There is a lot of attention being paid to the surprise move by the people of the United Kingdom who last week voted to exercise their right to opt out of the European Union, aka “The Brexit.” Those who benefit from maintaining the status quo are shocked and aghast. They should not have been so unprepared for the result. When you oppress a free people long enough and make them do things that they know are against their own self interest, and may even bring about the end of their own existence as they know it, at some point, they will revolt, as well they should.
Under the radar of most of the media, the same sentiment of discontent has been fermenting in America for quite a long time. It is now coming to a head as a segment of the population is now realizing that they have it within their own power to throw off the yokes of their oppressors. That segment of the population are known as physicians.
For centuries, (for right, and no question at times for wrong) the world of health care was lead by physicians. At least from the time of Hippocrates, the foundation upon which the concept of health care was build was the sanctity of the relationship between a patient and his/her physician. While history has certainly known its share of of quacks doing harmful procedures or selling snake oils, the vast majority of physicians during the past several hundred years have dedicated their lives to helping their patients as best they could with the most up to date medical knowledge available to them at the time. It was not a job. It was a profession. It was a vocation. Few questioned that physicians, by virtue of their training, their dedication, and their compassion should be responsible for making decisions in health care and shaping its future. This is not the case today. What happened?
Many will point to the introduction of modern health insurance as one of the reasons physicians have been disempowered. The introduction of Medicare and Medicaid during the “Great Society” inserted not only the private companies into the physician:patient relationship, but now the heavy hand of the federal government as well. The effect was incremental. At first, insurance was only used to pay for hospitalizations and surgeries. Over time, it became more and more intrusive, or as some would say, comprehensive. It became routine for subscribers to expect that all doctor visits should be paid by a third party, including routine care such as physicals, visits for minor illnesses and injuries, etc. It was akin to demanding that your auto insurance cover your gasoline and oil changes and your homeowner’s insurance pay for light bulbs and heating oil. The more mandates are put on coverage, the more it will cost to provide.
This paradigm shift where health insurance covered ALL health care services, not just catastrophic illnesses made it necessary for the insurance companies to get more involved in the daily decisions in health care. They could not let a doctor and a patient do whatever they had mutually agreed upon as medically necessary. If they did, the insurance company would not turn a profit. This ushered in the era of managed care. Since the time of legislation to legitimize the dreaded Health Maintenance Organizations (HMOs) in the 1970s, doctors have had to ask for the permission of the insurance companies to treat their patients. Physicians had lost control of their own destinies, and were at the mercy of third party payers, both private insurance companies and governmental bureaucracies. They were told that if they left the plantation of the third party payment system, they would starve. Against their own best interests, as well as those of their patients, they were compelled to stay in a system that was causing them harm.
Not only was the independence of physicians undermined by external forces, but also from within. Organizations were formed by physicians to advocate and protect the medical profession, as well as to protect the public from an occasional rogue or incompetent practitioner. They are the medical boards who oversee each specialty and do testing on new physicians graduating from residency. If they pass, they get the much coveted, but little understood by the public, title of “board certified.” Initially, the certification exam was only administered to newly minted physicians as a standardized way to be sure they had at least a minimum amount of knowledge to be considered safe to practice medicine. It started as a voluntary examination which was considered a rite of passage and widely accepted by the medical community as a whole.
Several years ago, things changed. Whether it was for the pursuit of money, power, or truly out of public concern, the individual medical boards, and their parent organization, the American Board of Medical Specialties (ABMS) changed the rules of the game. They decided that one exam was not enough. They demanded that in order to remain board certified, physicians would have to retake the examination every few years, even though much of the contents of the exam had nothing to do with their particular practice, and the material in the exam was often outdated by the time the test was taken.
The tests became more and more expensive to take, and these eight hour multiple choice tests have nothing to do with the way a physician actually practices in real life. (If a doctor doesn’t know something, they look it up or consults another physician.) The boards became more secretive about how they scored the tests, had more doctors fail them so that they could make more money on retesting, and often exempted their own executives from rules they made for everyone else.
When they did not make enough money with their recertification scheme, the devised “Maintenance of Certification”, or MOC. Now they required physicians to not only take these tests every few years, but they also required them to complete extra projects and study modules that usually had little to do with their own practices. The more they required, the more money to administer these new programs.
