Saving Private Osteopathic Medicine

Saving Private Osteopathic Medicine

Osteopathic medicine is dying and it is clearly evident as our national organizations move away from maintaining the separate and distinct nature of our profession through unmistakable actions. The fact that all of medicine is being irrevocably substituted for by a corporate/actuarial-disease-oriented model only worsens the effect. Healthcare delivery in either osteopathic or allopathic medicine is systematically being eroded by an exchange for the control of the healthcare dollar at the expense of the health of the patient. This is not a new problem and was clearly delineated as far back as 1957. The technology is different, but the problem remains very nearly identical with technology currently being employed to benefit shareholders at the expense of patient care. The problem is most evident in the arena in which it started; in the denial of care for medically approved, medically necessary, standard of care procedures and the overall shrinkage of coverage. The tools the government and insurance industry has utilized to manifest the rapid decline in overall healthcare quality include, but are not limited to, health information technology; maintenance of certification; medical assessment technology; other forms of information technology and lobbying for pro-corporatization legislation. Through these actions, the distinguished care of the private physician has been eliminated from our national healthcare system.

In order to understand several of the physician proposed solutions to this problem we must first know what the professional population is attempting to save. The distinctiveness of Osteopathic Medicine is only a small, yet very significant part of this understanding. Even showing this distinctiveness and its health seeking and health preserving qualities has been slow in its elucidation.

Dr. Andrew Taylor Still intended for all DOs to think and treat with an Osteopathic mind set, that is to say “To find health should be the object of the doctor. Anyone can find disease.” One of the first separate and distinct issues Dr. Still expounds upon in that work is the process of finding health, the basic underlying understanding of the four tenants of Osteopathy. These tenants are simple and clear. They are the fundamental principles shaping the philosophy of education for Osteopathic physicians and the foundations for formulating the diagnosis and treatment of patients.
1. The body is an integrated unit of mind, body, and spirit.
2. The body has self-regulating mechanisms, and has an inherent capacity to heal itself
through, self-defense, self-repair, and remodeling.
3. The body’s structure and function are reciprocally interrelated.
4. Rational treatment of patients is based on consideration of the first three principles. ,

Osteopathy was defined by A.T. Still as follows and it is worth the time it takes to fully examine:

“Osteopathy is that science which consists of such exact, exhaustive, and verifiable knowledge of the structure and function of the human mechanism, anatomical, physiological and psychological, including the chemistry and physics of its known elements, as has made discoverable certain organic laws and remedial resources, within the body itself, by which nature under the scientific treatment peculiar to osteopathic practice, apart from all ordinary methods of extraneous, artificial, or medicinal stimulation, and in harmonious accord with its own mechanical principles, molecular activities, and metabolic processes, may recover from displacements, disorganizations, derangements, and consequent disease, and regained its normal equilibrium of form and function in health and strength.”

Osteopathic Medicine is based on finding the health in an individual’s system and supporting the innate ability to heal by restoring his or her structure toward normal. The function will follow. The inter-relationship of natural chemistry and the structures that mitigate or optimize the effectiveness of the system as a whole are at the very root of the Structure-Function relationship now so gracefully labeled as somato-visceral reflexes in the neurological literature. Though this description is useful, it is insufficient for the understanding of the whole person without all the other well-defined reflex pathways both to and from the soma, the mechanics of the body. These include but are not limited; to viscero-somatic, psycho-somatic, somato-somatic and other reflexes. In addition, local reflexes – paracrine responses; autologous reflexes – autocrine responses; immune system – chemotactic responses and many other biological reflex negative and positive feedback systems. All systems have ultimate impact on the homeostatic balance and allostatic load that governs day to day operations within the machine we call the human body.

After more than a century of success, A.T. Still’s fruit is withering on the vine due to the forced intervention of insurance and government. “Private practice, in general and the patient Physician relationship is under attack.”, Individualized private practice is systematically being destroyed in favor of corporate medicine, by design, while corporate structures ignore the problematic issues that lie within. Information Technology, though offering many potential partial solutions, has yet to produce meaningful use data. Even so, the data is currently being collected and used to reduce costs at the expense of patient care and at the high risk of infringing upon if not ignoring medical standards of care under the guise of no longer covered and Hold Harmless clauses.

The American Osteopathic Association (AOA) embraced this information technology drive and the Electronic Health Record (EHR) rush, as did the American Medical Association (AMA). Curiously, these organizations should have had a majority of its member physicians in agreement, though large numbers of us spoke out against it, and the actual numbers, to our knowledge, of the direct membership votes have not yet been published, if indeed there were membership votes. How either organization determined what the remaining non-members thought about this remains to be explained, and should be. These organizations presented themselves to government as if they were in fact speaking for the healthcare industry and for all physicians and not just their respective societies in this endeavor.

Facts matter. As of 2012, The AOA only represents 47,472 from its membership of over 82,000 total in practice or about 58% of the total DO population. As of December 2012, the AMA membership was 224,503 while the total number of MD physicians in Practice is 789,788 representing just under 24% of the MD population. , All told, these organizations legitimately represent only 31% of the total physician population. The do not represent the majority.

These organizations often present themselves as representatives of the vast majority of physicians, as the AMA did in its 2011 annual report. The AMA is “Empowered by physicians from more than 185 state and medical societies, the AMA gives voice to the vast majority of our nation’s physicians.” If the AMA and AOA are to represent whole of the profession, and clearly they statistically do not, they need to make efforts to include people from the true majority; physicians who are not in their membership, in public law discussions, regulatory negotiations and fact-finding meetings. Seats should be set aside for private practice to be represented. Many former AMA and AOA members report that these two groups DO NOT consistently represent the majority of their own membership. This was a major reason for many to let their memberships lapse. The actual majority numbers, physicians in private practice who walked away from these official organizations, in fact have no real voice. Without specific affiliations to these two groups, they have no representation. That considered fraudulent behavior on the part of the organizations and, discriminatory against the largest portion of the people who actually deliver healthcare with real medico-legal responsibility of the highest order.

The main thrust of political negotiations by these groups 10-15 years ago was in the form of securing reasonable and customary payment from insurance and government payers in a more fair distribution and with more regularity in a nationwide effort to systematize payment rubrics.
Coding became central in that process and as payers began to adopt coding as part of the requirements for payment physicians began to lose the ability to get paid for services they routinely rendered prior to that time. As a result, intended or otherwise, payment for Osteopathic Manipulative Medicine (OMM) was marginalized away from mainstream family medicine and primary care specialties, toward the specializations of physical medicine & rehab PMR/ Osteopathic Manipulative Medicine OMM/Neuro-Musculoskeletal Medicine (NMM). This was couched in explanations that were largely based on time constraints in the offices and economic pressures created in the wake of increased productivity requirements in order to maintain cash flow at the private office level. One caveat is the trade off of no longer emphasizing treatment success, but emphasizing office productivity. This translates to: placing patient care in a secondary position to earnings. These specialties are now doing the more reimbursable injection procedures and medications and less actual contact OMM because their fee structure became dependent upon Insurance and/or government payments.

Osteopathic medicine is dying., In fact, the private practice of medicine by independent physicians is dying. This is not due to physicians’ lack of commitment or education, but the changing conditions. It began with Health Maintenance Organizations (HMOs) and includes the most recent third party intervening fee-shifting organizations, Accountable Care Organizations (ACOs). The February 2010 cover of Managed Care a monthly health insurance industry journal, broadcasts the following quote in bold letters, “Care coordination will improve as small practices disappear.” Their evidence for improvement was poor at best, but predictive of the collapse of private practice. Small and private practices are having greater and greater difficulty remaining in business even in places where there are no other services available.

Was the deliberate pressure to close private practice actually a government and health insurance industry planned event? Even if not, it would seem that the AOA has failed to defend free-market healthcare with that clear line drawn in the sand. The AMA actually made things worse by promoting The Patient Protection and Affordable Care Act (PPACA). Patients’ freedom of choice and physicians’ independence may have been traded at the same time by the AOA for a place at the bargaining table. Since that time it would seem the AOA has gone along in lock step with, all of the government and insurance matrix stakeholder model plans and decisions.

