From the President...

Fraud and Abuse: Other Considerations

James P. Weaver, MD

At our national meeting in Raleigh, North Carolina last fall, there were many presentations on the Kassebaum-Kennedy law provisions allowing for the investigation of fraud and abuse in the Medicare system. Physicians, it now seems, potentially face armed invasion of their "private" offices by federal agents who will be enforcing the ever increasing regulations of this misguided program. These new tactics, this escalation in the use of intimidation and terror, will come as no surprise to those who have examined the political and philosophical basis of Medicare.

At its best, Medicare, a medical care program for the elderly and the disabled, is a government program ultimately based on force --- and that is where the "best" ends. Medicare is a wealth redistribution scheme in which property in the form of taxes is taken from one group of citizens, by force, and then doled out by government bureaucrats to recipients of another group. Thus, it is a system where one politically powerful group spends other people's money for their medical needs and justifies it because the government says it's "OK." Obviously, there are some inevitable consequences of this type of a system.

First, those doing the spending will always want the "best that money can buy," and hey, why not, it's not their money! This flaw, the reality that in the consumption of medical care one uses other people's money, is the cause of the ever increasing rate of Medicare spending. The only just control on the price of services is missing from Medicare --- namely, people prudently spending their own money based upon the value they place on the service they are purchasing.

Second, this inflationary spending will necessitate justification because those individuals from whom the property has been taken will demand some explanation for these expenditures. Thus, we have the "fraud and abuse" provisions found in the Kassebaum-Kennedy law. But, there are far more insidious reasons for these draconian provisions than the simple justification of spending. I believe the actual thrust of this law is intimidation and subjugation of physicians.

Third, if the Medicare system is to survive, the physician of the future must be molded by this system. This "new" physician will literally be a slave to the system. He will no longer work for the patient, but for the government. Documentation will be the most important aspect of the "encounter," for if it is not there, one's career, indeed, one's livelihood, could be ruined. Notes will no longer be written to inform a referring doctor of another physician's reasoning and intended treatment or to recall a treatment plan, but rather, to satisfy the need to justify a charge to the government. The care of the patient will become a secondary byproduct of the "system."

As physicians' minds and behaviors are gradually molded by the ever increasing and coercive rules of the Medicare system, the very nature of their essential professionalism changes. What type of person will survive this onslaught of infringement upon personal liberty to practice medicine in the future? This is the question society must begin to ask, if it wants compassionate medical care in the not-too-distant future.

Infinite numbers of rules, arbitrary rules that no one can possibly follow to the letter of the law, will not save Medicare. A court system, the Administrative Law System --- financed by the makers of the rules --- will not save Medicare. A reimbursement scheme that negates the value of the service to the consumer and determines that "value" based upon the size of the "take" from the previous year's taxes will not save Medicare. A system that scrutinizes its victims, both patients and physicians, and has the power to economically destroy almost any of them at will, is not a system that will foster human creativity, ingenuity, and caring. Medicare is a system that is doomed to fail.

Our association, the AAPS, is attempting to reverse the direction of history, towards a period of a more just system. A system based upon service, professionalism, and caring. Such a system will foster an environment which will nurture the best that medicine has to offer this country. In the terminology of the field of medicine, it's called "private practice." In the field of politics, it's called "freedom." Call it what you will, it's exactly what we need to return medicine to its noble pedestal and restore the trustworthy patient-doctor relationship to the sanctity it deserves.

Dr. Weaver is a thoracic surgeon in Durham, North Carolina, and president of the AAPS. E-mail: