My reaction to President Obama’s speech to the AMA


I was seeing patients during the actual speech, so I had to rely on the transcript.

The points that interested me the most were any language pertaining to malpractice, addressing the AMA’s recent concerns about the public plan option, and reforming the physician payment system.

I think he did pretty well.

Regarding the physician payment system, he again addressed McAllen, Texas, which is fast becoming the symbol of what’s wrong with American health care. Not sure the city is comfortable with that notoriety.

Here’s what Obama said:

That starts with reforming the way we compensate our doctors and hospitals. We need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease. We need to create incentives for physicians to team up – because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes – so that we are not promoting just more treatment, but better care.And we need to rethink the cost of a medical education, and do more to reward medical students who choose a career as a primary care physicians and who choose to work in underserved areas instead of a more lucrative path. That’s why we are making a substantial investment in the National Health Service Corps that will make medical training more affordable for primary care doctors and nurse practitioners so they aren’t drowning in debt when they enter the workforce.

Standard policy-speak about bundling payments. But, unlike the majority health policy columnists and editorials in The New York Times, he goes out of his way to blame the system, not doctors. Obviously, this is because the President is addressing the AMA, but the way to court doctors is not to wholly blame them for the health system’s ills.

Regarding primary care, the idea of simply investing more in the National Health Service Corps is grossly inadequate. First off, any improvement in primary care numbers will be seen in 5 to 10 years minimum, and second, primary care doctors are needed everywhere, not just in underserved areas.

I like that he addressed the cost of medical education, but doing something about it is another matter entirely.

Here’s what Obama said about malpractice:

I recognize that it will be hard to make some of these changes if doctors feel like they are constantly looking over their shoulder for fear of lawsuits. Some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue. And while I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed, I do think we need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine, and encourage broader use of evidence-based guidelines. That’s how we can scale back the excessive defensive medicine reinforcing our current system of more treatment rather than better care.

These changes need to go hand-in-hand with other reforms.

Probably the best we could have expected. He acknowledged that malpractice reform needs to go hand in hand with health reform, and admitted that defensive medicine is indeed a factor in medical decision making today. I agree that malpractice caps are a non-starter, and like single-payer, hope that cap supporters realize that it’s a political impossibility.

I hope that this could be the start of a more constructive dialogue where doctors are offered liability protection if they adhere to evidence-based guidelines. Under the current political environment, that is probably the best scenario that doctors can hope for. And, to be honest, I think it’s a reasonable compromise.

And finally, here’s what he said about the public plan option:

Now, I know there’s some concern about a public option. In particular, I understand that you are concerned that today’s Medicare rates will be applied broadly in a way that means our cost savings are coming off your backs. These are legitimate concerns, but ones, I believe, that can be overcome. As I stated earlier, the reforms we propose are to reward best practices, focus on patient care, not the current piece-work reimbursement. What we seek is more stability and a health care system on a sound financial footing. And these reforms need to take place regardless of what happens with a public option. With reform, we will ensure that you are being reimbursed in a thoughtful way tied to patient outcomes instead of relying on yearly negotiations about the Sustainable Growth Rate formula that’s based on politics and the state of the federal budget in any given year. The alternative is a world where health care costs grow at an unsustainable rate, threatening your reimbursements and the stability of our health care system.

What are not legitimate concerns are those being put forward claiming a public option is somehow a Trojan horse for a single-payer system. I’ll be honest. There are countries where a single-payer system may be working. But I believe – and I’ve even taken some flak from members of my own party for this belief – that it is important for us to build on our traditions here in the United States. So, when you hear the naysayers claim that I’m trying to bring about government-run health care, know this – they are not telling the truth.

Good to see him address this important physician concern, namely, a public plan option using Medicare rates, and using this approach as a “back door” to a single-payer system. It’s clear that he’ll use the repeal of the SGR formula as a bargaining chip, perhaps to get the AMA’s support of a “weak” public plan.

Right now, there are no details of what a plan would look like, so I can’t really give an informed opinion on it. A plan that coerces doctors to take it on condition of accepting Medicare, or one that pays doctors less than 130 to 150 percent of Medicare rates, are the only deal-breakers, in my view. The AMA is clearly shooting for the moon when they say they were “opposed” to the public plan, and I think both sides will eventually settle on a “weak” version, meaning, it will remain but not at a marked competitive advantage with private insurers. I can live with that.

So, in the end, I thought the President did a pretty good job. Especially with his malpractice language, acknowledgment of the practice of defensive medicine, and the fact that he’s aware that doctors are concerned about the how “our cost savings are coming off your backs.”

Will it make a difference? We’ll see. But I can say that the speech could have been a lot more antagonistic to physicians than it actually was.


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