AMA sponsored coding that was clearly discriminatory against Osteopathic Medicine was one of the first issues that should have sent ripples through the medical community with repercussions, but did not. One of the few exceptions was for OMM manipulation codes that secured nothing in pay and ultimately did great damage to the private sector of OMM practice. This coding tool was one of the first wedges utilized, and continues to be used, to allow an insurance company or government payer to decline or delay payment for services rendered by honest men and women helping to maintain and protect an individual’s health, not just treat disease. This system of procedural coding, Current Procedural Terminology (CPT), was put in place in theory to standardize the language and therefore the payment for procedures. The outcome was quite different as the coding policies were regularly altered to refine definitions that the insurance industry used to further exclude or delay payments.

Many physicians currently assert correctly that CPT coding is specifically an insurance function, not a practice of medicine or patient care function. Coding, billing, and other insurance specific functions have been forced upon physicians and into their patient schedules. Worse, physicians have been denied the ability to charge additional fees for these services to either the patient or the insurers. In 2009, it was demonstrated that these insurance services and information technology expenses cost each physician at least $68,000. Additionally, the American Medical Association’s 2012 annual report on the health insurance marketplace suggests that 70% of metropolitan markets lack competition among insurers. Interestingly, if you want a copy of that study you have to pay a steep price.
“The AMA’s Competition in Health Insurance: A Comprehensive Study of U.S. Markets is free to members. Non-members can purchase the study for $150. To order the study, please visit the AMA Bookstore online, or call (800) 621-8335 and mention item number OP427112.”

The insurance industry has effectively created local monopolies in these environments and there are no controls on the pricing determined by these organizations. The spiraling cost of healthcare is in no small part being generated by insurance and big pharmacy, now ending a major merger and acquisition phase of corporate development. The scapegoats have been the physicians. The most damage has been to the patients with enormous losses of benefits and poorer quality of care under the guise of cost containment even against the best medical judgment available in the world. Americans spend twice as much as residents of other developed countries on healthcare, but get lower quality, less efficiency and have the least equitable system, according to a 2010 report, the coding problem gets further compounded when the insurance industry is given permission to deny payment based on technical issues in the coding rather than on the provision of services.

The AOA worked with the AMA and Centers for Medicare/Medicaid services (CMS) to develop OMM/OMT codes almost two decades ago. CMS Recovery Audit Contractor (RAC) audits, to this day, inappropriately target high utilizes of Modifier 25 codes for OMM/OMT at the time of a patient office visit. One of the problems is that no one in the AMA or AOA is keeping watch over the reviewers and auditors interpretation of Modifier 25 that is misaligned with the use in OMM/OMT. According to the various volumes of coding guidelines, these OMT procedure codes MUST be used with Modifier 25. They are not stand-alone codes like PT or Chiropractic codes. However, the insurance industry, and nearly all of its auditors assume that all manipulation codes are the same and act accordingly, lumping all manipulations under the same category with little recourse for physicians despite what the AOA professes about support. One solution is for the AOA to develop a position paper requiring the mandatory use of E&M plus Modifier 25 coding for all OMT services. The case is clearly defined in our literature where OMT is taught as an interactive procedure, responsive to the changing conditions at the time of the delivery of treatment and requiring evaluation and re-evaluation at every visit. The previous lack of support for leading and proposing legislation rather than waiting to react to policies put in place by others whose educational deficiencies preclude their understanding of these issues. This has led to discrimination against DOs; healthcare entity intimidation of DOs; and payment withholding and costly legal fees to defend the rightful use of this code. Insurance coding and billing has been permitted to be used to the detriment of both the patient and physician.

