President Obama's Speech to the AMA

Yesterday President Obama delivered a speech to the American Medical Association (AMA) in Chicago. When viewed it looks like his message was relatively well received, except for his comment on medical malpractice lawsuit caps, and that this reform appears logical to many of the doctors who were present during his speech. However, the media reports a mixed response being supported by some and skeptical by others. I read some comments by other providers and also watched some interviews from doctors who attended and it seemed that many of them have some of the same doubts that I had while reading, and then later watching this speech. The biggest concern I believe was that of a socialistic health care system.
Before addressing the concern of socialized medicine I want to point out one concern that I had with his speech and a concern I know many of my colleagues have as well. He addressed Doctors and Nurse Practitioners yet left out Physician Assistants as providers of health care. Maybe it was an oversight of the president but not recognizing the importance of PA's (who fall under AMA jurisdiction) as providers the president has alienated over 76,000 providers of medicine, a majority who fill the role of primary care providers, in this nation. Is it a bias on my part? Maybe, but still, this is my profession and his changes for reform will affect how I practice in the future and thus I, and every other PA, should be considered in his decisions. Not addressing us in his speech might suggest the contrary. For those PA's out there reading this blog who wish to let the president know of our importance in this nations health care system visit this site.
In his speech President Obama did all he could to assure the AMA that his goal was not a socialistic government, or a single-payer plan. He said, "If you like your doctor, you will be able to keep your doctor, period. If you like your plan, you will be able to keep your plan, period." He then goes on to say that his vision is to create a public plan (run by the government) that will provide fair competition to private insurance companies, but will still be able to cover those who have little to no insurance. This will ensure that every American has health coverage. He calls this Health Insurance Exchange but many skeptics are saying that he's just using semantics to cover up an eventual single-payer, socialized health care. What the fear is that with this new Exchange it will eventually drive the other insurance companies out of business and leave Americans with only one option for health care, this Exchange. The next fear is that with one company calling the shots decisions for medical treatment will then be made by bureaucrats rather than by doctors. Now, even though I see this as a problem with a socialized health care system I also see this already happening in our current system. The insurance companies decide to pay for what they want to pay for and use terms like "pre-existing condition," or,"prior authorization," to limit what they will pay for. I have seen this in my own practice. When having to choose between the two proton pump inhibitors Omeprazole (Prilosec) and Esomeprazole (Nexium) I have to weigh what my patients insurance will cover as first line treatment. Most companies will use Prilosec as first line treatment not because it has been shown to be more effective than Nexium (on the contrary, Nexium has been shown to be superior to Prilosec) but because it has gone generic and is now an over the counter (OTC) medication. In simple terms, Prilosec is first choice because it's cheaper, not better.
Ironically it's the government run system of Medicare and Medicaid that I have to deal with when getting prior authorizations for medications such as Prilosec and Nexium. It's Medicaid that chooses to use the cheaper as first line. This is another part of Obama's speech that I had trouble with. He cited an instance where a doctor spends 20% of his time filling out these prior authorizations forms or dealing with insurance companies rather than taking care of his patients. In my experience, that 20% of my time has been used dealing with similar circumstances...80% being Medicare and Medicaid problems that require prior authorization. Later on in his speech he states how doctors need to practice based off of Evidence Based Medicine (EBM) rather than what insurance companies are willing to pay for. I again will have you reference my Prilosec/Nexium example. EBM shows me that Nexium should be used, but government run Medicaid tells me I should use Prilosec first because it's cheaper. In fact, many of the providers I listened to or read comments from had similar concerns. They are concerned with the way Medicare and Medicaid have been running and see this only an insight to what the new reform will bring, and this scares us. We fear that these problems will only continue to exist in the new reform.
