LSU School of Medicine
Thursday, April 6, 2000
9:00 A.M.

E. Ratcliffe Anderson, Jr., MD
Executive Vice President
American Medical Association

Thank you for that warm welcome. It’s great to be here with you today.

I was LSU “all the way” as a student – I’m really proud to tell you. Undergraduate and medical school. A Tiger all the way. And let me tell you – you’re going to be needing those Tiger qualities out there in the real world – because it’s a jungle out there. With managed care and government mandates, you’re going to be glad that you’ve learned to be as bold and tenacious as a tiger in the world you’ll be entering.

I’ve got a pretty ambitious agenda of things we’ll be covering this morning so I want to get going. We’re going to be talking about MedPac and its relationship with graduate medical education. We’ll talk about physician organizing – not just housestaff organizations, but also the new PRN, the Physicians for Responsible Negotiation. And then I’ll be bringing you up to date on some federal legislation that helps empower physicians – and some that is designed to protect both our patients and our profession. But first, I’d like to put in a push for your involvement in organized medicine.

When I got out of medical school in ’64, I just thought all you had to do to be a good doctor was to be competent and take great care of your patients. Everything else would follow. You’d have social position, you’d have a good livelihood, you’d have instant acceptance by your community. You would be esteemed – and all that.

But – when my generation wasn’t watching – we let the business of medicine come in and enslave us. With the mentality that doctors are just employees. So we’re still working to get this situation rebalanced – and we’re going to need your help.

We all know from basic physics that the hardest thing to do is to overcome inertia. And we’ve done that. This thing is rolling now. The pendulum is swinging back to center. But we’re not there yet.

I don’t think for a minute that we could eliminate managed care. I think anybody who’s thinking we’re going to go back to the way medicine was thirty or forty years ago is unrealistic. But I do believe we’re going to get some balance here. Because, after all, if managed care were eliminated, what would take its place? My fear is that what might replace it would be what I consider the worst of all possible solutions: a government-run, single payor system. So I do believe what we’re struggling for here is balance. I would like to think that we would be able to work with the insurers and health plans to achieve that balance. And to keep in mind that there’s a big difference between working for someone – and working with them.

Back in November, the National Labor Relations Board overturned 23 years of policy by voting to recognize medical interns as employees. That decision grants interns and residents at privately owned hospitals the right to collectively bargain and to form unions. This is an important change. While most interns and residents train under favorable conditions – all of them aren’t as lucky as those of you here at LSU.

That NLRB ruling gives all of you physicians-in-training greater leverage to address patient-care, practice and workplace concerns with your employers. But we urge all interns and residents to use this new-found right responsibly – keeping medical ethics, professionalism – and most of all – your patients at the forefront of your negotiations with employers.

We at the AMA have supported the development of more than 20 Independent Housestaff Organizations, operating successfully in some of the largest health care institutions around the country. Now I don’t want to push you on this, but you know that the Housestaff Organizations at Tulane and Ochsner are up and running. And you can rely on the AMA for any help you need for making your own Housestaff Organization a reality here at LSU.

The AMA has been careful to make sure that interns and residents are able to address their workplace concerns – without diminishing or jeopardizing medical educational standards. The new national negotiating organization – Physicians for Responsible Negotiation – or PRN – created by the AMA is another vehicle interns and residents can use to bargain collectively with their employers.

Consider PRN a professional alternative to other trade unions and labor organizations. PRN represents physicians exclusively. It honors the highest standards of medical professionalism and ethics. For an example of that professionalism, physicians joining PRN will not strike by withholding essential patient care from their patients.

PRN will be recognized by the NLRB, which means that employers will have to sit down at the bargaining table with PRN physician members to discuss their concerns “in good faith.” PRN will help physicians in addressing those administrative hassles and breaches of contract, such as delays in obtaining authorization for appropriate care, downcoding, and prompt payment.

Another function of PRN will be to challenge abusive and unfair practices of insurance company giants. Especially those that seek to use their dominant market share to limit patient choice. Or to jeopardize patient care by not offering patients and physicians reasonable contract provisions.

Not all physicians can or will belong to PRN. In fact, only about one in seven physicians are considered employed – which may soon change, thanks to some federal legislation I’m going to be telling you about. We just like to think that PRN – which now operates independently of the AMA – simply offers just one more option for employed physicians to address concerns with their employers.

Now about that federal legislation. It’s known as the Campbell Bill – it’s a federal law-in-progress that will finally give self-employed physicians the right to negotiate collectively with health plans. We were very pleased to hear last week that our efforts to get this bill passed are paying off – the House Judiciary Committee overwhelmingly passed the Campbell Bill. This move out of committee – and into the larger arena of the House of Representatives – is just the first step for this bill – but it’s a big one, showing bipartisan support for leveling the playing field between enormous health plans, individual patients and physicians.

We’re counting on this bill to allow physicians to come together to negotiate with health plans over contract provisions – so we physicians can continue to fulfil our role as patient advocates. You see, our role as patient advocates can easily be undermined when we have no leverage in the face of large, controlling health plans.

The Campbell Bill’s move through committee puts us well on our way to repairing the damage being done by the current system in which health plans can choose profits over patients. The Campbell Bill will provide a counterbalance to the growing power of insurers as they merge into enormous bureaucracies. Last week’s victory puts us one step closer to fixing a system that allows insurers virtually unlimited power over our patients – and our profession.

Another law-in-progress is the patients’ bill of rights. The AMA has labored for more than five years to pass legislation that provides our patients with protection from managed care abuses. We are working toward patient protections such as:

• Allowing doctors to make medical decisions.
• Holding health plans accountable for their actions.
• Allowing patients to appeal if their care is delayed or denied.
• Applying these protections to everyone with managed care instance.

In a perfect health care delivery system, patients would not need a bill of rights. Instead patients would get the care they need, when they needed it, no questions asked. Unfortunately, the current delivery system is not perfect. Although the patients’ bill of rights issue received a lot of attention last year – it has not yet been signed into law.

Like the Campbell Bill, however, the PBR is moving through the system. The AMA fought long and hard for the Norwood-Dingell Bill, which the House of Representatives passed in October. The Norwood-Dingell Bill allowed for physicians to make medical decisions -- and for patients to appeal if their care is delayed or denied. It applied to everyone with managed care insurance and – most important – holds health plans accountable for their actions.

The Senate passed a weaker bill that didn’t include right-to-sue provisions and was more a HMO bill of rights than a patients’ bill of rights.

The bills are now in conference committee – in fact, the committee met yesterday – and I have high hopes that the protections we have lobbied for so long will soon become law. But to be realistic about the bill, we do have to take into consideration the well-financed campaign by the health insurers to frustrate the best intentions of the House – and the patients of America. But whatever happens – in committee or at any point in the process – the AMA will make sure that our patients are protected from the excess of the insurance plans. If not this Congress, then the next. And meanwhile, we are doing all that we can to ensure that the tough questions about the politics of American health care – are campaign issues that the candidates in Election 2000 cannot ignore.

The goings-on in Washington often seem very far away from our daily lives. I know they sure did when I was a student here. But if you don’t know already, you should be aware, that most graduate medical education funding comes from the Medicare program. And just how the money travels from Washington to places like LSU has been very much under discussion.

In the Balanced Budget Act of 1997 -- or BBA -- Congress made several cuts to Medicare that also decreased GME funding. Last year, the AMA was able to prove to Congress that the cuts made in 1997 were too harsh. Research showed that at least 100 teaching hospitals would be operating at a loss by 2002. So we worked with Congress to restore some of the funding to teaching hospitals.

As Congress continues to look for ways to decrease Medicare spending, it has debated various proposals to decrease GME funding. That BBA also established MedPac, the Medicare Payment Advisory Commission, an independent federal body to advise the U.S. Congress on issues affecting the Medicare program. Our AMA chair, Dr. Ted Lewers, serves on that Commission.

Last summer, MedPac issued a report that stated policymakers should reorient their thinking about Medicare’s payments for graduate medical education. Payments to teaching hospitals for the direct costs of operating approved medical residency programs should be viewed as payments for patient care, not as payments for training.

That’s why MedPac recommended that Medicare’s two payments to teaching hospitals that are currently labeled “medical education” be combined into just one payment. That one payment would better account for the higher costs of enhanced patient care that teaching hospitals provide to Medicare beneficiaries.

We will continue to study these proposals and will work to make sure that graduate medical education funding remains stable for future generations of medical students like you.

So, as you can see, organized medicine makes a big difference in our world today.Where does oversight of government payments for graduate medical education come from? Where is support for the Campbell Bill coming from, that federal bill that will allow self-employed physicians the right to collectively negotiate with health plans?

Where is the federal patients’ bill of rights coming from?

The answer to all of these questions is “organized medicine.”

And that’s why I want to make sure today that you understand the role that organized medicine takes in today’s world of American healthcare. And the role you must take in making sure that organized medicine is part of your future careers.

Let me tell you a story I’ve been telling to a lot of physicians. A story that to me says it all. It’s a story about an encounter I had this past fall. Soon after the Senate vote on the Patients’ Bill of Rights, I was lucky enough to be at the Ryder Cup, the international golf championship. And at dinner after the tournament – a friend of mine introduced me to Senator Don Nickles. Now, as you may know, Senator Nickles is a Republican from Oklahoma, the Assistant Majority Leader of the Senate – and a very influential man.

