by Rob Roper
We hear it over and over from proponents of single payer healthcare: “We need a system!” A “system” will bring efficiencies that will lead to cost containment. At least that’s the theory. But what else does a single payer, government run “system” do. According to Dr. Dan McCauliffe, a physician and dermatologist from the Rutland area, a government-run system has the potential to undermine the traditional doctor patient relationship to the detriment of patient care.
“The sanctity of the patient/doctor relationship is weakened when the physician becomes an employee,” explained Dr. McCauliffe,
lamenting the decline of private-practice medical offices and the drive to move doctors into salaried employment through hospitals. “And it can be worse when there’s government control….”
McCauliffe cited an example from England in which primary care physicians were discovered receiving bonuses from the government for not sending patients on to receive expensive specialty care. “That is such a violation of the doctor/patient relationship where the government is interceding and saying we want you to do this for the system’s sake, but at the loss of the patient’s benefit.” However, that is the exactly incentive doctors face when they feel more invested in and loyal to “the system” rather than the patient, and when the state becomes the customer rather than the individual.
“Let me take that one step further,” said Dr. McCauliffe. “There were several articles in a Canadian papers about doctors in Canada being bullied when they try to speak up for their patients…. That’s the problem when you have top down control of healthcare and the administrators have so much power that they can affect the physician’s relationships with their patients.”
Dr. McCauliffe believes that the parallel efforts to drive doctors out of private practice and patients into a mandatory healthcare exchange with little choice are all about control, and not so much about care.
“The death of private practice is happening in Vermont and is nation wide, and it’s a reflection of government payment policies,” said Dr. McCauliffe. “I think it has been a concerted effort to do that very thing – get physicians in employed positions where they’re more easily controlled. For example, cardiologists…. A couple of years ago all the cardiologists left private practice and joined hospitals. There was very little discussion in the local papers or the state papers on why it happened. What happened was the federal government cut the payment for some of their services by 40%, yet, if they go to the hospital and do the same services, they had a 45% pay increase. So, needless to say, it’s no wonder cardiologists are now all employed by hospitals.”
Citing another example, Dr. McCauliffe said, “Similarly, federal payment policies have driven primary care doctors into these Federally Qualified Health Clinics where they can earn substantially more money there than in private practice. Why are we trying to kill private practice?”
Dr. McCauliffe believes this concerted effort is part of a new definition of medical ethics that is asserting itself both at the national level through the Affordable Care Act and locally through Green Mountain Care. The gist of this new ethics is summed up by the controversial recess-appointed, and now former Administrator of the Centers for Medicare and Medicaid Services, Donald Berwick, “Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.”
“As a physician,” said Dr. McCauliffe, “I find that to go against the Hippocratic oath and against the way many physicians want to practice.”
This gets to the indirect negative impact a government run system could have on Vermonters – when there is nobody available to provide care at all.
“Vermont is not a country,” warned Dr. McCauliffe. “It’s not that difficult to leave…. I can tell you that with this healthcare reform is already affecting my practice. The only dermatologist in Bennington, Vermont, retired last year. He tried for over a year and a half to recruit someone. He actually was going to give his practice away, and no one came. I have patients driving from Bennington to Rutland now for care, and my waiting time is going up and up, and it’s stressing the system a bit.”
“We also has a primary care doctor in Rutland leave last summer,” Dr. McCauliffe continued, “and now he’s practicing in Maine. He sent a letter around (I actually talked to him on the phone) he said, ‘the uncertainty of what’s happening in Vermont, I’m just not going to wait for this to unfold.’ He moved.”
Dr. McCauliffe sees a bleak future if Vermont continues down its current path. “I think what we’re going to see as this unwinds is, if it doesn’t look good, we’ll probably have difficulty recruiting physicians. That’ll be the first thing. If physicians retire or leave, we’ll have difficulty replacing them. If it gets to the point where there are more ridged controls, and physicians are more susceptible to malpractice cases where they’re not happy working with the top-down sort of management, there may be an impetus to leave. And, I think that could really be bad for patients in Vermont. It could be bad for the whole system.”
“Whatever system we end up with, we need to have a system that preserves the patient/doctor relationship where the doctor is the patient’s advocate,” said Dr. McCauliffe. However, that doesn’t appear to be what our government is prepared to give us.