Much of what President Obama said in his discourse was nothing new to providers. We already know that electronic medical records saves not only time and money but also improves patient care. We know that preventing a problem is cheaper than fixing a problem and that preventative health will cut medical costs (it's my belief that preventative health care will not only put just a dent in the problem as the president addressed, but will blast a hole through it. He gave examples of five chronic problems that scourge our health care system which account for most of the cost. If we prevented the majority of these problems will it not then cut a majority of what we spend on health care? Preventative care will not just be a dent people in the system people.) Many of the things the president addressed we already knew, yet he spent a good amount of time discussing them. One of those points, however, I would like to address rapidly because I'm weary at how the president will bring about the change of preventative medicine. How will he get Americans to live healthier without forcing it upon them? I read an article about some of his goals (some I agree with, others I don't) and this change. But again, how will he make this change without forcing it upon Americans? Increase taxing of certain foods, alcohol, tobacco only makes Americans not consume them not because of health benefits, but because of costs.
Now comes the point of paying for all of this. We are a country already in debt and now we're looking to reform our health care by putting $1 trillion over the next 10 years into it. He states that this will be debt neutral and proposes a system of cuts and taxes to pay for it. He states that over the next 10 years he can cut $950 billion from our spending, thus almost covering the $1 trillion needed for reform. I don't know how all of that will play out, if it will work or not. But one thing that I'm concerned with is that this will take 10 years. At most he will only spend the next 7 years in office, maybe only 3. So what happens down the road when the next guy, or Congress decides to reform the reform? One of his proposed cuts was the amount of government money hospitals will receive for treating uninsured patients. He states that as the number of the uninsured go down so will the need for hospital reimbursement. The question at hand is which will come first? Will the number of uninsured go down first or hospital reimbursement? How can you pay for the one without affecting the other?
President Obama was openly opposed, even booed by some, when he said that he didn't support putting a cap on malpractice insurance lawsuits. However, he did recognize that the fear of a lawsuit did affect how providers practiced and that this increased costs. This is true, we do get that extra test just to be sure, even though we're 99% positive in the first place, so as to not be caught off guard by that disease that has an prevalence of 1%. All though he said he understood this as a concern, he gave no alternative or plan of action of how to address this problem, other than stating that he opposes caps. Now, in certain cases I agree, but the majority of malpractice lawsuits are frivolous and cause a huge strain on our system. I don't know how to fix it either, but then again I'm not the one bringing up the issue and then not having a solution for it. One thing the president must know is that providers will continue to practice defensive medicine while the threat of frivolous lawsuits still exist, and this will ultimately raise the cost of medicine.
I was pleased when the president addressed the problem with many insurance companies about "pre-existing conditions" and other hassles they give us as providers. I was also pleased to hear that insurance companies and pharmaceutical companies were willing to discuss what they can do to help stem the rising of health care. Personally I believe that there are some problems with insurance company policies that need changed and I'm glad to see the president take a stand on it. However, again it falls back on the concept of Big Brother stepping in and that worries me to a degree.
Overall I am skeptical of the reform laid out by the president. I agree with the need for electronic based medical records and preventative care, but question the Health Insurance Exchange program he announced. A change needs to be made, but I still maintain the belief that I don't think our government is capable of doing it. I believe that if we want a change then we need to make the change. Americans need to learn to practice preventative medicine and stop being so eager to sue. Insurance companies need to have a major overhaul in their policies about what they will and will not pay for (one theory of mine is that if the policy will not pay for a particular aspect of care then I should be refunded what I've paid to them over the years. At least I can use that to make a dent in my medical costs.) Pharmaceuticals need to change their spending policies so when their new drugs do come out they don't have to charge $200/month for them (spending policies: advertisement, luncheons, etc) I also believe that patents for medications should be shorter thus allowing generics to be made available earlier on. I believe that we in medicine could take a cut in our pay to serve the greater good or, if we are not willing to take a cut, then donate to our communities a generous offering, being money or time. Change is needed, we must be willing to work for it and not have Big Brother bail us out. Comments, opinions?