The Medical-Political Complex is Thriving

The Medical-Political Complex is Thriving

President Eisenhower first spoke of a “Military-Industrial Complex” in 1961. As he prepared to leave office, he was speaking directly to the country in his final presidential address, and the tone of his speech was one of alarm. He warned us of the potential danger in allowing unabated rise of power and influence of the thriving, post-WWII military armament industry over the political process in America. It is very important to note that when he introduced to us the phrase Military-Industrial Complex, President Eisenhower had already experienced the rapid build-up of a centralized US military force for the purpose of conquering a global threat, and the concurrent and well-anticipated emergence of a lucrative, private armament industry that was necessary to fuel the military machine along the way. This powerful and perfectly-matched relationship between government and private industry was necessary to achieve success, but also had the potential of developing a life and will of its own, and might even ultimately harm America.

When you listen to an audio recording of his speech, it is very easy to notice that President Eisenhower was fearful that the Military-Industrial Complex might become much more dangerous to our national security than it had been essential to win the war if allowed to infiltrate and corrupt our political process. Throughout his career, Eisenhower benefited from this government-private industry relationship, but he also had the character and wisdom to recognize the risk for corruption and to control the relationship (mostly) during his presidency. He did, however, fear that subsequent administrations might eventually succumb to its lure. Unfortunately, although in different form, his fear and parting caution to us all have now become reality.

Today, a new and no less concerning “complex” has emerged in our society. Our federal government has perceived a critical need to make health insurance available for tens-of-millions, and has passed unprecedented and industry-altering legislation (ObamaCare) to achieve this goal. As a direct result, a new crop of agencies and organizations, both public and private, have rushed in to create a mechanism to implement the many aspects of the law—broad coverage, cost control, resource management—with plenty of opportunity for political maneuvering, high profitability, and extraordinary influence over much of our population along the way. Within the executive branch of government alone, the Department of Health and Human Services has been charged to develop and implement hundreds of thousands of federal regulations—many of which will come to light and application over the next 10 years—to implement ObamaCare, and confusion and chaos in the process is inevitable, anticipated, and paralyzing for most doctors. To overcome this problem within the private industry, the legislation also allows for and facilitates the emergence of thousands of Accountabile Care Organizations (ACOs). But ACOs do not alleviate the concerns of doctors and patients. Instead, ACOs have the primary responsibility to collect, safeguard and manage billions of dollars received from insurance companies and federal and state agencies for the purpose of payment of healthcare services for each patient, to create guidelines for the eligibility and distribution of healthcare services to each patient based on medical complexity and other criteria, and to make payment to doctors, hospitals, and other providers of healthcare services rendered to each of their patients while guaranteeing conservation of healthcare resources and monies. Sound complicated? Well it is, and this is just the start of the Medical-Political Complex.

Here are 3 real and growing dangers to you and to me within the Medical-Political Complex:

1. PRIVACY
The right to privacy in our country must be preserved, without compromise at every level, for every aspect of our healthcare—medical conditions, medications, genetic risk, life-style choices—so that our very liberty is protected. For many centuries, doctors have pledged an oath of confidentiality for the healthcare of each of their patients, and, by doing so, their patients have confidence that they may confide and trust in their doctor without the threat of subjugation, oppression and harm. Within the confines of this sacred doctor-patient relationship, the privacy of one’s healthcare can be controlled and maintained; it is simple and direct, and accountability is well-defined. But within the ever-expanding Medical-Political Complex, the privacy of one’s healthcare is at constant risk of being compromised at a global and indiscernible level; it is complex and clandestine, and accountability is elusive.

Today, our privacy is at constant threat by individuals and agencies whose motives and purposes for knowing and using our healthcare information are far different than those of the doctor. So, until I see that every private sector employee and every government service worker who might have access to the private healthcare information of patients is both willing and required to acknowledge this profound privilege and responsibility, and to express their own oath of confidentiality to our patients, I am simply unwilling to accept their new role in America’s healthcare system. Furthermore, until the new healthcare system under the Medical-Political Complex is proven in its design to track and hold accountable each and every individual who through negligence or purposeful malfeasance misuses the privilege of having been entrusted with the private healthcare information of others, it is simply too high a risk. In the current administration, we have seen a number of examples in which our federal government has utterly failed to ensure reasonable and thorough accountability for inappropriate and possibly criminal activity within its own ranks. They simply do not make a convincing argument or demonstrate proven results that they have perfected self-management and self-policing at all, and I do not think it is worth it for any of us to allow them to take the chance with our healthcare information!

