Every once in a while, someone at a conference makes a statement that stands out from the usual platitudinous palaver. Earlier this week, that honor belonged to William Plested, the president of the American Medical Association. At the World Health Care Congress in Washington, DC, he was asked to comment on the Center for Medicare and Medicaid Services' efforts to set quality standards to inform (and, let's face it, one day determine) how doctors get reimbursed by the government's health care programs. He declared:
"There is a growing refrain that there is a crisis of quality in American healthcare. I want to make it crystal clear that I categorically reject this assertion. . . If there is a crisis in American medicine, it is a crisis like no other in history. It is not a crisis of failure, but one of unprecedented success."
Forget for a moment the front page New York Times article last Sunday cataloguing the dramatic increase in infant mortality in the American south. Forget for a moment the rising obesity epidemic and demographers' legitimate fear that it will result in a reversal of the past century's slow, steady rise in longevity. Forget for a moment the statistics that show that despite the U.S. spending anywhere from 150 percent to 200 percent of what other industrialized countries spend on healthcare, we have longevity and infant mortality statistics that rank us near Eastern European nations -- somewhere in the mid-20s among the 30 nations that belong to the Organization of Economic Cooperation and Development.
Plested's outburst came in response to Herbert B. Kuhn, the acting deputy administrator, who gamefully outlined the agency's goal of moving "from just paying bills to helping people get well and avoiding costs." They've given hospitals a small financial incentive (0.4 percent!) to report performance data; they've set up a physician group practice demonstration project; they've worked with the AMA in establishing physician performance standards, Kuhn said.
Plested's view on where all this is heading? "You and your loved ones may find yourselves in the hands of someone who foresakes ethics and for a pitifully insignificant reward will follow a cookbook of care designed primarily to reduce costs."
Physicians have embraced evidence-based medicine, he declared. Treatment must be based on careful scientific research and he insisted that payment reform be held to the same standard. "We are witnessing a pell mell rush to pay for performance programs based entirely upon grandiose predictions of great improvements in quality and massive savings in costs, predictions that are completely without any basis in historical fact. There is even a rapidly escalating body of literature that suggests that the exact opposite outcome -- lower quality and higher costs -- is much more probable."
I'm not familiar with that literature, so perhaps readers of this blog can enlighten me. Plested's insistence that the practice of medicine is strictly according to ethical standards and driven by evidence is way off the mark, though. Every study I have ever seen on the subject suggests that the massive variations in practice and outcomes around the country prove that quality and cost have almost nothing to do with each other.
Moreover, I wish he would have spent a few sentences in his talk addressing the myriad conflicts of interest that have enmeshed more than 90 percent of physicians. Is that what he meant by the ethical practice of evidence-based medicine? Yesterday, the New England Journal of Medicine released a study showing that free lunches, free samples and small gifts from drug reps are still the coin of the realm when it comes to determining physician prescribing patterns, and the physicians who sit on the committees that write clinical practice guidelines are still largely doubledipping on the payrolls of the providers with a stake in the outcomes of those guidelines.
It has been said many times that health care reform will not succeed unless reformers can gain the cooperation and collaboration of the nation's 700,000 physicians. I tend to agree. But hearing Plested this week reminded me that organized medicine -- the AMA -- has fought every successful reform movement of the 20th century -- from the coming of employer-based insurance and Blue Cross-Blue Shield to expansion of government services through Medicare and Medicaid. Yet after each successful reform, the profession adapted and thrived as never before.
Why did I ever think that the movement to contain costs while improving quality -- a must if we are going to weather the twin tsunamis of an aging society and advancing medical technology -- was going to be any different? Based on Plested's comments, it seems to me that the AMA is gearing up to be the bulwark against reform. This is one more war where organized medicine will be in its foxholes lobbing shells at the reformers.