American Medical Association
2007 Annual Meeting
Conrad Hilton
Chicago, Illinois
William G. Plested III, MD
President
American Medical Association
Recently we have been bombarded by claims that the quality of the care provided by American physicians is so inexcusably low that it is imperative that government
and insurers dictate how we practice. The outrageous lie about poor quality
has been repeated so often that it's like an urban legend, it is starting to
take on a life of it's own. I have even heard public pronouncements by people
who should know better that, like physicians, the AMA doesn't care about quality.
Give me a break.
Let me again patiently review with you a tiny bit of the proud history of the AMA as it relates to quality. The story starts with job one on day one. The AMA was founded in 1847. And at the initial meeting, the problem of the absence of standards for a medical education was the first item of business.
The first official committee to be established was the Committee on Medical Education. The AMA Council on Medical Education continues to this day. Next was the establishment of a code of Medical Ethics. Since that first day, the AMA code has not only survived, but has undergone constant updating and revision. Today, the AMA code of medical ethics stands as the most respected throughout the world. High ethical and educational standards are the essence of quality and of the AMA.
The Journal of the American Medical Association was founded in 1883. Once again, the quest for quality was the driving force. JAMA not only provided the vehicle for the dissemination of peer reviewed medical information, but remains as the most widely used medical journal in the world.
In 1904, the Council on Medical Education undertook the inspection of 160 American medical schools which were rated according to the quality of education provided by each.
The unwavering commitment to and focus upon educational quality led directly to the Flexner report which was published in 1910. This seminal report revolutionized medical education in the United States. Today, the Council is again involved in an in-depth review of medical education with its' Initiative to Transform Medical Education.
In 1905, the AMA established the Council on Pharmacy and Chemistry. This council pioneered the establishment of standards for the manufacture and marketing of drugs. The importance of this initiative was so great that the U.S. government followed the lead of the AMA and the very next year established the U.S. Food and Drug Administration.
The quality of continuing medical education was addressed by the Council in 1954. Fourteen years later, the AMA established the Physician's Recognition Award for physicians who complete approved courses.
The AMA pioneered efforts to improve our environment and adopted a statement on the dangers of air pollution in 1965. Five years later, the federal government again followed the lead of the AMA and established the Environmental Protection Agency.
The AMA established the National Patient Safety Foundation in 1997. Eight years later this effort was followed by landmark patient safety legislation. This patient safety effort led by the AMA is directed solely at the improvement of the quality of care rendered to our patients.
The year 1997 also saw the launch of AMAP, the American Medical Assessment Program. This attempted to measure the quality of care rendered by individual physicians, and led the AMA to convene the Consortium for Performance Improvement. This Consortium provides a forum for all interested physicians to collaborate on the development of practice guidelines that can be used by physicians to ensure that their patients are receiving up to date care.
This program to ensure quality was established long before anyone dreamed up the idea of hijacking professional practice improvement tools by substituting current Pay for Performance schemes.
This brief review highlights just a fraction of the multitude of programs that have been the focus of the AMA. Quality was the driving force behind the formation of the AMA 160 years ago. Quality has been at the forefront of everything we have done in the 160 years since. I am immensely proud of the AMA's unwavering commitment to quality. To those who now suggest that physicians and the AMA don't care about quality, I say simply that I am embarrassed by their ignorance, their naiveté' or their intentional gross distortion of fact.
Today, we have one of the greatest opportunities of any generation of physicians. For a variety of reasons, healthcare system reform is a topic of nationwide concern and will undoubtedly become a driving issue in the 2008 Presidential election.
We must lead this debate. Health system reform has been studied by the AMA for many years. We have strong policy and recommending reasonable reform. The most important feature of the AMA proposal is that it builds upon the strengths and corrects the weaknesses of our current system.
There is an abundant and rapidly growing body of evidence from around the world that the answer is neither an exclusively private nor public system. The only workable solution is a combination of both. This is especially true in the United States.
Let's review the basic features of the AMA plan for reform:
First, we feel that insurance must be owned by the individual patient. Ownership must be separated from payment. Those who work for an employer who provides insurance, or who can afford to purchase coverage themselves , must do so in a strengthened private insurance system
We are fortunate to live in a country where people help those who for whatever reason are unable to provide for themselves. Government can assume the cost of individual private insurance policies for these Americans. Individual ownership will guarantee portability and guaranteed renew -ability will reassure millions of Americans that their insurance coverage will not be lost.
Our second imperative is that the tax treatment of dollars spent for the purchase of health care insurance must be comparable regardless of who pays. The AMA's suggestion of using tax credits provides an excellent solution. We believe that tax credits should be inversely related to income, and should be provided on a sliding scale to a realistic level of 500 percent of the federal poverty level.