The essence of confidentiality drives a healthy doctor-patient relationship. Such privacy is tied directly to our freedom and liberty, and protects each of us from undue influence by those whose knowledge and use of such information might cause oppression and harm. The notion that a private or federal agency—its employees and contractors—must know an individual’s medical conditions in order to facilitate access to healthcare or provide insurance to pay for their healthcare is a dangerous proposition indeed. For many centuries, doctors have been trained to rise to and accept this noble privilege, and I am quite sure that neither health insurance companies nor government agencies understands the seriousness and solemnity of this privilege, and they are certainly not capable, let alone prepared, to do so.

2. SERVICES AND RESOURCES
The acquisition, distribution and application of healthcare services and resources in our country must be delegated, without compromise at any level, to those whose fundamental principle and expressed oath of healthcare delivery—above all else—is patient welfare. This is simply common sense. Doctors are the only professionals both trained and positioned to advocate for their patients. And I’m not referring to just any doctor. Rather, I am specifically referring to each patient’s specific doctor. In fact, doctors who work for insurance companies, for government agencies, and for ACOs cannot commit to advocating for their clients’ or their taxpayers’ welfare, because these doctors simply cannot establish a professional relationship with each specific patient whom their company or federal agency serves. Furthermore, these doctors have an inherent an unresolvable conflict of interest because they actually work for a company or an agency whose primary responsibility is to conserve resources and save cost. When this contractual responsibility to their employer conflicts with their moral obligation to their patient, which one wins? Most doctors and patients still don’t fully understand the long-term impact of having a Medical-Political Complex “middleman” destabilize the doctor–patient relationship, but it will become very clear to most when cost savings begins to overpower patient welfare in the new healthcare system.

To insurance companies and federal agencies, our healthcare has become a commodity. By acquiring majority responsibility and legislative authority for the payment of most of our healthcare, companies and agencies working within the Medical-Political Complex have created their own point of control in virtually every aspect of our healthcare. Unfortunately, and almost imperceptibly, it appears that as a direct consequence, each of us has also now become absorbed into a massive “risk pool” enabling insurance companies and federal agencies to assess and manage more easily the welfare of their clients. We have essentially surrendered our individuality in healthcare. We have become just a number, or a commodity, in the system. However, people are not and never should be reduced to commodities, which are routinely valuated, bought and sold, itemized on a ledger, or written-off. We are not stocks and bonds to be traded on a market, and we are not sterile, impersonal lists of medical conditions and medications. It has never been a part of healthcare that patients are seen as some type of data-depots that may be gathered and harvested as a tool through which funding for their healthcare services might be planned by an ACO. How dehumanizing! Yet, we will all be “treated” that way by the companies and agencies working within the Medical-Political Complex. We all understand that health insurance companies and state and federal agencies make most of the payments for our healthcare today, and they do so because for many decades we have allowed them to do so. But we also know all-to-well that the vast majority of us is paying ever-increasing health insurance premiums, higher deductibles, and even higher taxes for this convenience. In return, we are experiencing restricted services and longer delays for services. We are paying more in insurance premiums and healthcare taxes than we ever have in the past, and the return value of our healthcare system is dropping dramatically at the same time. We must not be a very good investment!

Under the Medical-Political Complex, the value of the doctor–patient relationship is diminished considerably. But when the doctor–patient relationship is uncompromised, there are no commodities, and there is nothing to get in the way of doctors working as hard as possible on behalf of each of their patients. At the simplest level, regardless of cost of care, limitation of healthcare resources, medical complexity, commitment to compliance of therapy, socioeconomic status, or political persuasion, each doctor is liberated to provide the best possible healthcare to each of his/her patients because this sacred and most critical relationship simply cannot be compromised by lesser influences. This is the foundation of an effective and efficient healthcare system in every society, and when compromised, for any noble or nefarious reason, the system is destined for collapse under its own weight. The doctor-patient relationship and its preservation and growth is the only mechanism by which the Medical-Political Complex can be kept in check.

