As Congress and President Obama square off over healthcare reform, one of the most prominent and widely courted voices in the debate is the American Medical Association, the country's largest physician organization. The AMA gave Obama a mostly warm reception when he spoke at its annual conference in June and made big news last week by backing the House's healthcare bill. The amicable tone is a departure from the 1990s, when the AMA helped defeat President Clinton's healthcare reform plan. U.S. News spoke last week with AMA President James Rohack about the prospects and challenges of healthcare reform. Excerpts:
The AMA surprised some people when it came out in support of the House bill last week. What was behind the endorsement?
The AMA is clearly committed to health reform this year. We believe the status quo is unacceptable. We want to make sure patients have access to a healthcare system that has affordable health insurance coverage for everybody. As we took a look at those principles and the bill that was being proposed, we knew that our endorsement would be helpful to keep the legislative process moving forward.
You also called the bill a "starting point," which suggests you're not totally satisfied.
We are committed to reducing unnecessary costs in healthcare, and clearly that bill did not address the unnecessary costs of defensive medicine [when doctors order extra tests to protect themselves from lawsuits]. So we are trying to work to get the bill amended so there can be ways to address the unnecessary costs of additional tests or therapies that are being done because of defensive medicine.
Politically, one of the big concerns right now is that the Democrats' plans don't do enough to make healthcare cheaper. Do you agree?
If Congress has the will to achieve a vision of affordable healthcare coverage for everyone—and we agree that's where we need to go to—they are going to have to address reducing unnecessary costs. Defensive medicine is an unnecessary cost. Antitrust barriers that prevent physicians from interacting with each other—that's another real barrier to reducing unnecessary costs. If Congress is committed, we're committed to work with them to come up with something that is going to be right for patients and right for the physician who cares for them.
You're a cardiologist. How has that shaped your view of what's needed for real healthcare reform?
Many of the patients I care for have medical conditions that they are going to have all their lives. Many times we have to use medications. One of the things I've recognized is that sometimes medications come out and you're not really sure which one is right for your patient. I think with health reform, there's an opportunity to say comparative-effectiveness research can be very helpful for a patient and a physician to know what's best for them—as long as it's not mandated that you have to go one way versus another, because patients are different. It's important information that right now we just don't have.
You've emphasized the problem of defensive medicine. Just how costly is it?
Some have estimated in the $200 billion range. Others have said it may not be as much. The bottom line is it is a significant contributor to tests being done to prevent problems in a courtroom down the road. People who show up to an emergency room now with abdominal pain wind up getting a CT scan. In the past, it was "Well, your belly isn't tender. Your white count is not elevated. The chance you have anything going on that's of concern is about 1 in a million." But say you didn't order the CT scan, and later on it comes back, and oops, you were one of the 1 in a million and you get a suit. So then everybody said, "OK, we're just going to order CTs on everybody." The problem is there is no protection. There is no safe harbor. If you follow the guidelines and don't order tests, you can still be sued.
What about chronic diseases? There are studies that say two thirds of the recent rise in healthcare spending is due to obesity, diabetes, and other chronic conditions.
When you take a look at mortality rates for heart attacks 30 years ago, if you had a heart attack and you made it to the hospital, you had a 30 percent chance of dying in the hospital. Now your rates are 2 percent or less. We have done wonderful, great things in the U.S. We just haven't kept up with the evolution of how we need to align incentives to have patients stay healthy and avoid the unnecessary costs.
So how do you change those incentives?
The most cost-effective treatment for diabetes is proper nutrition and physical activity. But guess what? No insurance pays for eating right or taking an hour a day for physical activity. But what they'll pay for is bypass surgery, stents, lots of drugs. So like many things, we need to have a discussion on how we can help people make choices.
Moderate Democrats say we need to change the way doctors and hospitals are paid and reward them for the quality of care they provide. Do you agree?
The AMA is very supportive of trying to allow our healthcare system to evolve. But the reality is that over half of healthcare in the United States, on the outpatient side, is delivered by individual doctors in their offices or by groups of less than three. Our antitrust laws prevent physicians from coming together to try to provide that better care [by sharing information]. So the issue is, it's a nice sound bite, but there are going to have to be some changes in barriers that currently exist that prevent doctors from coming together.
What could help?
People point to electronically integrated systems like the Mayo Clinic, Cleveland Clinic, even Scott & White healthcare, where I practice. We have our own electronic medical records that connect all 770 doctors, our hospitals, and our regional clinics. It's a wonderful environment to practice in, but our system doesn't talk to anybody else. In Temple, Texas, where I practice, we have a Veterans Administration, and we also have a military hospital, Darnall Army. None of them talk to each other. They've got three different electronic systems. So when I care for patients that are veterans, they go to the veterans system for their care, and they come to me for cardiology. We switch back and forth trying to figure out what's going on.
How did our healthcare system get to this state?
We are where we are because we have not focused on a goal. What's happened is that we have innovated, we have created wonderful ways to do stuff, but we still have a payment mechanism that's based in 1942, in which if the employer provides health insurance, it doesn't pay tax on it, but if the individual purchases his or her own health insurance, they have to pay after-tax dollars on it. And then we get to 1986, when you have the Emergency Medical Treatment and Active Labor Act, which says anybody who shows up in an emergency room gets healthcare. And then in 1997, the federal government says, 'You can't charge a Medicare patient more than what we are going to pay you.' So what's happened is that you have a confluence of cost shifting that finally has reached a point that we've got great technology, we've got wonderful ways to keep people alive longer, but we also haven't had a discussion of what's the goal.