Finally, by making the tax credit advanceable, it becomes a voucher to be used by those in need - only for the purchase of health insurance. Insurance reforms are the next pillar of the AMA proposal. Large pools will facilitate choice, rate competition, and risk equalization. Insured individuals need to be protected by guaranteed renew-ability, and benefit mandates must be minimized. Insurers should be able to market their policies on a nationwide basis.
Physicians must insist that true health system reform include the replacement of the tort system of medical liability. At this point, some may think that I am not going to say anything about the Profession of Medicine. Fear not. In my last formal talk to you, I will not pass up this opportunity to discuss what I feel to be the most important issue of our generation.
Now, some believe that I have spent too much time talking about pay for performance, and feel that I have a special vendetta against P4P. Actually, nothing could be further from the truth. For me P4P has been a gift. I could never have dreamed up a scheme that so vividly demonstrates the difference between a program designed by a profession, driven by quality, guided by ethics, and one concocted by others driven by cost control and guided by a dizzying array of rules.
Our experience with SGR has shown that when technology and demography combine to increase costs, government's knee-jerk response is to automatically reduce payments to physicians.
The same thing will happen with P4P. When technology and demography result in increased costs, P4P programs will limit in the treatment allowed or limit those eligible for treatment, or a combination of both.
P4P programs mandated by third parties set ceilings upon the treatment allowed, and increases in costs will automatically lower bar. In stark contrast, the professional approach exemplified by the Consortium is to develop guidelines that set a minimum standard of acceptable practice. From this baseline, physicians are encouraged to and do constantly strive to improve upon those minimums. This inherently raises the quality bar.
Ethics will always trump rules.
With the technology that is available today, the question is no longer whether our daily practices can be monitored. Whether they should be monitored. Or whether they will be monitored. The answer to all is a resounding, "Yes."
The real question for us is WHO will do the monitoring. I feel strongly that this is a professional imperative - one that can only be accomplished by our specialty societies. Only they have the expertise, the experience and the sensitivity to do this critical job fairly and ethically.
The one thing that is cherished by all Americans is freedom - the foundational concept of our nation. Freedom is a precious gift given to all of our citizens. We enjoy many freedoms and they cannot be taken away from us. However, every individual has the ability to give away those freedoms.
To say that a physician is substandard, if not factual, it is slander. To print such an assertion is libel. But today insurers are publishing lists of physicians that in one way or another identify many as "bad" doctors. This can only be done if the physician signs away his or her rights. Physician reimbursement is routinely adjusted at the whim of the insurer.
Many demand blind acceptance of P4P programs that are not clearly defined. All
of these actions violate precious rights. These rights are instantly negated
with the stroke of a pen when the physician signs a non-negotiable contract.
Physicians repeatedly tell me that the insurers have such a monopolistic hold
upon their patients that they have no choice but to sign their unfair contracts.
This is the thinking and behavior contribute to the position in which we find ourselves today. And it is the response that will destroy our profession. Today we are facing the greatest shortage of physicians in history. Physicians are our nation's most valuable resource, and they must be protected. This can only be done by preserving the profession that is governed by ethics, and that constantly strives to raise the bar.
The fact that is obvious to everyone but ourselves is that we really don't need them, but they desperately need us. We have been the brunt of all of these attempts to control what we do because they know that our patients trust us not them. This only changes when we betray that trust as we did when we fell for the managed care scheme. Once patients learned that we were telling them what was best for the insurer's bottom lines, not what was best for them, managed care collapsed overnight.
By now most of you know that I am fascinated by the history of our country. Especially the untold numbers of brave men and women whose sacrifices ensured the freedoms that we enjoy today. Not long ago, Tom Brokaw wrote a wonderful book that he entitled "The Greatest Generation." The spirit of this generation was epitomized by two outstanding leaders.
The first was a president who from a wheelchair, and with an oversized cigarette holder clasped at a jaunty angle in his teeth, said: "The only thing we have to fear is fear itself - nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance."
The second was a prime minister who was a pudgy, cigar smoking curmudgeon. Sixty-seven years ago this month he said: "We shall defend our island, whatever the cost may be. We shall fight on the beaches, we shall fight in the fields and in the streets, we shall fight in the hills. We shall never surrender."
These leaders captured the spirit of the greatest generation, but, in reality, the greatest generation was hundreds, thousands, and millions of ordinary people who at a critical time in our history did extraordinary things.
Recently, I was approached by a physician with a very emotional appeal. He said, "Bill, I'm a solo practitioner. I'm facing all these problems. I'm scared. I'm afraid for the future of my practice, my career, and my profession. I'm just one person. I'm all alone. All alone."
Well, that really affected me. I believe that doctor was saying what we all believe, what we all feel, at one time or another. But, I have a suggestion for him, for you and for me.
And this is it. I'm going to ask you to indulge me for a few seconds. I would ask everybody to stand up and take the hands of those on either side of you. Now, feel those hands in yours. Feel that network of hands that goes all around this room. And know with absolute certainty that you are not alone.
