Address of the AMA President
Saturday, Nov. 6, 2010
AMA Interim Meeting
San Diego, California
Cecil B. Wilson, MD
American Medical Association
Mister Speaker, members of the Board of Trustees, delegates to this House, friends:
Five months ago, I stood before you and asked for a unity of purpose – a concerted effort – to move medicine forward.
I offered prescriptions for what ails America’s health care system.
And I shared stories that, to me, suggest that the pastime of sailing in some ways mirrors life itself.
That organized medicine has encountered rough seas in recent years is no secret. The debate over health system reform is just one case in point. Not every physician agreed with the course taken by the AMA, or our destination.
The AMA is sensitive to those differences of opinion. They were honest, sincere, and often rooted in personal experience, philosophy or circumstance.
But so, too, were the motives of those who supported reform.
Those who sought to move the process forward. Who were willing to achieve some goals – instead of none. Who found a place at the table – instead of out in the cold.
Seeing the boats in the harbor here in San Diego, I am reminded that at my inaugural in June, I told a couple of stories of my adventures – or misadventures – sailing in my home state of Florida. And how they might illustrate a larger truth.
These mishaps begged the question: “Did I tell you the whole crew was doctors?”
Let me hasten to add that not all my sailing experiences included such mishaps – Betty Jane told me to say that.
But today, I have another one.
We sailed south from Ft. Lauderdale on a summer morning bound for the Yucatan peninsula of Mexico.
By nightfall we were off the west coast of Cuba. This was some years ago when Cuban authorities were known to seize boats that came too close to their shores.
So we closely monitored Cuban radio for signs of danger.
So closely – that we were surprised by an ocean-going tugboat bearing down on our path. A collision was imminent.
We frantically started to alter course to pass behind the tug.
And then – we saw it had three white lights mounted vertically on its aft mast.
We stared blankly until one of us remembered that the lights meant the tug was towing a barge on a cable longer than 600 feet – for you sports enthusiasts, that’s equal to two football fields.
Because of the length of the cable, the barge was invisible in the darkness.
If we stayed our course – we would be sliced in half by a steel towing cable – or smashed to bits by the barge.
Imagine the jolt of adrenalin as we scrambled to reverse course – and get out of harm’s way.
Desperately, we jibbed. But in our abject terror, we forgot to release the boom that had been tied to a deck cleat to better catch the wind in the mainsail.
As a result, the boom swept across the deck with great force, yanking out the cleat, leaving behind a hole that would swallow water anytime a wave broke across the bow. Which was frequently.
By the way: Did I say the whole crew was doctors?
Somehow, we managed to avoid the tug, the steel cable and the giant barge.
We patched the hole with masking tape and two days later limped into the harbor of Isle de Mujeres in the Yucatan.
After this brush with mortality, some might think our trip would have disintegrated into resentments and second guessing the captain. The course he had plotted, and the actions he’d taken – or hadn’t taken.
But out on the ocean, there’s a realization that we were all in the boat together. No one jumped overboard, without life jacket or lifeboat, into the shark-infested waters.
Had we acted solely as individuals, we would have triggered a shipwreck. Acting together, we avoided one – and lived to tell the tale. And to sail again.
The writer Richard Bode, who gave up the rat race in Manhattan and moved to Miramar, here on the California coast, described the adventure of sailing – and how it relates to life – this way, in his 1993 best-seller, “First You Have to Row a Little Boat.”
He wrote: “Without a doubt, navigating the wind and the water exposes our limitations and helps us to develop an acute awareness of the environment; it also tells us what we can and cannot control if we are to reach our destination.”
And he said this: “Sometimes the changes occur so fast we lose our bearings... We lack a sense of the appropriate because we haven't taken the time to figure out where we are."
In my travels these last five months as AMA president, I’ve noticed the truth in these words.
