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|American Society of Dermatology, Inc.
A Voice for Private Dermatologists Since 1992
by Melissa Kline Clements, M.D.
On an impossibly monochromatic, bitterly cold weekend in January, I enjoyed the
of three professional women skiing in the mountains of Colorado. Our hostess, a
marriage, works in the development, leasing and management of commercial
Another member of the Alpine party, a stockbroker and the primary breadwinner
family of six, was an acquaintance prior to the trip. Rounding out our foursome
Colorado native, cum Texan, who flourishes in a profession she called
management." All of us are married. Among us we have none children ranging in
age from two
to sixteen. While none of us purchased over-priced ski outfits or shopped in
and ate our meals "in", each of us anteed up $48 a day for lift tickets, paid $3.85
per « lb. At
the mid-mountain salad bar, $1.50 for an 8 ounce drink of Coca-Cola, and I
what we paid for a bowl of chili or a burger. Each of us talked about skiing with
children in March and pondered how most efficiently and economically to clothe,
transport and feed our families on the planned trips. In short, ours was an
hardworking, family oriented, cost conscious quartet with disposable income that
allows us to
periodically participate in an increasingly exclusive recreational pastime.
As one might expect in our three and a half days together we had time to make
in depth and
probing inquiries into the machinations of each others' lives and businesses. We
philosophies for attainment of financial security, discussed cosmetic
reeled in the behavioral idiosyncrasies and problems of hormone ridden
pondered the juggling of family and professional responsibilities.
I listened with great interest as the stock broker enumerated reasons that
salesmen, and cutrate/commissionless brokers had become the bane of the
brokerage industry. It was clear that the level of training, expertise, and dare I
specialization amongst individuals all wanting a piece of the investment pie is not
Nor is the level or risk that an individual stock or bond dealer is willing to assume
amongst these investment makers. The age old ploy of appealing to the lowest
denominator is alive and well on Wall Street. The message that we received was
prepared and willing to pay for expertise: do not be afraid of fees - they are the
price you pay
to guarantee superior knowledge and service. This message was again
emphasized when the
conversation turned to estate planners, specialty lawyers and their fees.
I was somewhat appalled to learn moments later that this same individual is
enrolled in an
HMO and for the most part is pleased with the product she and her family
comments were couched with the qualifier that she had long time friendships with
nearly all the
physicians whom she had selected on her plan and feels as if she can ask for
information and assistance when dissatisfied with the product delivered by some
in the HMO chain. Her personal prominence within a community relatively
gatekeeper rationing has been skirting blockades established to ration care. I
was pleased to
note that her dermatological services are provided by physicians who have never
in an HMO or capitated contract, my associate and myself.
My initial appeals recognize the immoral side of the existence of HMOs - doctors
working for their patients but for insurance companies, rationing of care for the
personal enrichment, the "dumbing-down" of the American medical community,
were met with
responses of "I'm the sole support of nine people; with my contracts I know how
to work the
system; I cannot afford anything else." I volleyed back with please to recognize
the source of
obscene corporate profit, i.e. high premiums and care rationing. I soulfully
presented the case
of the individual practitioner and tried to explain the difference between a
physician and a
:healthcare provider." In frustration I turned my gaze to the fire wishing to steer
conversation in some nonconfrontary issue.
After a week's reflection, I have decided to turn my frustration into an opportunity.
opportunity to educate a bright and successful businesswoman about the choices
for herself and her family regarding health insurance. An opportunity to explain to
individuals, NOT their employers, should own their health insurance policies. An
to explain why there is no economic sense in providing first dollar coverage of
expenditures and how this concept has utterly distorted the most basic precept of
coverage: that of insuring against major and or catastrophic events and losses.
An opportunity to explain why physicians cannot concurrently act as patient advocates while serving as corporate consorts or pimps. An opportunity to explain the urgent need for the establishment of medical savings accounts. An opportunity to explain the difference between generic primary care and specialty medicine.
Yesterday I delivered two books to my skiing companion. One is a copy of CODE BLUE by Edward R. Annis, MD which chronicles the intrusion of government and corporate bureaucracies into twentieth century medicine and offers a free market approach to restore doctor patient relationships, make healthcare affordable to working Americans, and provide care to the medically indigent. The second is a small paperback book entitled PATIENT POWER written by John C. Goodman and Gerald L. Musgrave. Perhaps between these accomplished authors and my often repetitive and occasionally articulate verbiage, I can achieve a conversion or help salvage another victim of what is so aptly referred by the FrontLine’s guest columnist, Dr. Edward R. Annis, as “the war.”