3. PERSONAL RESPONSIBILITY AND ACCOUNTABILITY
Today, there is a lot of discussion about “Universal Healthcare”. But, healthcare is universally personal and private, and no more. And, like it or not, each of us has ultimate responsibility to obtain and pay for our own healthcare. However, for many decades, the insurance industry has gradually assumed the primary role of paying for healthcare services, and in doing so, has positioned itself to exert greater influence and power over the day-to-day healthcare decisions of its clients. Furthermore and concurrently, the integrity of the doctor–patient relationship has degraded, and the drive and desire of doctors and patients alike to restore their relationship has been feckless. In the face of increasing costs associated with the delivery of healthcare services, fewer patients seeking preventative healthcare and making cost effective medical decisions in consultation and cooperation with their doctors, and the growing apathy of patients to assume responsibility and accountability for their own healthcare, the Medical-Political Complex has once again stepped in to fill the gap. But the Medical-Political Complex can never mandate or legislate personal responsibility and accountability! It can only punish those patients who fail to manage their healthcare appropriately according to their ACO by restricting services on the back end, and punish those doctors who fail to control the cost of the delivery of healthcare by abiding by the ACO’s guidelines by reducing their reimbursement, and publicly and openly characterizing their practice as “inefficient”. It is precisely this heavy-handed control and influence over each of us that is frightening in the long-term. By relinquishing responsibility and accountability for our own healthcare, we lose our liberty and freedom along the way. What a shame!

Long before ObamaCare, our culture has failed to prioritize, foster, and develop long term, preventative healthcare practices, and for this shortcoming there is plenty of responsibility and accountability to go around. Patients simply have not made the time to see their doctors routinely, and to develop the type of professional relationship with their doctors that might serve as a catalyst for making better healthcare decisions. They have also come to rely heavily and almost exclusively on their insurance companies to make payment for even the most simple and straightforward healthcare services. Doctors, on the other hand, simply have not been as accessible to their patients or as willing or able to tackle long-term preventative healthcare issues, which requires a great deal more time with the patient. They have also found it almost impossible to break away from the growing restrictions and requirements of insurance contracts in order to restore the purity and supremacy of the doctor-patient relationship. For an industry as intimate and personalized as healthcare, both patients and doctors alike should have seen long ago the onset and progression of a separation in their relationship, and could have done something to repair and restore the relationship before someone else—the Medical-Political Complex—intervened.

Neither healthcare nor health insurance is an entitlement in this country. Medicare, a federal healthcare insurance plan, certainly is an entitlement; but remember that Medicare is designed to provide payment for some of your healthcare, not to provide healthcare itself. In the same light, the Affordable Care Act (ObamaCare) is a mechanism by which patients might obtain health insurance—not healthcare—and, as it turns out, it is certainly not proving itself to be affordable to individual patients or to the taxpayers. The Medical-Political Complex is the perfect union of a massive federal bureaucracy and a profitable, private healthcare industry and uses the crises of apathetic, irresponsible patients, overwhelmed, over-regulated doctors, and a rapid rise in the cost of healthcare services to legitimize sweeping legislation to capture control of the entire industry. This control will never be relinquished to each of us, unless each of us is willing to recapture our own responsibility and accountability in the industry. It is up to us.

President Eisenhower’s sage insight in 1961 clearly has application now that we have this new Medical-Political Complex to deal with. In the end, he described a formula for corruption that is destined to emerge any time our federal government facilitates or allows any private industry to fuel its own appetite for centralized power over the people. It is also as powerful and compelling a reason for each of us to remain vigilant for such circumstances to prevent devastating consequences in our Republic. If President Eisenhower were alive today, he might say something like this to us:

“Until the latest of our healthcare crises, the United States had no government-controlled health insurance industry. This conjunction of an immense health care establishment and a large government-subsidized health insurance industry is new in the American experience. In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the Medical-Political Complex. The potential for the disastrous rise of misplaced power exists and will persist.”

Michael J Lucherini MD MS

Dr. Lucherini specializes in Internal Medicine and Pediatrics. He practices at Summit Medicine and Pediatrics in Mesa, AZ, and is a Pioneer in Direct Access Medicine. His opinions expressed herein are personal and do not necessarily reflect the opinions of his staff, his patients, or his colleagues.