What started as voluntary became much less so. The boards convinced insurance companies that they should not have doctors who are not board certified in their networks. They convinced hospitals that they should not let non-certified physicians practice within their walls. They ran ad campaigns warning the public that it may be dangerous to see someone who won’t pay for their propriety seal of approval, despite the fact that there are no independent studies to prove that physicians with current board certification are any better than physicians without it.
Most doctors now submit to the humiliation of having their bodies searched, bags gone through, and being treated like criminals as they go into these computer testing centers, spend countless hours preparing for a test rather than being with either their patients or families, and spend thousands of dollars for the privilege, not because they want to do so, but because they are told they would starve if they didn’t.
There has been a sea change brewing for the past few years, and it is a good thing. Perhaps it is because the situation of present day physicians is so much worse now than it had been in previous decades that enough have reached the breaking point. For some physicians who were struggling to keep their practices afloat, they saw the passage of the so-called “Patient Protection/Affordable Care Act,” aka Obamacare, as the last straw with promises of more rationing of care, less independence, less pay, and less ability to care for their patients. For some it was being told that they had no choice but to adopt very poorly designed electronic health records (EMRs) that were enormously expensive, impeded rather than helped communication, add several hours to a physician’s workday, and basically make a person with a doctoral degree not much more than an entry level data entry clerk. Perhaps it was the fact that physicians have been working harder and harder over the years, but are paid less and less, to the point that they must sell their practices or retire before their time. Patients complain that healthcare costs are going through the roof and blame their physicians, who are the easy targets, but the wrong ones. While physicians are going broke because they are not being paid by the insurance company, the insurance executives are paying themselves tens of millions of dollars.
More and more physicians are lifting their noses from the grindstone and realizing that they are both the workhorse and scapegoat. They are the ones providing the health care in our society. At the same time, they are the ones who get disproportionately blamed for rising costs, medical errors, and price gouging. The physicians of America are now just starting to realize that they have far more power than they thought they did. They have always had it. They let themselves be blinded by the politicians, the bureaucrats, the insurance industry, the administrators, and also by their own so-called leaders who collaborate with the enemy rather than support their own. We are now rediscovering that without physicians, there would be no healthcare system.
Physicians are using social media and blogs to communicate with one another across the country and realize that each individual is not the only one suffering in silence. Physicians are acknowledging to each other that they are not the only ones who feel that their self appointed spokesmen at the American Medical Association headquarters often acts against the interest of the ever dwindling membership. Physicians openly question the motives of the American Board of Medical Specialties, and its member boards, and are publishing very damning research they have done on what they are doing with their vast revenues.
A few months ago, in the UK, before the Brexit vote took place, something unprecedented happened. The junior physicians took to the street to demonstrate and protest the fact that their crumbling system of socialized medicine, the National Health Service, was treating them as slaves, and paying them slave wages.
In the United States, shortly after the passage of Obamacare, a small, but rapidly growing number of family physicians, the men and women who provide most of the routine care for our population, who are paid a small fraction of what their sub-specialist colleagues are, started a revolt. Because they were being squeezed by the ever increasing costs of regulatory burdens and diminishing reimbursement for services they provide in good faith, they realized that they had to do something more drastic than protest. They quit.
They did not quit medicine. They quit playing the game that they could never win, the insurance game. They did something so bold and so different, many called it radical. They stopped contracting with insurance companies and started contracting directly with their patients. This is how the Direct Primary Care (DPC) model was born. Because they no longer had to worry about maintaining complicated computer systems and hiring several people for every physician to deal with insurance claims, doctors could do something that they and their patients were both desperate for…they spent more time with their patients. They were able to listen to them again, and to truly care for them the way they had always deserved. They and their patients got off the assembly line. The best thing is that they are not starving without insurance contracts. They are thriving. They are happy, and so are their patients.
Something amazing happened last week in Chicago as well. At their annual conference, the American Medical Association’s House of Delegates voted to withdraw its support for the repressive Maintenance of Certification process imposed by the medical boards. Like Brexit, it was a shock to the hierarchy at the AMA. Its members are realizing that they have the real power and that their leaders are only there by the consent of the governed.
There is revolution in the air. It is not just in the streets and pubs of the United Kingdom. It is also in the halls of medicine in both the UK and the United States. First we had the Brexit. Next, perhaps with the awakening of the oppressed physicians, we will also have the exit of doctors from their paper chains. Perhaps it will be the DRexit?
Michael A. Ciampi, M.D.