The ACP initially accepted the challenge, but quickly withdrew from the field. Nonetheless, several entertaining posts resulted. If nothing else, the following posts clearly outline the glaring deficiencies of the medical professions’ “New Ethics.”

Part 1 – DrRich Issues A Challenge To the ACP: Since the Weblog Awards have seen fit to throw us together in a formal “contest” about medical ethics, let’s take this opportunity (for the sake of the voters) to debate the following proposition: The New Ethics promoted by the ACP is harmful to patients, and destroys the ethical underpinning of the medical profession.

Part 2 – DrRich Renews the Challenge: While the ACP cogitated on whether their new Weblog Awards finalist status obligated them,  the mighty ACP, to respond to DrRich (best known as some guy in the blogosphere), DrRich revealed for them the Right Way to think about medical ethics.

Part 3 – The ACP Issues a Formal Response, and DrRich Rebuts: The Chair of the ACP Ethics, Professionalism and Human Rights Committee responds, and informs DrRich that he makes much ado about nothing. DrRich offers a devastating rebuttal that, in the end, proves to be dispositive.

Part 4 – Further Goading By DrRich: Attempting to entice the ACP to respond to his rebuttal, DrRich becomes just a touch less polite, by offering a commentary on the ACP’s astounding exhortation that physicians practice “parsimonious care.”

Part 5 – Advice to Primary Care Physicians Who Labor Under the “New Ethics:” Having demonstrated the fundamental bankruptcy of the New Ethics, and the inability (or unwillingness) of their professional organization to respond to a reasoned challenge, DrRich offers some advice to the very physicians who are expected to work under these untenable ethical precepts.

Part 6 – Taking the Loss Philosophically: While considering himself to have won the Great Medical Ethics Smack Down (by default, if nothing else), DrRich graciously congratulates the ACP for their astounding, stroke-of-midnight victory in the Weblog Awards.

In a remarkable article that somehow* was accepted for publication in the Annals of Internal Medicine, the White House offered some friendly advice to American PCPs who may be wondering how Obamacare will affect them. That advice, to summarize, is: “We are the Borg. Prepare to be assimilated.”
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* DrRich is forced to wonder whether yet another group of medical editors is auditioning for the death panels.
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The article was written by Ezekiel Emanuel from the White House’s Office of Management and Budget, and Nancy-Ann M. De Parle, who is Mr. Obama’s Czar of Healthcare Reform. (A third author was from the McKinsey Group.) After reminding physicians of their moral obligation to the collective, the White House authors rhapsodized about all of the wonderful changes inherent in Obamacare that will help physicians to realize this obligation.

There’s actually no need to read the entire article, assuming you heard any of the 400 speeches President Obama delivered in his unsuccessful attempt to convince the public that his healthcare reforms ought to displace the holy writ as The Good News. The meat of the article, if you’re a physician, appears at the end:

These reforms will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination….These coordinating functions, to the extent that they currently exist, traditionally have been managed by hospitals or health plans….As physicians organize themselves into increasing larger groups — patient-centered medical home practices and accountable care organizations — they are, out of necessity, investing in information technology tools that are becoming both cheaper and more capable and investing in the acquisition or development of management skills that could provide these organizing functions efficiently for physicians groups….For physicians, this means a profession that is more rewarding, more productive, and better able to realize its moral ideal.

DrRich translates this message thusly: “Physicians! You have been neglecting your moral obligation to the collective, in favor of your archaic devotion to the individual patient. Under Obamacare you will need to join organizations which are devoted to the collective goals of Obamacare, and which therefore will guarantee the proper moral ideals. You must function not as individual decisionmakers, but as integrated cogs in a vast healthcare continuum, which will stretch from the centralized bastion of gleaming moral authority (from which we pen this message) all the way down to the humble tip of your stethoscope. You will be rewarded for your cooperation, or suffer for your resistance (resistance, of course, being futile).  So rejoice for the health of the collective, and for your own well-being, and prepare to be assimilated.”

Ostensibly this message is for all American physicians, but it was submitted to the Annals of Internal Medicine for a reason. The Annals is the journal of record for doctors who practice internal medicine, and who comprise the largest group of PCPs. The White House in this article is speaking directly to American PCPs.

This is because PCPs pose the greatest short-term threat to Obamacare.

Most medical specialists have already been “assimilated.” Because they require lots of expensive stuff to practice their specialties – things like gamma cameras, operating suites, catheterization laboratories, hordes of highly trained medical technicians, &c. – it is very difficult for most specialists to function as independent operators. If you want medical specialists to follow the rules, all you have to do is make following the rules a requirement for keeping their access to all the technology and the complex infrastructure they need to practice their specialties.

Only PCPs can fairly readily make themselves independent from the collective.  And more and more PCPs are choosing to do so.

