Dear Mr. Consolazio,
I just wanted to take a moment to thank you...I enjoyed reading your poem ["Memorial Day," Medical Sentinel, Summer 1997, p. 104] and feel that you are right on target and indeed a Patriotic American.
...[T]hank you for all that you do to help defend our Second Amendment Rights.
First Vice-President, NRA
Kudos Medical Sentinel
Thank you indeed for the copies of the Medical Sentinel. I am reading them slowly, with great interest and delight in the depth of your Editor-in-Chief's classical education and scholarship.
I find your choice of articles to be an outstanding selection, a gathering of minds occupied as the mind should be with attention to historical foundations while examining the follies that choke our mental productiveness today.
One member of your editorial board intrigues me ---- Russell Blaylock, M.D. Some 26 years ago, I knew a fine surgeon at Ochsner Foundation Hospital with the same name...
I have enclosed a check for two subscriptions. Please enter a subscription for me, and a second one for a dear physician friend...
Barbara C. Anderson
Port St. Joe, FL
I am involved in a number of initiatives to promote practice outside managed care. I helped to found a group of mental health
professionals in Burlington who work outside managed care. I am also quite involved in the University of Vermont psychiatry residency training program. I provide a role model for the residents of a psychiatrist who practices long-term dynamic psychotherapy, which runs counter to the managed care notions that all psychotherapy should be brief and that psychiatrists should only prescribe drugs, not talk to people. And rest assured, I am not of the school that believes insurance plans should be mandated to cover long-term psychotherapy: if people value it, they can pay for it out of pocket.
I have recently been appointed Chairman of the Ethics Committee of the Vermont Psychiatric Association. There are a multitude of ethical issues to be concerned about, of course, but my primary personal interest is in the ethical dilemmas created for physicians who participate in managed care.
If we enforced our ethics code strictly, managed care would not exist; this is especially true of psychiatry, with our special emphasis on confidentiality.
It remains to be seen how much can be accomplished on this front within the framework of organized medicine, but I am heartened that I was appointed to this position when my colleagues are quite aware (because I hector them about it frequently) that I view participation in managed care as inherently incompatible with our ethical code...
The Medical Sentinel is extremely important to me as I carry out these activities, giving me hope and inspiration. The AAPS is the only medical society with the backbone to fight managed care and Medicare, and the Medical Sentinel is the only journal which dares to challenge the current orthodoxy that we must comply with the demands of our would-be overlords. Thank you for all your hard work.
Robert S. Emmons, MD
[Other AAPS physicians serving on ethics committees include: Dr.
Jerome C. Arnett, Jr., Ethics Committee of the American College of Chest
Physicians; and Dr. James Weaver, president-elect AAPS, Bioethics Committee
of the North Carolina Medical Society. -Ed.]
AMA-HCFA E&M Guidelines
Thank God for the Association of American Physicians and Surgeons (AAPS). While the AMA has been busy selling its name to the Sunbeam Corporation and giving its seal of approval to HCFA in return for profits from the sale of coding books, the AAPS has shown yet again it's unwavering commitment to the patient-doctor relationship and professional ethics. While the AMA is busy collaborating with the enemy (HCFA) to bring us increased government bureaucracy, the AAPS is fighting back by filing a lawsuit against HCFA.
For those who say that you have to "go along to get along," and you "can't fight city hall," we note it was the AAPS that successfully sued the Clintons over the illegal secrecy of the Health Care Task Force (AAPS v. Clinton --- judgment in favor of AAPS $285,000 against the Clintons for violation of FACA law). The AAPS exposed the conflicts of interest of Task Force members and other secrets of the Health Care Task Force and in so doing helped to derail the train heading for totalitarian, socialized medicine in this country.
Physicians in this country owe a great debt of gratitude to the AAPS for having courage to stand up and fight back against big government intrusion into the practice of medicine (unlawful interference in the case of Medicare --- Sec. 1801 of the Act). Laying down and "just taking it," or worse, collaborating with the enemy, only brings more government bureaucracy and more unlawful government interference in the practice of medicine. It's time to stand up and fight back!
Lawrence R. Huntoon, MD, PhD
In the March 2, 1998 issue of AMNews, your headlines glared: "AMA acts to quell E&M flap," and then, on the glossy cover of AMNews (March 23, 1998), you also beamed, "With a powerful, unified voice an AMA/Federation of Medicine campaign is pushing hard for substantial improvements to Medicare coding documentation guidelines that more and more physicians say are unfair and burdensome. Medicare's 'documentation guidelines for evaluation and management (E&M) services' are at the heart of the situation --- which AMA President Percy Wootton, MD, calls a 'pressing priority.' " But then, who claimed credit in the same (March 23, 1998) issue of AMNews for authoring this oppressive and anti-competitive E&M guidelines in 1992? The AMA! Well, it seems as if the famous possum of the Okefenokee Swamp of Georgia, Pogo, was wrong after all. We have met the enemy, and it is not us! It's the AMA pragmatic leadership which keeps shooting itself in the foot --- and the rank-and-file physicians in the head!
Miguel A. Faria, Jr., M.D.
Editor-in-Chief, Medical Sentinel
[The two previous letters were sent to but not published in AMNews. See News and Analysis on page 114 of this issue for updated information. ---Ed.]
Health Care Tyranny
"Life, liberty and the pursuit of happiness" is a myth for some in this world. Consider a country that would limit the amount of money that certain highly trained workers could earn for doing their work no matter what their skill level. Consider a country that encouraged a non-competitive environment for only this type of worker. Consider a country that would make it a crime for these workers to privately negotiate compensation outside of a government-imposed fee structure. Consider a country that would selectively drive the incomes of these workers' down at a time when other workers in other industries enjoyed increasing prosperity. