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It's not just about us

Saturday, Nov. 8, 2008

2008 AMA Interim Meeting
Marriott Orlando World Center
Orlando, Florida

Nancy H. Nielsen, MD, PhD
President
American Medical Association

Five months ago in Chicago, my dear friend and colleague, Dr. Ron Davis, shared with us all the importance of hope and the joy that he felt along his "journey through the circle of life." By now, you know that Ron has passed away. He was with his cherished wife Nadine and their three sons. On behalf of all of us here assembled, Ron, you are a hero to the profession.
We will miss you terribly, and we will honor you always.

This afternoon, I want to talk about our profession, about a time of change, about focusing on the patients we serve. That was the spirit that infused our work in Washington, D.C., and across the country last spring and summer. Call it the summer of the Medicare meltdown, if you will. I'm thinking of a particular Thursday at the end of June.

On your behalf, I went to the halls of Congress to ask the Senate to do what the House of Representatives had done, that is, keep the promise of Medicare alive for patients and the doctors who treat them. Standing with me at the press conference were seniors and the disabled. Standing with me were physicians and champions for medicine. We all stood together because someone had to stand up for our patients and for those who take care of them. Standing against us were the health plans who believed their work was more valuable than ours.

You know this story. Late that night, the Senate failed to stop the 10.6 percent cut. And then, they went home. It was the 4th of July recess. But, thanks to you, we made sure it was no picnic. We made sure our patients knew exactly who in Congress opposed us. In tens of thousands of phone calls and e-mails, our patients made sure Congress knew their outrage.

We knew that would upset some in Congress, and upset those who wanted to protect health insurance companies. But we believed it was long past time for Congress to do the right thing. Our efforts were the work of every state and specialty society - everyone in this House of Medicine. Those efforts grew into a crescendo roar of doctors, patients and many others who believe that Medicare should protect seniors' access to care.

You know the rest of this story. The Senate voted, in a veto-proof majority, to stand with doctors and patients. And that vote held, despite a presidential veto. We went from a 10.6 percent cut to a 1.1 percent positive update in January. That's a big swing That's real money for every physician in the nation who sees Medicare patients and it's a victory worth celebrating.

We stood together, and that made a huge difference. But, you also know the story really doesn't end there. You know that a bigger specter looms.

This time, the stakes are higher, much higher. We're facing a 21 percent cut in January of 2010. And this time, our nation is in the midst of one the most challenging financial crises in our history.

So, we have only 14 months to work with Congress as they create a new payment formula, only 14 months for them to replace the fatally flawed SGR.

We need to use the next few months to have intensive discussions between our states and specialty societies. We've already convened some of those discussions. Many things are under consideration in Washington. The options include bundled payments - surgeons have had those from some time, but it's new to other specialties. They include the medical home, accountable health organizations, and payment for quality sometimes called "value-based purchasing."

There may be more options. There will certainly be more discussions. And, for us to protect our patients' access to care, we must all continue to work together. So that's an update on Medicare payment and it's a preview of serious discussions and decisions that must be made which will affect us all, both with Medicare and with private payers who often link closely with Medicare fees. There is absolutely an urgency, given the preposterous 21 percent cut that is programmed to occur in 14 months. But there is lots more for us to do than Medicare payment.

There's an old Chinese saying, "What makes one tired is not the high mountain far away, but the sand in one's shoes."

There was a recent worldwide survey of physician attitudes about their work. It will probably not surprise you that North American physicians are the most unhappy in the entire world. It's the constant "sand in our shoes." Each of us could write a book about what makes up that sand. It's lots more than payment issues. It's interference with our ability to make necessary decisions for our patients, fears about unfair medical liability cases, pressure on time spent with patients. We could catalog the grains of sand alphabetically or chronologically. It's all the things that hinder our power to heal, all the things that leave us drained and disheartened.

We need fundamental change in our health care system for ourselves, for our patients, for our nation. Right now annual health care costs exceed $2 trillion. That's 16 percent of our nation's GDP. Costs are estimated to reach $4 trillion and 20 percent of GDP in 10 years.

Right now, annual health care costs are the number one reason for bankruptcy. Right now, Americans get about half the preventive services that are recommended. Right now, we rank 19th among 19 developed countries in mortality that could be helped by health care. That means deaths that might have been prevented by health care. Nineteenth out of 19.

Forty-six million Americans have no health insurance, and another 29 million are underinsured. Those 75 million Americans are delaying or failing to obtain preventive care.

In our nation's sick economy, job losses mean the loss of health insurance. Just yesterday, the government reported that employers cut 240,000 jobs in October alone. And so far in 2008, some 1.2 million jobs have been lost.

We as a nation have to do some serious soul searching. We are the most innovative, resilient, determined, self-reliant and creative nation in the world. Our health care system ought to be the best in the world but currently it is not.