America remains one of the few countries on earth where the citizenry have the ability and can create the opportunity to air and right its social ills in an arena absent of violent political revolution. Not all wars are fought on a battle field at the point of bayonets or with grenades. Freedoms surrendered or lost are rarely regained and then only at great personal and social expense. Our profession and the people whom we as physicians serve deserve more than corporate America and/or the government can give. I join Dr. Annis in saying that we are at war fighting for that which America has stood for more than two hundred years - FREEDOM. It is the heritage and love of freedom and the hope of yet a better, stronger and more free America to give to my children that calls me to the ranks. Dr. Annis, I happily join you in battle.
Oklahoma City, OK
President, American Society of Dermatology
"We are at war"
by Edward R. Annis, MD
One of the first lessons learned in high school debate is the necessity for defining terms. Words and issues during debating conflicts must be clearly defined and have a fixed meaning. Todays failures to clearly delineate the meaning of Managed Care is cause for careful deliberation.
Prior to the intrusion of government, with a promise for a Great society, in the early sixties, medical care in the United States was generally well managed in a pluralistic fashion. Great numbers felt secure with their family physicians, confident that if and when specialty services were required, their doctor would direct them to the proper sources.
Inevitably, and in a steady evolutionary manner, we experienced rapid expansion of new knowledge, new drugs and new technology providing better ways to prevent, to detect and to treat accidents and medical and surgical problems. Many physicians concentrated time and effort to become especially proficient in circumscribed areas leading to specialization in many fields of medicine.
Many physicians, especially in rural America, continue as solo practitioners. In recent years, cognizant of needs for family and recreation, great numbers have joined together in many different groups. In increasing numbers they have joined together as family physicians, single specialties, multi-specialties and some have joined the large and often well renowned medical centers designed for research, teaching and tertiary care as well as referral centers for the rare and the unusual. (The first group practice in the United States was established by the Mayo brothers in 1887.)
As the nations population expanded medical graduates found opportunities to serve in both rural and urban America. With the growth in communication and
transportation the vast majority of the nation’s population benefited from the Managed Care provided by their doctors with decisions being made by patients often with their families, especially for the young, and their doctors. It was this system which during my first twenty five years in the profession provided managed care in a manner which
justifiably gained pre-eminent world recognition.
Today managed care is no longer clearly defined, but rather has taken on many and often decidedly different connotations. Proper professionally managed care has many salutary benefits. Many patients can safely stay in a hospital for fewer days than in the past. Many surgical procedures that previously required hospitalization are
now safely performed in day surgery and most medical practices have adopted
reasonable clinical guidelines to produce predictably favorable and sometimes better outcomes. These updated measures to managed care are merely a continuation of the evolutionary manner in which the profession has always continued to provide good care to those in need of medical professional services. It also reflects the kind of care still being provided to the two hundred million people not yet corralled by employers or persuaded that HMOs and other types of managed care will best care for them and their loved ones.
Threats to patients and their physicians are growing at an alarming rate because of another type of managed care. With strong support from government a new class of entrepreneurs threatens to undermine the ability of doctors to provide the quality care
that people need and want. Many employers, as well as some political leaders, have been convinced that money can be saved by contracting with them for managed care. Already successful in many parts of the country are large and well financed companies which dominate the delivery of health
care. Physicians are denied the anti-trust law protection that enables insurance companies and managed care enterprises to use their economic leverage to force physicians to accept unfavorable terms in contracts or be left out.
It is the predatory practice of some managed care entities which violates the very essence of the patient-doctor relationship. Their arbitrary and unilateral dictatorial methods are inherently unethical and immoral. It is not most physicians involved in managed care who are unethical because vast numbers, hand cuffed by discriminatory anti-trust laws, have been intimidated, sometimes threatened and often unwillingly forced into contracts in order to feed, cloth and educate their families. As the large
managed care companies continue to gobble up smaller operations they increase their marketplace dominance and even further quash physicians ability to avoid them.
Many managed care programs are awash in cash. News reports of some for profit HMO purchases have been in the billions. Some medical loss ratios have been reported at seventy percent, sixty percent and some under fifty percent. Such obscene costs and profits from money raised for health and medical care are siphoned off for high administrative costs, returns to stockholders and multi-millions for salary and benefits for their CEO’s.
In the past it was steadily increasing government intrusion that interfered with
patients and their doctors. Today, because of government encouragement, by giving job-based health care unfair tax breaks, it is business operations that are promising a vast array of ‘free service’ by arbitrarily dictating ever diminishing fees.
News reports that 50 million employed people have chosen managed care are
false. It has not been employee decisions, but rather that of employers whose prime concern is to limit payments as a cost cutting measure. Employee compliance with minimal complaints derives from the belief that someone else is paying their bills.
If government granted to individuals full tax deductions on health related expenses, as it does for employers, individuals wold be empowered to make decisions and choose their doctors and hospitals as was done before government's intrusion in the sixties. Such changes would encourage medical savings accounts and the return of true insurance with adequate deductibles and much lower premiums for protection against costly medical or surgical problems. Insurance is the most
expensive way to pay for ordinary medical care since it first filters medical dollars through non medical avenues. With such reasonable changes physicians and other so-called providers would have to offer their services at reasonable and fair prices knowing that it was the patient and not some third party paying for services rendered.