The White House does not like this.  The Annals article, DrRich thinks, is the administration’s first official attempt to curtail the PCPs’ fledgling independence movement. The threat is veiled – the article instead appeals to the PCPs purported moral obligation to the collective, and emphasizes the rewards that will follow when PCPs allow themselves to be assimilated into the Borg.

So this first attempt, for the most part, is merely creepy. The next step will not be as benign.

DrRich urges his PCP friends to take heed. If you have any thought of striking out on your own, and starting a direct pay practice – thus reasserting your profession’s real moral obligation, which is to your patients – you had better act now, before it becomes a federal crime to do so.

It is quite popular for certain medical bloggers who count themselves as scientifically sophisticated to disparage so-called “alternative medicine.”

Indeed, some have built entire websites to demonstrate (Penn-and-Teller-like) that various forms of alternative medicine – such as homeopathy, therapeutic touch, the medical application of crystals, Reiki, naturopathy, water therapy, bio-photons, mindfulness training, energy healing and a host of others – are completely devoid of any scientific merit whatsoever; are pablum for the uneducated masses; are, in short, irreducibly and irredeemably woo.

These same bloggers are scandalized into virtual apoplexy by the fact that the NIH has funded an entire section to “study” alternative medicine, and worse, that some of the most respected university medical centers in the land now seem to have embraced alternative medicine, and have established well-funded and heavily-marketed “Centers for Integrative Medicine,” or other similarly-named op-centers for pushing medically suspect alternative “services”.

(An astounding list of prestigious institutions of medical science now sporting Centers of Woo is maintained by Orec.)

Until quite recently, DrRich counted himself among the stalwarts of scientific strict constructionism. He was truly dismayed that the NIH and some of our most well-regarded academic centers (under the guise of wanting to conduct objective “studies” of alternative medicine) have lent an aura of respectability and legitimacy to numerous bizarre ideas and fraudulent claims masquerading as legitimate medical practices. To DrRich, such developments were yet another clear and unmistakable sign of the End Times.

Furthermore, DrRich (a well-known paranoid when it comes to covert rationing) saw a more sinister advantage to the official and well-publicized support that government-funded institutions were giving to the alternative medicine movement. Namely, fostering a widespread impression among the unwashed rabble that alternative medicine is at least somewhat worthwhile (and plenty respectable) advances the cause of covert rationing. That is, the more you can entice people to seek their diagnoses and their cures from the alternative medicine universe, the less money they will soak up from the real healthcare system. With luck, real diagnoses can be delayed and real therapy put off until it’s far too late to achieve a useful outcome by more traditional (and far more expensive) medical means.

So, for several years alternative medicine was seen by DrRich pretty much as it is seen by all of the anti-woo crowd – as an unvarnished evil.

But in recent days the scales have fallen from DrRich’s eyes. He now realizes he was sadly mistaken. Rather than a term of opprobrium, “alternative medicine” may actually be our most direct road to salvation. Indeed, DrRich thinks that far from damning alternative medicine, we should be blessing it, nurturing it, worrying over it, in the precise manner that a mountaineer trapped in a deadly blizzard would worry over the last embers of his dying campfire.

What turned the tide for DrRich was a recent report, issued by the U.S. Centers for Disease Control and Prevention, estimating that in 2007, Americans spent a whopping $34 billion on alternative medicine. That’s $34 billion, for healthcare (in a manner of speaking), out of their own pockets.

The implications of this report should be highly encouraging to those of us who lament the impending creation of a monolithic government-controlled healthcare system, and who have been struggling to imagine ways of circumventing the legions of stone-witted, soul-eating bureaucrats now being prepared (Sauron-like) to descend upon us all, doctor and patient alike.

This is why DrRich has urged primary care physicians to break the bonds of servitude while they still can, strike out on their own, and set up practices in which they are paid directly by their patients. Such arrangements are the only practical means by which individual doctors and patients can immediately restore the broken doctor-patient relationship, and place themselves within a protective enclosure impervious to the slavering soul-eaters.

One reason so few primary care doctors have taken this route (choosing instead to retire, to change careers and become deep-sea fishermen, or simply to give up and become abject minions of the forces of evil) is that they do not believe patients will actually pay them out of their own pockets.

Well, ladies and gentlemen, this new report from the CDCP demonstrates once and for all that Americans will, indeed, pay billions of dollars from their own pockets for their own healthcare – even the varieties of healthcare whose only possible benefits are mediated by the placebo effect. DrRich believes that many of the people buying homeopathic remedies are doing so less because they believe homeopathy works, and more because they feel abandoned by the healthcare system and by their own doctors, and realize they have to do SOMETHING. The CDCP report, in DrRich’s estimation, reflects the magnitude of the American public’s pent-up demand for doctors whose chief concern is for them, and not for the demands of third party payers.