Those magic words Gary Epstein gave us are not just a slogan or a mindless platitude. That those four words are real. He said, "Together we are stronger." You can touch it and feel it and know it, that that truth and our profession quite literally are in your hands.
Last month, I was a guest at the annual meeting of the German Medical Association. Physicians in Germany like physicians around the world are facing the same problems that confront us. However, in Germany their government is being even more aggressive than ours.
Starting January 1, 2008, DRG's for Physicians will be instituted. Federal law will mandate P4P-type treatment protocols developed by government to control costs. Can anyone question where P4P leads?
The president of the German Medical Association delivered a passionate appeal to German physicians to rise up and protect their profession. He ended with this poignant observation. He earnestly pointed out that all the physicians of Germany want is freedom.
Freedom to practice medicine according to the ethics of their profession. He
said, "The sad reality of today is that if physicians want freedom, they
must become freedom fighters."
.
I have covered a lot of ground in a very short period of time and there are
5 critical points that I want you to remember.
One: Conviction. If anyone challenges our commitment to quality, do not be cowed. Stand tall with your head held high. We have a long, proud history of commitment to quality that is without equal.
Two: Communication. We are on the threshold of a marvelous opportunity to shape the future of health care delivery in our country. The AMA has an outstanding plan - and it is incumbent upon each and every one of us to communicate this plan to our patients and to see that it becomes a reality.
Three: Control. Practice monitoring and measurement is a professional imperative that must be assumed by our specialty societies. If your society is not doing this today you must demand change. The alternative is to surrender this key function to those who will simply mandate mediocrity.
Four: Courage. I shall echo the words of our German colleague who reminded us of the Lessons taught to the world by generations of brave Americans: Freedom is not free. It is won by freedom fighters.
Five: Cooperation. To prevail will demand the extraordinary efforts of ordinary physicians. But this does not mean that any individual is alone.
What is being asked of us is daunting. However I have absolute faith in our ability to do what needs to be done. The reason for my optimism is the foundational basis of the patient physician relationship: trust.
I know that you will succeed simply because you are physicians. Your patients trust you. And I trust you.
Let me summarize by telling you a story that is not made up but personal experience. Years ago, as a young vascular surgeon, I was often called to see patients for whom the only possible treatment was a major leg amputation. I would carefully review with the patient and his or her family all the reasons, all the medical logic, all the scientific evidence that made amputation the rational, correct, unmistakably right thing to do.
Yet, in spite of my best efforts, this discussion invariably became highly emotional, and very difficult for both my patient and myself. After long hours of trying to better deal with this difficult situation, I finally came to a new understanding. It became clear to me that I was talking about present reality, but the patient was consumed by memories. Memories of joyous times of running, jumping, hiking, and dancing on strong, young, healthy legs
Clearly the crux of our dilemma was that no one can live only with memories. Memories are precious and remain unchanged and can bring joy forever. However, we all must all face up to the realities of today and move on.
Today, American Physicians are in the same predicament that my patients with gangrene were facing. We have extremely fond memories of the ways things were. But all too many of us are married to those memories and trying to pretend that we are still living in those past days when there was no SGR, no medical liability disaster, no unfair "take it or leave it" contracts, no insurance executives making medical decisions, no P4P schemes, no mindless bureaucracies.
But those days are past. And, for our own good, we have got to lock away and cherish those memories. We must face the fact that what we loved and lived for is gone.
Wishing will not bring back the past, but that does not mean that we cannot make today's reality much, much better. Now, 231 one years ago, at this very time of year, a group of proud and fiercely independent people - got together and said, "Enough." They conceived of a nation based upon a single, foundational principle. That principle was freedom. That idea was mocked, scorned, belittled and dismissed by rulers around the world.
But, it captured the imagination of people like no idea before or since. Our forefathers boldly proclaimed this radical new idea with a declaration, a Declaration of Independence.
We must remember that even in those critical days, there were those who chose not to join the fight, feeling they would be better off on their knees before the king. But those who chose to fight, won that independence as the world watched.
Today, throughout the world, the Profession of Medicine has been subjected to an unrelenting assault that threatens the future of all physicians. If we do not stand up for the prerogatives of our profession, it will be generations of our patients who will suffer.
The time has come for the Physicians of America to stand up to the tyranny that has been visited upon us and to issue our own Declaration of the Independence, the independence of our profession.
Some say that taking back the profession means to say, "Hell, no, we won't go." To demand privileges without accepting responsibility.
The truth is just the opposite. Taking back the profession really means that, by assuming the responsibilities of our profession, we not only do a better job but we win the freedom to practice guided by ethics and the interest of the patient.
That is my Declaration of Independence for Medicine.
That is my extraordinary challenge for ordinary physicians.
That is the freedom that can be won if we are willing to fight.
That is the reality of today, not the memories of the past.
That is what the word "profession" means.
It means freedom. This is my challenge to you. And this is the legacy we can leave for those who follow.
Now is the time. This is the place. Carpe diem. Seize the day.
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