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"The Future of American Health Care"
Carolinas Medical Center Core Curriculum

Carolinas Medical Center
Charlotte, North Carolina
July 5, 2000 – 7:00 a.m.

Randolph D. Smoak, Jr., MD
American Medical Association

Good morning – and let me say what a pleasure it is to be here with you at Carolinas Medical Center this morning.

Personal acknowledgments as appropriate, including Dr. Rick Greene, friend for more than 20 years.

And I can’t think of anywhere I’d rather be than here today, for one of my first official acts as the AMA’s new President.

They say a prophet is without honor in his own country, but you’ve deeply honored me with your invitation today.

As for the prophecy part, however – I don’t claim to be an oracle. But for many of you as new residents, and for all of you as attendings, fellows, residents and administrators – today I’d like to talk a little bit about where health care is headed for the future.

You’ve chosen to be part of the most exciting, vital profession in the world. But it’s also a profession that is rapidly changing.

Medicine has advanced so far, just in the years that I’ve been in practice. And the truth is, no one can adequately predict all of the technological innovations we’ll see in the years and decades to come.


Just in the past week, the airwaves have been flooded with news of an advance we wouldn’t have dreamed of when I sat in those seats where you are now.

I’m talking about the completion of the mapping of the human genome.

Amazing advance. With amazing potential to help patients.

At the same time, a major new area where we as physicians will need to work to protect our patients.

Francis Collins, head of the Human Genome project, minced no words when he appeared on Good Morning America recently. He told America that the key challenge now is to use this information to benefit patients – without allowing insurance companies and employers to misuse it to withhold coverage from patients at risk.

This is only one of many areas where the changes in today’s technology and today’s health care marketplace are forcing physicians to take steps to protect those in our care.


Of course, you’re all familiar with the Patients’ Bill of Rights debate in Washington right now.

At the AMA, this has been a key concern for six years and more.

Now, we are coming in to what may well be the final stretch.

We should all take heart in seeing the broad, national, bipartisan support for the our continuing battle for meaningful protections of the rights of patients in this country.

But the overwhelming support we found in the House of Representatives -- the Norwood-Dingell bill – was never matched by the Senate.

Unfortunately our Senators caved in to the $100-million-dollar propaganda campaign by the insurance industry.

And they passed what I would call the insurance industry protection bill.

Now a joint Senate-House conference committee is working to resolve the wide differences between these bills. The process has been lengthy – but we are hoping for good results.

To bring pressure on some of those members, the AMA has been running ads in their home states – calling for real patient protection.

You might have read about it in The Wall Street Journal earlier this summer – the AMA has launched an aggressive advertorial campaign to help members of that committee see the light, so to speak.

It asks, “How long does it take for an elephant to give birth” and “How long does it take for Congress to pass a Patients’ Bill of Rights?”

And it answers those questions – two years for an elephant – six years for the bill of rights – and counting.

And keeping the pressure on – with a major press conference in Washington last Thursday

Meanwhile, the American Association of Health Plans began its own campaign -- a scare campaign that blames medical errors on physicians and calls them the real problem with health care today.

The AMA yelled “foul.” We wrote an open letter to the AAHP saying, “Your recent ad campaign sets a new low.”

“The AAHP is only interested in patient safety as a tool to block enactment of meaningful patients’ rights legislation.”

The President has said he’ll sign a bill that protects patients.

We are closer now to success than at any time than since we began – but the issue is still in the balance.

Today, I’m hopeful – that the conference committee will do what it should do – protect the patients of America not the insurance companies of America.

If the House-Senate conferees agree on the right kind of bill, you and your patients will be free of the often-disastrous interference by health plans.

And if they can’t agree, and Congress chooses to let the status quo continue, the AMA won’t quit.

We’ll keep on fighting for you and your patients – no matter what. Bringing that failure to the attention of every voter we can between now and November.

Congress may go away, but the issue will not.


