HAIL FROM THE CHIEF
When the American Medical Association selected Nancy W. Dickey, M.D., to be its president in June, it marked a dramatic departure from the Marcus Welby-like mold favored by the nation's largest physician organization in the past. Dickey, a board-certified family physician, is the first woman to head the 294,000-member professional organization, where she has held a variety of leadership posts since 1977. She was elected to the board of trustees in 1989, and has chaired it since 1995. Dickey received both her M.D. and residency training at the University of Texas Medical School at Houston. In addition to maintaining an active family practice, Dickey, 47, serves as the program director for the Brazos Family Practice Program, associated with Texas A&M University in College Station, Texas.
In recent weeks, health reform efforts have focused on bills before Congress that would create a Patient Bill of Rights. President Clinton acknowledged the importance of the AMA in the patient-protection debate when he visited the AMA's Washington office in July to discuss the issue with Dickey, other AMA leaders and a group of people whose families had been affected by managed care coverage delays or denials.
Since this interview took place, the House of Representatives defeated the Democrats' patient-protection bill by a vote of 217-212 and passed an alternate version, sponsored by Speaker Newt Gingrich, by a vote of 216-210. President Clinton indicated that he would veto the Republican bill if it passed the Senate in its current form. The Senate is expected to consider various patient-protection bills during September. Dickey spoke to Senior Contributing Editor Patrick Mullen about these bills and other issues.
MANAGED CARE: Where do things stand with the legislative battle going on over a Patient Bill of Rights?
NANCY W. DICKEY, M.D.: This of course has turned into an extraordinarily hot topic. It is a long-term issue for the AMA. We've been seeking a legislative solution since 1994 or so, particularly since January of this year. We believe taking care of our patients is not a political issue but a patient issue so we would like to see a bipartisan solution. The vehicle that currently includes the five components we think are most important is HR 3605, the Patient Bill of Rights Act, also known as the Ganske-Dingell Bill [for sponsors Rep. John Dingell, D-Mich., and Rep. Greg Ganske, R-Iowa.] That bill includes prohibitions on gag clauses or restrictive language. It includes prudent access to emergency services, internal/external review processes, accountability for medical decision making and the recommendation that patients should know what's covered and what's not covered by their plans. We did spend time with the speaker of the house discussing the Republican bill [HR 4250, the Patient Protection Act]. The speaker pointed out that the bill included some gag-clause language and an appeals process.
MC: When you talk about accountability for medical decision making, does that include the right of managed care plan enrollees to sue a plan for malpractice?
MC: That is not in the Republican proposal. That seems to be one of the sticking points.
DICKEY: Indeed it is. The Republicans have taken the perspective that they want to avoid increasing bureaucracy and want to avoid increasing liability activities. At the same time they have concern for our patients. I think we'll see a great deal of conversations about language and discussion about ways to try to achieve a bipartisan solution.
MC: Another health reform the AMA favors is medical savings accounts. How do you respond to those who say that, essentially, they will attract wealthier, healthier folks and create even more problems for the less affluent and sicker population who will be left in horribly expensive risk pools?
DICKEY: Until they give us an opportunity for a meaningful pilot project, we're not going to know if there's any truth in that accusation or not.
MC: So you don't consider the pilot that was in the Balanced Budget Act to be meaningful?
DICKEY: It's an extraordinarily small pilot, and it's difficult for people to access. It is likely to get a skewed group of people in it, only people who are adamantly demanding that they find a way to make this work. Medical savings accounts ought to be extraordinarily easy. If people are interested in doing it, they should have five or six financial entities in a community that are willing to work with them. Now. I have not personally attempted to open a medical savings account. I should, just for my own edification.
MC: So, in your view, medical savings accounts haven't been given a fair shot?
DICKEY: That's right.
MC: You would also like traditional indemnity insurance to be an option. Again, that would seem to be opening the door to higher costs. Wasn't that the problem that managed care was devised to solve in the first place?
