks can throw them back on the public rolls. One of the major advantages of Direct Primary Care for low income individuals just above the Medicaid threshold is unlimited access to high-impact primary care. They can get minor illnesses treated quickly, before suffering serious illness requiring hospitalization. In addition they have access to prevention, care coordination and chronic disease. The technology that goes with Direct Primary Care, like secure video and texting is of particular importance to people whose trips to the doctor often impact their income. In jobs without benefits, if you don’t work, you don’t get paid.

In policy circles Direct Primary care suffers from an image of care for the elites. But the low price point makes it most appropriate for low and middle income individuals. These are the people most likely to benefit from a close relationship with a primary care provider.

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Employed Physicians

This old post is here because I have been thinking a lot lately about the impact of employed physicians on a community’s health. Since this post was written, I have worked for a large hospital-based primary care practice where I was being pressured to produce referrals and tests. When I left, the company waived any non-compete clauses. If they had elected to enforce them, my current community would have been deprived of a family physician in an area of primary care penury. So the lack of independence in primary care may lead to overuse of specialty and technological services and deprive communities of the specific function (primary care) that makes health systems more efficient. This 2008 post contains the seed of an idea to develop a sustainable business model for the independent primary care physician in the interests of the public health. But there are several steps I will have to fill in, so stay tuned. Meanwhile, enjoy…

 

I had an interesting conversation with a feller from Texas the other day. I was telling him how I had formed my impressions of docs in employed situations from my experience on the East Coast. It just seemed that the solo practitioner was almost dead, if not completely so. Even in rural Maryland, it was more likely to find groups of two or three docs in private practice fiercely holding on to their independence in the face of large single- or multi-specialty groups encroaching from the suburbs. Many of the large groups have found Stark-compliant ways of working with nearby hospitals, or, in some areas, are outright owned by the hospitals.

I reflected to my acquaintance how different it was out here in the Western desert regions, where it seemed the employed docs sometimes felt they could act like it was their own shop and close up with less than a day’s notice to stay home with the kids or go duck hunting or take whatever break is justified by a hard-working, highly-valued provider of a needed service by a grateful community.

You can’t do that when there are 50 physicians and 300 employees whose work schedules are dependent on physicians providing billable services on razor-thin margins.

Well, maybe you can. It’s all about the supply and demand equation, isn’t it? If there aren’t enough primary care physicians to go ’round, the tolerance for behavior inconsistent with a larger organization’s overall well-being is better tolerated. And certainly the local physicians’ culture has an important role to play. Texas docs, I was told were nearly never in large groups and they never tolerated overbearing administrative intrusions to their clinical or vocational independence.

I walked away from my conversation with a tall and lanky Texan (sorry for the cliche, but he was tall and nearly lanky), with an understanding of how different the situation is for physicians across the country and how my approach to change management and performance management is colored by my East Coast experience.

In areas where managed care penetration is high, employed physicians predominate by choice, and a high regard for academic analysis output exists, there is an atmosphere of understanding and willingness to work within a corporate environment. Evidence-based medicine, quality and performance improvement are all perceived as methods to improve health care delivery systems for the betterment of the community. Physicians understand the choice to enter employed positions and accept the trade-offs, giving up some independence for the sake of fewer administrative headaches, better benefits and perhaps, a reasonable lifestyle.

In areas where one or more of these conditions do not hold, physicians resent encroachment on their judgment, style or authority and mistrust the motives of administrators of all stripes. EBM, QI, and PI are bridles of control to be avoided at all costs and administrative entities are regarded to exist for their personal betterment and not the benefit of communities nor the doctors, Such physicians enter into an employed arrangement begrudgingly and only if they feel that their work is not subject to the kind of oversight that will reduce their independence.

OK, I’m dumb. I didn’t realize the obvious until now. I have grown up in academic environments which are so dominated by various stakeholders that the independence of the community physician a distant recollection from the stories of William Carlos Williams; the vague memory of a historical work of fiction read in childhood. The East coast and its large cities are places where independent practitioners are aberrations or mavericks worthy of awe, disbelief and admiration.

