Tuesday, August 24, 2010

Conflicts Galore

The public has a very clear need for disclosing conflicts of interest in medical journals. Today, the Annals of Internal Medicine published "The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges" authored by Robert Kocher, MD; Ezekiel J. Emanuel, MD; and Nancy-Ann M. DeParle, JD. The only author affiliations disclosed were that of Dr. Kocher ("Dr. Kocher's service at The White House ended on 9 July 2010. He wrote the paper while he was working for the National Economic Council.").

Should Dr. Emanuel not have noted his relationship as White House advisor for health care policy and his relationship with his brother, White House Chief of Staff Rahm Emanuel? And should Ms. DeParle's disclosed her role as President Obama's so-called health czar with significant ties to private equity firms?

According to the Annals own Conflict of Interest Policy (emphasis mine):
Conflict of interest exists when an author, editor, or peer reviewer has a competing interest that could unduly influence (or be perceived to do so) his or her responsibilities in the publication process. The potential for an author’s conflict of interest exists when he or she (or the author’s institution or employer) has personal or financial relationships that could influence (bias) his or her actions. These relationships vary from those with negligible potential to influence judgment to those with great potential to influence judgment. Not all relationships represent true conflict of interest. Conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment.

Authors, editors, and peer reviewers must state explicitly whether potential conflicts do or do not exist. Academic, financial, institutional, and personal relationships (such as employment, consultancies, close colleague or family ties, honoraria for advice or public speaking, service on advisory boards or medical education companies, stock ownership or options, paid expert testimony, grants or patents received or pending, and royalties) are potential conflicts of interest that could undermine the credibility of the journal, the authors, and science itself.
Perhaps such disclosures only for the little people in health care who try to publish their work.

But we should ignore this editorial blunder, right? After all, the "Affordable" Care Act is our next great health care challenge ahead!

But the veiled threat in the opening paragraph of this work might not be the best way forward:
To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change. The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups. The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity, and patient experience.
But one only has to read Sermo's message board (registration required) to get of flavor of what many doctors think about the law and this article in particular:
They ignored us the whole time they were putting this monstrosity together and ramming it through the legislative process. They got sham-"providers" in white coats for photo-ops so they could pretend we were on board. They got the AMA to play ball, knowing that the public perception would be that we were on board. In short, they were soooooo sure they didn't need us.

And now they're in a predicament with their white elephant, and begging us for some support after the deed's been done.
The reality on the ground is that the law has passed and change is coming. The reality on the ground is physicians continue to see significant cuts to their profits. The reality on the ground is the physician pay fix remains unresolved and will be expensive. And the reality on the ground is doctors provide the care and the administration needs doctors to facilitate the implementation of the many health care changes that lie ahead.

Edicts are not away to lead health care reform. Unless and until doctors feel there is meaningful collaboration between the bureaucratic powers responsible for the Affordable Care Act that shares mutually agreeable goals, there will continue to be even bigger conflicts with doctors that will make moving this legislation forward challenging.


Ref: The Reuter's news release.


Robert W Donnell said...

The Annals article is largely a propaganda piece. It may have been appropriate for one of the ACP's newsletters, but not for what purports to be a premier scientific journal. I'll post on this tomorrow. Thanks for calling it out.

Anonymous said...

Yes, hold their feet to the fire. And while you're at it, perhaps you'll spread the word that another character needs some calling out - the guy who just won the Florida Republican primary for governor. His company, Columbia/HCA, while under his leadership, was having some difficulty in managing Medicare guidelines that resulted in $1.7 BILLION in fines and settlements. I'd call that something of a "conflict" in his ability to run a honest organization.

American Medical Association said...

The AMA supports the goals of health reform, and while this new law is an historic achievement more work remains, chiefly fixing the Medicare physician payment system that now projects steep cuts of about 30 percent. Far from being a mere “distraction” as the authors claim, fixing the broken Medicare physician payment system is essential to the success of health system reform so that physicians can continue to care for seniors and lead and participate in improvements to the way health care is delivered. Medicare is the driver for many of the health care delivery changes in the new health reform law, and the current payment system erodes Medicare’s physician foundation and harms seniors’ health care. How can physicians be expected to invest in new technology when Medicare is not covering the cost of providing care to seniors?

Physicians are committed to providing patients with high-quality, coordinated care, but policymakers must remember that there is no one size fits all solution to the way that care is delivered in our uniquely American system. The majority of American physicians are in small practices and health care policies must help all physicians optimize the care they provide, regardless of their practice model. The AMA is currently providing education for physicians on new models of care, like accountable care organizations, and on health information technology so that they can be the vanguard of changes to our health care system.

Ardis Hoven, M.D.
Board Chair, American Medical Association

DrWes said...


Great point. There are scoundrels on both sides of the aisle.

Dr. Hoven-

Most of us have appreciated the efforts of the AMA to advocate for physician payment reform. For those of us outside the Beltway who have viewed the political sausage-making process that has resulted in the PPACA law, I recall that the AMA was an early ardent supporter of the bill before many of the legislators had even read the bill. In part, we were told by then President Rohack many of the reasons for this, chief among them was the physician payment reform that was part of early versions of the bill. Later, those provisions were stripped from the bill when the CBO estimate of the legislation returned with an estimated cost of the bill well over a trillion dollars. The AMA still supported the bill.

