Letters to the Editors
[Winter 1996; Vol. 23 No. 4]
A fee schedule for physicians authorized by the Maryland legislature ((House Bill 1359 in 1993), is soon to be implemented. Although details are still sketchy about the timing and the actual fees, many of our colleagues, whose practices have been devastated by managed care, labor under the illusion that a state takeover will be a good thing. They fervently hope that a fee schedule will provide a “floor” to prevent further cuts in fees by managed care. As a result of this reasoning, there has been little effort by organized medicine to protect the public or us from the disaster that the politicians have hatched.
State controls will not cure the ills of managed care, nor is it necessary to invoke a state takeover to solve our problems. As the public becomes more and more distressed by the horror stories of managed care, and the rapacious and unconscionable profits reaped by its owners, the tide will turn towards a truly free market economy that will allow patients a greater degree of control over their own health care. Once instituted however, “Big-Brother” government controls packaged as a public “benefit” will be infinitely more difficult to restrain or to remove.
I urge all colleagues to fight the fee schedule. We must insist that Med Chi pursue a vigorous legal, legislative, and public education policy to defeat this threat to health care in Maryland. A fee schedule for physicians clearly discriminates against a single group of professionals. It portends more than economic control. A fee schedule will result in state control over patient records, and over the ability of doctors and patients to contract with each other. Ultimately, it would lead to state control over medical decisions.
Although managed care has been devastating enough for the physician-patient relationship, government management is sure to make things worse, as is evident from the deterioration of the situation in Canada, and from our experience with government controlled medicine here in the United States. While managed care companies can impose gag clauses, withhold payment, and remove from their panels physicians who advocate too loudly for the patients government employs even more draconian punishment to enforce its will. The same computerized profiles and arcane rules used to prosecute physicians under Medicare and Medicaid regulations will undoubtedly be employed to enforce a Maryland state fee schedule. What will happend to our initiative, our creativity as clinicians, and our ability to be honest on behalf of our patients, when we are intimidated by the specters of confiscatory fines, bankruptcy, and imprisonment?
Think about what happens to patients in government run health programs. The contrast with private medical practice has always served to elevate the expectations for government medicine. If private medical practice is destroyed by fee controls, bureaucratic mediocrity will become the standard for the community.
By such mechanisms, state mandated fee controls are sure to cause severe damage tot he health of our patients, the health of our loved ones, and to ourselves. If we, without a valiant fight, allow ourselves to be turned into “Stepford” Doctors, groveling for an illusory minimum wage allowed to us the government bureaucrats, we will lose that essential independence to advocate for patients that has enabled American physicians to be so effective.
Even if the state of Maryland guaranteed fees that were higher than the amounts now allowed by managed care (a spurious assumption at best and subject to fee reduction each subsequent year), ti would still be an immoral and foolish bargain to accept--for we would be selling out our patients and our own professional ethics in the process. If physicians lose the trust of the ocmmunity, if we ignore the computerized data collection of our patients’ records wihtout their consent, if we sell out independent medical judgement out of hopes the state will pay us a few cents more, we will no longer be effective professionals. For these reasons, I urge you to contact Med Chi (from Maryland only 800-492-1056, or 410-539-0872), and urge that they join in our fight to preserve the physician-patient relationship in the “Free State” of Maryland.
Richard S. Epstein, M.D.
Dr. Epstein is current Chair of the Ethics Committee of the American Psychiatric Association. He is a former President of the Washington Psychiatric Society (1994-95).