* At the time of this speech, Dr. John G. Black was President of the South Carolina Medical Association.

April 30, 2010 - John G. Black, MD, FACP

When I wrote my President’s report which is Report Number B1 in your Handbook, I did not know what the vote would be in Washington on the Health Services Reform Bill. We now know that the Bill passed. I would be remiss in my duties if I did not comment on this situation, because such discussion is not on our official agenda.

I know that there are physicians who are happy that the Bill passed, and there are those who are sad. It is hard to speak about this Bill without making someone mad. But, I will try to address what has happened to our profession through this federal legislation. I will not be reading my President Report, but I hope that you read it.

Most of us agree that the status quo in health services is unsustainable. We just disagree on how to get to a solution. The SCMA leadership got overwhelming input from our membership that the Bill was not something that we could support. And, you have seen and heard us argue this point. We disagreed with the American Medical Association who supported the legislation. Most of us do not understand the actions of the AMA since much of the Bill goes against House of Delegate policy. The AMA should never have supported a particular bill by number, but should have pointed out what was good, and stood firmly against what was not its established policy. They did not do this and, thus, have been losing membership throughout the year.

I will quote an editorial in the Wall Street Journal on March 22, which was the day after the House vote to accept the Senate’s Bill.

We also can't mark this day without noting that it couldn't have happened without the complicity of America's biggest health-care lobbies, including Big Pharma, the American Medical Association, the American Hospital Association, the Federation of American Hospitals, the Business Roundtable and such individual companies as Wal-Mart. They hope to get more customers, or to reduce their own costs, but in the end they have merely made themselves more vulnerable to the gilded clutches of the political class.

SCMA joined a Coalition of state medical associations and physician organizations that was formed earlier this year. This Coalition decided to work within the AMA to try to guide the AMA Board and House of Delegates in a direction back towards HOD policy. Whether this can be done is a hard question to answer.

Certainly, we all should be happy that the Bill is increasing coverage to an estimated 31 million people over the next 10 years. But, with increased coverage will be increased costs. The legislation will eliminate denials for pre-existing conditions and forbid the cancellation of insurance when someone gets sick. It will actually reduce insurance costs for some older and sicker persons, but does this by increasing costs for the young and healthy, reflecting a cost shift.

But, the Bill creates a new national entitlement and results in a federal takeover of our health care by a narrow partisan majority and against so much popular opposition. In my opinion, this law is just too expensive at a time when our national deficit spending is already inflated by numerous promised but unfunded entitlements. Additionally, many more people are shifted to Medicaid. In South Carolina, 480,000 new children and adults will be added to Medicaid rolls. Will these patients really have health care if the physician payment remains so low that physicians cannot afford to have them as patients?

It is difficult to really know exactly what the Bill includes because it is so hard to understand when it is read and because the rules and regulations have not been written yet by the bureaucrats. Let me list some things that appear to be in the Bill and that will severely impact physicians, whether one likes the Bill or not.

1. There is no significant medical liability reform except for some proposed studies.

2. There is no repeal of the Sustainable Growth Rate formula which dictates a 21.6% reduction in physician payment this year.

3. An Independent Payment Advisory Board is created which would make arbitrary cuts in physician payments with little or no Congressional oversight.

4. There is a federally mandated insurance benefit plan for all without the ability to choose what benefits one wants.

5. It is mandated that employers and individuals purchase insurance coverage, or be penalized with a fine. Listen to me now. Never before has a US citizen been required to purchase a service or product simply to remain a law-abiding citizen.

6. Quality determination will be by a federal agency rather than by a consensus of physicians based on independent medical studies. It is likely that these decisions will be based more on cost, and therefore will ration care with less quality.

7. It mandates participation in Medicare’s Physician Quality Reporting Initiative with penalties for non-participation. Up until now this has been voluntary.

8. It does not guarantee the right of patients and physicians to privately contract without penalty.

9. As I stated earlier, more citizens are put into Medicaid, shifting costs of care to physicians and states.

10. It calls for implementation of Accountable Care Organizations which function as regional HMO’s that pay with capitation where physicians have to limit care or suffer with payment reductions. This goes against our ethics because we are placed in a position to benefit if we withhold care, or be underpaid if we do appropriate testing and treatment.

