AMA to White House: Don't Dictate Care

President Obama is calling for flexibility and compromise from stakeholders in the healthcare reform debate, but the nation's largest physicians' organization warns that any attempts by the federal government to use evidence-based medicine to dictate how physicians provide individualized care would be a deal breaker.

In an interview with HealthLeaders Media, American Medical Association President Nancy Nielsen, MD, says she's already made that clear in her two summit meetings with the president in the last two weeks.

"Government control of the doctor-patient relationship is a no deal," Nielsen says. "Although there is no question that we need to be sure that the best science and evidence is used when we deal with a patient, it isn't that easy. People who think that 'we just put out a guideline and if you don't follow it, we will smack you down,' well, it isn't that simple because patients aren't that simple. What we have to get to is the concept that what needs to be done is what is appropriate for that patient."

The "smack you down" people that Nielsen is referring to would include White House Budget Director Peter Orszag, who has emerged as a leading figure in the Obama administration's drive to reform healthcare—in part because Kansas Gov. Kathleen Sebelius has yet to be confirmed as HHS secretary. The Obama administration included $1.1 billion in last month's $787 billion stimulus program to launch "comparative effectiveness" research, and Orszag has said that evidence-based medicine could be used as a financial incentive to guide physicians toward cost-effective care.

"We have a set of financial incentives that encourage more care rather than better care," Orszag told a Robert Wood Johnson forum last year. "In order to change that we need to do a lot more testing of specifically head-to-head comparisons of what works and what doesn't and we need to pay for what works and not so much for what doesn't."

That raises questions about whether an impasse may soon emerge for physicians as the Obama administration calls for compromise from all key stakeholders in the health reform debate to cap soaring healthcare costs. Nielsen says she's confident that common ground can be found.

"Peter is not a physician and we are going to help educate him," she says. "He is a good man and a smart man and he has studied a lot about healthcare. He knows that we can do better and we can. We are going to help everyone who needs to understand that sometimes there are reasons why you don't do what the guidelines say."

For physicians, it's not just a matter of policy, but an ethical responsibility to protect the doctor-patient relationship that has existed for thousands of years, Nielsen says.

"We are not going to start with an antagonistic approach that 'you don't know what you are talking about.' Our role is to say 'when you are making rules of the road let's talk about this because the people who walk that road are patients and doctors.' We are going to help them figure it out," she says.

However, some healthcare policy experts believe that—in order to achieve systemic savings—the patient-doctor relationship will be greatly affected by evidence-based medicine.

Bill Roper, MD, the CEO of UNC Health Care and the former director of CMS and CDC, supports evidence-based medicine. However, he told HealthLeaders last week that the public will most assuredly have to make sacrifices in their own healthcare services to make any meaningful reforms work. "To cover those other approaching 50 million uninsured people means taking something that is currently being spent on you and me and spending it on a person without health insurance. That by any other name is a sacrifice," Roper says.

Roper says evidence-based medicine "means we will come up with better information on what works in what setting and that means we will say 'no' to your request for knee surgery or x, y, or z procedure."

"That means a sacrifice. The American people are owed our honesty in this debate and I'm delighted that we are beginning to do that," Roper says. "To go around saying, 'We have the world's best healthcare system,' which we don't, and saying, 'You can keep every bit of healthcare you got if you want to keep it,' are just not going do it."

Whatever healthcare reforms emerge in the coming months and years, Nielsen says she's not sure how it will impact physician compensation. "I think they will probably be paid differently," she says. "I haven't heard people talking about cutting the payments, although there have been some comments about certain areas. In the stimulus bill, they put in some things that are going to make it harder to get imaging unless it appears appropriate for that patient. So, there are areas that groups of doctors are obviously going to be concerned about and try to deal with."

"We really have to focus on the needs of the patient first and then we will definitely make sure that doctors can stay in practice," Nielsen says. "The last thing you want as a nation is to do something that is going to so demoralize those clinicians that they would hang it up and leave the practice. And if you read the president's budget, they recognize that Medicare and Medicaid underpay compared to private plans. They know that clinicians have to be paid somewhat comparably to those private plans. Otherwise it isn't going to work."