Today we pay twice what other countries with better health outcomes pay. But we rank last or next to last in many health indices. And, that's compared with Australia, Canada, Germany, New Zealand and the United Kingdom.

Now, we can try to protect the status quo. But the status quo is not serving patients well, and doctors are angry and unhappy. It is high time we do something about it and I'm not talking about single-payer. I am, however, talking about comprehensive change. I'm talking about responsible change that builds on the strengths of the current system. Isn't it time to build a bridge to a new and better health system? A system where patients are better served and physicians are happier and more fulfilled in their work?

We need to come together to deal with what is driving our national debate about health care and that is cost. It is no different in other countries. Even before the global financial meltdown, concerns about cost took center stage. And now, concerns about cost will be the all-consuming issue.

We need to be prepared to be constructive rather than defensive in these discussions because our services are 21 percent of health care costs and what we order is a much bigger slice of the pie.

I want to share with you an analogy made famous 40 years ago by scientist Garrett Hardin in his essay, "The Tragedy of the Commons." The allocation of scarce resources is likened to a herd of cattle grazing on a common pasture, the "commons." Each farmer depends on the commons to raise his herd. Each farmer also has an understandable interest in raising more cattle to improve his own livelihood.

The farmer thinks, "Just one more cow won't cause stress on the commons." Yet when each farmer has an extra head of cattle grazing, the commons is depleted, and all who rely on it suffer.

In 1976, Dr. Howard Hiatt, then dean of the Harvard School of Public Health, wrote about the "medical commons" and how it was at risk. The resources that society can devote to health care is the medical commons.

Hiatt's seminal article raised issues that continue to plague us today. Our profession demands that we put the needs of the patient before other concerns. Dr. Hiatt reaffirmed that the "physician must do all that is permitted on behalf of his patient" because "the patient and the physician want no less, and society should settle for no less." The challenge for the medical profession which he posed, and the challenge that remains today, is how to join with others in decisions about the medical commons.

Joining with others that is the key if we are to protect the commons that serve us all. But physicians don't feel part of a commons, do we? We have no assurance that any money saved by actions on our part would go to expanding health care or covering the uninsured or reforming our nation's health care system.

Physicians and patients with insurance are insulated from the real costs of medical care. At the same time, our livelihood is threatened by hostile insurers with clever schemes to delay and deny payment. Our ability to care for patients is threatened by the uncertainty of the annual death dance with Congress over Medicare fees.

And what is the response by our critics? "Oh it's easy," they tell us. "Why don't you just work harder and see more patients?" That sounds a whole lot like putting lipstick on a pig to me.
And it sounds just like the farmer adding one more head of cattle in "The Tragedy of the Commons." Individually, we don't think too much about it. But the size of our country's medical commons right now is 16 percent of GDP, twice what any other country in the world spends.

And maybe that would be fine if we had better health outcomes, but we don't, particularly in dealing with chronic conditions. During this economic downturn, is it really credible to believe that the size of the medical commons will grow? Probably not.

So let's look at that amount as the medical commons. Let's ask what we can do to serve our patients better. Let's consider how to preserve our ability to practice medicine sustainably and protect the viability of the resources we have so that all Americans can obtain the health care they need.

Let's think about what we need to do ourselves. We have to acknowledge that orders we write drive up health care costs. We have to advocate for comparative effectiveness research so it is clear what new drugs and devices and technologies are worth the cost and which are not.

We have to work strenuously in our specialty societies and in the Physician Consortium to develop good measures of appropriate care. We have to be honest enough to recognize that more is not always better; it sometimes even is harmful.

But who should be making the decisions about appropriateness of care, about overuse or misuse? It is our professional responsibility. We will likely not be alone in these decisions, but we can't be left out. And, we should be leading the discussion, because we know the science, and the clinical variations that patients can present.

The nation will be well served by learning from our professionalism. But we have to recognize that when one or another among us is driving a John Deere through the medical commons, mowing it down, we must be willing to step up and do something about it.

A few specialty societies have done this, and we should emulate them. Waste and abuse harm the commons, harm patients, and harm all of us. But these high costs are absolutely not just about us. Administrative costs in the United States are at least twice what they are in other countries that have better health outcomes. Shareholder profits and outrageous CEO salaries scandalize us. A warped medical liability system drives up costs and enriches the wrong people.

So there must be a shared responsibility to protect the medical commons. It's a responsibility that our patients must share as well, because we all use the commons.

Do you remember this pivotal question during one of the presidential debates? "Is health care a right, a privilege or a responsibility?" Whatever our personal convictions on the answer to this question, the broader population seems to be moving fairly rapidly to the view that health care is a right.

But who will pay for this right, if that's the country's decision? Who will define the parameters of this right to health care? Because everyone cannot have everything, and society should not have to provide everything, nor can it afford to do so.

Take education as an example of setting parameters. Our society has decided that K-12 education is a right, but post-secondary education is a privilege and a responsibility.