© 2015 Summit Medicine and Pediatrics
All Rights Reserved

Medicine in America: We are not in Santa Monica Anymore

Medicine in America: We are not in Santa Monica Anymore

Today, I found the copy of Gray’s Anatomy given to me by my mother many years ago after I told her that I wanted to be a doctor. It reminded me of how often I’m asked about when I decided to become a doctor. And, for most of my life, when asked that question, I have quipped that I couldn’t think of anything else that I was as capable of doing that was both fun and would pay the bills. In the last several years, however, it has not been as easy for me to snap off that retort. Things have changed in the profession of medicine, and drastically so, in the last several years. The art and science of medicine have now been overwhelmed by the politics and economics of healthcare, and I fear for us all—patients and doctors alike—as the fun, the finances, and the integrity of medicine itself fade away.

The truth is that my decision to become a doctor was influenced early on by Hollywood. As a child, I watched the television series, Marcus Welby, MD. Dr. Welby and his associate, Dr. Kiley, were in private practice in Santa Monica, California, and they modeled for all of us in America the ideal medical practice. They were quite simply America’s doctors. I recall one particular evening at home in Massachusetts, in our tiny living room with my mother and my teenage brother, as we watched Robert Young show us exactly how medicine is supposed to work. It was my first lesson in becoming a skilled and compassionate doctor. Leonard Rosenman’s dramatic music set the mood, and Dr. Welby approached his sick patient, lying helplessly and hopelessly in her own bed at home, placed his black bag on the floor, and held his patient’s hand during the entire scene. I can’t recall what they talked about, or the outcome of his visit. But even to this day, I remember distinctly making a decision at that moment that most children make at some point in their lives—to be a doctor.

I don’t ever remember seeing Dr. Welby open his black bag on the show. He had lots of medical instruments in his office, wore a long white coat, and occasionally used his stethoscope to listen to his patient’s heart and lungs while making pleasant conversation. But the point of the series wasn’t to teach the science of medicine; Hollywood simply wanted to use the dramatic ups and downs, twists and turns—comedy and tragedy—in the doctor-patient relationship to its advantage. It wasn’t until after high school that I learned a good doctor needs to know a lot more than just how to have a compassionate touch and how to give sound advice to solve patients’ medical problems. So even if Dr. Welby didn’t have to open his black bag in Hollywood, I would have to fill my own black bag with lots of tools and instruments (including the tool of medical knowledge) to do the job in the real world of medicine. Still, I had a good feel for the art of medicine at a young age as I tackled the science part in the following years.

After training, I made a rare decision. Unlike most of my peers I decided to open a private medical practice. While many of my colleagues elected to specialize further or to accept a salaried teaching position, it seemed natural for me to start a private practice. I had always envisioned myself in a small office, taking my time with patients, and developing long-lasting, professional relationships with extended families in the community. Most would argue that it is a more challenging path to take. And I suspect that the influence of Dr. Welby had much to do with this decision, although I am reluctant to admit openly that Hollywood had shaped my career at its earliest stage. Nonetheless, I had great fun building a successful community practice over 15 years, and, after the first few years of practice, I was able to pay my bills along the way. Initially, medicine was a comedy.

But medicine was not always fun. At the outset, I did not anticipate the immense pressure associated with negotiating health insurance contracts, maintaining hospital credentials, managing office personnel and marketing my business in private medical practice. I was neither prepared for nor warned about the challenges of these business aspects of medical practice during my training, and, in order to be successful, I had to learn fast while I cared for my patients. Along the way, it seemed that I got better and better at the practice of medicine, but I could never quite master the complexities of the business of medicine. I had to hire and rely on self-proclaimed “experts” to explain to me the need for participation in a “HMO”, or the advantage of signing a contract with a “PPO”, and it took years for me to understand the process of medical billing with ICD-9, E&M, CPT and “Modifier” codes, and the ever-changing restrictions and limitations of benefits given to Medicare patients. With all that I had learned in 8 years of training to be a doctor, it just wasn’t enough to simply take care of my patients in order to have a successful medical practice. I also had to accept the responsibility of participating in an evolving and increasingly complex healthcare system, most of which was outside of my understanding and influence and had nothing to do with the practice of medicine itself. I guess all that extra stuff was handled by Dr. Welby—or by his agent—behind the scenes.

Now, after 15 years of practice in medicine, things have really changed for the worse. In the end, I just could not seem to fix the myriad of problems in the healthcare industry as they affected my small private practice. The federal government has stepped in to create a massive bureaucracy that I call “FedMed”, and the resulting confusion and chaos has simply destroyed my ability to care for my patients. As hard as I tried to make sense of FedMed and to adapt my practice to comply with its requirements, I just could not find a way to do so without compromising the doctor-patient relationship. So, I left the practice I created in search of a better way to deliver healthcare to my patients. In the wake of my departure, it was easy to see that the fun, the finances, and, most alarmingly, the sanctity of the doctor-patient relationship—the basis upon which the entire industry of healthcare rests—is now in jeopardy throughout the healthcare system. FedMed failed us. The changes are happening fast, and it seems to me that we are all to blame.