Elsewhere in the country, in smaller cities and younger landscapes, the independent practitioner has thrived and the battle for physicians’ independence is much more vigorous.

It is possible to engage physicians any number of ways in future improvements to health care. The lessons of the East tell me that the best way is not confrontational. Without physicians, no meaningful reform is possible, despite the best efforts of other stakeholders. On the East Coast, docs have been beaten into submission. It took a long time, created a lot of ill feelings and did not accomplish much. The rest can do it faster, more collaboratively and with greater focus. The first step is to get a clear understanding of the situation and adapt to local environments.

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Revolution or Evolution

I resurrected this old blog post because it reflects some of the most basic and fundamental issues that were not addressed by the ACA. It is as current today as in 2008. Changes in health technology, consumer-facing health tools, payment reform and Meaningful Use have not moved the needle on establishing a unified view on the the nature and purpose of health care systems in general.

 

Call me a skeptic, but this health care system (which does not serve the majority of its stakeholders) is not likely to change overnight, even (especially) if Obama wins the election. What we have in the US is an undesigned, organic, chaotic system which accomplishes exactly what it is designed to accomplish. Problem is, everybody thinks it is designed to do something different and the result is incoherent.

Some treat health care as an entitlement. It is the right thing to do because nobody should ever go without access to care in the face of illness. Illness is frightening, as are many other things in the world. But fear of getting sick is about as good a justification for universal health care as universal access to… say, attorneys. It may be a good thing to do, but I would rather push for universal access to information.

Many physicians see the health care system as a vehicle for the intellectual challenges and exercises in skill required of the practice of medicine. As an exercise in meritocracy, health care should be more available to those best able to pay for it. There has always been and will always be value in having uncommon skill or knowledge. I firmly believe that this drive, rather than the profit motive, is what pushes most physicians to specialize, sub-specialize and constantly and marvelously push back the limits of what can be done with the human body.

Health systems are also an opportunity to find a margin. Yes, health care is a business and in America, profit is not a dirty word.

Health care is also as “issue” for politicians, and to the extent that it affects voters, it influences the government agenda. It represents a way to get a vote.

Health care can be seen as a public health measure, which I tend to do. This suggests that those interventions that are most likely to help the health of populations (as distinct from the health of individuals) should get the most resources. With all due apologies to my sub-specialty colleagues,who are critical to our health care infrastructure from many perspective, it is here that primary care wins out hands down.

In fact, the broader the definition of health, the less medical it becomes. Securing water, adequate shelter, safe employment, reliable food sources, traffic safety and basic literacy are health issues that hardly fit into our usual conception of health care or the current reform debate. Immunizations, prenatal care and primary care are the most cost-effective things the medical world has to offer. PAHO and WHO publish guides for policy makers.

A health system like ours is at cross-purposes. Many advocate a total overhaul but that’s not how change happens. Incremental change is more likely. Even if we were to reach some sort of tipping point in technology, or delivery, or insurance we will not likely see a complete change in a high resource service sector. Despite the complexity of the health system, care is still delivered one-on-one. All other discussions remain MBA-speak appropriate for the Harvard Business Review and little else.

Don’t get me wrong, I like what I see in the health reform world. I like Dr. Val. I like Steve Case for that matter. I think what they are doing in consumer-driven health care is valuable. Jay Parkinson sounds like a smart guy and I might even ask him what he thinks about spreading his model to rural areas. I believe that the Future of Family Medicine project has enormous potential for change as evidenced by the TransforMED project and the rising popularity of the medical homes concept. PHR‘s have potential. RHIO‘s even more.

But none of these ideas are sufficiently transformative to represent the answer to a broken health system. Together, they represent a significant change in direction that incrementally may have an outsize impact.

The single notion that could have the greatest effect is the one that says we cannot and should not provide for every possible health benefit under the sun.

Rationing by cost (a barrier to access) is more acceptable than rationing by mandate, regulation, insurance company ruling or queuing. No rationing does not exist in any industry.

This means we must prioritize the things we cover. We make decisions all the time about what is covered and what is not covered, but we currently decide based on politics; that is to say the sum total of influence exerted by stakeholders and lobbies.

