I am honored to be elected to be the 84th President of the BCMA and thankful for the opportunity to help doctors help patients. I also applaud all of the people that touch a life and make one better to reduce human suffering on a daily basis.
We are at a crossroad today. Real and timely information and communication are key provisions of the role we take in uniting together to better the health of our community and ourselves. I would like to share with all of you some facts, major issues, my views, plans and future solutions for practicing medicine at this critical time and juncture.
HONOR OF BEING A PHYSICIAN
In the course of the past few years, the health care delivery system has created an environment that has made it difficult for physicians to practice medicine. Physicians are obligated to devote more time to the business of medicine just to stay afloat.
Declining reimbursements, increasing expenses and looming reform experiments forced physician and hospitals to examine how to best work together and stay competitive. While there are major consolidations in hospital systems, insurers, and physician groups, the majority of health care in the US is still provided by small efficient quality practices that choose to remain independent without being employed or joining a large group.
MEDICAL STAFF ADVOCACY COMMITTEE
In 2008, the Medical Staff Advocacy Committee was created at the Broward County Medical Association to address that need. The structure was created to facilitate communication and dialogue between various parties which include physicians, hospitals, insurance companies and networks as well as government and accrediting agencies.
As physician rights have eroded they become alienated, disenfranchised and disempowered that the well-being of patients and alignments let alone any dialogue was thereby threatened.
In fact it is our understanding that the well-being of physicians, patients and the community are inextricably linked, for wellness cannot exist for one when it does not exist for all. We therefore created the first Bill of Rights and Responsibilities model for physicians and medical staffs in the United States (see side bar). It defines our basic rights in the delivery of that care, so as to once again empower our profession to fulfill its calling and to have our voice heard without political or monetary compromise.
A second step is the adoption of these rights and responsibilities into hospital medical staff bylaws and discussions about healthcare reform and alignments recognizing that its value will significantly improve the practice environment, quality and cost efficient care.
More importantly it opens a line of dialogue similar to having a physician hot line for concerns and suggestions and making everybody’s voice count. It is our purpose to address all matters in a cooperative fashion and in a way that promotes productive working relationships, and most importantly, safe and quality healthcare in our community.
HEALTHCARE IN THE U.S. AND TIMELINE
There is no dispute that the increased cost of healthcare has become one of the most important issues in our country. The current economics of medicine demands that we should know the facts and educate ourselves first and foremost and help the system be fixed. The future is unpredictable. There will be lots of new terms such as Accountable Care Organizations and Clinical Integration and some may be misunderstood. And any meaning may change over time. Not unlike IPA’s (Independent Physician Association) and PHO’s of the recent past, today, an ACO and or Clinical Integration could be an organization of group medical practices, networks of individual practices, hospitals and others that join together to manage a large patient population of Medicare or other insurance beneficiaries. But that is still in development including any potential bonuses from CMS or insurance companies for generating savings to the government and meeting their quality benchmarks and or the lessening of the FTC guidelines for an organization that self refers. So when we talk about adapting to current economical climate and aligning together with hospitals or other entities we will need to address the current economic climate and the Medicare and Medicaid structure in our community and the U.S.
As we all know, Medicare became a barometer for payment to physicians and hospitals by the government and insurance companies. A “public option” in Medicare or Medicaid places enormous burden on federal resources. Inherent to this social obligation is the question as to whether healthcare is a “right” or a “responsibility”. I say both.
Patient responsibilities are key issue to health care reform specifically: who will pay for it? While most patients are financially responsible and empowered when making decisions, a substantial number ignore that responsibility. Health insurers are reporting stronger earnings in 2010 in no small part simply because fewer of the members are going to their doctors. Plans are spending less on care because of the current economy and higher deductible plans. Despite these profits, insurers do not have a plan to lower their premiums.
Some 45 years after Medicare, our government is attempting to re-structure the healthcare delivery system addressing the question of rights and responsibilities in the form of the global insurance reform (Patient Protection and Affordable Care Act (PPACA) of 2010) to the people who pay for it, try to get it and to those who cannot afford it. In fact it prevents insurance companies from canceling a policy if a patient gets sick. Beginning in September 2010, discrimination against children with pre-existing conditions will be banned - a protection that will be extended to all Americans in 2014. It prohibits setting lifetime limits on insurance policies issued or renewed after Sept. 23, 2010.
Even more aggressive than lifetime limits are annual dollar limits on what an insurance company will pay for health care. For the people with medical costs that hit these limits, the consequences can be devastating. It allows patients to designate any available participating primary care doctor as a provider. A patient will be able to keep the primary care doctor or pediatrician they choose, and see an OB-GYN without referral. It also removes insurance company barriers to receiving emergency care and prevents them from charging a patient more because you’re out of network.
The Patient Protection and Affordable Act also establish an attempt at transparency with the costs of care to insurance companies as a balancing act. It requires Insurance companies to spend the majority of their collected premiums on direct patient care. I believe that if we can have private insurers truly spend 90% of the premium they collect on direct patient care it will allow our nation to count on private companies and move away from a single payer system (Complete socialized system).
These are all good provisions and in fact have already helped numerous patients in our community so why are we debating such. The answer is the same questions: Who will pay for it? And is Healthcare a right or a responsibility? This massive law was also enacted with the understanding that health care needs to be reformed in its entirety. A key provision states that Americans have a responsibility to buy insurance. Jurists differ on its constitutional legitimacy with implications extending beyond the commerce clause. Recently, in Florida a judge called the entire Act unconstitutional.
It is likely that such question will reach the supreme court of the U.S. and will have a domino effect on the entire Act by placing a roadblock for its implantation in the various states. But all of us at one point or another in our lives will receive healthcare and generate financial implications for our country particularly in the beginning and end life and have to come to grips with the reality that we are not living in a vacuum and have some minimal responsibilities.
FLORIDA MEDICAID REFORM
The Medicaid program will be expanded as the only logical vehicle to provide care to the uninsured. Medicaid payment rates to primary care doctors will increase to match Medicare payment rates for primary care doctors, facilitating further access.
Florida Medicaid Reform is a demonstration that was looking to improve the value of the Medicaid delivery system. The program operates under an 1115 Research and Demonstration Waiver approved by the Centers for Medicare and Medicaid Services in 2005 for 5 years. The program was placing Medicaid patients into managed care organizations (HMO’s) and Provider Service Networks (PSN’s) in several counties in Florida. The Medicaid reform pilot is due to expire in 2011.
After 5 years there is no clear and convincing evidence that the experiment has produced cost saving or ensures access and quality care. There is growing evidence that there is increased cost, decreased access, deficient provider networks as well as instability and inconsistency in the Medicaid plans available to patients.
The fundamental reason that it is so difficult to obtain both specialty and primary care is that very few doctors are willing to participate in Medicaid HMOs or PSNs. This is due to a Medicaid reimbursement rate too low to cover providers’ overhead, and bureaucratic barriers implemented. As a consequence, medical care access through the emergency rooms is on the rise.
The Georgetown Health Policy Report for October, 2008, raises the critical question: Do any potential savings represent efficiencies that plans are making, or simply reduced access or reimbursements to necessary care?
From my experience and observations regarding Medicaid Reform: there is decreased access to care, inaccurate information provided, higher costs, poorer care, fewer services, more forms, less satisfaction and no informed choice. I do not know how long we want to hurt patients. As you may know, this Reform was called an “experiment.” In the U.S., we cannot do an experiment on the most vulnerable population. In my opinion, as a physician, Medicaid Reform must be immediately stopped and or re-directed.
As a physician who has seen the program at the trenches and in real time, I wrote a letter of concern to the Director of the Center for Medicaid and State Operations, Department of Health & Human Services in Baltimore, Maryland on March 30, 2010. The letter describes my experiences regarding Florida’s Medicaid Reform Pilot.
Following public outcry and testimony, our letter and by no small part by consumer protection groups such as Florida CHAIN and Florida Legal Services, CMS send a letter to AHCA and did not simply extend the waiver but will only process the state’s request under the 1115(a) social security act provision and modify the special terms and conditions of the demonstration to address concerns. Unfortunately since the state of Florida is in budget crisis legislators refuse to believe that Medicaid reform experiment should be stopped and or redirected.