At this point, many of our country’s doctors became concerned that the AMA’s financial conflicts inherent to the licensing fees the AMA receives from the government for their CPT and ICD-9 coding revenues trumped their very real and ongoing financial concerns of today’s doctors. We knew that without holding the politicians feet to the fire on the doctor fix issue before the legislation passed (the reasons for which you so nicely outline above) that the AMA’s negotiating strength would greatly diminish if the bill were passed without that provision. Doctors were told the fix would be added to other legislation instead and promised it would not be forgotten. Yet a 21% cuts in Medicare funds did occur earlier this year, albeit briefly. Congress later voted to suspend the cuts a bit longer after they returned from their vacation, er, recess.

By then, bill was already passed and the writing was on the wall for America’s doctors. The law contains many complicated mechanisms to pay physicians now, chief among them a plan for “bundled payments” made to large health care systems. The solo doctor does not stand a chance if this is the only mechanism for physician payment. Discouraged, many doctors have or are closing their practices, unable to float them on their personal loans because of government delays for payment caused by these legislative snafus. Many others are becoming employees of larger health systems in an attempt to buffer themselves against further cuts. You note that “the majority of American physicians are in small practices and health care policies must help all physicians optimize the care they provide, regardless of their practice model.” And yet this untested bundled payment scheme makes the ability for small practices to remain intact very unlikely since “systems of care” will receive payment, rather than the individual doctor. It would be critical for the AMA to delineate how to preserve the option of a small or solo practice any longer. Physicians would eagerly await progressive guidance on this topic. Any ideas?

Meanwhile, they see the hospital systems benefiting and building larger facilities, insurers making record profits, and patients paying more, too.

These are the realities. Doctors are now very skeptical since they realize the limits of what can be done now that this law has passed and our bargaining leverage squandered. Still, we are the ones who do the work, day in and day out and interact with our patients. As such, we will have to be the ones who fix it. Perhaps if nothing else, these realities will allow time for those of us who remain to become more involved in the political and legislative process. That will be a good thing. The AMA’s challenge now will be if they can put in place meaningful actions that will serve to get the disgruntled back.

American Medical Association said...

Dr. Wes – Thank you for your comments. Physicians should be able to practice in the model of their choice, and AMA is working to help physicians in small practices have the tools they need to not just survive, but thrive, in our health care system. I encourage physicians to sign up for our Physician Management e-mail alerts, which are designed mainly for physicians in the small practice setting. Our practice management center helps physicians manage the business side of their practice more effectively with resources that help physicians implement electronic efficiencies and challenge unfair payment practices. The full bevy of resources is accessible at www.ama-assn.org/go/pmc. We’re also offering education sessions on health IT and new payment models.

We are committed to increasing the AMA’s value to physicians, especially in the important areas of practice management, health information technology, advocacy and public health. We are identifying and expanding our array of member benefits that appeal most to physicians, and AMA’s new president, Dr. Cecil Wilson, is hosting monthly conference calls with AMA physician and medical student members to listen to their concerns and input so we can provide them with needed resources.

I do need to correct the comment on AMA’s revenue. There is no conflict of interest. The AMA does not receive CPT licensing fees from the government, and we do not license ICD-9. We are proud that CPT® codes are physician developed and maintained. Dr. Wilson blogged about AMA’s work on CPT earlier this week, and I encourage you to read his take on the issue (posted on www.hsreform.org). Untrue statements about CPT were spread during the health reform debate, and I am glad to have the opportunity to set the record straight.

Ardis Hoven, M.D.
Board Chair, American Medical Association

DrWes said...

Dr. Hoven-

According to the AMA's latest 990 financial statement (2008) membership dues accounted from $44.8M in revenue, while royalties garnered $55M and sales of inventory garnered nearly $41M in revenue for the AMA.

According to Dr. Wilson's blog:

"In 1966, the AMA established CPT® codes and they were subsequently and voluntarily adopted in the United States as the code set of choice for insurance claims filing. This meant that physicians could use one code set regardless of the insurance payer. In 1983, the AMA House of Delegates voted to have CPT codes adopted as Medicare’s official terminology.

The association later finalized an agreement with the Health Care Financing Administration, now named the Centers for Medicare & Medicaid Services, to adopt CPT® for reporting physician services under Medicare and related programs. This agreement is not exclusive (CMS could sanction other code sets) and not binding on private insurance companies. And the AMA derives no income from the federal government for the agreement."

Then he goes on to say:

"The financial resources invested in the development and maintenance of the CPT® codes has been provided solely by the AMA. The AMA in turn sells and licenses the CPT® codes for use in other publications, and uses the funds received to assist important programs in support of the medical profession."

Now I suppose it depends on which comes first, the chicken or the egg, right? If the financial resources to support the CPT are made solely by the AMA, but the AMA gets those revenues from sales to a multitude of government agencies, the insurance industry and the entire electronic medical record industry, might conflicts arise when the revenues received from those entities exceed the AMA's membership dues?

I find it interesting that you feel there are no conflicts inherent to these financial interdependencies.