LOWER COSTS ARE NOT THE ONLY FACTORS IN MEDICINE
July 19, 2009
Thank you, Dr. Nielsen, for your leadership in bringing us to these crucial moments in the history of medicine. In my year as AMA President, I will carry this fight forward.
But first, I’d like to share a few thoughts this evening about the Evolution of Medicine-the Art and the Science that make it useful – and the Ethics that make it meaningful.
Evolution is a fitting theme, since this year marks the 200th birthday of Charles Darwin. But I am not going to address the Origin of Species. Instead, I’d like to talk about evolution as a trait of an Individual, an Organization, a Profession and a Society.
As individuals, we are brought into this world through the miracle of birth. Our parents create us and our families support us. Through this mystery of nature and nurture, we evolve to the point that where we’re ready to face the world on our own. I would like to thank my father, who is home in East Rochester, New York; and those who are here: my mother, my 4 sisters, my brother and their families for their love and support over the years.
A constant in my life for the last 29 years is my wife, Charli and our daughter Elisha. Charli is my best friend, my partner, and the love of my life. And Elisha is the light of my life. Both give me perspective through the prism of life and don’t let me forget the most vulnerable among us.
They are part – the most important part – of my evolution as a person. And I thank each of you for allowing me to be here tonight and stand as President of the American Medical Association.
When I was 18 I left East Rochester to travel to Texas. As journeys go, it may not have been as dramatic as early man braving the Bering Strait but the impulse was the same – leave behind the drifts of snow and head south to a warmer place.
In Texas I came of age. What I am as a physician I owe to the formal – and informal – education I’ve received from colleagues at the University of Texas Medical Branch at Galveston, the Texas Medical Association, Scott & White Healthcare, Texas A&M Health Science Center, and the National Quality Enterprise. They are part of my evolution to this time and place.
All of those who enabled me to succeed and allowed me to fail, who never lost faith, and made it possible for me to learn – all of you are part of my evolution to this time and place.
Would my family, friends and colleagues from Scott & White, Texas Medical Association, American College of Cardiology, American College of Physicians, American Medical Group Association, Texas A&M Health Science Center, the National Quality Enterprise and our American Medical Association, please stand and allow us to thank you and those who could not be here tonight who have supported me – with a round of applause?
Charles Darwin, who knew something about evolution, wrote that what separates man from animal – is a uniquely human trait that the most vulnerable among us– those suffering from illness or injury, we save from harm. Call it Compassion. Or Altruism. Or even Enlightened Self-interest.
“Our medical men exert their utmost skill to save the life of everyone to the last moment,” he said. And Darwin – a botanist who dropped out of medical school – didn’t mean this as a compliment. But the notion of “survival of the fittest” has never been at home in medicine.
Since recorded time, the human race has searched for a purpose. Different civilizations – in different places – amid different conditions – driven by different cultural and material needs – still share common themes.
All have found a place – a need – for spirituality. A recognition that the spark of life on this planet may be forged from a higher force. As such, it is sacred. As human beings, we seek out each other for the caring and compassion a safe place provides.
This impulse has driven physicians to evolve. An evolution from the shamans who provided just a hope of physical healing but always comforted the spirit. Through Hippocrates, and Galen, through the pursuit of the four humours, through the use of leeches and foxglove, the black bag, the house call, the HMO – medicine has gone through its own epic changes across the centuries.
But what hasn’t changed in the Soul of Medicine is the capacity to listen, to touch, to show a fellow human being our willingness to serve.
There are those that say the Art of Medicine is a lost art. That the intangibles of healing have been eclipsed by the coldness of performance measurement, the boundaries of documentation and the realities of liability.
Like it or not, these are the components of what it means to be a physician in America in 2009.
But there’s no reason that the regulations and paperwork imposed on our profession can’t be made to co-exist with the Art of Medicine.
Indeed, they must. Being a physician embraces many ideas and emotions, duties and ideals.
Altruism, Responsibility and Accountability.
Leadership, Caring and Compassion.
Communication, Excellence and Scholarship.
Respect, Honor and Integrity.
These are the hallmarks of a professional. Yet they also frame the canvas of the Art of Medicine. And all are products of the Evolution of Medicine.
