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| ISSUE: 3/2008 | VOLUME:
35:3 |
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Answering
the Call
David V. Cossman MD
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 I spent the better part of the 1950s with my head between my knees under my desk preparing for a nuclear attack. As far as
I can recall, it was my first act of compliance with a federal mandate. The Sunday night “Ed Sullivan Show” had
terrified us all with an incredibly graphic animation of eyeballs melting in their sockets from a thermonuclear blast, so
I took those civil defense drills seriously. Arlene Gill, the girl who sat next to me in school, didn’t take the drills
seriously. That was my first exposure to noncompliance. It never occurred to me that she was right and I was wrong. I trusted
authority. I knew I would be saved, while her pretty little blonde head would be vaporized. I just hoped I’d get to
kiss her first.
Then Nikita Khrushchev took his shoes off at the United Nations and started banging them on the table
for the whole world to see. I put my head even farther under my desk. My mother told me the Russian people didn’t want
to die any more than we did and that level heads would prevail. That calmed me down a little.
Then in college I learned
about nuclear mutually assured self-destruction. We studied the Xs and Os of nuclear engagement. The possibilities looked
like an NFL playbook, but the outcome was always the same—certain annihilation for all and a 5,000-year nuclear winter
that would last until two foolhardy nitrogen molecules crawled out of the primordial ooze to start civilization 1.2.
For
those of us who grew up during the Cold War, the sight of dancing students tearing down the Berlin Wall brick by brick in
1989 was about as surreal as bumping into Henry Kissinger and Richard Nixon at Woodstock in 1969. The possibility that the
“Evil Empire” would be crushed under its own weight and capitulate to the forces of freedom without a single megaton
blast never occurred to any of the Sovietologists. In fact, if the Sovietologists agreed on anything (and there were plenty
of them because every newspaper, TV channel, college campus and political party had at least one), it was that desperation
born of the failures of socialism and communism would trigger World War III.
I was happy to stop worrying about being
blown up, but I lost faith in pundits, experts, consultants, politicians, game theorists, newsmen and historians. Not one
of them was close to accurately predicting what happened, and they made me spend my youth with my head between my knees under
my desk. I became a cynic. Cynics are those people who rely more on taxicab drivers than consultants to understand the world
around them. Now, I rely mostly on myself to understand the world and predict the future.
This is what I see:
A
tsunami of unprecedented proportion is about to put our health care system under water, and like the fall of the Evil Empire,
none of the experts have the slightest clue that this is about to happen, or why. The current crop of presidential candidates
who yammer endlessly about the current “health care crisis” have no clue. Only practicing doctors can sense the
approaching swell. This is the 11th presidential campaign in which the “health care crisis” has been paraded as
an issue that requires an immediate solution. A “crisis” is not a crisis if it lasts for 40 years. The usual suspects
of not enough money, poor quality care and insurance availability are not crises. They are problems that can and will be solved.
We found $2 trillion to wage war in Iraq that was not budgeted for prior to the September 11, 2001, attacks. The money is
available to pay for the quality of care most Americans expect. If there were no money to pay for care, that would be a crisis.
Deciding whose money to use is an issue for debate, but it is not a crisis.
Furthermore, the health care crisis has
nothing to do with the 45, or 46, or 47 or the 48 million uninsured because many if not most of them have the means to purchase
insurance but elect not to. Legislation is needed to require everyone to buy health insurance and then in turn require the
insurance companies to use those dollars to purchase care instead of siphoning the money off for oversized executive pay packages.
That just shouldn’t be that hard to do. If we have a government that cannot get that done, that’s a crisis.
I’m
not surprised one bit that those politicians who pander to popular fears about the cost, quality and access to health care
have failed to identify the real crisis that is on the verge of destroying our health care system. They missed the crash of
1929, Pearl Harbor, the fall of the Evil Empire and the threat posed by terrorism until a 767 revved its engines 500 feet
above Madison Avenue. And now they are blind to the real blight that will have health care on life support unless someone
calls a code right now.
There is a rising tide of physician dissatisfaction in this country that is rapidly coalescing
into a coherent movement that will threaten access to care for most Americans in the not-too-distant future. Demoralized by
decreased reimbursements, endless regulatory rituals, useless compliance exercises and a distrustful patient population, physicians
are on the ledge, and it won’t take much more to push them over the edge. Frankly, I’m disappointed Congress didn’t
cut another 10% from Medicare. I can’t stand getting whittled to death and pretending that disaster has been averted.