Even now, in many parts of the country, seven months after passage of the Affordable Care Act, there persists a litany of myth and distortion about the law and what it means to our country. It is a deafening cacophony of partisanship and discord.
And what’s missing is a sense of proportion – of the appropriate.
The AMA is an easy target for potshots and falsehoods. They create headlines, but not leadership toward moving medicine forward to tackle the problems in our system.
John F. Kennedy said: “The great enemy of the truth is very often not the lie – deliberate, contrived and dishonest – but the myth, persistent, persuasive and unrealistic. Belief in myths allows the comfort of opinion without the discomfort of thought.”
But I believe a different, encouraging picture is emerging among large segments of the medical community.
Since September, I’ve visited six state medical associations and three national specialty societies. There, I have found physician members and their leaders are focused on how to help physicians deal with the realities of the new law.
Instead of pointing fingers and finding fault, they are working to enable physicians to be leaders in new delivery systems such as accountable care organizations and the patient-centered medical home.
An emerging majority in our profession is seeking to make reform effective – to make it better – and to make it work for patients and physicians.
I hope what we do at this meeting will reflect that sentiment – that we have an opportunity to move medicine forward. We need to seize it.
In that effort we are called upon to:
1. Energize the profession – to stay the course.
2. Engage the public – to let their voices be heard.
3. Educate the government – to do the right thing.
No issue requires that we do all three more than the repeal of the flawed SGR formula that determines physician reimbursement under Medicare.
A massive cut in Medicare payments has been postponed until Dec. 1, but without further Congressional action, physicians face a cut of 25 percent by January. Congress not only needs to stop it, but they need to do it in a responsible manner – for a change.
The nonchalant way they dealt with these cuts in the past year played havoc on physicians’ practices.
Some physicians had to seek loans to meet payroll and keep their doors open. Many deferred their own compensation. All because Congress dithered and delayed.
Unfortunately, permanent repeal of the SGR between now and the end of the year is unlikely.
Congress has been more focused on the November elections than facing their responsibility.
Now, with those elections history, we expect the coming cuts to be addressed during a short, cautious and contentious lame duck session with many high-profile issues competing for time on the agenda.
History tells us that this won’t produce the kind of sweeping reform we need – and that it won’t be a pretty sight.
The political reality is that we will pursue this goal in a series of steps.
First: Stabilize physician payments at least through 2011.
Second: Work with the new Congress to develop payment system improvements for the long term.
The priority is to eliminate the SGR. Toss it overboard. Drown that sucker.
To underscore this point, the AMA is taking out a full-page ad in Monday’s USA Today to urge Congress to act – and to encourage grassroots action to drive it home. You can see the ad on the big screen.
Now, finding a long-term solution is important. But it doesn’t address acute pressures physicians face right now.
Medicare pays only half the direct costs imposed on physician practices — and the first wave of baby boomers entering the program in 2011 will swamp it.
Here in California, looming cuts would remove 2.2 billion dollars for the care of the elderly and disabled – directly affecting the state’s five million Medicare patients and 850 thousand TRICARE patients in military families. This is playing out across the country.
Ultimately, there’s no guarantee that Congress will act – or if they do, that it won’t disrupt physician practices.
And to be blunt, the steadily mounting cuts threatened by the current payment formula are so deep that many physicians may not find it feasible to see Medicare patients.
Nearly one in three primary care physicians and nearly one in five of all physicians say they have already been forced to limit Medicare patients in their practice.
Why? The continuing threat of future cuts – and the unavoidable fact that Medicare payment rates were already too low.
The AMA has devised a kit to help physicians make informed decisions about their Medicare participation. About what to do if you’re forced to make changes – that includes opting out. This information’s at our website, ama-assn.org.
One way we expect to make the system better is to change the way physicians conduct business under Medicare.
At the request of this House, the AMA has developed draft legislation to give Medicare patients and their physicians the right to privately contract without penalty.
Currently, physicians can negotiate a separate fee only by formally “opting out” of Medicare, which removes the physician from the program for two years.
And the patient has to sign a statement acknowledging that he or she cannot be reimbursed by the government. That needs to change.
Instead, we seek a new patient-centered payment category envisioned by our Medicare Patient Empowerment Act that will allow seniors to use their Medicare benefit fully for the health care they need.
It states that physicians, patient-by-patient, could contract privately for a fee different from the Medicare payment schedule. The patient would retain the right to be reimbursed by Medicare for the allowable fee.
This is an important issue, and we need to approach it in a strategic, well-considered manner.
We are engaged in a four-step process:
One: Public opinion research and message testing.
Two: Using tested messages in a grassroots effort – that involves both physicians and patients – to educate Congress.
Three: Secure a formal bill introduction.
And Four: Enlist Congressional co-sponsors.
We need active participation throughout the Federation for all these activities. We aren’t likely to see hospitals, health plans, unions, PhrMA, the device industry and other stakeholder groups help us promote our cause.
We are counting on all of you to help us achieve this goal.
Independent Payment Advisory Board
Another element of reform has the potential to create even more mischief – that’s the so-called Independent Payment Advisory Board.
This board would propose Medicare cuts if a predetermined “target growth rate” is exceeded.
The last thing doctors need is additional cuts triggered by a new expenditure target. We all know how the SGR turned out.
We will continue to push for changes that ensure the scope and authority of this Payment Board are clear and that physicians are not subject to double jeopardy.
New Delivery Reforms
The AMA is educating physicians about other provisions within the new law.
For instance, delivery mechanisms such as accountable care organizations (ACOs) and the medical home.
The AMA has a two-track strategy.
First, educate physicians about how they can take the lead through a program we call Payment Pathways, and also through a series of seminars.
For updates, go to the AMA website and look for “payment pathways.”
Second: The AMA is working to influence CMS rules on accountable care organizations and exploring how the new Center for Medicare and Medicaid Innovations can help physicians adopt payment and delivery models. Grants to help with start-up costs is one example.
In short: Physicians have to prepare themselves immediately to be leaders – and not pawns.
Delivery Reforms: The Bottom Line
So this new world of delivery reform offers opportunities for physicians – but also challenges and dangers.
Most office-based physicians in the United States – 78 percent – work in practices with nine physicians or less. Most are in solo practice.
For this system to work, physicians must be able to lead. That means rules that allow them to participate, not restrictions that tie their hands.
But existing rules make forming an ACO difficult for physicians in small practices.
The AMA is calling for the establishment of waivers and safe harbors for physicians, and reforms to allow physicians in all practices and regions to participate.
And speaking of safe harbors, the AMA continues to work toward establishing effective medical liability reform – nationwide.
This would help trim the estimated $70-$126 billion spent on defensive medicine aimed at reducing the threat of lawsuits.
To stem this waste of resources, the AMA is supportive of evaluating alternatives – including safe harbors, early offer programs and medical courts.
Such programs may ease the liability burden – if effective. We’ll monitor the progress as these ideas are tested.
But to find the best example of tort reform, one only has to look outside this room.
For 35 years, California has had the gold standard for medical liability reforms that achieve justice – and fairness – for every party involved.
That’s why insurance costs here have been far more stable than elsewhere. The reason: caps on non-economic damages. They’ve worked here. They would work everywhere else.
I’ve spoken today about what the immediate future may hold for organized medicine.
But being here in California – in particular, San Diego, a place with a rich history and tradition tied to the U.S. Navy – has made me reflect on my own, personal past.
Part of my military service was spent at the US Naval Hospital – Balboa. Just a mile or two from this room.
There, I treated many casualties of conflicts in Southeast Asia. But one group of patients stands out in particular. Let me tell you their story.
This was long before the enactment of HIPAA, but I will note that what I’ll describe is in the public record and that patient-physician confidentiality will not be breached.