The Governor’s “Health Care Transition Team” also issued major recommendations and they include consolidation of the state’s health care agencies, repeal of the federal health care law, and the continued shifting of Medicaid patients to managed care. Some of these recommendations are flawed because they fail to safeguard and account for the availability of physicians and hospitals to provide quality care and access for patients creating new financial implications and inherited bureaucracy. In fact most physicians do not agree with such an approach.
Of particular interest is the section about hospitals and the federal and state financial plan as well as Medicaid reform. It is highly educational, well intended, descriptive and explanatory when describing terms such as LIP payments (Low income pool), UPL, DSH, and IGT (a system of sophisticated intergovernmental transfers).
But sobering statistics are at play in light of our current economy. According to the dept of children and families, there are over 2 million calls a month from patients requesting Medicaid coverage’s and food stamps yet it can only handle 300,000. So patients are in this void of unable to obtain care and services in a timely manner along with a freeze on hiring state workers who are going to be integral to facilitate any state or federal healthcare reform. It is ironic that the recommendations are to repeal the Patient Protection and Affordability Act because of constitutional values yet Florida wants to take away the constitutional rights of patients to choose their providers by shifting all Medicaid into managed care and to a program that failed to show any increased access, decreased costs let alone true benefits to the people.
My Conclusion and Plan The consensus by health experts is that unless patients and physicians are happy with any new system, it is likely to fail. To find a solution we have to start with physicians since we have a few thousands of years of experience treating patients and staying in business. Our voice and seat at the table when decisions are made will only matter if we persist and define all of our physicians’ rights and responsibilities and lead the way to better the health of our community along with our own.
We should pause and get to know the facts and educate ourselves first and foremost to help the system be fixed especially regarding any Healthcare reform. It is like any patient who experiences an illness for the first time and is most fearful of the unknown. Physicians and Hospitals are fearful of the unknown.
It is my strong belief that Healthcare is both a right and a responsibility in the U.S. and that should always be a platform for our healthcare reform. And yes to be responsible to purchase insurance is just as constitutional as paying taxes. So this is the time of opportunity to be engaged in dialogue through organized medicine and keep it simple. Do what we do best. Which is to practice quality medicine and advocate for the well-being of our patients and continue to be a unified outspoken voice of reason, compassion and sensibility to find solutions.
WE SHINE THE MOST AT THE MOST DIFFICULT TIMES.
I will dedicate myself to working together with physicians, hospitals, the State of Florida, the federal government and simply all patients to continue the unfettered practice of medicine which is our passion. Through the Broward County Medical Association I will promote dialogue, education and solutions to our current medical practice and healthcare reform.
I would like to thank my parents: Judy and Pinchas Elkin. Without them I would not be here. I have become who I am because of what they thought of me and the unconditional love I received.
Last, but not least, I would like to dedicate the following to my daughter Alexis Jayde. Being an Obstetrician you learn all the science about life, parenting and children. But not until you have a child of your own do you appreciate the beauty and miracle of life. I am still learning from you.
Bill of Rights and Responsibilities:
- The right to care for patients without compromise
- The right to freely advocate for patient safety
- The right to be compensated for providing care
- The right of medical staff to be self governed and independently advised
- The right to care for our own well-being
- The right to full due process when our privileges are challenged
- The right to privacy
- The right to be evaluated by unbiased peers who are actively practicing physicians in our community and specialty
Since there can be no rights without responsibility, we hereby declare that the following are core responsibilities inherent with the above.
- The responsibility to provide our patients impartial diagnosis and care
- The responsibility to advocate for our patients when they are in jeopardy
- The responsibility to provide care to those who cannot afford it
- The responsibility to participate in peer review
- The responsibility to care for our patients, our families and ourselves
- The responsibility to play an unbiased, active role in the fair hearing process
- The responsibility to carry out our professional obligations
- The responsibility to play an active role in the governance of our medical staffs