We’re keeping the full-court press – holding Washington’s feet to the fire – on for more than Patients’ Bill of Rights in this election year.

It is one of the themes of the new AMA National House Call – a grassroots, state-by-state, city-by-city effort begun in December – to make sure each presidential candidate takes a strong, positive stand on health care issues.

Not just Patients’ Bill of Rights.

But meaningful Medicare reform, adequate coverage for the 44 million Americans not insured today, proper use of the tobacco settlement funds –

And other healthcare issues that poll after poll show are the number one or two or three top issues in the minds – not of the politicians – but of the American people.

And the grassroots approach is paying off.

They know those questions are coming from us or from the media, who we brief wherever we go.

They know health care is number one with voters in poll after poll. Recently, Wall Street Journal quoted a GOP strategist who said – and this is her quote – “You cannot be a majority party unless you talk about issues that the majority of people care about.”

I call that a bipartisan quote about a bipartisan issue.

Now we have to see what the partisans do about it.

This much is certain – from television ads to the talk at town forums, health care issues are front-and-center in this year’s campaigning.

And as a physician, and an AMA physician – I’m proud to say we’re a key part of that.


But it’s not just patient issues that are on the line. There are physician issues in the balance right now as well.

Last Thursday, a key vote was taken in House committee on a piece of legislation you should know about.


Now moves to full House vote, and we hope next to the Senate.

Because it’s one of the issues Congress, strategists and the presidential candidates -- and all Americans should be talking about -- not just physicians:

I’m talking about the Quality Health Care Coalition Act of 1999 – the Campbell bill.

It would allow self-employed physicians the right to negotiate collectively with health plans.

It would offset the enormous advantage insurance companies have in dictating what the underwriters think is appropriate patient care – and appropriate levels of quality.

Hoping for passage this Summer. Now is a good time to contact your representatives – regardless of party -- and remind them of how essential it is to level the playing field for physicians.

Because while this is nominally a physician issue, in the end it is a patient issue, impacting the quality of care we can provide.

And we need all the help we can muster to get that point across in Washington – and around the country, for that matter.


The AMA was deeply disappointed in the results of last week’s committee vote.

Because it’s one of the issues Congress, strategists and the presidential candidates -- and all Americans should be talking about -- not just physicians:

I’m talking about the Quality Health Care Coalition Act of 1999 – the Campbell bill.

It would have allowed self-employed physicians the right to negotiate collectively with health plans.

It would have offset the enormous advantage insurance companies have in dictating what the underwriters think is appropriate patient care – and appropriate levels of quality.

We made major headway this year, and will keep working for passage in the future.

Because while this is nominally a physician issue, in the end it is a patient issue, impacting the quality of care we can provide.


In the meantime, there is positive news to report on the negotiation front – concerning the new vehicle for physician advocacy named Physicians for Responsible Negotiation – or PRN.

It is up and running independently of the AMA.

It is working on its first contracts to represent physicians who – until now – had little or no voice in dealing with their big, managed care firm employers.

Because of laws governing employed physicians, only about 100,000 physicians are currently eligible to join. But thanks to an NLRB decision last fall, residents are eligible to be a part of this exciting program. Although thank goodness, here at Carolinas Medical Center, you have responsive leadership, and it’s my guess you don’t need it.

Not all physician are so fortunate. PRN has its first bargaining assignment – representing physicians working for the Medicaid HMO in Detroit named Wellness Plan.

Those physicians – like many of our colleagues across the country -- feared they would have no say in the plan’s future.

And we physicians have a very critical stake in the future of any plans –

Especially where patient care and quality of care issues are concerned. It’s our job. And PRN will help us do it.

Of course, PRN will negotiate without strikes, without shutdowns or slowdowns, without any of the abuses its critics claimed.

Like so much of the criticism aimed at AMA issues – PRN criticism tries to scare a public that really is more fearful of HMO abuse than physician organization.

PRN is a simple, direct, American way to settle disputes – and fight back again unjust abuse of power.