Insurance billing and denial has increased further as new policy changes have been continuously and sequentially implemented without much resistance from many national organizations, most of which were concerned about keeping their place at the table, or more precisely, keeping access to the large amounts of money at stake. Frequent rolling Health Care Finance Administration (HCFA) changes and its morphed successor the Centers for Medicare & Medicaid Services (CMS) lead inexorably to greater pushes for utilization of information technology supporting the governmental money machine. Through technical errors in paper work, denials were significantly increased. The continued pressure to increase insurance corporate earnings fostered bypassing more secure solution proposals, for a fast track to manage data, and to own it, trade it and use if for marketing purposes. This is no different than what Wall Street structures currently do everywhere in the world with sales data. Health Information Technology (HIT) with all its complexities and serious flaws designed to protect patient and physician rights was traded away. Consequently, patients were turned into a commodity, a source for privacy hacking, and the fuel for a brand new major business built on the exploitation of patients and their private information – the same private information that physicians have pledged to guard for thousands of years. The insurance information technology business is currently unable to supply the demands placed upon it to produce its end products and cannot maintain any real level of security over centralized data acquisition and storage. The expense is being shouldered by the taxpayer and the patient premium payer, not by the corporate structure. The actual outcome, patient privacy has been ultimately destroyed. Rebekah Kearn, lucidly highlights the dangers in centralizing private healthcare information with its unique identifiers, private patient data such as social security numbers, names, addresses, etc., included in the centralization efforts. One example is enough to show the danger clearly. “San Diego (CN) – A lurid but vague class action accuses corrupt and abusive IRS agents of stealing 10 million people’s medical records without a warrant – including “intimate medical records of every state judge in California.”

Electronic Health Records (EHR) were advanced and became law too rapidly and without due diligence in protecting both patient and physician rights to privacy. This occurred without apparent resistance and often with frank support from national organizations that should have been fighting for the maintenance of value, security, privacy and statistical significance. There was not a shred of evidence for the improvement in patient outcomes. It did; however, take money away from physicians and further decreased the care for patients through denial of payment for treatments. Additionally confounding, forced data entry and extraction – for proposed payment schemes, pay for performance, was launched. It was and is by design, a method of paying for productivity, not successful health care delivery to patients. These issues created the leverage by placing huge financial burdens on the patient and physician side, to bring about sweeping governmental changes through the PPACA, and the associated support for Accountable Care Organizations (ACOs). Physician teams working together for the benefit of a single patient have always been a part of medicine. Those teams were built on mutual trust and respect, not on contracted relationships. There has never been a need to make a corporate structure for enforcement. Inappropriately, the anti-kickback laws were used to dismantle the existing team healthcare process. This last transgression against the physician/patient relationship put the corporatization of healthcare and the disease model of medicine at the forefront of the health business. The insurers tied ACO success to capital earnings, implied efficiency, contracted productivity and limiting treatments to one complaint at a time (ICD code), rather than treating one patient at a time. This cemented the foundation of shutting down private practice entirely. Their ACO solution proposed savings by limiting physician income through salaried physician contracts. ACOs would then require productivity at reduced costs and pay. Referrals could only be effectively accountable if they stayed with an ACO. The ACO then keeps all the money in self-referrals, something that is illegal if done by the physicians. This is of benefit for the insurance business model translating to seeing more people and spending less time problem solving. The entire business model now supersedes the benefits of prevention for chronic, recurrent care. Seeking true healing and working toward a better quality of life for patients is no longer the primary purpose. Patients have been removed from the discussion except as units of cost. The healthcare industry should be mining health rather than disease. Instead of being independent health gold-miners, physicians are being turned into salaried government-designated canaries in the healthcare industry goldmine.

This sad state of affairs can be summarized in our government’s and our population’s lack of clear thinking when examining lobbying efforts that successfully distract policymakers from attending to the simplest of facts. “If you don’t get in this game, then . . . you’re on the menu,” quipped U.S. Chamber of Commerce President Tom Donohue at a recent healthcare forum at the White House. This statement is an indication that Congress and the Executive Branch are blind to the real issue. When will our government in all its branches, and Wall Street’s chess playing with the world economy realize this is not a game? This is about real people, real lives and real individual’s health. As previously mentioned, “Care coordination will improve as small practices disappear” is continuing to manifest in part as small practices disappear and patient care is less readily available.

