Professional Physician Organizations: A Continuing Necessary Ingredient for Ongoing Health Reform

This JAMA article on "Professional Organizations' Role in Supporting Physicians to Improve Value in Health Care" reminds readers that "organized medicine" continues to have an important role in national health reform.  The Population Health Blog agrees and adds that these doctor professional organizations have not only been underestimated recently, but will continue to be a force to be reckoned with - both a national and state level.

The article points out that groups like the American Medical Association (AMA) along with the various sister specialty physician organizations, along with health systems, practice associations and various non-governmental entities, are critical to the success of the Affordable Care Act.  These doc groups been long-time advocates for health reform, are still trusted by a significant number of providers, collectively represent a majority of docs and bring insights to a complicated health system.

And what are they doing to help with reform?  According to the authors, they've been serving as "conveners," helping to marshal resources, are creating standards and helping regulators.  While the JAMA article naturally mentions a number of national initiatives (such as Choosing Wisely), the PHB points out the same kind of important activity is occurring at the state level.  A good example can be found here.

Before some PHB readers tut-tut the faux importance of the AMA and its many national and local affiliates by having you believe that docs have transitioned their loyalty from their profession to their employers, the PHB would point to three sentinel events that say otherwise:

1. Even the White House believed that organized medicine was important enough that it sought to circumvent the influence of the AMA by fostering its own professional doctor group called "Doctors for America."  While it hasn't worked so well, imitation is the sincerest form of flattery.

2. The Patient Centered Primary Care Collaborative's Board of Directors has a significant number of members with deep roots in organized medicine.  It's testimony to a vital constituency on which the success of the Patient Centered Medical Home depends.

3. While tort reform has been outside the scope of this blog, an important ballot initiative dealing with California's benchmark Medical Injury Compensation Reform Act (MICRA) will be put before the state's voters this fall.  The lead organization of an impressive coalition of labor, business and consumer groups that has been created to defeat the proposition and preserve MICRA is, you guessed it, a state medical association.

The lesson for population health providers?  Reach out to and work with the physician groups at all levels of reforming the system.

The Concentration of Naiveté

The Population Health Blog's car garage is not the size of a football field. 

So, when the PHB spouse parks our car inside, she tends to err on the side of safety.  She pulls far forward so that the rear bumper doesn't get "dinged" by automatic closure of the garage door.  That obliges the Population Health Blog to inconveniently squeeze past and climb over the front bumper when it wants to use the PHBmobile.

The win-win fix to our travails arrived last Christmas when the perspicacious PHB gave the spouse a positionally adjustable ceiling-mounted laser. It blinks a ruby red light through the windshield onto the dashboard when the car is in optimum position.  Pull too far forward, and the beam will be directed on the floor or a front seat. 

Since it's been installed, the PHB spouse has ignored it.  The laser beam is effectively pointing at the back seat.

The good news is that the PHB's naiveté was limited to parking habits, one house's garage and a spend of $19. 

Not so for Ezekiel Emanuel's work in health reform in the White House and a spend of far more money. 

According to this article in this weekend's Wall Street Journal, the well-meaning Dr. Emmanuel couldn't change the habits of Medicare's vast bureaucracy or of Mr. Obama's formidable political advisors.  As a result, bundled payments remained the stuff of demonstration projects, while the closure of tax exclusions for employer sponsored health insurance was limited to "Cadillac" plans.

What's more, professional liability reform died in the crib thanks to the White House chief of staff Rahm Emanuel's unwillingness to stir the political pot:

He immediately cut me off: "Shut the f— up! We are not doing malpractice. Period. Every time the AMA comes in here, they don't talk about malpractice." Their first, second and third priority, he said, was the formula used by Medicare to determine doctors' pay. "We don't need to do malpractice for the doctors, and I am not alienating the president's base for nothing," he barked. "Stop it."

Rahm's reaction told me everything that I needed to know about the politics of the issue. Democrats would accept malpractice reform under two circumstances: if they needed it to keep the AMA's support for the bill, or if they needed it to attract Republican support. Neither was true. In backroom negotiations, the AMA was solely focused on securing higher physician payments—not on malpractice. And not a single Republican in Congress would even negotiate.

The president had already aggravated liberals by forgoing a "public option." He'd offended unions by limiting the tax exclusion. He wasn't going to antagonize trial lawyers, another core Democratic constituency, for no gain.(from the WSJ, March 7 "Inside the Making of Obamacare.")

In its own small way, the PHB called attention to the AMA's narrow-minded focus on the SGR five years ago.  But the AMA's blunder and PHB's prescience are not the point.  Or, rather, points:

1. The health reform that eventually passed was a curious mix of White House naiveté and Washington inside-the-beltway politics. The result was the Affordable Care Act which continues to spawn quick-fix delays and throw sand in the gears of government.  We deserved better.