Perhaps more importantly, this new report implies that it may be somewhat more difficult than DrRich has thought for the government to outlaw private-sector healthcare activities. As DrRich has carefully documented, a government-controlled healthcare system will require the authorities to make it illegal for Americans to spend their own money on their own healthcare, thus rendering direct-pay medical practices illegal, and putting the final stake into the heart of the doctor-patient relationship.

But the rousing success of the alternative medicine universe will make such laws difficult to enact.

To see why, consider just how encouraging this new CDCP report must be to the third-party payers. Thanks in no small part to the efforts of the government (and the academy) to legitimize alternative medicine, Americans are spending $34 billion a year on woo. This amount indicates tremendous savings for the traditional healthcare system. The actual amount saved, of course, is impossible to measure, but has to be far greater than just $34 billion. Some substantial proportion of patients spending money on alternative medicine, had they chosen traditional medical care instead, might have consumed expensive diagnostic tests, surgery, expensive prescription drugs, and other legitimate medical services. Furthermore, those legitimate medical services (as legitimate medical services are wont to do) often would have generated even more expenditures – by extending the survival of patients with chronic diseases, by identifying the need for even more diagnostic and therapeutic services, and by causing side effects requiring expensive remedies. (While alternative medicine is famous for being useless, it is also most often pretty harmless, and tends to produce relatively few serious side effects – except, of course, for causing a delay in making actual diagnoses and administering useful therapy, but if you’re a payer, that’s a good thing.) So the amount of money the payers actually save thanks to alternative medicine must be some multiplier of the amount spent on the alternative medicine itself.

What this means is that payers (which, let’s face it, will soon mean the government) will be loathe to do anything that might discourage the success and growth of alternative medicine, and this fact alone may stop them from making it illegal for Americans to pay for their own healthcare.

Still, we musn’t be too sanguine about these prospects. Under a government-controlled system, the imperative to control every aspect of healthcare (in the name of fairness) will be very, very strong, and it will be very tempting to the Feds to declare at least some varieties of alternative medicine to be covered services.

But the alternative medicine establishment (bless it) will be largely impervious to government control. Practitioners of alternative medicine are expert at designing vague products and services whose techniques, theories, processes and protocols are fluid, nebulous and ill-defined. So if the Feds declare, say, homeopathy and therapeutic touch to be legitimate, covered services under the Fed’s health plan, why, the alternative medicine gurus will simply come up with entirely new forms of alternative medicine, specifically to remain outside the government plan. (New varieties of alternative medicine already appear with dizzying speed, and can be invented at will. No bureaucracy could ever hope to keep up.)

Therefore, as long as the central authorities depend on alternative medicine as a robust avenue for covertly rationing healthcare, the purveyors of woo will always be able to flourish outside the real healthcare system. And this, DrRich believes, represents the ultimate value of woo, and establishes why we should all be encouraging and nurturing woo instead of disparaging it.

DrRich has speculated on various black market approaches to healthcare which could be attempted by American doctors (and investors) should restrictive, government-controlled healthcare become a reality. But now, thanks to the success of alternative medicine, there is a direct and straightforward path for American primary care physicians to re-establish a form of now-long-gone “traditional” American medicine, replete with a robust doctor-patient relationship, right out in the open – the kind of practice where patients pay their doctors themselves.

Simply declare this kind of practice to be a new variety of alternative medicine. Likely, PCPs will need to come up with a new name for it (such as “Therapeutic Allopathy,” or “Reciprocal Duty Therapeutics”), and perhaps invent some new terminology to describe what they’re doing. But what’s clear is what they will be doing is so fundamentally different from what PCPs will be doing under government-controlled healthcare as to be unrecognizable, and nobody will be able to argue it’s not alternative medicine. In fact, it will seem nearly as wierd as Reiki.

The success of medical woo, in other words, can provide American doctors who want to practice the kind of medicine they should be practicing with the cover they need to do so. And this is why we must support medical woo, and celebrate its continued growth and success.

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Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

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Part 1 of Limiting Individual Prerogatives

Part 2 of Limiting Individual Prerogatives

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The thing about Progressives is that the characteristic which makes them most endearing (and, which makes them most attractive to the unaware), is the very characteristic which makes them the most dangerous.

Fundamentally, Progressives believe in the perfectibility of mankind, or at least, of society. Indeed, they have discovered the very Program which will lead to the perfect society, a society which will maximize the good of the whole. Their vision is so compelling, and their ends so utterly and undeniably right, that it becomes legitimate for them to engage in whatever means are necessary to achieve it. (Indeed, for those who have been paying attention, “By Whatever Means Necessary” appears to have supplanted “Hope and Change” as the catchphrase of our current political leaders.)

The thing that always trips up Progressives (and their more revolutionary cousins, the Communists), is, of course, human nature. In order for their Program to work, it is necessary for each individual to behave in the prescribed fashion. And, at the end of the day, a substantial proportion of the population (any population) will insist on striving for their own individual benefit, rather than (as the Program requires) for the benefit of the collective.

The major competing system of societal organization – capitalism – recognizes this facet of human nature (i.e., the essential imperfectability of mankind, as manifested by the non-suppressibility of self-interest), and attempts to channel it into relatively productive and non-destructive (but still competitive and individually-directed) behaviors that limit the damage, and maximize the public good to a reasonable degree.

In contrast, Progressives attempt to change human nature to fit their inherently superior Program.

The fact that you cannot change human nature to fit the Program is what makes them dangerous. Their initial wide-eyed optimism that us folks will just “get it,” once they explain it to us, invariably evolves to an essential contempt for our limited intellectual capacity. This contempt justifies all manner of prevarications, to fool us into going along. Even in societies where the tyranny of correct-thinking has gone so far as to elicit the cooperation of the people at the point of a gun (rather than through the preferred methods of “education” or misdirection), the achievement of the predicted perfect society is invariably prevented by the recalcitrance of human nature. (The final realization that not even an all-powerful central authority can make people behave in the prescribed way always produces a nearly psychotic frustration that – in virtually every Communist country – has led to atrocities against various subsets of the recalcitrant people.)

DrRich does not believe there will ever be pogroms in the United States.

But this does not mean that the Progressives will always be kind and gentle as they attempt to achieve their goals. As DrRich sees it, in the U.S. the Progressives have clearly evolved to the “contempt for the masses” phase of their Program, a phase which justifies all manner of techniques – just this side of violence – to get us all to cooperate. Currently they are intent on demonizing their opponents as being racist, stupid, uneducated, selfish, overly dependent on outmoded supernatural beings, violent, and (of course) obese. This demonization is quite useful, since there is obviously no need to address any actual ideas put forth by such as these, even if they were capable of the feat of “ideas.”

Healthcare is, at present, the chief battleground in the war between Progressives vs. non-Progressives in the U.S., and the outcome of this battle will likely determine the success or failure of the entire Progressive Program. And the most fundamental (and emblematic) aspect of this battle is over what to do about the “doctor-patient relationship.”

The classic doctor-patient relationship was a celebration of the primacy of individual rights. And, for over 2000 years (at least since the advent of the Hippocratic Oath) guaranteeing the sanctity of that relationship was the basis of all medical ethics.

Until very recently doctors, patients, philosophers and ethicists recognized that, when you are sick, you are no more capable of navigating a complex and hostile healthcare system than are accused felons a complex and hostile legal system, and you are no less in peril if you run afoul of that system. And, just as the felon has a right to a personal advocate, a professional whose job is to protect his individual interests against the conflicting aims of the “system,” so does the patient. That is (quaint conventional wisdom held), when you are sick, you should be entitled to at least the same protections as when you rob a convenience store. And the doctor-patient relationship was supposed to guarantee you that right.

This is why, throughout the ages, the basic precepts of medical ethics were aimed at guaranteeing the sanctity of the doctor-patient relationship. Fundamentally, these ethical precepts required the physician to place the needs of his or her individual patient above all other considerations.

It should be clear to everyone that, under either our “old” healthcare system or the one that Obamacare promises us, this formulation of the doctor-patient relationship cannot be allowed to stand. Neither the insurance executives nor government officials can allow spending decisions – that is, decisions on how to spend their money – to be made by individual patients (and their personal advocates). For this reason, the classic doctor-patient relationship had to go.

And so, in 2002, official medical ethics was formally amended to require physicians (while still giving lip service to their obligation to individual patients) to strive for a “just distribution of healthcare resources.” That is, official medical ethics now makes it ethical for physicians to ration healthcare, covertly, at the bedside – and indeed, makes it unethical for them to fail to do so.

The New Ethics has been enthusiastically supported by medical ethicists worldwide (a field which now seems to be dominated by utilitarians), and worse, has been embraced by all the world’s major medical professional organizations. DrRich has not embraced the New Ethics (on the grounds that it places individual patients at great peril, and destroys the profession of medicine), and neither have many (possibly a majority) of older physicians. But it has been taught in medical schools around the world for over a decade, and in another decade it is likely that the vast majority of practicing physicians will accept as a matter of course that their primary obligation is to control healthcare costs, and only secondarily to try to meet the needs of their individual patients.

The plan, therefore, is for Obamacare to provide physicians with directives from expert panels on which medical services to supply to which patients and when, and for the New Ethics to allow physicians who go along with such directives to live with themselves. The feasibility of this plan depends entirely on physicians acceding to the program.

So, incentives are being put in place to “help” doctors cooperate. Quality measures will be implemented, with “quality” being defined as doctors doing what they’re told, and reimbursement will be tied to one’s quality rating. Possibly more persuasive will be the fact that the Feds can construe the failure to follow handed-down rules, regulations and guidelines, at any time, as a federal crime. (Even doctors who don’t mind being labeled as “substandard quality” – perhaps even considering the label as a badge of honor – will mind going to jail.)