More evidence follows:

NEW YORK (CNN-Money) — Doctors in America are harboring an embarrassing secret: Many of them are going broke.
This quiet reality, which is spreading nationwide, is claiming a wide range of casualties, including family physicians, cardiologists and oncologists.
Industry watchers say the trend is worrisome. Half of all doctors in the nation operate a private practice. So if a cash crunch forces the death of an independent practice, it robs a community of a vital health care resource.
“A lot of independent practices are starting to see serious financial issues,” said Marc Lion, CEO of Lion & Company CPAs, LLC, which advises independent doctor practices about their finances.
Doctors list shrinking insurance reimbursements, changing regulations, rising business and drug costs among the factors preventing them from keeping their practices afloat.

The regular corporate capture of the entire practice of medicine is underway. EHR is one such tool. The failure of EHR to yield truly persuasive data on its effectiveness is one place where intelligent minds should be questioning the reasons for the forceful entry of this technology into the environment of healthcare. Why was there such a powerful success in EHR adoption? There was not. It has been forced upon physicians. Physicians and physician groups have been baited with financial rewards for its adoption. Hospital systems have been awarded large multi-million dollar grants for adoption. It has been professed as the tool that will improve the delivery of safe and cost effective medicine. Not a shred of evidence has been brought forward in proof. The evidence of the expense of doing this is mounting and the data is alarming. The security of private patient data has never been more at risk. And now, non-adopters are being threatened with loss of privileges at local hospitals if they do not comply. Some are even being forced to buy into a hospital system in order to remain privileged. Refusal to relinquish patients’ privacy and security risks the loss of one’s legally earned right to practice.

When examining the timing of this occurrence, and the technology required to do what is being asked, we wonder why there was such an impossible timing schedule placed on the date limits for adoption? The first clear answer has to be found in the lobbying by the EHR and IT industry in Washington, DC. What did that really mean? There was money to be made and a great deal of it. But there was and remains a more deeply disturbing motive, the capture of fully identifiable patient data. Patient data is now easily be turned into billions of dollars per year for multiple businesses that prey on or profit from that data. These same businesses prey upon patients and physicians, under the guise of providing services and goods by generating fear regarding the data. The pharmaceutical industry has been preying on fear since it won the right to advertise on television here in the United States; all under the impression of providing health solutions. As an example, commonplace indigestion has been elevated to the status of the disease gastro-esophageal reflux. Rather than changing a patient’s diet and eliminating the simpler problems, individuals undergo endoscopy procedures, and are routinely placed on acid pump inhibitors at major expense and with significant side effect risks that are, in many cases are unnecessary. Electronic Health Records (EHR) may have inadvertently been the Trojan Horse built to capture patient data, but history on Wall Street speaks loudly to willful intent. The national organizations largely signed on anyway in the hope of potential benefits. The adage, follow the dollar could easily have proved those erroneous at an early stage had it been applied responsibly. Yet, It is not too late to do so.

Insurance companies and government oversight of physician offices will not pay claims unless payment structures conform to the industries own arbitrary standards. On its website, Aetna states it will “get (price) information from FAIR Health, Inc., a not-for-profit company formed to create an independent database not owned by any health insurer. Health plans send FAIR Health, Inc. copies of claims for services they received from providers.” Reading further, one discovers that its pricing is based on the pricing of other insurers and qualified entities all of whom benefit from lower payouts to physicians. The fee structure is not based on, nor does it consider, what physicians actually charge. The insurance industry currently has no public oversight and is only accountable to its stockholders and Wall Street industry rankings. These two conditions constitute a huge conflict of interest generating circumstances that essentially capture the entire practice of medicine under the industry’s control. Legally, insurers have been able to force nearly all medical practice into a cost-per-unit disease-model and away from prevention and quality health maintenance. Volume versus value has become the largest issue in the actuarial assessment process. Who determines the value complicates that more so when the companies determine what is valuable and simultaneously exclude the patient from the formula. The protection of corporate dollars has successfully produced increasing chronic disease by preventing timely and complete treatment protocols. Poorer health outcomes are due to shorter periods of patient contact time. The number of primary care physicians available to care for America continues to drop as a result. The prediction for the near and intermediate range of primary care graduates is glum. Those who might remain in the health industry machine now, may be forced to act like mechanics whose tools have been locked away, unable to provide the care needed to get people well. Unfortunately, that leaves patients at highest risk in this terminal experiment. The health insurance industry, with its unilateral rule changes and hold harmless clause contracts, has run the practice of medicine into the ground. Physicians have been given the opportunity to take an insurance contract or not; and negotiations for a single practitioner are and have been for some time, nearly impossible; regardless of what the insurance websites say about it.