2. By concentrating risky decision making in Washington DC, the upside gains in big government may be undercut by the downside of unintended consequences and half-baked decision-making in all 50 states.  It's scary to think that the likes of Dr. Emanuel had such power.

Lessons learned.

A Health Policy Test

The Disease Management Care Blog remembers those frustrating medical school exams that asked for the best combination of answers from two columns. Unfortunately, the DMCB never quite mastered the professors' trickery.

In response, the DMCB has fashioned it's own test. The good news is that for this quiz, there is no right answer!

Match the numbered statements to the best lettered conclusion below:

1) Asking the White House to fix healthcare.gov's "back-end" enrollment problems will be like.....

2)  Labor leaders are discovering that the Washington DC's commitment to AMA-style special carve-outs is like....

3) The White House's surprise that health insurers act like, well... health insurers when it comes to reconciling price, quality and network access is like......

4) Having the "non-partisan" Kaiser Health News saying "it will be challenging for the Affordable Care Act to fully live up to it's name" is like....

5) Assuming market-dominant hospitals will do the "right thing" for the Affordable Care Act is like.....

+++++

A) ..... trying to sell Putin bobble-head dolls at a LGBT Pride parade

B) .... hiring the mayor of Atlanta as the tour guide on a trip to the Peoples' Republic of Northeast Vortexistan

C) .... giving Justin Bieber a dozen eggs and a bottle of Xanax.

D) .... the NFL kicking off a "we're knocking concussions out of the game" ad campaign.

E) .... being surprised that a smart former chief federal law enforcement officer in New Jersey has no evidence of personal involvement in a revengeful plot to close some bridge lanes

State Medical Societies: Obamacare's Early Warning System

A canary for the health care reform mine

The Disease Management Care Blog has a theory.

Whatever you think of health care reform, there is a possibility that its implementation could be troubled for years to come.  Too few healthy young people could sign up, provoking an upward insurance cost spiral.  Bureaucratic meddling could further increase administrative burdens. Washington DC's political and fiscal woes could erode fee schedules.  Large regional delivery systems, saddled by inefficient capital, workforce salary inflation and overly optimistic risk contracting could become stressed.  The medical-industrial complex's bubble won't necessarily burst, but increased demand and less money could mean a painful contraction.

What will be the first signal that that's happening?

It won't be the pronouncements from the intelligentsia running HHS. It won't be a late Friday press release from the White House. It won't be a breaking news report from the clueless reporters in any of the major media outlets.  And, unfortunately, it won't be in a prescient posting by the DMCB.

It'll be an uptick in physician membership in 50 state medical societies, followed by phone calls their affiliated professional liability insurance brokers.

The DMCB is talking about the state organizations that largely make up the base of the American Medical Association (AMA).  After seeing many of these organizations up close, the DMCB can assure readers that that is where the resemblance ends. Being much closer to the ground level of clinical practice, these entities are acutely aware of the decline in private practice. Many have watched their membership - and their income - go down as the result of docs joining salaried settings where membership dues are a cost and meetings are time away from patient care. As a result of their hunger for business, the state societies have responded in part by making their suite of member services more turn-key and easy to use than ever before.  They have to do that to hold onto their current membership.   

Fast forward the possible bleak future described above. The most expensive part of a hospital system's work force will no longer look quite so affordable.  Some physicians will have their contracts euphemistically non-renewed, while others will be beat up by less "fixed" and more "performance-based" variable salary arrangements.  Since its reasonable to assume that the health reform's malaise will be nationwide, it's unlikely that these disgruntled docs will be able to simply pull up stakes and get hired in some other comfortably suburban setting in the next county or next state.

They'll think about private practice.

They'll wonder if they can start their own businesses, negotiate their own insurance contracts and do so with less overhead and without being told what to do by clueless administrators.  They'll be wondering about finding a practice manager who knows about coding and billing. They'll think about about cutting out the insurer middleman with a cash-only option. They'll think about dropping of out Medicare. And they'll realize that they will probably need to buy "malpractice" insurance and want a quote.

There are many good companies that offer support services to physician-owned practices. They'll get phone calls too, but not like the state organizations. They'll be the first to know.

They'll be the canary in the mine.

And in case you think the DMCB is being a pessimistic weenie, consider this anecdote: decades ago, physician staff unhappiness with one health system's managed care contracting led a renegade group of docs to call a state medical society for help.  The society obliged and participated in a series of after-hours presentations on physician practice that was attended by almost a third of the staff physicians. The young physician DMCB was in the back of that room.

If the DMCB was in the Obama White House, it would advise that it assign one of its health policy interns to regularly call the execs of a number of state medical societies.  If they describe sharp upticks in membership, that'll be cause for concern.

Image from Wikipedia