I believe the future of our profession is bright – as long as we remember that the human touch cannot be replaced with a Blackberry text message or a 140-character entry on Twitter.
Even as we witness the rapidly multiplying marvels of science and technology, we must never forget our basic human compassion for the most vulnerable among us.
The evolution of our science takes one breathtaking turn after another.
The ability to take a cell and use it to regrow any organ is a reality, not science fiction. The ability to map one’s genome to understand the risks of disease one might face is reality, not science fiction. The ability to halt and reverse disease processes with medications and devices is reality, not science fiction, and continues to evolve at a rapid rate. The 21st Century is overflowing with promise.
So – amid this dramatic change in our science – and the challenges to traditional ways of practicing medicine – how has the American Medical Association evolved?
To illustrate, let me take you back in time.
In 1776, America declared its independence and noted three inalienable rights – Life, Liberty and the Pursuit of Happiness. A progressive notion in 1776 – but those rights were restricted to white male property owners.
Over time, our democracy evolved. And the notion of professionalism expanded.
In 1847, the AMA was founded to create a national medical organization, adopt a uniform standard of medical education and a common code of medical ethics.
What was missing from those founding principles was the notion of access to medical care for all people.
It was not until 1957 that we entered our next stage of evolution – and adopted in our AMA Code of Medical Ethics the 9th Principle: A physician shall support access to medical care for all people.
But a principle requires more than a vote to adopt the words.
We had to evolve.
We had to become more inclusive.
We had to live up to the principles we espoused and strive for an evolution of understanding – to come to the realization that each of us as human beings has worth and value.
And it is for this reason, I am excited and firmly believe that in 2009, we are ready to fully embrace a principle that for all our good intentions – has gone unrealized for more than 50 years.
We as a nation are ready to have health insurance coverage for ALL Americans.
This is not some of kind of empty slogan or semantic exercise.
This is an effort that will define our organization; that will define our nation; and will define each and every one of us.
Our American capitalist system has always secured a higher level of medical care for those who succeeded compared to those who fell by the wayside. For them, medical care depended on the charity of others. Charity, bad debt, allowances-all words that do not reflect the human face of suffering.
We have learned that those without health insurance, who can’t afford a visit to a personal physician, who access care only through an Emergency Department – live sicker and die younger. In the wealthiest, most technologically advanced society in the history of the world – that is unacceptable.
The victims of this crisis of the uninsured too often are members of minority groups.
Our AMA had to evolve. In our past, we tolerated discrimination in our membership toward many groups – African-Americans, women, those in group practice, international medical graduates and those with different sexual orientation.
Ethnic, racial and gender minority groups that are already faced with disparities in care.
Our profession and our society have evolved – and this state of disparities can no longer be tolerated.
We have practical solutions available, such as increasing educational opportunities – including the option of medical school — for those who have suffered discrimination over the decades.
Our AMA Foundation is addressing this situation by granting minority scholarships.
Our Minority Affairs Consortium and the Commission to End Health Disparities – formed with the National Medical Association and National Hispanic Medical Association — contributes through the Doctors Back to School program in elementary and high school, which offers mentors and role models for students in medically underserved areas.
But more needs to be done. The process needs to evolve.
That’s why I am excited about working this year with my fellow graduate of the University of Texas at El Paso, Willarda Edwards, as she becomes president of the National Medical Association. What a great Invocation she gave tonight. Thank you Willarda.
Together, we’ll take the message to local communities about the many intersections of education and health.
I’ll use opportunities whenever I can to support AMA policies that seek to eliminate disparities in healthcare.
Every physician in this nation should know they can make a difference. Every physician should do so.
But how do we make this happen? How do we evolve to reach this point?
For the sake of our society, America is now challenged to reform its entire health care system – to combine both the individual and curative – and the social and preventive.
The need is unmistakable and urgent.
Rising health-care costs strain individual, business and government budgets. The demographics of we Baby Boomers as we reach age 65 and beyond – and the disease burden of widespread obesity portend a tidal wave of costs that may drown our nation. What our society needs to spend to hold back this tide can’t be sustained.
These rising costs contribute to many Americans being uninsured. They put premiums out of reach for many families. For some, the price makes paying for treatment impossible.