My friend introduced me to him as: “Andy Anderson, the EVP of the AMA.”

The Senator said, “I know. And I’m not very happy with the AMA these days.”

So I said right back to him, “I know, Senator. And you need to know that the AMA is not very happy with you, either. The bill your party passed out of the Senate – was a sham. It doesn’t protect patients – it protects the insurance industry."

I told him that we’d had any number of physicians calling the AMA to tell us that they’re not happy with the Senate bill – and that their patients aren’t happy, either. And then I told him: “I know you don’t care about 750,000 physicians, but you’d better care about 280 million American patients.”

The point is, we’re doing what we’re doing – not for politics, not for headlines, nor for the greater glory of ourselves and our practices. No, we’re striving to preserve the core values of high quality care and the role of physicians as strong and effective advocates for the needs of their patients. And that’s the solid foundation that supports our involvement in organized medicine.

But there’s just one problem about all this that really bothers me. And that is, all that we achieve through organized medicine – goes to everyone, every physician whether or not he or she pays his dues or shows up at meetings. I keep telling folks that we all have to be on the membership committee. All of us. Every single one of us. And that includes interns and residents. Because we need the other two-thirds of the profession. We need their resources -- and even more important -- we need their representative voices. With that, our power grows exponentially.

If we could get all the physicians of America together when we go and speak to Don Nickles and whoever else . . . If we could remind our legislators and regulators that we represent every physician in the country . . . If we could really show them that we’re all united on this and so are our patients . . . I tell you, we would be invincible. We have potential clout here that is unquantifiable. It is enormous.

But too often, rather than bringing it together, we run around like particles in Brownian movement. Spinning our wheels instead of maximizing the efforts we have made.

So what are we going to do about this? What I’m telling you we need to do is for every one of us to go out there – and make sure all our partners – all our colleagues -- are supportive of organized medicine. And even go beyond that. Peer pressure is such an enormous thing in our profession. At our scrub sinks and in our conference rooms – and even out there on the golf course and tennis courts.

And we’ll have it right when we say, “Charlie – or Charlene -- isn’t it great what organized medicine’s done for you. The NLRB recognizing medical interns as employees. The right to collectively negotiate with health plans. Patient protections that actually protect our patients – and not the insurance industry.”

Now. I’m sure you recognize that it is not our nature, physicians’ nature, to go out and do battle with health plans. We just want to take care of our patients – and that’s all we ought to want to do. But with the health care environment what it is today – we’ve just got to go out there and stand up for ourselves and our profession.

And speaking of working with others, before I leave I just want to make sure you’re aware of some new tools the AMA has developed to help keep organized medicine working together effectively.

I hope you’re all familiar with the AMA website. And use it to keep in touch with emerging issues in American medicine. The AMA website offers you a great way to contact your lawmakers in Washington -- through its comprehensive Grassroots Action Center. For those of you who haven’t yet visited it – you’ve got a treat in store for you. With just a few clicks of the mouse you can have a front-row seat for what’s happening in Congress.

And easily contact your Senators and Representatives to let them know what you think about what’s going on. Because the more they know about our needs and wants -- the better they hear our common voice -- the better they can represent our interests in Washington. And this service is free to our members – as well as to all of organized medicine.

The AMA website also gives AMA members free access to our new Compliance Interactive Tutorial System, or CITS. That’s an Internet-based tutorial and reference system with practical information on current fraud and abuse regulations. You may not need that information now – and I hope and pray you won’t need it in the future – but CITS is a terrific tool to protect yourself and your practices against the overzealousness we’ve been seeing on the part of HCFA.

The first course in CITS outlines what you need to know about government investigations and how to respond when Medicare carriers allege billing errors or seek repayment for “overpayments.” Additional courses will come on-line this year concerning supervision and billing rules for non-physician employees as well as rules governing Medical Director/ Medical Advisor agreements. We recognize that one of the greatest challenges in the highly regulated world of medicine is complying with more than 100,000 pages of health care regulations. So we developed this new on-line program to help educate physicians and their staffs about the laws, regulations and policy shifts that govern federal fraud and abuse enforcement. It’s a good way to deal with the ever-growing regulatory burden we bear – without the expense of outside consultants.

So here we are at the very beginning of the twenty-first century. Working together for common goals. Sharing the latest technology – as well as the most time-honored ethical foundation. And you know as well as I do, that whatever we do for and through organized medicine – we are doing, not for ourselves. We are doing this for the patients of America. Because it is the right thing to do.

Together, we can make medicine’s agenda a reality for all American patients and all American physicians. With your help, that’s exactly what we are going to do. So I thank you for all you have done for American medicine – and for all that you are going to do. And thank you, too, for bringing me back here today. Go Tigers!

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