Osteopathic smart phone applications, apps for telemedicine, AOA approved EHRs, burdensome Maintenance of Certification (MOC) and Osteopathic Continuous Certification (OCC) will not save Osteopathic Medicine from extinction. This may in fact accelerate the profession’s demise by adding significant expense to screening and triage. It will further reduce the time spent with patients. The proposals for testing physicians more frequently and forcing them to sequester more data from patient charting, provide little if any proof that there is any benefit to the costly imposition of MOC and OCC to prove physicians true value to patients. Technology, insurance administration, and legislation continues to encroach upon the patient physician relationship to the point at which nearly the entire patient encounter is occupied by this busywork; taking precious time away from the caring part of the decision making process. In the allopathic world that is a calamity. In the Osteopathic world that travesty becomes catastrophic, as providing a real treatment beyond writing a prescription becomes impossible. There is no mechanism of reimbursement for this lost time, the adoption of the technology, and e-paperwork either. In fact, collecting for these additional services is most often denied entirely by contract. Additionally, there are now plans to ensure that reimbursement for these mechanisms will continue to be denied to private physicians, while insurance companies are permitted to provide these telemedicine services through their ACO care organizations. Hospitals have expanded into extended care multidisciplinary self-referral complexes. On its website, the American Telemedicine Association (ATA) professes all the potential good that can be obtained with this technology while not mentioning any of the negative issues. The site conspicuously ignores the removal of physician level assessment and experience from the process until more severe patient complications arise. State licensure laws, potential malpractice liability, patient privacy and security concerns are just a few of the issues impacting and endangering telemedicine adoption. That our profession has had no real voice in this developmental process could be catastrophic. We should be frequently contributing to this discussion at a national level, and should have representation from private practice on committees and regulatory commissions beside AOA and AMA representation. AOA position papers should be plentiful, specific and committed on these subjects, defending the rights of the patients as a priority, just as the AOA mission statement indicates. An extensive report on the level of complexity and cost involving telemedicine was published in 1996, and though the technology has significantly expanded the assessment tool base; ease of use of the technology and the effective utilization of such technology, the cost remains high. , We still face very pressing questions regarding the appropriateness of its usage, total cost of utilization, risk vs. benefit analysis, security risks to personal data and legal risks to any party using the instrumentation or storing/transmitting the data. These issues have significant potential to super inflate the total cost of utilization and worse, may delay necessary one-on-one direct contact with a patient. There are no guarantees that the transmission of information will be reliable or that it will be complete information due to the currently available technology today. This places the patient at increased health risk until these serious issues can be better resolved.