But by whatever means necessary, the happiness of the government is to be the doctor’s first consideration, and not the happiness of their individual patients. The classic doctor-patient relationship is being terminated with extreme prejudice.

To see just how important it is to destroy the doctor-patient relationship, one merely has to observe what is happening to primary care doctors who have the audacity to leave the system, and set up a direct-pay medical practice.

Part of the problem, to be sure, was caused by these doctors themselves. The first few to do so unabashedly catered to rich patients, and to attract the rich, referred to themselves as “concierge” practitioners. This name (and its elitist connotations) have been forcibly affixed to all direct-pay practitioners, even as this style of practice has evolved into a much more democratic form. Today, more and more doctors are starting direct-pay practices (in which patients pay the doctors out of their own pockets) which are easily affordable to anyone who can afford a cell phone or cable TV contract.

While many direct-pay practices offer patients certain benefits they can usually not get from primary care doctors who remain in the approved system (such as phone and e-mail access, same-day appointments, appointments lasting as long as necessary instead of the allotted 7.5 minutes, etc.), the fundamental benefit, to both the patient and the doctor, is that it restores the classic doctor-patient relationship. The physician’s primary obligation is no longer to the 3rd-party overlord, or to the Progressive ideal of social justice, but to the patient.

And while critics (who abound) attack direct-pay practitioners for their elitism, laziness, and greed, their real issue is that direct-pay practitioners are acting as if their primary duty is to their individual patients, and not to the needs of society. This latter fault simply cannot be tolerated.

Having gained nearly complete control over the behavior of primary care practitioners, it is critical for Progressives – in making sure that practice by handed-down “guidelines” is not simply the only legal way to practice, but also the only ethical way to practice – to shut the door to any alternative forms of primary care. Direct-pay practitioners are a menace because they threaten to raise the expectations of both doctors and patients. Perhaps, doctors and patients might tell themselves, there really is a way to maintain individual autonomy within the healthcare system.

The attacks on direct-pay practitioners have followed the usual scheme Progressives follow when they discover a faction they need to suppress. First, they were ridiculed. “For a Retainer, Lavish Care by ‘Boutique Doctors,’” said a headline in the New York Times in 2005. Then, they were demonized, widely attacked for their elitism, laziness, greed, and lack of fundamental medical ethics. In this latter effort, it was not difficult to find fellow physicians – generally, from the medical organizations which promulgated the New Ethics – to lead the attacks. There are countless examples. DrRich will give just two.

Anthony DeMaria, then President of the American College of Cardiology, criticized the practice of direct-pay medicine in an article in the JACC in 2005, saying, “Personally, I do not mind if people acquire yachts or personal trainers if they have enough money, nor would I object if they secured a physician at their beck and call. However, unlike yachts, health care is not discretionary, and everyone should be entitled to the same quality.” As a matter of social justice, direct-pay physicians improve healthcare quality for only some patients, and so have no place in the healthcare system.

In an article in the New England Journal of Medicine, Troyen A. Brennan (M.D., J.D., and M.P.H., so we know we’re in trouble) really gets to the point. Referring to direct-pay practices as “luxury primary care,” he notes that “traditional medical ethics is rather poorly equipped to address issues related to luxury primary care.” That is, while “traditional” medical ethics always places the individual patient first, that kind of thinking is now outmoded. “(M)ost ethicists now agree that the financial structure of health care is an important subject for ethical consideration. Access to health care, in particular, is a salient ethical issue.” Direct-pay practitioners threaten (by their elitism and the limited size of their practices), to limit access to primary care, and thus are in fundamental violation of medical ethics.

The argument here, for those who missed it (advanced by fellow physicians no less), is that, of the two competing ethical precepts now established by New Medical Ethics (i.e., the physician’s obligation to the individual patient vs. the physician’s obligation to society), clear primacy is to be given to the physician’s obligation to society. Physicians must (like it or not) participate in covert bedside healthcare rationing. Physicians who take the only path remaining to them that allows them to make the individual patient their primary obligation are to be castigated as ethically deficient.

When ridicule and demonization fail to suppress their opposition, Progressive dogma indicates it’s time to resort to force. The first pass in this regard, of course, is always to render the opposition illegal. (Actual violence is reserved for criminals who persist in their misbehavior, despite more polite efforts to get them to behave lawfully.)

Making direct-pay medical practice illegal has not been accomplished yet, but clear efforts have been made in this regard. Noting with alarm the rise of direct-pay primary care, numerous Congresspersons have issued statements of concern, suggesting that perhaps Congress should look into the propriety of such activities.

