COALITION STATEMENT: Patients Must Be At The Center of Health System Reform

June 26, 2009

AEI Speech June 26, 2009
Donald J. Palmisano, MD, JD, FACS


Thank you for inviting me to speak here today.

In the brief time I have today, I wish to cover three topics:

1-What is the Coalition to Protect Patients’ Rights and why I became the spokesperson.

2- Several of the key issues in the Health System Reform debate, namely the “public plan”, private contracting, the enormous cost to the system of the broken medical liability system, and finally, the importance of correct statistics.

3- A way to put the patient and physician in control with individual responsibility following a proven method to reduce costs in other fields.

During the discussion, we can expand on any of the topics not covered or explore these in more depth.

The Coalition

I am the spokesperson for the Coalition because it believes in the trusted patient-physician relationship without government interference in the care of patients.

The Coalition to Protect Patients’ Rights is a nonpartisan, grassroots coalition of patients, healthcare professionals, advocacy groups, and engaged citizens who are concerned about the current healthcare debate going on in Washington.

Agreeing that more must be done to reign in healthcare costs and provide affordable access to healthcare for uninsured Americans, the Coalition believes that the private sector can and must be involved in healthcare reform.  Recognizing that each of us are different and have different healthcare needs, we support choice and options in our healthcare – not a one-size fits all approach that simply provides everyone with the same level of substandard care.  The Coalition also believes that all medical decisions must be left to the patient and doctor.  We believe that allowing a government bureaucrat to exercise any authority over personal healthcare decisions would lead to diminished quality of life for all Americans.

Coalition members will work together to support reforms that strengthen the healthcare sector for all Americans, allows patients to keep their doctors and chose their health coverage, and will support new medical innovation and discovery.

The Coalition to Protect Patients’ Rights will work with reform-minded policymakers, third party groups and concerned citizens to aggressively advocate for a vision of health system reform that is an alternative to the heavy-handed government intervention model being advocated by the majority in Congress.
To learn more, visit the Coalition Website at: www.protectpatientsrights.org/

All of this is consistent with my advocacy in medicine for decades.

Correct Diagnosis, Danger of Wrong Treatment

Now, we are engaged in a great struggle concerning the future of medical care in this land of liberty called America.  President Obama and the Congress have a grave responsibility.  They made the correct diagnosis when they said the current system needs fixing.  But it would be a disaster to give the wrong treatment.  Government intervention brought about most of the current problems we face with strangling regulations, price-fixing, loss of the right to privately contract with patients without penalty, failure to address medical liability reform, the disconnection of the patient from responsibility for the cost of medical care when covered by insurance of most types, and yes, the monopsony power of some health insurers in certain communities.

Current Problems
-Uninsured
-Cost of medical care

Solutions used by government over the decades of Medicare and Medicaid increase the uninsured, escalate medical care costs, and drive the public government programs into insolvency.  To do more of the same will lead to loss of access to medical care.  You can’t force a bad treatment using intimidation and ad hominem attacks against the only persons qualified to give medical care, the physicians.  Don’t destroy the healers!   When people give a “disconfirming opinion”, stop calling them “fear mongers”.  To those in the administration and in Congress who do such acts, get out of your protected bubbles, stop pandering to voter blocs and acting like the “The Opportunists”, the souls condemned in the Vestibule of Hell in Dante’s immortal poem The Divine Comedy.

And remember what the famous scientist Louis Pasteur said when Washington comes up with grand untested schemes:

“Imagination should give wings to our thoughts, but we always need decisive experimental proof . . .”

Don’t let Washington frame the issue!

Let’s look at the way ABC framed the issue when President Obama was the TV Special this past Wednesday night:

The program was led off by ABC's medical editor, Dr. Tim Johnson, who framed the issues as follows as shown by these excerpts:

“First, Access and Choice:  The President constantly stresses that, if you like what you have, you can keep it.  But, he also wants to offer more choice and competition with a one-stop shopping list of approved, private insurance plans through a so-called "Health Insurance Exchange."  So far, he has also insisted that a Public Option be one of the choices.  It has sometime been described as "Medicare-like," meaning that the government would be involved with the financing, but patients would be able to choose their own doctors and hospitals.  He says this Public Option would keep pressure on private insurance to hold down costs.  Critics say Government's advantages - easy funding, huge bargaining power - would eventually put private insurers out-of-business, which could affect your current coverage.”
 
“Second, Effective Treatment:  The President agrees with experts who say that about 1/3 of what we now spend on health care is unnecessary.  He says, we reward doctors and hospitals the wrong way - paying for simply doing more tests and procedures, rather than paying for good outcomes.”
 
And, finally, Cost Control:  The President insists that increasing coverage without controlling costs is a formula for economic disaster.  That will be a tough job given that estimates for reform now run between 1 and 2 trillion dollars over 10 years.”

Are we to believe that a “public plan” will be a fair competitor?  Unlimited taxpayer funding and the “public plan” makes the rules and can change the rules at any time!