DICKEY: You're absolutely right. The thing we have to keep in mind is that for the market to work, the actual consumer has to be involved in the market activity. So we need to move toward individual selection of plans. The way to get there is to have something called a defined contribution, where the employer says, "I'm supportive of you having health insurance, I will put forward this amount of money, now you buy whatever plan you want." Then if I want an old indemnity or 80/20 kind of traditional insurance, I have to pay the difference. That forces me to make some decisions. Am I willing to subsidize something where the incentives are in overutilization, not underutilization? Is it worth the out-of-pocket money for me to have essentially unlimited choice? When the indemnity plans were paid for exclusively by the employer, the patient was protected from having any knowledge or concern about the cost of care. It created all the wrong possible incentives. If I'm the one that's going to look at the price increases each year, you would think that I would be somewhat more motivated to try to keep utilization of that plan down to a minimum. At least I would have to annually make the decision of whether it was worth the extra out-of-pocket costs for me. But then I look at people who drive cars that cost more than the first house I bought. To me that's not a wise expenditure of money.
MC: Are you concerned that the defined-contribution approach undermines the notion of collective negotiating that takes place now mainly between employers and health plans?
DICKEY: We're aware of the fact that we're going to have to find some mechanisms that will allow the collective or the group discounting that currently comes from an employer. However, it is terribly important for the individual selecting the insurance to actually be able to select from among choices. Currently, over 50 percent of people who get their insurance from an employer get no choice. Of the ones who get a choice, it's frequently between HMO A and HMO B, not a real smorgasbord of choices. Moving to individual selection, even if it means losing some of the power of collective negotiating, should make the insurance industry much more sensitive to the actual consuming unit of the market, the patient. If patients are frustrated with the system today, the best I can do is send them to the health benefits manager and hope that manager is willing to listen. I talked to a patient the other day, not my patient but someone who had sought me out, having seen my name as president of the AMA, who works for a very large employer and has a substantial problem with a major plan. I suggested she see her health benefits manager. She said she had, and the health benefits manager let slip that she was one of many who complained not only about the plan but about a particular physician. I asked what he was going to do and the patient replied, "Well nothing until this fall." I said, "No, no, no. You need to go back and tell him he's got three weeks or six weeks to do something before you go to his boss." But it's an unusual patient that I can actually motivate to go and be that kind of an advocate. It would be much more effective if I could say to my patient, "Look, this may be an acceptable plan, but if it is not meeting your needs, change plans."
MC: Are you still seeing patients?
DICKEY: Yes, I am. Actually I have an appointment as soon as you and I get done talking.
MC: How many managed care plans does your group work with?
DICKEY: I think we have nine contracts.
MC: What has been your group's experience?
DICKEY: Some plans are good, some aren't. I'm not a terribly shy, retiring person and I haven't had a lot of problems with the plans. When I call a plan because I think some service is necessary and a voice on the other end says, "I'm sorry," my retort is usually, "I certainly understand. I need your name and either a last name or an ID number." And usually this poor voice asks why. "Well, because I need to enter in my chart that we've had this conversation. I want to be very sure who's giving me the ruling so that if something bad happens to my patient, you can come help explain why we did what we did." I've never had much trouble talking to a doctor.
MC: Have you found that that's a message you need to get out to practicing physicians?
DICKEY: I speak about it at podiums and teach my residents about it. Of course that's part of what this legislation in Texas last year — that allows managed care enrollees to sue plans for malpractice — and in Congress this year is about, to see that plans are held responsible. If that person on the other end of the phone has been taught, "Give the doctor your name because they can't do anything to us," then my ploy is meaningless. The stories that we hear are not about denials. They are about delays in decision making that are so prolonged that by the time the approval came, it was no longer necessary. The cancer had advanced, the disease had progressed, the patient had died.