Indeed, the first step by Congress has already been taken. In 2003, as part of the Medicare Prescription Drug, Improvement, and Modernization Act, Congress directed the GAO to study and report on the effect of direct-pay practices on Medicare patients. The GAO did so in 2005, and a fair paraphrase of its report is as follows: “The practice of direct-pay medicine is not currently a threat to Medicare patients, because the direct-pay movement is not large enough yet to have an impact. If it does begin to have an impact on Medicare patients, action will have to be taken.” That is, direct-pay medicine was considered OK in 2005 not because it was inherently an ethical and legal form of medical practice, but simply because there were not enough practitioners at that time to significantly affect Medicare patients. The clear implication is that Congress stands ready to pass laws outlawing – or, at least, severely limiting – direct-pay practices, as soon as those practices begin to “impact” the system.

Certain state governments are not waiting for Congress to ban direct-pay practices. The state of Maryland (and a few others) have taken the creative position that, because many direct-pay practices work on a retainer basis, they meet the definition of a health insurance company. And as a health insurance company, to be considered legal entities, they have to have millions of dollars set aside to pay for unforeseen “claims.” (Interestingly, this same argument was not applied to Maryland lawyers, who also often work on a retainer model.) According to the Baltimore Sun, the state’s stance in this regard has already successfully caused several primary care physicians to abandon their plans to become retainer practitioners.

Less devious (but more draconian) than the state of Maryland is the state of Massachusetts (whose universal healthcare system, we’ve all heard, is a preview of Obamacare circa 2015). A bill is under consideration in the Massachusetts Senate (Bill 2170) which requires doctors, as a condition of their licensure, to accept payment rates as determined by the government. If it passes, it will be the first actual legislation in the U.S. to ban direct-pay medicine, if only by making it completely impracticable. (Thanks to Dr. Wes for pointing out this important development.)

Since medical licensing is controlled by the various states, of course, it would take 50 bills like the one in Massachusetts to really get rid of direct-pay healthcare. But there are other ways for the Feds to accomplish the same thing. Now that the federal government directly controls all student loans, for instance, it would be a simple matter to make those loans contingent on agreeing to become primary care doctors working strictly within the government controlled system, or to offer loan forgiveness for doctors who agree to do so, or to rescind favorable re-payment conditions (retroactively, and decades after the fact, if necessary) for doctors who go to a direct-pay model later in life.

DrRich does not really know how the Progressives will actually place the final nail in the coffin of the doctor-patient relationship. All he knows is that they have – well, more than the desire – the deep and abiding need to kill that relationship, once and for all. Unless we the people decide we ought to stop them, this is going to happen.

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Part 4 of Limiting Individual Prerogatives

And now DrRich must turn to his loyal readers, to try to assuage what must be their bitter disappointment. We are, many of us, surprised, if not stunned, by the outcome of this vote. After all, the Covert Rationing Blog led the voting by a reasonably substantial margin throughout most of the two-and-a-half-week voting period, and indeed remained with a comfortable lead when most of us retired last night (Sunday, Feb. 14). Then upon awakening this morning, we find that our worthy competitor had received a truly impressive onslaught of last-minute votes, in the few hours before the polls closed at midnight, to secure the win.

DrRich cannot, of course, completely wipe out the disappointment for most of you. The pain, understandably, must be far too deep for mere words to vanquish. But allow DrRich to leave you with some thoughts to ponder as you work to resolve your frustration.

1) This election result merely reflects modern American political reality. While it is commonly said that, in elections, the winning strategy is to “Vote early and vote often,” the more assured path to victory is, “He who tabulates his votes last votes best.” That is, don’t let the opposition know how many votes you have until you yourself know how many votes you need. This rule was established by Mayor Daley (the original one) in the presidential election of 1960, and it has held up very nicely for 50 years. The ACP, which is largely a political organization, may be aware of this axiom.

2) For those who believe that the last-minute, stroke-of-midnight outpouring of support for the ACP (on a Sunday! on Valentine’s Day!) seems suspicious, remember who you are dealing with here. This may be difficult for readers of the Covert Rationing Blog – who tend to be salt-of-the-earth, red-blooded, lusty folks, who (no doubt) spent the last few hours of Valentine’s Day with their loved ones doing, well, Valentine-y things – to understand. But you’re dealing with doctors here, and not with the let’s-just-go-cut-the-damned-thing-out surgery types, either. You’re dealing with internal medicine specialists. These are the guys (and girls) you knew in college who looked forward to football Saturdays because the library would always be so much quieter. It is not so unreasonable to visualize the ACP membership entering into their Blackberries a few weeks ago a notice to vote for the ACP at 11:59 PM on February 14. They knew they would probably be logged on to their computers at that moment anyway, reading the latest research on the complement cascade.