Why not use the following method to fix access and choice.  Allow everybody to have individual ownership of the policies. Let the policies be funded by defined contributions. Also, allow tax credits to purchase insurance.  Let patients chose the company that serves them best.  Find a non-government controlled method to get bargaining power and eliminate the escalation in cost of a policy because of pre-existing conditions.   For effective treatment, make fees and clinical information about treatment options available to all citizens.

In this debate on health system reform, it is critical to get valid statistics and throw out studies that have bias such as errors in sampling or analysis.  Compare apples to apples!

Let’s remember George Orwell’s comments,
In a time of universal deceit, telling the truth becomes a revolutionary act.

Let’s have some revolutionaries who present unbiased information.

Books to Read

As I said a week ago Thursday on the Mark Reardon Show on KMOX in St. Louis, it is especially important now to read three books that are relevant to our current debate on finances and health system reform:

Economics in One Lesson by Henry Hazlitt
    Hazlitt states the lesson: “…the whole of economics can be reduced to a single lesson, and that lesson can be reduced to a single sentence.
 The art of economics consists in looking not merely at the immediate but at the longer effects of any act or policy; it consists in tracing the consequences of that policy not merely for one group but for all groups.”
    
The Road to Serfdom by Friedrich A. von Hayek (Awarded the 1974 Nobel Prize in Economics)

Animal Farm by George Orwell
A cautionary tale of how promises can turn into dystopia.

Congress and Promises Made and Broken

Physicians remember very well a promise of Congress when Medicare was passed.  Section 1801 of the Medicare law states “Prohibition Against Any Federal Interference” in the practice of Medicine.  This is just one example of why physicians have difficulty with promises of Congress.

Section 1801 certainly was broken with price-fixing, failed trials of pre-admission certification forcing physicians to talk to a clerk looking at a checklist and overruling the physicians clinical judgment about a sick patient in the physician’s office.  I testified previously in Congress about one of those examples concerning a patient of mine.  The patient was having transient blindness in the right eye and transient paralysis of the left arm on two occasions within one hour.  My exam discovered a murmur in his right neck artery, the carotid, which brings blood to the brain.  He needed emergency admission. The last attack occurred in my presence.  Because he recovered his vision and the use of his arm at the time of the phone call for permission, the clerk turned down the admission stating the form said that if the patient had recovered, the patient could be evaluated as an outpatient.  I continued with the admission and had to go through three individuals before I got a doctor who finally agreed to the admission.  I did an angiogram and confirmed the ulcerated plaque in the carotid artery and operated the same day.  At operation, half of a clot reminded in the pothole of the plaque.  The clot and plaque were removed and the patient recovered without further difficulty in the years after the operation.

Imagine if Congressional salaries were pegged to the Sustainable Growth Rate Formula and the Gross Domestic Product as doctors are now under Medicare?  Or, if members of Congress got Medicaid as their medical plan with its price-fixed formulas?  Some say the best way to get rid of a bad system is to have it apply equally to everyone. And keep in mind, the physicians are not employed by the government and have to follow more regulations than the tax code and get reimbursed for less than the cost of delivering the service.  

What about innovation and discovery?  No time for that in this system.

Liberty and Free Enterprise

What happened to the hallmark of the free enterprise system, the right to privately contract?  Is not liberty the absence of coercion?  Why are physicians kicked out of Medicare for two years if they privately contract with Medicare patients? Why are the patients punished by not being able to receive any Medicare payment because they agreed to pay the physician more than Medicare allows.  They can’t even receive the money set by Medicare for that treatment for a “participating physician”.  That is an example of government coercion and penalty.  And don’t forget, under former Inspector General Richard Kusserow’s fraud alert, physicians break the law if they tell patients not to worry about the co-pay.  That by law is fraud unless the physician does means testing on the patient.

It is important not to let the Congress frame the debate saying it has the right to price-fix physician fees.  The correct framing of the debate is Congress has a duty to be prudent with expenditures and it can decide what it will pay for any service.  But it doesn’t have the right to state that physicians cannot balance-bill for the true cost of the service.  And to say that physicians signed a contract is not appropriate as the contract is one of adhesion because of unequal bargaining power and coercion.

Price-fixing throughout history leads to rationing of the service or product.  More doctors will stop seeing Medicare and Medicaid patients.  The patient-physician relationship will erode.

Are we to think the future unproven plans of Congress will be any different with expansion into a public plan and refusal to convert current Medicare into a defined contribution or voucher program with an array of choices of private insurance?

1976 Testimony

In May of 1976, I testified on behalf of the Orleans Parish Medical Society in New Orleans at a field hearing of the Subcommittee on Health of the Committee On Ways and Means of the U.S. House of Representatives.  The chairman was Representative Dan Rostenkowski of Illinois.  At that time I stated,

“We are opposed to any national health insurance scheme.  So that my message may be clear, I repeat, we are opposed to any form of socialized medicine.
We oppose a collectivist, socialistic medical system and advocate the
Free Enterprise American system for many reasons.
National health insurance results in rationed care of a lower quality.
National health insurance costs more.
Remember, you get nothing for nothing.
The public always pays in the form of increased taxes.
The trusted doctor-patient relationship can only exist in a system where patients and doctors can have freedom of choice through the selection of each other.”