MC: In the near term, regardless of what comes through Congress or doesn't, it seems we're going to continue to have things like the dispute over reimbursement in Dallas between physicians and Aetna U.S. Healthcare. Is it your view that battles like that are going to have to be fought over the next few years? What role will the AMA play?
DICKEY: Absolutely, beyond a shadow of a doubt. The AMA is gearing up to be sure that we are prepared to respond on short notice to the needs of our members, whether it be contract negotiations or disputes regarding how to appeal or utilize existing rules. It's such a complicated field and physicians are so busy simply trying to remain up to date and effective in their practices that they need someone to rely on to say to them, "Here's how we negotiate this minefield." We're trying to do everything in our power to be prepared to respond to requests for assistance, to do so in a timely and aggressive manner.
MC: The AMA has endorsed the notion of collective bargaining by physicians. Why is that necessary and what will it achieve?
DICKEY: Power has so substantially shifted into the hands of large plans that physicians can virtually be held hostage. We are not in favor of unions and the philosophy of using all possible tactics, including strikes. We are in favor of taking the combined voice of a substantial number of physicians, particularly physicians who are highly thought of in their communities, and making it easy to negotiate on their behalf. We're trying to help them find ways through their professional organizations to add clout to their voice.
MC: When you say you're in favor of collective bargaining but not in favor of unions, how meaningful a distinction is that? Is it correct that work slowdowns would possibly be a tactic that would be used?
DICKEY: I've spent a fair amount of time over the last three years learning from physicians in Europe. We still have some extraordinary philosophic differences about labor tactics that they use over there, as opposed to what's been acceptable in this country. We believe that simply the collective voice and utilizing negotiations and, frankly, the press at times, should go a long way towards improving the ability to represent physicians. We have ethically opposed strikes and continue to do so. I don't recall having heard discussions about those gray areas of work slowdowns and so forth. If a physician is faced with a contract that would so inhibit his or her ability to give quality care to the patient, either because of specialty access or the appeals process or the ability to make medical decisions, we have to help that physician represent that perspective and find alternatives. Whether the alternative is not signing the contract and therefore patients have to change plans or use a different physician, or whether it's sitting down and trying to find a negotiated middle ground with the plan, it's a process that the current system has forced us to. For the interim, while we look at reforming the whole system, we have simply got to do this on behalf of doctors and patients.
MC: Is it amazing to you that we're speaking about physicians as labor — a way of looking at the medical profession that would have been considered ridiculous thirty years ago?
DICKEY: It would have been thirty years ago. The very concept of somebody outside of the profession having substantial influence over medical decisions was such an anathema thirty years ago that they passed laws in virtually every state opposing the corporate practice of medicine. They wanted to be very sure that no employer could influence a doctor's recommendation of what was best for the patient. We have become so consumed with concern about how much money we spend on health care in the last few years that we have denigrated the professionalism of medicine to the point that many plans believe physicians are simply part of the labor force. That is not conducive to our patients' well-being. We have to return clinical decision autonomy to physicians, but we have to do it with a great deal more sensitivity to appropriate cost-effectiveness. There's good evidence that the highest quality medicine — doing the right thing at the right time — is also the least expensive medicine. There have been some good things, I suppose, from managed care and maybe even from this strong philosophy of cost management for the last few years. They've taught us some mechanisms to measure what we do, to try to seek out not only the most effective treatments but to also look at cost implications. We have, frankly, made some decisions based on the bottom line that have hurt patients. We've got to find the right balance, including making sure that physicians are treated as professionals and that the expertise they've garnered after decades of training is given the appropriate role in health care.
MC: Is the clinical complexity of medicine so great that it makes sense for physicians to work as salaried employees and let someone else handle the management side?
DICKEY: Certainly one of the fastest growing groups in medicine today is employed physicians. Our role with employed physicians is still to look to the quality standards of their education and their licensing, and to establish ethical standards. We also have to assist them to be sure that even as employed physicians they are able to maintain appropriate independence when it comes to medical decision making. If the practice setting physicians like the best is an employed-physician setting, that's fine so long as the components of that setting don't have an opportunity to substantially influence their medical decision making. We have to identify potential conflicts and find ways for physicians to resolve those conflicts in the best interest of their patients.