Perhaps what is most relevant to our profession’s distinctiveness, that the body can tell us things that the patient’s mouth and technological data cannot. There is a universal thought in medical education, that physical diagnosis is as critical in the decision making process as is a complete history. A physical analysis of the patient’s condition at the time of each evaluation is central to OMT and all of medicine. This is singularly a hands-on technique that uses technology to support those findings only when necessary. We DOs call it Osteopathic Diagnosis and Treatment. Though telemedicine might help determine the severity of some conditions at a distance, the technology is not advanced enough to substitute for a trained mind connected to trained hands in seeking the cause of disease. More significantly, finding the health within the patient can only be achieved through hands-on evaluations and treatment. Furthermore, only skilled hands can turn that access to the health within, and bring it to bear on the deranged system(s) at risk. Assessing this kind of skill in a testing environment or in a GME situation can only be accomplished by measuring performance objectives under artificial circumstances. Testing this does not improve healthcare delivery. It does; however, potentially measure knowledge of procedures and protocols, as well as may assess technique patterning behaviors. It cannot test a physician’s ability to use these skills and interpret the significance of their findings. It is the actual delivery under real circumstances in real medical environments that are the only true test. Observations of routine and exceptional circumstances in daily practice would be prohibitively expensive and highly disruptive to the medical office. Outcomes measures provide a much better chance at getting a sense of physician application of knowledge and skills. Preparing for simulated patient care, similar to residency training, is of benefit to those in training but re-testing that after being in practice is not a good measure of reality nor is it a wise use of patient and physician time or money. MOC/OCC only serves to worsen the burden on physicians with additional fees, regulations, more time lost, increased data submission responsibilities, and the introduction of more surveillance of issues that will be used to deny payments, not improve patient care. It will most certainly be used in the future to restrict state DO licensure and interfere with hospital privileges and insurance reimbursement, forcing physicians into contracts with ACOs. The only reasonable solution would be for the AOA and the AMA and their respective component societies to advocate for the only stakeholders that matter, patients and their physicians. Improving the already existing GME system only requires broadening its curricula and setting higher standards The curriculum should include: “Professionalism, Patient Care and Procedural Skills, Medical Knowledge, Practice-based Learning and Improvement, Interpersonal and Communication Skills, Systems-based Practice (e.g. coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions or sites). In the Osteopathic world, this is already in our system of recertification, and additionally includes coding, safety and medico-legal concerns as part of the process.

In looking at the Wall Street assessments of the healthcare industry we see huge consolidations of insurance organizations in mergers and acquisitions over the last ten years with nearly 400 smaller companies being acquired and larger companies consolidating their influence in regional zones. The net result has been a nearly 200 percent increase in premiums and the most significant profits in history for the Health Insurance Industry in the last four years; especially after the approval of PPACA. Health Insurance Exchanges, as part of the PPACA plan, may significantly increase those already astronomical profits. “There will be a new 60 billion dollar market in 2014.” The health insurance industry by itself now represents nearly 18 percent of the Gross National Product (GNP). With that thought in mind, the insurance industry is clearly a driving force in cost, if not the single biggest cost in healthcare delivery. The question is how much of this cost is necessary? With the biggest health insurers CEOs earning tens of millions in bonuses and salaries in 2011, where are these costs really going? “The 10 highest-paid executives at the Chicago-based mutual company — which operates Blue Cross plans in Illinois and three other states — earned a collective $41.7 million, 65 percent more than the $25.3 million they were paid in 2010.”

One solution for this uncontrolled healthcare disaster has to include the restoration of a true free-market healthcare model for physicians and their patients and the health insurance industry itself. Free-market solutions imply varied things in different environments, so defining that in detail matters. First, insurance companies should be able to provide services to their patient populations across state lines promoting competition among insurance companies. With over 20 billion in profits last year alone, and with limited competition within the country’s regionalized provider service, insurance companies can clearly afford to be subjected to more fierce competition. The competition should provide direct reimbursement to the patient; not to physicians or hospital systems. Secondly physicians should collect directly from patients and not from any other third party sources. Removing the conflict of interest and restoring responsibility to all the players will bring a balance built on supply and demand and not artificial pricing based on biased statistics. Unlimited License Physicians are by law are currently free to practice in any setting. Fee for service with direct pay for services rendered promotes competition at local levels and encourages patient responsibility both for fees and for their own health via compliance. The quality of service provided by physicians will be rewarded while a lack of quality will drive down fraud. Doctors must be able to enter into private practice protected from health insurance rules and government edicts that take away physician individual rights. The AOA, AMA and all physicians must fight for freedom to ensure patients the best care choices. This would enable DOs and MDs to continue to practice in an unlimited manner. In particular, it will foster a growth environment for Osteopathic Medicine at present and into the future. Patients would be free to choose holistic preventive hands-on DO care for their families as they have done for over 130 years and stay with their physician of choice without having to answer to insurance companies.