At the end of my testimony I quoted Dr. Phillip Sandblom, formerly of Sweden, who wrote an article in the Bulletin of the American College of Surgeons entitled, “The Tragic Development of Socialized Medicine in Sweden”.  He said, “…in order to put pressure on doctors, doctors who try to practice private medicine, the Government punished their patients.”  He further stated, “The introduction of these various regulatory measures has resulted in an enormous growth in the numbers of medical administrators at all levels of incompetence. Medical care is systematically made less effective because of the administrators’ idea that a hospital can be handled like a factory.

Whereas humanity, sympathy, and a feeling of personal responsibility used to be the main inducements of a good performance, there is now a spreading bureaucracy that hampers initiative and kills the joy of working.”

Here is an except from the ending of my testimony:

“I bring to the attention of those who have yet to treat a sick patient, but who desire to “tinker with our medical system: the works of a son of a physician, written in the year 335 B.C.

We observe that persons of experience are actually more successful than those who possess theory without experience.
…
Hence, if one possesses the theory without the experience and is acquainted with the universal concept, but not with the individual facts contained under it, he will often go wrong in his treatment; for what has to be treated is the individual.

The physician’s son’s name? Aristotle.”

I ended the testimony with the following:

“If the cost of medical care is one of the main reasons for having hearings, then we should, perhaps, ask the Representatives and Senators when you get back to Washington to consider ways to make all people equal under the system, as far as the abuse of the present law regarding malpractice suits where people can file frivolous unmeritorious suits, and even when it’s proven to be frivolous and unmeritorious, the doctor cannot countersuit, he cannot win unless he can prove malice.

This one fact alone is driving the cost of hospital beds up $10 per day or more in our city, and it’s causing insurance to rise in some places as high as $36,000 per doctor.”

Over years Congress did not pass medical liability reform despite the majority in the House and the Senate favoring it as well as the American public in 2003.  A filibuster in the Senate on July 9, 2009 killed the bill that passed the House.

Of course, when I was president of AMA during 2003-2004 and traveled the nation for 300 days during that year, I saw the effects of the broken medical liability system with loss of access to care and rates as high as $249,000 per obstetricians and neurosurgeons in some communities such as Dade and Broward Counties in Florida.  

The Need to Reach Conclusions Based on Correct Data

Peter Orszag, the White House Budget Director, said in Senate testimony that caps on non-economic damages don’t work. So did Dr. Ezekiel Emanuel, advisor to President Obama, in his book, Guaranteed Healthcare.  He says caps are not effective. Let them all go to Texas and see the results when the legislature changed the law and a constitutional amendment gave approval to caps in 2003.  Dramatic drop in rates in the first year and so many doctors moving to Texas in response that the medical licensing board had to hire additional staff.

For Mr. Orszag and Dr. Emanuel to state that caps don’t work causes concern about other conclusions being reached by advisors to Congress and the President.  How valid is the information being given to the policy makers?  President Obama told the AMA as I sat in the audience that he understood doctors didn’t like people looking over their shoulders.  He gave the impression he felt the doctors’ pain and stress.  But then he said he was against caps.  OK, but what specifically is he for?  Following guidelines?  And then what?  A giant missed opportunity for President Obama.  If he had said he was for an administrative system or health courts and then deliver details, including plans for trial demonstration projects in states without effective caps, he would not, in my opinion, have gotten any boos in that part of the presentation.  Time to end the generalities.  Time to get specific and use proven performers.  If innovative, do trials in volunteer states.  Don’t blanket the USA with unproven treatments.

So when the majority of physicians hear the siren songs from Congress and the Administration, they remember what has happened in other countries and in our USA.

As I said to The Hill in a recent interview about Congress,
"They promise you Utopia, but frequently they give you Dystopia.”

More Recent Tales of Government Medicine in Other Countries
Finally, let’s compare what I heard in Great Britain at the Annual Meeting of the British Medical Association in 2003 with what I quoted in the 1976 testimony from the Swedish experience.  Familiar ring?

During my year as president of the AMA, I was able to visit and see firsthand the success and failures of other health-care systems. I recall meeting with the chairman of the British Medical Association in June 2003, when he characterized his nation's single-payer health-care system as "the stifling of innovation by excessive, intrusive audit ... the shackling of doctors by prescribing guidelines, referral guidelines and protocols ... the suffocation of professional responsibility by target-setting and production line values that leave little room for the professional judgment of individual doctors or the needs of individual patients."

So in this debate, let’s stop using the enemies of effective communication: vagueness, generalities, and jargon.  Let’s get specific, respect the rights of all Americans who live in this great Country, and used proven performers rather than pipe dreams of fantasy.  See my writings in the Journal of the American Medical Association for more details.

Finally, do not forget what “The Future” statue outside the Archives Building in Washington, DC, has inscribed on it, "What is Past is Prologue."  Past actions of Congress are not reassuring.


Donald J. Palmisano, MD, JD
DJP@intrepidresources.com