Through Accountable Care Organizations (ACOs), doctors are now expected to prioritize control of medical costs above the welfare of their patients, or pay a financial penalty if they do otherwise. “Pay-for performance” reimbursement contracts incentivize doctors to accept fewer, healthier, and more treatment-compliant patients into their practice and to reject patients whose poor health and poor compliance with treatment plans will place the doctor at financial risk. With shrinking health insurance reimbursement to doctors and hospitals, limited numbers of contracted physicians and panels of patients, and restricted health insurance benefits for patients, most private practices with a fewer physicians must see up to 40 patients a day to keep their doors open. Now, the doctors accept spending less time with their patients and risk making errors in patient care. And so it is very likely that we will see the emergence of large, multi-specialty medical clinics, with rotating doctors—many of whom speak English as a second language—and limited availability, long wait times in the reception area to see the doctor, even longer wait times just to get the appointment to see the doctor, and less time with the doctor once you get back to the treatment room.

The cost of healthcare is rising, the pace of healthcare is quickening, and the quality of healthcare is diminished. I am convinced that our culture is not prepared for this transition.

Patients, already confused about the difference between health insurance and healthcare and increasingly upset at having to pay higher health insurance premiums for, in many cases, less coverage, now question the value of the relationship with their doctor. Their false assumption that the higher cost of their health insurance should translate into more available and affordable healthcare is shattered when patients realize that they are first responsible to pay enormous deductibles to their doctors, and then have to wait longer times at every turn to receive their healthcare. Patients feel betrayed by the very men and women into whose hands they are expected to place their lives, and they find little reassurance and satisfaction when given a packet of written information about how to make appropriate lifestyle changes at the end of their office visits instead of being given opportunity to discuss their concerns—face-to-face—with their doctor. Most feel that they can get the same information with a simple online search and avoid the hassle of waits, delays, and impersonalized medical care at the clinic. And I don’t blame them. Medicine is transitioning from the personal to the population, from the relationship to the regulation, and from managing the disease to managing the dollar.

Doctors, on the other hand, feel the awkward burden of collecting payment for services before even giving medical care to their patients, or risk receiving no payment at all. And, even worse, doctors are realizing that they have lost control of their industry. For decades we have allowed willingly and with little resistance the health insurance industry to acquire control of the flow of healthcare finances, all for the short-term benefit of receiving a guaranteed, contractual payment for services received on behalf of our patients. The consequence of selling out in this manner is that doctors have placed themselves at the choke-point for payment of services, and we now have grown accustomed to defining our relationship with our patients through the perceived value and strength of the patients’ health insurance companies. Our patients are no longer our “patients”. Rather, they are our “panel” and we are their “primary care physician (PCP)”.

The doctor-patient relationship has degraded from a covenant-based commitment to a contractual agreement. And this is precisely the point at which medicine has become a tragedy.

Once again, we are all at fault. Doctors and patients alike are beginning to realize that the entire system of healthcare has changed in a way that is causing doctors by the tens-of-thousands, crushed by the weight and confusion of FedMed, to leave their profession, and patients by the tens-of-millions to experience true abandonment and victimization. It is no wonder that the doctor-patient relationship, the very foundation of healthcare in America, is broken. The real question now is whether or not we have the will to change course and find a way to restore this trusted and noble relationship, and rebuild healthcare in America from the ground up.

Marcus Welby, MD was on television for 8 seasons. I lasted in a traditional private medical practice for 15 years. I believe that we should start taking back America’s healthcare by watching the series episodes because the message for Hollywood and for each of us is quite clear: “We are not in Santa Monica anymore.”

Michael J Lucherini MD MS

Dr. Lucherini specializes in Internal Medicine and Pediatrics. He practices at Summit Medicine and Pediatrics in Mesa, AZ, and is a Pioneer in Direct Access Medicine. His opinions expressed herein are personal and do not necessarily reflect the opinions of his staff, his patients, or his colleagues.

© 2015 Summit Medicine and Pediatrics
All Rights Reserved