But there needs to be a distinction between cost and value. Our discussion cannot be simply about lowering costs. It has to focus on reducing unnecessary costs. Medical care will always cost something.
Last Monday I had my usual 15 patients in my clinic, I reviewed the chart of each before I saw them. One patient reported shortness of breath. I noted in our electronic medical record that 3 weeks ago he had a significant bleed from his bladder. His hemoglobin had fallen below 10. I did not need an imaging test to tell me that that if you don’t have enough oxygen carried by your hemoglobin in your blood, you are going to be short of breath. My treatment was iron supplements, not a heart cath.
But our current payment system rewards us when we do a procedure – but not when we listen and think. The value of the Art of a Shaman to comfort the spirit should be paid for as well as the coordination of care a physician provides.
The wisdom of life is found in shedding what isn’t essential. We need to stop the administrative waste in healthcare that does not contribute to patient care and drives up premiums and taxes. Physicians have plenty of examples of excessive paperwork imposed on them by both the public and private payers.
The AMA is committed to get more value from our health care dollar. We want to bend the spending curve downward and move forward on health reform.
The AMA-convened Physician Consortium for Performance Improvement, combining the best efforts of more than 100 state and national medical specialty societies, continues to develop measures to improve health-care quality and value.
Led by the AMA, our medical profession is working to address appropriateness of care, the overutilization of unnecessary services and avoidable hospital readmissions.
Defensive medicine is real and it’s costly. We need medical liability reforms to help physicians provide the best care without feeling pressure to order additional tests. We need to know that if you follow the evidence-based guidelines you should be protected from the risk of the courtroom. Otherwise, any savings from not ordering a test or procedure will vanish in a fog of frivolous lawsuits.
All Americans must be part of this evolution. The combination of national initiatives and an individual patient’s own healthier lifesteps toward prevention and wellness is key to reducing spiraling health costs, preventing chronic disease and keeping America healthy.
Our patients are partners in their medical care, and we have to challenge them to get healthy and stay healthy. How else can we evolve our health care system?
Could we prescribe physical activity and pay the patient for weight loss to control diabetes rather than a polypharmacy of pills? How do we deal with the patients who don’t respond exactly the way we need them to? Will they be cast aside because they can’t or won’t follow a treatment plan that affects their doctor’s ranking or payment? That goes against everything physicians believe in.
Designing a system that protects these patients from making bad choices must be the next step in this evolution.
For instance, we’ve seen how mandatory seatbelts have reduced costs spent treating trauma. How about we go a step further by making breath locks mandatory on all vehicles, which could reduce by half the billions spent on alcohol related motor vehicle injury and death?
The AMA is working to evolve our health sector beyond its silos – and toward a free range of cooperation and coordination. It is one strategy toward the reform of a system that, to survive needs to evolve.
One necessary element to this overhaul of the system is payment reform. It, too, needs to evolve.
We need to remember the basic principles of payment for medical care.
As a physician providing my services to my patients I should expect fair and reasonable compensation. And patients should be able to privately contract with their physician for medical care without penalty.
This contract is as old as medicine itself. Payment is the individual’s responsibility. Treatment is the physician’s responsibility. In an ideal world, it would be that simple. But there are many players on the stage of American health care – and not everyone is reading from the same script.
The problem with the systems proposed by insurers and the federal government is that often the rewards are not timely and do not involve directly the individual patient when they receive that medical care. This creates a widening gulf between the patient and the physician.
I saw this principle in action during my undergraduate days, when I did non-human primate behavioral research. If a banana pellet only dropped once a year, our primates would not push that lever very long. As homo sapiens, our DNA is very similar to those primates.
These experiences – and my day to day life as a physician – has led me to think long and hard about how health policy could help carry us into an evolved future.
Allow me to make a few observations – about some of the possibilities. A bit of out of the box thinking about what the future might hold.
For instance, imagine if we evolved the payment system so those who pool money through premiums, like a private insurer, or through taxes like a government system, pay a standard base fee for medical care when it is provided regardless of where the patient lives?
Then, the physician, or patient-centered medical home, hospital, or accountable-care organization could decide if they wanted to charge an additional service fee.
If a patient could not afford to pay, a physician would not be obligated to charge the fee. Under current law, that is illegal.
If the fee is charged, then the patient would decide if the medical care they received met their expectations. Whether it met those goals of timely, safe, equitable, efficient, effective and patient-centered care. They would either pay the service fee or if not, they would need to provide feedback on why their expectations were not met.
In my experience, this would evolve quality care much faster than any government or insurer proposal I have seen. It provides real time feedback for quality, makes both the patient and physician accountable to each other and still preserves the pooling needed to keep health insurance affordable.
It is worth remembering the words of Nobel Prize winning economist Milton Friedman, who noted:
“If you spend your own money on yourself, you are very concerned about how much is spent and how it is spent…But if you spend someone else’s money on yourself, you are not too concerned how much is spent or how it is spent….”
Government now pays for more than 56 percent of health care in America.
If the use of federal taxes to significantly pay for health care defines a public plan, one already exists – the Federal Employee Health Benefit Plan. Let individuals whose employer does not provide health insurance coverage buy into that federal plan with advanceable tax credits inversely related to their income.
I’d like to add to that my own modest proposal. Perhaps federal spending priorities can evolve by linking the health premiums of elected officials to those of their constituents. Pool individuals along Congressional District lines. That might result in more communities with safe gyms and open fields for physical activity and fewer bridges to nowhere.
Payment is just one piece of the health care reform puzzle. It’s important – but it’s not the defining trait of medicine.
The 9th Principle of Ethics trumps all. A physician shall support access to medical care for all people. And as these payment scenarios evolve, that principle is paramount. We will still care for our patients. No matter what.
The AMA’s proposal for health system reform delivers the sort of strong, evolutionary changes we believe are the best way to deliver the best care we can – to the largest number of people – with the best value.
Evolutionary change. Not revolutionary chaos. Radical plans may lower costs in the short run, but in the long run it will cost us dearly. Our American health care system is sick and getting worse. If we approach change with a hatchet instead of a scalpel, we will lose the patient.
I can promise this: our AMA is committed to offering guidance, our expertise, the benefits of our relationship with patients, and the powerful voice of our profession – to help the powers that be make the right decisions.
So which path will the next stage of the evolution of health care take?
Perhaps someday we can evolve from a predominantly employer-based system to one where the individual has the same tax advantage to own their own health insurance policy.
A system more evolutionary than revolutionary.
And now we must help educate our patients. We see advertising all the time by insurance companies who seek to sear their brand into the psyches of consumers.
But will the loyalty of patients be to those who pool premiums? Or to those of us who get up at 2 a.m. and provide their care?
As physicians, we have to be united, work together and speak as one. My greatest fear, is that the increasing specialization in medicine when we are threatened by government or payers — will force us into warring tribes.
When survival is threatened, those who change – survive. The evolutionary gain is not always to the swift, the strongest or most intelligent – but to the most adaptable.
If we as physicians scatter among the banners of specialty – and fragment ourselves among organ, gender, age, limb, diagnostic and therapeutic components of being a physician, we forget the lessons that being human mean.
As humans, we are the sum total of all our parts – physical, emotional, spiritual. These must act together to function best. As physicians – we must act together to function best. We must act together to stay strong for our profession. We must act together for the sake of our patients.
It is all part of the evolution we as living beings – as physicians – have always done and will continue to do – as individuals, as organizations and as society.
In this extraordinary moment in our history, we as physicians must not only anticipate change, or respond to change, or adapt to change – we, ourselves, must be the change we hope to see in our health care system. I’m excited about it, and confident we can do it.
Confident, that we will continue our evolution as an organization that embraces the challenges of the practice of medicine in the 21st century and meets them with science, innovation and creativity.
To lead the way toward a uniquely American system that discards what doesn’t work, builds on what is strong, and offers value, innovation and access. Most of all, to stay true to the letter and the spirit of the 9th Principle of Ethics.
To support access to medical care for all people.
This evolution of the AMA reflects our dedication to provide affordable, quality health insurance coverage not just for some, but for everyone.
Throughout the centuries, the science of medicine has evolved, but the Art remains the same. Caring… Comfort … Compassion.
Remember this: As physicians, we are blessed. And with that comes a great responsibility. We must hold true to our Ethics as the Evolution of the American health care system unfolds. And never forget that we as profession exist for the patients we serve. Thank you. God Bless America and God Bless our AMA.