Letters to the Editor - April 25, 2005

Political skills needed to protect responsible practice of medicine - Motivate Medicare's auditing contractors to find underpayments - A two-tiered system of health care is a solution to physician supply question

Political skills needed to protect responsible practice of medicine

I was able to participate for the first time in the AMA's National Advocacy Conference programs during March. Being able to meet fellow AMA Foundation Leadership Award recipients and hear their stories was nothing short of inspirational. The travails of postgraduate training and wrestling nontherapeutic issues of countertransference too often lead residents to feel that their humanity is being eroded.

On the surface, it would seem that the political activism and lobbying that followed lay in direct opposition to the commitment embodied by the Leadership Award and Pride in the Profession awardees. What I learned, however, is that without political literacy, the responsible practice of medicine and patients' access to care are jeopardized as the future of medicine is being shaped ever more by attorneys and third-party payers. If we are to uphold the integrity of our profession and remain advocates for patients, this activism is essential.

My time in D.C. is an existential rebut to those who regard the AMA as a "union of doctors " with all its implicit negative connotations. My experience afforded me renewed faith in the mission of organized medicine and affirmed the spirit of service imbrued in the work of good doctors. Our paucity of numbers may make a Million Doctor March infeasible, but it is my hope that the effervescence of those in attendance may inspire an ever- stronger voice to present themselves at future lobby days, advocating for patients and promoting public health.

--Michelle Nichols, MD, St. Louis

Editor's note: Dr. Nichols is a resident at Washington University/Barnes-Jewish Hospital.

Motivate Medicare's auditing contractors to find underpayments

Regarding "Doctors wary of Medicare audit plan's incentives" (Article, April 4): Medicare recovery audit contractors are to receive government compensation for monies recovered from physician overpayments.

Incentives always spur one's efforts. If the government is providing incentives to outside contractors to ferret out Medicare overpayments, would it not be an eminently practical suggestion for the AMA to sponsor physician underpayment incentives? To wit, let the AMA establish a program for physicians to voluntarily reimburse 5% of all underpayment monies they receive to the same contractors. This could very well level the playing field as the contractors search for errors.

--Leslie Bennett, MD, Queens, N.Y.

A two-tiered system of health care is a solution to physician supply question

Regarding "Physician shortage? Push is on for more medical students" (Article, March 14): The issue is not how many doctors we will need, but how many we are willing to pay for.

I believe that the number of physicians needs to be determined by studying the overall Medicare budget and determining how many doctors our country is willing to pay for. From that point, we must determine policies that will rationally allow those doctors to provide "the greatest benefit for the greatest number."

This may require a "two-tier" system such as it exists in England at present. Obviously, this will involve a great deal of discussion at all levels of society.

An attempt to increase the number of physicians without increasing the amount of funding will be very detrimental to the limited bargaining power that physicians now possess. Presently, we have almost no control over our fees unless we are busy enough to drop a particular plan or plans. This is really the only leverage we have as a group. Once there is a surplus of physicians, we will lose even this leverage.

At present, I feel like my fees are frozen but my overhead keeps rising. The types of actions that would help me control overhead, such as tort reform and the streamlining of regulatory requirements, evades our profession, while at the same time, I am unable effectively to raise fees.

Another issue has to do with the hospital beds and facilities: At the present time, the hospital where I work is experiencing periodic shortages of bed and/or operating room space. Will the government provide, or allow to be built, facilities for these new physicians to work? The other issue is that many institutions are currently training physician assistants, nurse practitioners and other types of professionals: It seems more practical, with a limited budget, for physicians to extend the volume of their work by integrating physician extenders into their practices. This seems more logical and more consistent with our budgetary constraints.

The only alternative is to switch the entire system to fee for service and abolish our state-mandated insurance. This would likely increase the amount of money generated by our medical system. This would allow employment of more professions; however, in the short run it could be very disruptive. I believe a two-tiered system is a reasonable answer and would allow a progression to reduce the inefficiencies of state-run medical care.

--F. Andrew Morfesis, MD, Fayetteville, N.C.