Let them stick the fork in and get it over with. Whether they cut or not, the message is clear: No one values the service
we provide. This is the 11th straight year of cuts and The New York Times and its readers still believe the fundamental problem
with our health care system is that doctors make too much money.
Despite denials by the Centers for Medicare &
Medicaid Services (CMS), a sudden and unanticipated physician shortage is about to explode onto the front pages. CMS is counting
heads but has no understanding of what is going on inside those heads. Manpower needs in health care are loosely estimated
on a generational basis taking into account 10-year-old census figures and a headcount of practicing physicians and trainees.
Foreign-trained physicians who can be titrated up or down to bring supply in line with demand have always been the ace in
the hole to cover any minor miscalculations. What would happen, however, if conditions within our profession acutely deteriorated
to the point where physicians suddenly dropped out of practice, retired earlier than historic norms, abridged their practices
to prune cases with low risk–reward ratios, concentrated only on revenue-producing activities and started to drop out
in droves from managed care and Medicare? Have you heard one word from the presidential candidates about these possibilities
and what they would do to the availability of health care services that we now take for granted? Or the possibility that maybe
your doctor, loathsome as he might be for not washing his hands, operating on the wrong side and killing 100,000 people a
year, will not be there in the middle of the night when your child has appendicitis because he’s finally said “no”
to the $300 the HMO is paying for a life-saving operation that takes 15 minutes to do, but 15 years to learn how to do it?
In
fact, there is a silent strike, or more aptly, a silent secession of surgical talent going on and no one recognizes or acknowledges
it. A 2007 survey by Merritt Hawkins & Associates that came over the Reuters wire recently found that 50% of physicians
between the ages of 50 and 65 plan to reduce or end practice in the next one to three years. That’s one-third of the
most experienced part of the workforce that is going offline—soon. More perniciously, many surgeons who have followed
advice to develop new avenues to generate practice incomes have found that these avenues don’t involve direct patient
care, and carry little of the heartache, liability and expense of traditional surgical services. It’s a sorry day for
the profession when a vascular surgeon finds out that he cannot make a living doing fem-pops, aneurysms and carotids, no matter
how busy he is, so he keeps his practice afloat by doing medicolegal reviews, owning a surgical center and a vascular lab
and getting a stipend for some bogus medical directorship from a hospital that wants his admissions. I can only assume that
these avenues of income do not include taking out an appendix in the middle of the night for $300. If the assumption is that
developing “creative and better ways to practice and [that] general practice income”1 will subsidize surgeons
and ensure their availability to perform traditional surgical services at greatly discounted rates, think again. It won’t
be long before traditional surgical services are abandoned altogether, leaving a huge and dangerous void in the health care
delivery system.
I am having a hard time getting my head around the fact that after six to eight years of training,
the graduating surgeon has to do something other than surgery to pay the bills. Acceptance of this concept is the death knell
for our profession.
The insurance companies continue to issue rosy forecasts of future manpower and suppress troubling
data about physician defections that will rock the foundation of our health care delivery system. All trends start in California,
good and bad, and according to the California Medical Association, 24% of physicians have delisted from Blue Cross in the
state, and another 48% are seriously considering it. In 2006, 86% more physicians dropped out of Blue Cross than in 2005.
Maybe it is because Blue Cross has been accused of illegally transferring $1 billion to the home office in Indianapolis to
be distributed to executives instead of to doctors who provided legitimate services for that money. Not that dropping out
is easy. Read your contracts. It takes time and could have financial repercussions, since dropping out will inevitably find
you in violation of some covenant you agreed to when you signed up without reading the contract. Don’t be surprised
when money due you for out-of-network services is withheld because the payer retroactively finds you in violation of a trivial
provision embedded in your former contract. Don’t worry about it. Freedom is worth every penny of the penalty.