A number of major corporations have given employees an opportunity to manage their own funds for routine care with great success and with significant savings for both the company and their employees.
Serious objections to such a reasonable approach already have produced major opposition from H.H.S. bureaucrats and insurance companies, the former determined to maintain their absurd rules and regulations and the latter determined to protect their profits for ‘managing” doctors and hospitals.
Many avaricious for profit managed care operations, like cancer, demand radical surgery.
Physicians must have the right to practice medicine and manage the care of their patients unencumbered by restrictions constructed by business or government bureaucrats.
Whether we are socialized by government dictates or quasi-socialized by business dictates, the result is the same. However, socialism of any kind is not inevitable despite the present well financed push toward what Hilaire Belloc called the servile state. It cannot and will not be reversed if great numbers lack the courage to attack its basic faults.
Too few physicians recognize that we are at war, and fewer still have enlisted to
serve in the fight. The issue is freedom - for patients and their doctors. Things don’t just happen in our society, people make them happen. Let’s go to war!
Miami Shores, FL
Why a National
Practitioner Data Bank?
by Chester C. Danehower, MD
Have you ever wondered why a National Practitioner Data Bank exists, or have you ever questioned why one is even necessary? The theory is that the public needs to be protected from incompetent physicians, incompetent dentists, and other incompetent health care providers. At first glance, this theory seems reasonable. However, upon deeper evaluation one discovers that no other profession has a national data bank for its so called wrong doers unless you consider the most wanted by the FBI to be a profession. In fact, the National Practitioner Data Bank was established prior to congress' even considering a data bank for sexual molesters. Could it be that we are viewed by society and our elected officials as being as dangerous to society as child molesters and the most wanted by the FBI?
This conclusion, of course, is ludicrous, since we are recognized the world over for providing the finest health care available. In addition, there is already an excellent mechanism in place to protect the public. The federation of State Medical Board Examiners and the AMA work together in a comprehensive manner to this end. If a mechanism is already in place and congress is looking for ways to save money, then why does not congress just eliminate the National Practitioner Data Bank? In addition to the millions of dollars that were originally spent by our federal government to implement the data bank, several million more dollars either have already been or will be spent in the near future in updating this program. Attorney Kent Masterson Brown in his address at the third annual meeting of the ASD stated that when some action seems irrational, then money or sex is usually the reason. However, in this situation, I feel that a third more powerful force is at play, and that is the quest for power. Implicit in this quest is control over other individuals. In this case medical doctors are the primary target. By far the largest percentage of individuals listed in the National Practitioner Data Bank are medical doctors. When you consider how easy it is for a physician to be listed in this infamous data bank, it is really frightening. To be listed all a health care provider has to do is lose or settle a malpractice claim for any amount. In addition, various disciplinary actions also have to be reported to the data bank. Once an individual is established in the data bank, the name is never removed! The National Practitioner Data Bank 1994 Annual Report states that "at the end of 1994, a total of 72,931 individual practitioners had disclosable reports in the data bank." Most of these individuals are medical doctors. The data bank was opened in 1990. At this rate it will not be long before most medical doctors are listed!
When the National Practitioner Data Bank was first implemented, it was agreed by our government and the AMA that the data in the bank would not be open to the public. Unfortunately various consumer advocate groups along with Congressman Ron Weyden attempted last year to have the data released to the public. Legislation introduced by Congressman Weyden fortunately failed. Not to be dismayed, Congressman Weyden is again at work this year, and is again threatening to introduce legislation for release of data bank information. In fact, the newspaper barrage against physicians has already started with recent articles by Ann Landers and a Sunday September 17th front page headlined article in the Denver Post entitled "Doctor-data demand grows." This activity reminds me of a witch hunt, and will accomplish nothing positive, but it will stir up distrust by the public of the medical profession and will be detrimental not only to physicians but to our patients as well. It is simply a misguided attempt to denigrate the medical profession.
If you think that there is not an attempt to denigrate the medical profession in this country, I need only point out OSHA, CLIA, the RBRVS, and various PRO activities. These activities are each just as ridiculous as the National Practitioner Data Bank, and have all been implemented for the purpose of discrediting our profession and instilling fear in physicians. If the public distrusts our profession and if physicians cower in fear then we can easily be controlled, and control is power.
What must we do? We must work ceaselessly to abolish the National Practitioner Data Bank, and oppose any other activity that attempts to discredit our profession. We must again take control of our profession, and we must once again be allowed to discipline our own. We must provide the best possible care for our patients because it is our professional obligation, and not because we are forced by our government through burdensome regulations and threats of fines and jail sentences. We should start with the National Practitioner Data Bank!
Immediate Past President