That is the essence of his paper, but he has slipped in a zinger at the beginning of his argument that deserves much further public debate.
He mentions the reform that health insurance companies and pharmaceutical companies have offered to hold down the cost of medical care, and then opines that physician support "has been made contingent on promises that physicians' income would not be negatively affected by reform."
He goes on to remind us that physicians have "sworn an oath to place the interests of the patient ahead of their own interests-including their financial interests." He also notes that none of the for profit health care industries that have promised cost savings have taken such an oath. Well, true enough, but medicine has not taken a vow of relative poverty either, and this deserves further discussion.
Physicians deserve to earn a good living just as the leaders of the pharmaceutical and insurance industries do. And no, they haven't taken such an oath. The millions they earn each year and the way their customers are manipulated and swindled is indisputable proof of that. Physicians earn more than most of us, so is it wrong for them to want to preserve their incomes?
In most clinical situations today, the financial relationship between the physician and patient is not material. Both parties have fallen into the paradigm that the third party controls this aspect of the relationship. Physicians have little leverage over reimbursement from third parties for the noteworthy work they do. Medicare typically pays about 30% of charges, and Medicaid pays worse. To make matters more inequitable, the "private insurers" tied their payments to Medicare over ten years ago in a exquisitely perceptive move to relentlessly lower their payments to physicians.
Over five years ago, the Annals of Thoracic Surgery published an article that dealt with the question of the "purchasing power of thoracic procedures." Their analysis by noted economists showed that the "purchasing power" from the income of thoracic procedures had decreased 50% over the preceding ten years. It has not gotten any better in the last five years, and it doesn't look like it will improve in the next five either.
Physicians are members of the "learned professions." We all know that the interests of the patients are primary, but physicians have financial obligations like everyone. I recently talked to a family doctor who owed over $200,000 in loans from her education. Don't physicians have families, and homes, and other expenses that we all have? Professional athletes commonly earn in the six figures, and many earn much more, and all they do is entertain us. How much is it worth to us to pay someone who will save our life?
I don't agree with Nancy Polosi about many things, but I do agree that the insurance companies (including Medicare) have strangled the economic rights of providers and patients while maintaining a comfortable margin of profit for themselves. This is why medicine must say that it wants to preserve its income when and if health care is reformed. Physicians believe that an inequitable portion of the proposed "cost saving measures" will come out of their pockets because they do not believe they have any significant leverage or clout in the negotiations. They have not had much influence in the past and the future doesn't seem any brighter.
On a one to one basis, I believe most physicians will treat their patients with understanding and respect when it comes to economic matters of reimbursement. Putting the third party in the middle of that relationship has damaged the basis of medicine's professionalism- our relationship with our patients. Preserving physician's income will help to reinforce the bond of service that physicians have promised by paying providers closer to what they are worth in the delicately intimate and consequential exchange the transpires in health care encounters.
James P. Weaver, M.D., FACS
Durham, N.C.
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