Frankly, it’s not a bad way to do it; I don’t believe in central planning. Look at Canada. But a better way to do it is follow the data. Otherwise every right wing crackpot and left wing entitlement-creator will have outsize say according to the way the political winds blow. Right now, we have two nutty ideas floating around: one way is expanding health care coverage under government tutelage and the other is giving tax credits to poor people to buy health insurance (source: Pikalaina). As far as I’m concerned, government should only guide and create an environment for market forces to accomplish common goals (in this case, health.) Expanding government programs is not the way to do it. Tax credits for poor people are ridiculous; I can’t get my poor patients to spend on bus fare if there is no IMMEDIATE benefit.

McCain is also promoting an idea to allow insurance companies to compete across state lines. Bob Vineyard at Insureblog seems to feel it won’t work because of differing state mandates (the analogy is with credit card companies). In other words, states are already making choices about which benefits are to be covered. This may be viewed as rationing, or alternatively, choosing which parts of health care to subsidize. In fact, I prefer the subsidy position, because it puts us on more firm moral ground. If we chose to subsidize any industry, we should do it on the basis of data and a specific goal in mind. A utilitarian like me will view government’s responsibility as creating the greatest common good i.e. the most wellbeing. This merges nicely with the broader definitions of health.

What I like about the McCain idea is that it represents incremental change. To address Vineyard’s correctly pointing out that state mandates represent a serious obstacle, they are not insurmountable. A federal rule for companies selling insurance across state lines could be that they meet or exceed the benefits coverage of most states. These policies will be more expensive than policies sold in low-mandate states, but provide useful alternatives for those willing to pay. They will represent real competition in high mandate states, which are sufficiently populous to get people asking questions. There are other legislative and regulatory hurdles to get over, but ideas should not be discarded before a full and public airing.

Transparency in the insurance industry and in hospital pricing, expanding coverage for the uninsured and under-insured, a more flexible tax code to allow for the purchase of alternative insurance products, increasing adoption of IT and maximization of its potential in measuring and affecting quality, aggressive changes in models of care delivery and defining different levels of coverage according to health impact analysis are all a small part of the solution. Overall, there is a tremendous amount of value yet to be unlocked in the US medical system, but tearing a system apart to rebuild it from the ground is not a good option. Revolutions tend to be more destructive than creative.

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Underfunded, undervalued

This is one of my favorite posts from The Physician Executive, which is especially relevant today as we enter the conversation of reforming payment from our current fee-for-service model to a pay-for-value system in which primary care may finally get the recognition it needs to actually serve its role within the health system.

 

Funny that people complain about how hard it is to get a good doctor. Sometimes it is important to ask why things are as they are, rather than complain about why they are not better.

I remember a conversation with an internist a couple of years back, who was complaining about how her family physician was so useless…it takes forever for the office to get back to her, appointments are a bear to get, refills take forever and it’s like getting teeth pulled to get him to call her back.

If a primary care doc is running all day trying to get patients through, then I assume he’s busy. That’s good thing. I’ve never waited for reservations at a bad restaurant. A good rule of thumb is that the better doctors’ offices are more crowded.

I know some physicians who have also had the business sense to build incredible systems that can get 30 patients or more in and out daily and still do a good job at it. Not everyone has the administrative skills to do that, even if they are excellent doctors. If the doctor doesn’t spend enough time to listen, the question must turn to what they’re paid for.

Generally, I view phone calls as a waste of time, because they frequently represent an inappropriate service to deliver by phone. Some advice can be safely dispensed at a distance, but nothing is certain without a proper examination. Oh, and that’s what usually what physicians are paid for. They are not paid to dispense advice, provide basic health education, prescribe medication without an assessment, complete forms for patients who haven’t been seen in two years and coordinate referrals for patients who bypassed them entirely and went straight to the specialist. They are paid by the visit, where an examination frequently takes place.

