If you haven’t noticed it yet, you soon will. The Obama administration has launch-ed a full-court press to sell the president’s “signature” achievement, Obamacare, or the Affordable Care Act, to the American public as well as to the 800,000 American physicians it directly impacts.
As one of those doctors, it was no surprise when an article in the Journal of the American Medical Association by lead author Dr. Ezekiel Emanuel attempted to convince American physicians that they will enjoy expanded autonomy and greater liberty under the new act.
Dr. Emanuel helped create the 2,700-page law and has now been enlisted to sell it. As a bioethicist of considerable acclaim, Dr. Emanuel goes to great lengths to establish his case, maintaining that with new payment models promoted by the law, doctors will be in a position to free themselves from the fee-for-service system that he and others have worked to vilify in the physician-patient relationship. What he misses entirely is that it’s the opaque economic arrangement caused by our third-party payment systems, not the honest exchange of payment for a service that is the root cause of the soaring costs in American health care today.
The law promotes a “new” model, the Accountable Care Organization (ACO), in which an entity that covers a specified number of Medicare patients is given a fixed pot of money. This is quite similar to the HMO capitation systems that caused tremendous backlash in the early 1990s. In both, if the doctors can provide care for less than what is in the pot over a defined period, they get to share the leftovers. If, however, the doctors overspend the pot, they are financially liable for the consequences. With sleight of hand and fanciful re-packaging, Dr. Emanuel attempts to convince physicians that this gallows for private practice somehow improves and enhances autonomy. Nice try, but doctors have been fooled once, which is quite enough.
Do you see the problem? It should be obvious to all physicians and the public. When you see your doctor, what do you want the caregiver to have foremost in mind: your medical needs or the doctor’s income? Is this ethical? Hardly. But this is the reality of any payment model that ties physician income directly to the unstated decision to withhold expensive services. Either consciously or subliminally, the message is the same: The less you spend on patient care, the more you gain financially. This is the reality of the ACO model and the “new ethics” of government cost control in medicine, courtesy of the Affordable Care Act. Shouldn’t economic and professional decisions be transparent in medicine, where doctors and patients make joint decisions based upon available resources, not some underlying, unspoken financial advantage for the physician to offer the patient less.
This administration held up the Mayo Clinic, the Cleveland Clinic and others as shining examples of the best medical systems in the country. They didn’t tell you that when Dr. Charlie and Dr. Will Mayo opened the Mayo Clinic in 1889 and when Dr. George Crile and colleagues opened the Cleveland Clinic in 1921, they were not coerced by any government entity or law to provide honest medical care under the most ethical economic model that exists - fee-for-service - in which the doctors care for the patient and the patient pays the doctor.
Using the terms “autonomy” and “liberty” in the same paragraphs as descriptions of Affordable Care Act and the ACO is disingenuous at a minimum and laughable when you know even a portion of what this law contains. Obamacare endows the office of the secretary of Health and Human Services with more power than any Cabinet officer in history and to virtually control the American health care economy by 2014. Any argument asserting that autonomy and liberty are enshrined in the thousands of pages of regulations emanating from the Cabinet secretary is risible.
What occurred with the Catholic Church and its associated organizations over contraception services last week is only a small preview of what is in store for the remainder of the United States. Attempts to frame this law as promoting enhanced physician autonomy and liberty is akin to rearranging the furniture in a prison; you can seat yourself on the loveseat or a chair, but you can’t leave the premises.
The Mayos and Crile would not be amused. My sense is that the founders of our nation would spit on Dr. Emanuel’s shoes - or worse.
Dr. Richard A. Armstrong is the chief operating officer of Docs4PatientCare (docs4patientcare.org).