The times are changing
Hosni Mubarak has relinquished control of Egypt. As I write, Libya has fallen into total chaos. Moammar Gadhafi, despite using extreme force against his own countrymen, will likely lose control. Demonstrations and riots are occurring not only in Morocco, Bahrain and other Arab countries, but also in Greece. There are reports that organizers are attempting to initiate demonstrations in China.
These certainly are historic times that we live in. I wonder what will ultimately happen. I wonder how this will end.
In the 16th century, Etienne de la Boétie, in his essay, “The Discourse on Voluntary Servitude,” linked obedience and domination. In it, he explains that it is not just fear that allows a group of people to be oppressed by their rulers. For it to happen, they must also give their consent. Thus, rulers, including tyrants, have power only because people give it to them. By pointing out that such consent can be voluntarily withdrawn, he became one of the first advocates of civil disobedience. Today, in these various countries, we are now seeing the people withdrawing their consent. And despite brutal force being used against these demonstrators, lacking the consent of the people, the leaders are falling.
Is there a correlation in health care? Perhaps. Within the past few years, there have been massive demonstrations in Europe by physicians (See images). However, these events have not been well reported in the United States. In Spain, thousands of physicians took to the streets when they were being ordered by the government to limit their follow-up patient visits to 7 minutes. In Germany, Belgium and elsewhere, physicians have taken to the streets, by the thousands, to protest their poor pay.
Here, in the United States, one can often hear physicians complaining bitterly about the poor Medicare reimbursements they receive. Do they not realize that these reimbursements can only occur because they have consented to them? They might have given it grudgingly, but nevertheless, they gave their consent.
Unfortunately, the United States, after many years of deficit spending, is now deeply in debt. The unfunded liabilities for the CMS and Social Security alone are now measured in the trillions of dollars.
To address this shortfall, Medicare is applying stricter price controls while scrutinizing doctors much more closely. It is implementing prior authorizations, drug formularies, step therapies and other procedures, including financial incentives and disincentives, which directly affect the most important thing that the physician brings to the patient-doctor relationship — his or her best medical judgment. The physician is finding himself in a dilemma in which he is trying to serve two masters: one is the patient; the other is Medicare. Insurance companies are placing him in similar situations with his non-Medicare patients. Nothing can be more frustrating to a practicing physician than to know what treatment his patient needs but being unable to give it because a third-party payer is not allowing it.
Photos courtesy of: Edelman Communications 2008
Some physicians are responding to this by withdrawing their consent. They are opting out of Medicare. In fact, many are refusing to sign up for any insurance plan and are instead seeing patients “out of network.” By establishing what are called “patient-direct practices,” no third-party payer is between them and the patient. Their relationship is with the patient and no one else. The only master whom they serve is the patient. They tell me that they relish this new found freedom. They tell me that their overhead is much less because they do not require as many people in the billing department. They tell me that they have much more time to focus on their patients, rather than having their time consumed by the demands of third-party payers.
As of today, only some physicians have opted out of Medicare. What would happen if more opted out? What would happen if we all opted out?
I wonder what will ultimately happen. I wonder how this will end.
Richard Dolinar, MD, is a senior fellow in health care policy at Heartland Institute in Chicago and a clinical endocrinologist in private practice in Phoenix, Ariz.. He is also an Endocrine Today Editorial Board member.
Disclosure: Dr. Dolinar reports no relevant financial disclosures.