We are fighting back – also – against a potentially unjust abuse of power in the wake of the Institute of Medicine’s report on medical error.

For all of the media coverage and emotion generated by the report, the issue comes down to no disagreement –

No debate or argument – over whether medical error exists or whether we can’t learn from mistakes and move on.

The debate, the disagreement, the argument has to do with the extent to which mandatory report of errors will result – not in learning and improvement – but in blame and lawsuits.

Long before the IOM report -- the AMA helped launch the National Patient Safety Foundation, with the help of physicians, medical societies and health care and consumer stake-holders from across the nation.

And we did so with the avowed purpose of adapting airline and aerospace industry practices to error detection and correction.

That approach creates a culture of cooperative learning and mutual improvement – as opposed to a culture of blame and trial lawyer enrichment.

And that’s what we’re urging on the Congress now.


Let me depart from legislative and labor issues at the national level and talk for a minute about direct, local actions the AMA has been taking.

We have partnered with 49 state medical societies to form the AMA Litigation Center.

It currently is pursuing 22 cases – in state and federal courts – on behalf of physicians and their patients.

Some samples:

  • Sued Aetna/US Healthcare with the Medical Association of Georgia for money damages under Georgia law resulting from late payment of physician claims;

  • Sued United HealthCare Corporation and Met Life with the Medical Society of the State of New York – accusing the two firms of knowingly using flawed, invalid data to reduce their payments for medical services;

  • Fostered an investigation of anti-competitive practices within two Pennsylvania Blue Cross and Blue Shield associations.

The list goes on – but the message is the same:

The Litigation Center advocates in the one way our adversaries understand – in the courtroom.

There’s a second private sector advocacy initiative you’ll be interested in.

It’s the AMA Model Managed Care Contract – now updated and unveiled at AMA House just two weeks ago.

The revised model contract speaks to such emerging contract issues as “all products” policies, reimbursement issues and plan bankruptcies – as well as strategies you can use to challenge health plans when your time comes to enter the marketplace yourselves.


And speaking of challenges – that’s just what the AMA did in forcing HHS to update payment systems in last fall’s Balanced budget Refinement Act.

We went after HCFA to increase Medicare physician payments – to catch up with reality – and HCFA announced a 5.8 percent target growth rate for this year’s Medicare physician payments – a record level for them.

The original Sustainable Growth Rate would have been 2.1 percent. Now it’s 5.8.

The next step AMA is taking is pressure to force HCFA to update the methodology that produced the imbalance in the first place.

Last December we sued them – and we’ll keep advocating – to replace fuzzy thinking with real-world data and inclusion of new technologies in the backward-looking SGR process.

In the meantime, the White House announced earlier last month that it will propose adjustments to hospitals, nursing homes and others, to the tune of $21 billion dollars over the next five years, offsetting some of the reductions you’ve felt as a result of the BBA as well. Vital news for academic centers like Carolinas Medical Center.


Finally, today, I’d like to talk briefly about one more issues – tobacco. It’s a concern near and dear to my heart, and of course, a major political hot potato for all of us here in the Carolinas.

The AMA has been fighting a pitched battle with Big Tobacco for many years now – beginning with the efforts of our Resident Physician Section many years ago, which led to the ban on smoking on domestic aircraft.

Now, we are leading pitched battles in the states to assure that the dollars from the tobacco settlement are used for anti-smoking education and prevention. Working to assure you have the tools you need to help your patients quit – or better yet, never start.

A report released last week by the U.S. Public Health Services tells us that we’re not giving enough support to patients in helping them to quit. And that as little as three minutes of our time can make the difference in their success, along with support for prescriptions for patches, gum, therapy, etc.

Statistics say that this year, 20 million Americans will try to quit smoking – but only 1 million will succeed.

And it’s not just an American problem. As tobacco companies lose customers in this country, they are targeting markets abroad. By the year 2025, tobacco-related illnesses will claim 10 million lives worldwide every year – the entire population of New York City every year. And that’s not acceptable.

And that’s why, later this summer, the AMA will be sponsoring the World Conference on Tobacco OR Health, August 6-11 in Chicago, to create strategies to change the political and economic values that lead to tobacco usage.

Joining us in hosting this event will be the American Cancer Society and the Robert Wood Johnson Foundation.

And we expect more than 3,500 people at this world gathering – from physicians to leaders in government health ministries, cancer societies and other interested groups.

And I hope that if your schedules permit, you will decide to be there, too. And if not, that you’ll follow the results online.


Today, I promised you I’d talk about the future of medicine in America. But as you can see, there are so many events in the works now, it is hard to predict what the future will hold.

The rise of Internet medicine, and the need to be aware of patients’ growing desire for information.

The emerging technologies of genetics.

New imaging techniques that mean we don’t even have to operate in many cases to find out what is wrong with a patient. . .

All of these are vital areas of growth. But they go hand in hand with changes in the marketplace.

In the past 30 years, we’ve seen an unprecedented – and unpredicted – level of change in our delivery systems. And for the future – all I can promise is that more change is ahead.

But while I can’t tell you what all of those changes will be – I can give you a tip that will help you stay on top of them.

It’s this simple: Join the AMA.

You’ve heard a lot this morning about what the AMA is doing for the physicians and patients of America. And that is only the tip of the iceberg.

For a long time, medical societies in this country have been suffering from membership decline. Now – those trends are changing. Physicians are realizing that only the clout of our unified voice can get the job done for our profession and those it cares for.

And the AMA, as the oldest and largest national medical association in the nation, is leading the curve in patient and physician advocacy.

We are involved in literally every sector of medicine today.

From our work with the organizations that accredit medical education and residency programs, like the:

LCME (accredits medical education programs in 125 U.S. and 16 Canadian schools; AMA is one of two sponsors)

ACGME (accredits residency programs; nominates members to all residency review committees – one for each specialty; AMA is one of five sponsors)

To the ACCME (accredits continuing medical education; AMA is one of seven sponsors)

To sponsorship of the Educational Comission for Foreign Medical Graduates

And beyond accrediation, to fighting for research dollars for our academic medical centers.

To all of the initiatives I’ve described this morning.

We’re there. We’re everywhere.

Now all we need – is your involvement.


Yesterday, this nation celebrated its independence. Its freedom from tyranny from outside our borders. And the earned right to determine our own national future.

That’s what July 4th is all about – celebrating those achievements. And there have been many of them.

In many ways, America is a model for the world, and others seek to emulate what we have created.

No less is true of American medicine.

But just like those dedicated signers of the Declaration, to continue to achieve our freedom to practice medicine as we know it should be practiced, we must commit to make a stand.

That’s what membership in organized medicine is all about. And that’s why I’m urging you to join us.

Because with all that has changed in American medicine, and all the changes ahead – one thing remains constant. And that’s the essential caring relationship we share with our patients. And our pledge to do all that we can for their good health.

Never forget that each and every one of them looks to us, their physicians, to care for them in the critical moments of their lives. To care about not just their bodies, their organs, their vital systems, but to actually care about them as well as to care for them.

In a day when one study shows patients have less than a half-minute to tell their doctors what’s wrong; when managed care moguls spend $100 million dollars to lobby against Patients Bill of Rights; when America is hunting for leaders, we have an opportunity to lead.

For 153 years and more, the AMA has been providing that leadership.

We are heirs to a rich tradition – participants in a worthwhile cause – and as physicians, the best hope our patients have.

I thank all of you for your commitment to patients, and for your decision to be a part of this wonderful, amazing, powerful profession.

And I thank you for all that you will do, in the months and years to come.

You are the future of American medicine – and together, we are a force to be reckoned with.

Thank you, and now I’ll be happy to take your questions.

Last updated: Aug 01, 2000

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