Our physicians at a facility for low-income individuals are allocated fully 20% of their time to do unremunerated administrative functions, only some of which ethically seems appropriate. We stretch the rules in recognition of our patients’ socioeconomic constraints and only because we receive sufficient grant income to support the loss. In private practice… fuggedaboudit. The only reason to do it, is to preserve goodwill, which doesn’t really pay the bills. (This only applies to traditional fee-for-service environments. More about capitation some other time, because that’s a whole different ball of wax.)

Why do physicians with very busy offices have to be so busy? I mean, are they just greedy, churning people like so many little factory widgets? I suspect, while there are some bad apples in the barrel, the majority are skating trying to cover their overhead, payroll, malpractice and hopefully come close to the national average of $150,000 in income. Remember the big bucks are usually reserved for cardiologists, neurosurgeons and other proceduralists, without which no health system would have credibility (source: healthcareerexplorer.com/salaries/neurosurgeon/). What’s the use of preventive services if there is no available curative services should prevention fail?

My friend, the internist completed her rant by saying there was no value to primary care since her family doctor couldn’t provide the service she required.

I wondered out loud if that was the way the world always worked, “Underfund the service you need so that it can’t do the job and then complain that it has not value.”

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Employed Physicians Becoming More Common

I am on a roll finding old posts from The Physician Executive that are still relevant today. In fact, this post is more relevant today than it was in August 2007.  We now must need to be concerned about how physicians are being managed and in the face of large integrated health systems with an incentive to encourage increased testing and referral. This will still be a major policy issue for the next decade.

Interesting post by Dr. Reece about physician-hospital collaborations at medinnovationblog. There is no question that community hospitals exist in a challenging environment, but each specialty now has its own financial realities that can color the relationship between physician groups and hospitals. My comment, is the most recent trend towards hospital-employed physicians accomplishes two things:

1) it puts physician executives in greater demand
2) it may put more hospital functions under greater physician influence or control.

Surely there are numerous other forces at work here and only the smartest and best informed physicians will win. I don’t believe the golden age of medicine was very good for patients, at least on a population basis. However physicians are often well-positioned to consider the patients’ best interests. Hopefully, the current grass-roots push towards more accountability and better quality-of-care data will combine with a strong physician perspective and professional management skills at hospitals to improve health outcomes overall.

Then again, the landscape may prove just too complex to navigate.

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Breast Feeding: Froelich & CDC

This is another old post from The Physician Executive that I expect is still relevant because old habits like supplemental feeding in hospital nurseries die a hard death when they are the path of least resistance. It was originally published on June 16, 2018

Edwina Froelich, founder of La Leche League, passed away last week. La Leche League used to state that the three main obstacles to successful breast-feeding were doctors, hospitals and social pressure.

My experience has been one of utter frustration with maternity nurses, who should know better, but frequently feed their wards sugar water for no reason. Some kids can get hypoglycemic, but certainly not three quarters of the nursery. Some kids may lose weight, but that is a normal phenomenon, with the natural history of birth being a decline in weight and return to birth weight by day 10. It is not abnormal to lose weight, but it is abnormal to get formula or D5 on day 1.

These practices appear to me (on an anecdotal basis) to be widespread in places I have worked in the US, but they would be unacceptable in other places of which I have some knowledge: Montreal, England, or France. I understand from a cousin in Dubai that at least one hospital reflects the US’s breastfeeding dysfunctions, so I am sure there is tremendous variation from country to country, especially by socio-economic class.

The harm done is that by allowing alternatives to breast feeding, we don’t give a woman a reasonable chance of establishing her breast milk in the first place. To establish breast feeding, you need an infant sucking on a nipple, which provides the hormonal stimulus to produce milk in the first place. The more concerned you are that the breast milk may “not be enough”, the more you assure the fact.

The problem with personal observations is the tendency to generalize. Finally, the CDC surveyed hospital infant feeding practices, as reported in MMWR. American hospitals persist in providing alternatives to breast feeding to infants, such as sugar water and formula. I am sure that most well-meaning maternity ward nurses will explain that they are trying to make sure babies gain weight or not become hypoglycemic. Unfortunately, entire wards of infants are not likely to suffer from the risk factors for hypoglycemia and weight loss in the first three days is a natural phenomenon that does not get babies in trouble if skilled observation and timely intervention is available.