11. Bundling of payments and quality based payments are planned. Paying for performance is nothing more than a form of rationing or at least a way to decrease one’s payment. Quality will be hard to measure.

12. It allows public reporting of physician claims data to develop performance reports.

13. Recovery Audit Contractors (RAC) are expanded. I call these bounty hunters who get paid if they find ways that you may have charged incorrectly, as you have to return payments to the government .

14. It establishes a process outside of the AMA Relative Value Update Committee (RUC) to adjust so called mis-valued CPT codes.

15. It fails to include antitrust relief to allow independent groups of physicians to collaborate on quality, care coordination, and other ways to improve their practices.

There are other details, but these are enough to get us thinking about problems that the law might cause in the delivery of medical care. It is a shame that the writers of this legislation rely on some solutions that have not worked in the past.
 
And, the writers ignore problems that common sense shows will get in the way of the actual care of the patient.

Additionally, we will spend more time with documentation than with the actual care of the patient.

Experts are realizing in recent weeks that the costs of national health care will go up under the Bill and that physicians and hospital will face large cuts in payments. The actuary for Medicare predicts that 15% of hospital budgets will go in the red. A senior vice president of Loyola University Health System, which is a Catholic-Jesuit facility, was quoted as saying: “With no (profit) margin, there is no (hospital) mission.”

I do not know this as a fact, but I suspect that physicians who support the Bill actually want a single payer system and chose this Bill when single payer was off the table. But, few of us can support the provisions that I have just outlined unless one is protected in an academic or employed arrangement, no longer see patients for a living, or does not understand or care about the ramifications of the law.

How can we influence any changes? I have heard some say “You lost, just accept it.” One reader of The State newspaper commented on m op-ed by saying, “Mr. Black, what planet do you reside in?” Losing the vote on health reform is not the point. To have a viable practice of medicine, some things need to be changed. Otherwise, doctors, hospitals and insurance companies will over time become public utilities. Government will set the priorities based on cost alone and determine what kinds of treatment options patients are allowed to receive. Medicare's price controls will be incorporated into whatever is left of the private sector.

I think that we have to remain organized. We must continue to be members of the South Carolina Medical Association whether you choose to join or renew membership in the AMA. It is through SCMA that we have input in the Coalition that is going to try to influence the AMA direction. And, we will be supporting our AMA delegation in their efforts to influence change.

Additionally, a strong SCMA can have significant influence on legislation in our own state. We have to develop more contact and discussion with legislators, even when no legislation hangs in the balance. By educating our legislators before the fact, they will better understand the problems of increasing the scope of practice of para-medical personnel like optometrists, chiropractors, podiatrists, and physical therapists. There will be enough work for all of us physicians in the future. The scope of practice issues are not about protecting one’s turf, but about protecting the public from less sophisticated treatment by undertrained individuals. Let us work together to know our legislators better.

Let me end with a thank you. We Board members could not do our jobs without the membership support, and few of our plans could come alive without our SCMA staff. And while these are changing and unsettling times for our profession, keep in mind that with changes come opportunities. As we proceed further into the new decade and new leadership, let us use every opportunity to provide better care for our patients: after all, that is what we are about.

My parents started medical practice in 1946 in Dillon; this is ancient history for many of you. I was not born until 1950. Their first SCMA Annual Meeting was the Centennial Meeting in 1947, celebrating the first 100 years of SCMA. And, 63 years later, here we are again with their son finishing up his year as President. And, we are back in Myrtle Beach, where so many earlier Annual Meetings were held. We have so much history at these meetings that passes from one generation of physicians to the next. It is so important to make these meetings successful each year.

Thank you again for your support of me during my year as President. And I offer sincere appreciation for the support from my co-workers in West Columbia, especially my partners. And, I could not have done it without my patient and loving wife, Anne, who also served as my editor. I could not have represented this organization without all of your help. I am a better man and a better physician after this year-long journey. As I move to the role of Immediate Past President, let us all give our best for our new President, Greg Tarasidis.