In
a previous column, I wrote that I felt a little different about dropping out of Medicare because Medicare wasn’t sequestering
a lot of money to make a few people rich. I got a lot of hate mail about that, if you consider a death threat hate mail. Modifying
Medicare to allow balance billing might stem the tide of defections. Surgeons need to realize, however, that every Medicare
reform up to now, from the Medicare Economic Index to the Resource-Based Relative Value Scale in 1989, to cuts made in accordance
with the Sustainable Growth Rate (SGR) that caps Medicare spending and mandates 5% cuts for nine consecutive years, is a cost-containment
strategy that disproportionately hurts surgeons. Surgical services are anatomically and pathologically fixed. You only have
two carotids, one aorta, and two legs and you can only fix them when they need fixing. Evaluation and management providers
like internists can dial up the volume of their “incident to” services (such as laboratory and imaging) to recoup
cuts in face-to-face services. We can’t increase the volume of our services. Because overall CMS expenditures are fixed
by the SGR cap, surgeons get penalized for overutilization by other specialties. Although our political action committee is
trying to bring this inequity to the attention of lawmakers, politicians respond to votes and dollars, and the number of surgeons
is too small to make a big impression in Washington, until someone important needs an operation or shortages of essential
surgical services become headline news. So I’ve changed my mind about Medicare and I now believe that the only way we’re
going to get the attention of Washington is to drop out of Medicare.
Since I started writing these columns a few years
back, I have been honored by invitations to speak in every section of this country, and I have been overwhelmed with the number
of surgeons who have already dropped out of managed care and Medicare. I am mystified that this trend has not become headline
news and predict that within the year, shortages of surgical services will become headline national news. I suspect CMS is
secretly concerned about this trend and that explains why they lose the paperwork to delist at least three times before they
finally let you out. Once the defections have reached a critical mass, there will be no shortage of pundits to explain why
this happened. A recent state-sponsored investigation into the shrinking physician population in Maryland concluded that physician
retention would improve with increased reimbursements, improvement in the liability environment, and lightening of the regulatory
and compliance requirements for physicians. Wow. Go figure.
If everyone continues to turn a deaf ear to the demoralization
of doctors, and if the unavailability of care creates panic in emergency rooms across the country, my guess is that CMS, the
insurance companies, the courts and Congress will respond with heavy handed-remedies that will deepen physician grievances.
One option will be the Emergency Medical Treatment and Active Labor Act (EMTALA) for physicians, which will mandate physicians
render services when and where they are needed or face criminal penalty. This will amount to an unprecedented seizure or “taking”
of our skill, experience and knowledge without compensation in order to provide for the public welfare. To my knowledge, the
Fifth Amendment allows for the appropriation of private property for public use (eminent domain) after reasonable compensation,
but does not allow for the “taking” of intellectual property under any circumstances. In broad strokes, the medical
profession has already been seized in an unwanted and uncompensated taking that has no constitutional or commercial precedent.
I doubt, however, that we’ll get our profession back through any legal challenge, but it would be amusing to watch the
insurance industry argue in court that the Founding Fathers intended the eminent domain provision of the Fifth Amendment to
provide a rational basis for the usurpation of the medical profession by Blue Cross and United Healthcare.
There is
a complex calculation that occurs when the beeper goes off in the middle of the night with a surgical emergency. For 35 years
I jumped out of bed, no questions asked, to answer the call. A patient who needed me was at the other end. My profession,
my professors who trained me, my partners, my family and my conscience got my carcass out of bed with an inaudible protest
at best. It felt so good to be a doctor. For a variety of reasons, all of which are painfully familiar to you, the calculation
comes out on the wrong side of the line now. I’m not going out on strike like the Hollywood writers, although I would
think that if anyone deserves residuals for his or her work it would be a doctor who saves a life instead of the genius who
writes an episode of “Mork and Mindy.” We’re not seeking “residuals” for the faithful application
of our trade, just the restoration of the dignity and sovereignty that our profession deserves and requires to remain viable.
Until that happens, I’m not answering the call. I know I’ve been invisible to health care policy planners who
never acknowledged my presence. Maybe my absence will make a bigger impression.
It is not impossible to destroy a great
American institution like health care by misguided attempts to improve it. Other great American institutions like our public
school system and the workplace have already been degraded into unproductive battlegrounds of warring social, political, legal
and religious values that compete at the expense of educating students and promoting an efficient workplace. The public schools
have been finely tuned to accommodate every cultural sensitivity but remain indifferent to education so everyone sends their
kids to private schools if they can. There will be no sanctuary from universally poor health care that is staffed by a demoralized
and uncommitted workforce. This is the real health care crisis and it’s right around the corner. Is anyone listening?
Dr. David V. Cossman
is a vascular surgeon in Los Angeles, California.
Reference
1. Russell
TR. "From My Perspective." ACS Bulletin. September 2007.
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