So breast feeding suffers for entire populations as we chase the shadows of unusual and uncommon poor outcomes that rattle us to the point that it is easier to just chuck formula into every crying newborn’s mouth.

Hopefully there will be more Edwinas around to take up the cause.

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Are You At The Table?

In case you’re wondering, this is my piece for the Clark County Medical Society newsletter, summer 2013.

There are just under 900,000 licensed physicians in the U.S. Current AMA membership numbers about 224,500, rising up to levels not seen since 2009 when the AMA’s endorsement of Obamacare apparently precipitated a 5% drop in membership. Local Medical Societies are often loosely affiliated with the state and national medical association and can compare themselves to the national benchmark. Clark County has a better percentage than the national average, but barely. Nearly a quarter of the county’s physicians belonging to the medical society.  
In my few months as President of the CCMS I have watched with interest as some counties struggle without any physician cohesion as others have active and dynamic medical societies that contribute much to their communities’ well being.  It would be enlightening to understand what accounts for low membership in the AMA and local county societies.
The most significant drivers of membership seems to be related to the employment status of a growing number of physicians.  In the much storied  past of American Medicine it was necessary to belong to a local medical society as a source of referrals and recognition within that local medical community. As more and more physicians find themselves employed by large multispecialty groups, the relevance of a medical society diminishes. In addition most specialists seem to believe that their interests are better represented by their societies.
Perhaps at some point in the past couple of decades, the House of Medicine lost its ability to extract growing concessions from the rest of society and thus external conflicts became intra-professional conflicts. Despite the larger world relying on progressively greater degrees of specialization, it seems unwise to perpetuate internal conflicts. We each have a role to play in the larger system, including the generalist role in primary care and care coordination.
What seems self-evident is that a fragmented medical profession is easier to control and manipulate than a united one.  There was a time when a nationwide group of educated, professional healers were felt to be the best hope for advising on the population’s health. Some social theorists have suggested that the medical profession squandered its social capital on protecting its economic welfare. I would argue that a small minority of narrow-minded and short-sighted physicians temporarily hijacked an organization whose role has always been nobler than its own economic welfare.
We all have colleagues who will not join the AMA because of positions it had taken in the past. Well, the trouble with that is that no one has a voice who is not at the table. There should be no illusions about how political organizations work and how advocacy comes about; we may lose the occasional internal battles but still fight for common goals. A medical society works for the interests of its members but it would be a mistake to take a shortsighted view of what that means. Medicine based on scientific proof still safeguards the public’s health. Thus, there is no way of continuing to safeguard the public’s health, either by prevention or treatment  without a highly trained, professional force working to create a health system that is both effective and efficient improving the health of the entire population.
Health care has a knack of exposing the weaknesses of a free market system but I have also worked in a socialized health system that shared different weaknesses, but of equal magnitude.  It seems the US medical system is evolving into some sort of hybrid system midway between different ideologies. Anxiety comes with any change and we are being presented with a major change in the environment of medical practice.
Whatever your politics and personal philosophical structure, much of this change has happened with nominal input from organized physicians groups. It is important for the House of Medicine to speak with one voice whenever it can come to a consensus. My thoughts and opinions have been well-received at the state level where they have differed from the official position of the WSMA. Clark County has been particularly active at the state level, especially when it comes to advocating for the health of the Medicaid population. We have been involved in discussions regarding CUP, physician wellness programs, Prescription Monitoring Program funding (in the future, it will no longer be from your license fees), exempting physicians from the state B&O tax, the role of physicians in the state disciplinary body MQAC, and disseminating information about the upcoming state health insurance exchange.
We need to focus on what is best for the health of our population and not just what is best for ourselves. However, we must also stand up for ourselves because without a professional workforce, the population will suffer. We must face the fact that the industry of which we are an integral part extracts $2.7 Trillion from the general economy and we are being held accountable for the value we return in exchange for our share.  

One thing is sure. This is no longer your father’s AMA! It is YOUR AMA! And its actions depend on your participation at the local level in your County Medical Society.