3) It would have been greatly embarrassing for the ACP to lose in this vote, while it was not at all embarrassing for the Covert Rationing Blog to lose. DrRich took great pains to make it so, what with his loud, persistent (and, if you’re the ACP, annoying) challenge to the New Ethics promulgated by the ACP. Especially when the ACP made a fairly ineffective and dismissive early effort to respond to DrRich, and then assiduously ignored him thereafter, DrRich did not think for a moment that this large and influential organization would allow this embarrassment to happen. Anyway, by virtue of the ACP’s victory, there is much less embarrassment in the universe today than otherwise would have been the case. And that’s a good thing.

4) DrRich never really believed he would be able to beat the mighty ACP in this competition. Their resources are simply too great. His only chance of victory, he understood from the beginning, would have been to remain entirely silent about the Weblog award, and hope the ACP did not take much notice of it. But instead, DrRich decided to use the fortuitous occasion of being named a co-finalist with the ACP in a medical ethics competition to call them out on medical ethics. By relentlessly poking away at what might otherwise have remained a sleeping giant, DrRich assured his own loss. But, dear readers, getting the ACP to respond publicly to this challenge was far more rewarding, and far more important, than winning a Weblog award. DrRich, for one, feels more firmly now than ever (based on that anemic response) about the ethical bankruptcy of the New Ethics.

In this process, DrRich hopes he was able to call the dangers of the New Ethics to the attention of at least a few of his readers – especially some of the patients who have become entirely marginalized by the New Ethics, and some of the doctors who are considering extricating themselves from the quagmire, and re-establishing the doctor-patient relationship outside the traditional system. If so, the experience will have been very worthwhile and very satisfying.

DrRich would like to thank the people at medGadget for selecting him as a finalist, and especially for selecting the ACP as a co-finalist; and he would particularly like to thank all the hundreds of people who went out of their way to vote for the Covert Rationing Blog. The magnitude of your support – which (judging from the evidence) may have required an extraordinary last-minute effort on the part of the mighty ACP to eke out a face-saving victory – is truly humbling.

The New Ethics was explicitly born of the frustration felt by physicians as a result of the multitude of coercions the payers have thought up to force them to place the needs of the payers (the proxy for “society”), ahead of the needs of their patients. Thanks to the New Ethics, doctors can now bend to this coercion without violating their ethical standards.

Coercion by the payers was, of course, quite effective even before the New Ethics made capitulation ethical. This is because the third party payers – both private insurers and the government – have long had a stranglehold on the individual physician’s professional viability. Nonetheless, the fact that the New Ethics now formally divides the physician’s ethical obligations between their patients and society has very practical implications. By eliminating the remaining (relatively low) hurdle of ethical nicety, the New Ethics clears the way for even more sophisticated, more “official,” and more enforceable methods for achieving bedside rationing. (We have even seen the phenomenon, DrRich submits, of professional organizations going along with – and even assisting with – the development and implementation of such methodologies.)

As DrRich has described before, it is the primary care physicians who, so far, have borne the brunt of payers’ efforts to force bedside healthcare rationing. And to the very great credit of PCPs, despite the New Ethics aimed specifically at “curing” their sense of guilt and frustration, a majority of them remain very disturbed by the increasing pressure to make the needs of their patients their secondary concern.

Indeed, if anything, their frustration has grown. In the past, when they were torn between laying out an expensive but likely beneficial medical option for a patient, and not offering it because doing so would anger (say) the government, they could at least rely on classic medical ethics to back them up if they chose the less expedient path. Today, they have ethics as well as expediency pushing them, in such a case, to remain silent about that more expensive option.

To many PCPs with a strong sense of obligation to their patients, the coercive nature of the payers, combined with new ethical standards that virtually obligate them to give in to the coercion, have made modern primary care medicine a nearly untenable proposition.

Thus has the New Ethics rendered the practice of retainer medicine a matter of transcendent importance.

DrRich here uses the term “retainer medicine” as shorthand for any practice arrangement in which the doctor is paid directly by the patient, and not by third party payers. In some of these arrangements, patients actually do pay their physician a retainer fee of a few hundred to several thousand dollars a year. Such formal retainer arrangements – often called “boutique” or “concierge” practices – first began to pop up a decade or so ago. More recently, practices have begun appearing in which there is no actual retainer fee, but instead, patients pay their doctors the same way they pay their plumbers – on a fixed payment schedule according to the time the doctor spends with them. These pay-as-you-go practices generally are inexpensive enough to be affordable to any family that can afford cable television, or cell phone service.

Many retainer practices also provide amenities you often don’t get when your doctor is paid by Medicare or an insurer, including access to the physician’s cell phone, e-mail correspondence, same-day appointments, and plenty of face time during appointments. But whatever the specifics of a particular practice may be, the key that defines “retainer medicine” (as DrRich is using the term here) is that the doctor works for the patient, and nobody else.