On Christmas Eve, 1968, 82 members of the crew of the U.S.S. Pueblo, imprisoned 11 months earlier by the government of North Korea, arrived for medical treatment in San Diego.
It was 36 hours after they limped across the icy Bridge of No Return that separated their captors in North Korea from South Korea.
These 82 casualties of the Cold War had been beaten, tortured, starved and humiliated during nearly a year as prisoners – and it showed -- in their eyes, faces and damaged bodies.
But not their spirits – or their souls.
The Pueblo, a communications monitoring ship, was captured on January 23rd, 1968. After being spotted by a Soviet submarine four days previously, the ship was approached by a North Korean sub chaser, which ordered the Pueblo to stand down or take fire.
The Pueblo attempted to maneuver away, but was much slower than the sub chaser, which was quickly joined by four torpedo boats, another sub chaser and two MiG-21 fighter jets.
Then and now, the U.S. Navy and the crew insist the Pueblo was miles beyond North Korean territorial waters; North Korea claims otherwise.
The Pueblo avoided capture for more than two hours until a sub chaser opened fire with a 57 mm cannon, killing one member of the crew and wounding ten others.
The crew of the Pueblo signaled its surrender and began destroying classified material – but there was too little time – and too much to burn.
The crew had their hands tied, were blindfolded, beaten, and prodded with bayonets. The Pueblo was impounded at Wonsan. It’s still there.
During captivity, the crew was twice moved among POW camps. The brutal treatment got worse when the North Koreans realized that crewmen were flashing obscene gestures in staged propaganda photos.
Commander Lloyd Bucher, the skipper of the Pueblo, endured beatings and mock executions in an effort to make him confess to espionage.
He finally relented when his captors threatened to kill his crew one by one before his eyes.
Since none knew English well enough to write the confession, Bucher’s captors had him write it himself. They failed to catch the pun when he said "We paean – [spelled P-A-E-A-N] – the DPRK (Democratic People’s Republic of Korea). We paean the Korean people. We paean their great leader Kim Il Sung.”
“Paean” is an accolade. Bucher meant something different.
If you still don’t get it, ask one of the urologists sitting nearby.
After a sham apology by the U.S. government, North Korea released the 82 remaining crew members. And after a stop at an EVAC hospital in South Korea, they were flown to Balboa Naval Hospital.
Today, how Commander Bucher, the captain and the crew of the Pueblo conducted themselves in captivity is taught as a model of resistance for POWs.
But in those highly charged times, a Navy Court of Inquiry would eventually recommend Bucher face court-martial.
That was rejected by then-Navy Secretary John Chafee, a Marine veteran of Guadalcanal and Iwo Jima and later a US Senator from Rhode Island. He said the crew had “suffered enough."
That’s something I can verify.
I was part of the team of physicians that examined the crew and treated some of the physical results of that suffering.
Malnutrition, hepatitis, respiratory infections, and bruises, facial lacerations and worse from beatings, the toll of a year in captivity amid the most brutal conditions imaginable.
What struck me the most was not only their quiet courage and will to live, but their generosity of spirit. As a group, they had bonded. Among them, there was no finger-pointing; no assignment of blame. No hunt for scapegoats, no search for conspiracies.
It is brave men and women like this I hope you’ll reflect on when we observe Veteran’s Day on Thursday.
They had passed through a hell not of their own making, but had stuck together, bound by a common plight and a common cause – service to country.
It serves as a lesson for us all, no matter our walk of life or views on the world. If they didn’t break under the brutalities of torture, then it should be easy for the rest of us as a profession.
We are not captives. We face no physical danger. We can help determine our own fate. And the fate of medicine. The surest path to failure is to succumb to those who sow dissent – who would have us submit – divided, and conquered.
If we resist division, and if we work together – If we stand tall together – we can move medicine forward to a better place. This is our path. This is our quest. This is our charge.
Together we are stronger. Thank you.