In order to prevent extinction, the AOA must achieve independence from the pseudo-stakeholder complex of government, insurance and AMA. If not, its principles and practice will be destroyed as we are further sidelined into obscurity or into underground practice.

Medicare law makes it illegal to do pure charity for its members if the physician participates in Medicare. Physicians have been in charge of, and held responsible for, the care they provide and the charity they freely elect. Charity by a physician is the physician’s right and privilege to deliver and cannot be mandated. If Medicare pays the patient, the patient becomes empowered to choose what works, therefore the physician has to work for it.

Health insurance in the last century operated in a manner similar to the auto insurance industry today by paying for major expenses. Health insurance could easily do the same, further reducing costs and promoting personal health responsibility. The industry has manipulated and lobbied itself into a position where most of the industry’s work is done for it by physicians and their staff. Nearly all insurance aspects of care from offices, checking patient eligibility to determining and collecting visit co-pays, prior authorization of tests, precertification of medications, coding, billing and denial appeals are managed at the expense of physicians. Health insurance procedures and processing wastes a huge amount of patient, physician and staff time and money. The AOA and its physicians need to redevelop inexpensive major medical indemnity patient reimbursement plans to free physicians and their patients to seek the best care together.

The healthcare equation for success:
Free-market + competition + transparency + direct patient pay + indemnity insurance +/- voluntary charity = empowered healthy patients + efficient healthcare + reasonable cost.

The AOA and nearly all physicians realize that we cannot beat the government or health insurance industry; especially when they can unilaterally change the rules at any time in their favor. This will always, by design place us in a losing position. Physicians MUST seek reimbursement from patients only, not through insurance or government. We have seen hard facts that government and insurance payment systems are unsustainable. The government and insurance industry must be held responsible and accountable to the patients they are supposed to serve. Effective humane healthcare is bottom up, not top down. Patients must choose, invest in and participate in their care at their will and if not, at their own personal risk. Poor decisions on personal healthcare should not hurt the public. This is the only solution designed to improve care and outcomes.

MOC/OCC is self-serving and cost prohibitive as it is currently proposed and thus, is not a reasonable substitute for the current GME system of maintenance of licensure at least in the Osteopathic profession. It represents an untested concept that is unnecessarily burdensome in time and money and proves nothing about physician qualifications, patient care or outcomes. Continuing with time-tested quality residency training, a single written and practical examination at time of completion, and lifelong CME programs for staying current with progress in our respective fields has provided a very safe environment and excellent patient outcomes. There is always room for improving the system, but a complete overhaul is not indicated and will be less so as physicians compete to provide the highest quality care rather than to merely get paid.

Osteopathic uniqueness in thought and deed is too vital to humanity to be bludgeoned to death by insurance and government big money stakeholders. The AOA advocating for free-market healthcare is logical in view of these issues. Individual health freedom for physicians and their patients is our only hope for the survival of Osteopathic Medicine and medicine in general. What we need is to use computer algorithms, symptom-based population medicine, to provide better decision making information to trained physicians who share this with their patients, explaining what patients need explained and helping the patients to take responsibility for and make their own choices. The computer and/or non-physicians should not be making the decisions for the patients. The government-insurance-AMA stakeholder model supporting the disease-model ust be removed and the health-model must be reinstated. Physicians cannot be replaced so easily and experience is even harder to transfer.

Now more than ever your individual opinions and thoughts matter. Make yourself heard by writing or e-mailing to the JAOA, and copy it to the AOA, the AAO, and other media. Make everyone aware of a more complete perspective of the profession; about the work we should all be defending, and with regard to our professional rights:
1. to private independent practice,
2. to protect and defend our patients,
3. to protect patient information privacy,
4. to protect physician privacy,
5. to demand the each organization (government, corporate, or professional) take responsibility for their decisions, actions and inactions, AND
6. to have patients take responsibility for their personal health both financially and behaviorally.

“Anyone can find disease…” A.T. Still

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