Defining parameters for health care "rights" and "responsibilities" will require society's honest deliberation and some difficult decisions. For sure we have to define the expectations of personal responsibility. What is fair to expect the individual to do? What should be up to the individual, and what should be society's concerns?

There was a time in our country when thrifty Americans could save for the rainy day of illness and hospitalization. We're not there anymore. Costs of treatment, costs of bio-engineered medications and costs of hospitalization have far outstripped the means of most Americans, even those who work very hard at being responsible.

As we have learned better how to save lives and improve lives, the cost of medical care has skyrocketed. Right now, government funds 48 percent of the health care costs in this country. It is naïve to think that government won't have a role to play in health care financing. So let's not yearn for the impossible past. Let's come together to deal with what's driving the debate in this country as in others--cost.

During the presidential campaign, costs were cited by both candidates as a serious concern, but how they would be controlled was not spelled out. Just today, the Bush Administration has proposed cutting services to Medicaid patients to preserve "fiscal integrity." Here's the choice - cut benefits or control costs. And cutting benefits won't address why costs are rising.

As we participate with the rest of society in this debate, we cannot allow the discussion to descend into ideology and inflammatory labels. If we do, if we allow reason to be trumped by rhetoric, then we will have lost our chance to shape the change, to build the bridge to a better health system.

So I ask you, are we prepared to participate in that societal debate? Because the debate is going to happen. This is not just about doctors. It is not just about us. But physicians and patients will have to live with the outcomes. That's why we have a central role to play.

We all use the commons and that is why we all have to do our part to protect it. Make no mistake, I am not in favor of a single-payer system. I am in favor of a health care system that works better for all of us, patients and physicians.

We're in a time when our country is demanding change. We need change. Let's harness that energy for our patients and ourselves. For sure, this is for us - we have to remove the sand from our shoes. But it is for so much more than us.

As Hillel said so many centuries ago, "If I am not for me, who will be for me? If I am only for me, what am I?"

There are about 900,000 physicians in this country. We are heterogeneous in our backgrounds, in our ideological beliefs, in our political views. The medical profession and our patients are well served by this diversity. Our House of Delegates is well served by our strong opinions and vigorous debates.

We can pass an 18-point plan of "Thou Shalt Nots" and add them to the more than 4500 existing House policies and directives on the nation's health care system, including 570 relating to Medicare alone. But in the current environment, instead of concentrating on what divides us, let's concentrate on what unites us, on those core principles upon which our profession is built.

Because if we go into the coming debate with our arms crossed defiantly across our chest with our options pre-determined, then we may be excluded from the reform debate just as we were excluded 15 years ago. But this time, it will be our fault. This time, we will bear the responsibility.

So let's be firm in our resolve, flexible in our strategies, and grounded in the ethical principles that have been the bedrock of our profession throughout the ages.

We learned them in medical school: beneficence, nonmaleficence (do no harm), autonomy and justice. Being responsible stewards of medicine is an act of justice. It requires us to take a hard look at how we do things, to balance autonomy and justice.

To put it in perspective, let's look at two things that are happening in other countries with health outcomes that are better than ours.

First, dramatic rises in health care costs are forcing them to debate how to sustain their health care systems, and this includes countries with single-payer systems. They are also debating the proper balance between the role of government and the private marketplace.

Sound familiar? We also are struggling with costs and questioning what is the appropriate balance of government and the private sector. But we have an additional burden because so many are uninsured.

We need to return to the core values that brought us to medicine in the first place, to the transcendent themes that have been part of our profession throughout the ages and across multiple cultures, of serving humanity with humility, self-awareness and a commitment to excellence.

Don't think that the current economic crisis will take the spotlight away from health care or that the global financial meltdown will make it impossible for reform to occur. Remember that Great Britain in 1948 crafted its National Health System just after London sustained widespread bombing and destruction.

In many countries, when people are scared, they turn to government for protection. Even though many do not trust Washington politics, they may see it as their only option. There is great concern in our country. We need to help calm those fears. We need to embrace our role as healers in a time of need. We need to help craft a solution that is based on our professional ethics--one that is equitable and just, one that builds on the strengths of our system, addresses current weaknesses, and allows us to regain the joy and simple dignity of caring for our patients.

We must build a bridge to a health care system that serves Americans more justly, and removes the sand from our shoes. I believe we can do this, together. I believe in this land of boundless freedom and opportunity. I believe that we can and should have the best health care system in the world. I believe that we have the talent and dedication to step forward and build that health care system. I believe we have the courage to do it now.

Every day and every night, physicians across this land offer heroic service to individual patients. It's time to bring the best of ourselves to the nation. After 9/11, British Prime Minister Tony Blair said, "The kaleidoscope has been shaken. The pieces are in flux. Soon they will settle again. Before they do, let us re-order this world around us."

As our nation speeds toward change, America's doctors stand ready to help.

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