MC: There have been a number of attempts by physician organizations to start managed care plans, with mixed success. Is it possible that there are management skills that are beyond the scope of most practicing physicians, so there needs to be a meeting of the minds between physicians and nonphysician managers?
DICKEY: We have certainly seen some successful physician-sponsored networks. Physicians in Connecticut built Physicians Health Services, talked themselves into selling it, and are now in the process of building a second plan that appears to be equally successful. So some entities have been able to put something together and make it function.
MC: Is a physician-run plan considered a success if it ends up being sold to an insurance company?
DICKEY: Well, there were several people who were very unhappy about that decision to sell PHS. They chose to sell it, and at that point it's no longer physician-run. Once it was sold, they discovered, "Whoops, it's not ours anymore," and so they started building a second one. So there are some success stories. In Harris County in Houston, it may be a little too early to make a call, but it looks like they're on their way to a success, and it is clearly physician-established and physician-run. To some degree, like HMOs, this is only a part of the solution. This works well for some people in some places and provides a part of the answer, but our whole philosophy of pluralism says there is no single answer that works for everyone. Therefore, if we keep looking for easy answers, we're likely to continue to be thwarted. We do want physician-sponsored organizations to have an opportunity, and we want physician-run HMOs to have an opportunity. We're supportive of HMOs that are not physician-run but that have been run with the right philosophy — Kaiser for example.
MC: Are you concerned that the AMA risks becoming unrepresentative of physicians, for example as the membership ages faster than the overall physician population?
DICKEY: Membership is certainly an issue that we spend a lot of time and energy on. Frankly, we've seen slippage in our numbers. One of my goals is to spend my year in the presidency to assure young physicians that this is not the AMA of the 1960s. Medicine is different from what it was in the '60s. The issues we face are different than they were in the '60s and the way we resolve the concerns will be different than we did in the 1960s. However, the one thing that is the same is the need to have an organization that represents the diversity of medicine. That means across specialties, across geographic areas, but also across ethnic, gender and age groups. We do have solutions for some of the issues facing young physicians, but we also have a great need to have their input and their perspective. Hopefully they'll begin to see that they need us as much we need them. It's a message we'll continue to try to deliver loudly and clearly.
MC: What is your response to medical students, residents and new doctors who don't see the relevance of the AMA to their lives?
DICKEY: We do reasonably well with students and residents, but one of the groups that we have the least penetration in terms of membership is physicians in their first five years of practice. When I've had the opportunity to sit down with one or a group, I say, "Okay, try me, tell me the three issues that are of greatest concern to you." I'm willing to bet that the AMA has been both active and appropriate in addressing those issues. If there's a burning issue that's enough to keep you out then I also believe that the best way for you to change the stand that has been taken is to enter the association and work through the process to change the stand. We're not infallible; we are just human beings and we need that kind of passion about our profession. If the concern is ethics, then I would say that for 150 years we have been the standard setter, not only in this country. Increasingly, ours are the standards that are followed across the globe.
MC: In addition to the issues we've discussed, what else do you want your time as AMA president to be remembered for?
DICKEY: My platform for this year includes the fact that it is absolutely untenable that the American Medical Association has not, up until now, exerted at least a substantial piece of its voice to address the issues of the uninsured. Part of our job as professionals has to be to tell members of Congress and senators that the status quo is not tolerable. It is imperative that we address those problems. We are already substantially the solution, in that the country believes that charitable care is the answer. In fact, over 12 percent of the care physicians give is uncompensated care. Most of those cases are not bad debt, but care we knew up front we weren't going to get paid for. The system's too complex to rely entirely on that as a solution. But if America's physicians don't raise our voice on behalf of the uninsured, we probably won't have an answer for another decade.
MC: Thank you.