Retainer medicine has been under steady attack, from the moment it first appeared, as being elitist, unethical, and divisive. The argument goes: While retainer medicine may be good for individual selfish doctors, and individual wealthy patients, this style of practice threatens to do much harm to the greater good. Critics maintain that retainer medicine threatens to create a two-tiered healthcare system (one for the wealthy and one for the poor). Plus, they say, if any substantial number of physicians were to adopt this odious new style of practice, there wouldn’t be enough PCPs to go around. Many critics have even called for making retainer practices illegal, and some states have already taken action to do so. The rationale for banning retainer medicine, boiled down, is: It is bad for doctors, patients and the public good.

To DrRich, the vociferous objections being raised against retainer medicine strongly suggest something deeper. DrRich believes that critics would simply find it far too “inconvenient” to have a bunch of wild retainer practitioners running around, disclosing to patients ALL their healthcare options, when the more well-behaved doctors are disclosing to patients only the healthcare options approved by government-assembled panels of experts. Retainer practitioners, in other words, will make covert rationing much more difficult. However, this is not a point of view which critics have been willing to express publicly, so DrRich will let it lay.

But even the publicly-expressed objections to retainer medicine – the notion that it is bad for doctors, patients, and the public good – are wrongheaded. Indeed, thanks particularly to the New Ethics, the opposite is true. Retainer medicine is perhaps the only pathway toward rescuing patients and the medical profession – and thus for best serving the public good. For PCPs to continue practicing under what has become the “traditional,” third-party-payment system is, in fact, the far greater threat.

It has become impossible – both in practical terms and now, in ethical terms – for “traditional” PCPs to fight the pervasive pressures being visited upon them to ration healthcare at the bedside. To escape this fate, they must either become specialists, deep-sea fishermen – or a retainer practitioner. That is, PCPs must choose between remaining in a system that ruthlessly pushes them toward a practice of bedside rationing (which many find an unethical, demeaning, and harmful style of practice), or, one way or another, getting out of traditional primary care medicine altogether.

To argue that retainer medicine is unethical is completely backwards. Retainer medicine restores the professional integrity of medical practice, and re-establishes a doctor-patient relationship in which the physician can again assume the duty of a true advocate. It is perhaps the only remaining means to restore the foundational (but now officially obsolete) medical ethic of always placing the patient first.

To argue that retainer medicine somehow threatens patients completely ignores reality. Retainer medicine may be the only remaining viable pathway toward restoring protections that patients are supposed to have when facing a healthcare system that is utterly bent on avoiding spending money on them.

To argue that retainer practitioners are creating a two-tiered healthcare system is ridiculous on its face, in a society that gives mere lip service (though, to be sure, plenty of it) to the problem of 47 million uninsured, and in which physicians already cannot afford to care for patients on Medicaid (or increasingly, on Medicare), because they lose money each time such a patient walks in the door.

To argue that retainer medicine will create a subpopulation of elites (because it provides a mechanism by which some individual patients can escape the deadly obstacles that have been intentionally laid before them), is as absurd as arguing that George Washington was wrong to free his slaves upon his death (or even that New York State was wrong to abolish slavery at about the same time), because it created a subpopulation of “elite” (i.e., free) African Americans; that until all slaves were freed, no slaves should have been freed. Rather, freeing at least some slaves – and forthrightly stating why it needed to be done (see: Declaration of Independence) – was not only ethical, but also showed what was possible, and over time created an expectation that eventually could no longer be ignored.

Finally, we should recognize that any innovation that can potentially spare patients from some of the harm the healthcare system has in store for them will necessarily be applicable to only a minority of patients at first. That’s how disruptive processes work. They begin as niche products or services, attractive only to a few high-end users; too expensive or too marginal for the vast majority; ignored, ridiculed or castigated by current providers and by most experts. But if at their core they’re offering something fundamentally useful, they will slowly demonstrate their worth – and eventually all the potential users will see the light, and demand for the product will become explosive. When that happens, the means are found to make the new product affordable and available to meet the demand – often by making significant “adjustments” to the original concept, that nonetheless preserve the core benefits. And when that happens, the traditional providers (who never saw it coming) are suddenly out of business.

It may not be that retainer-style medicine plays the personal computer to the traditional healthcare system’s mainframe. But it is inarguable that what retainer medicine offers to patients – at its core – is every bit as vital and every bit as indispensable. And if a critical mass of the public can be made to understand what is really being offered here, there will be no holding it back.

There never has been anything even slightly unethical about retainer medicine. The arrangement by which patients pay their doctors directly was, after all, how Marcus Welby practiced medicine, and how nearly every PCP practiced until the 1970s.

The problem began when third party payers were interposed between doctors and their patients, and it became progressively more difficult for doctors to honor their primary ethical obligations. The New Ethics has escalated the problem, however, from one where basic ethical precepts were merely being violated, to one where the precepts themselves were abandoned.

And by so doing, the New Ethics has elevated retainer medicine from something that was merely an ethically justifiable curiosity, to the last refuge for classic medical ethics, and the last best hope for patients, the profession of medicine, and the doctor-patient relationship.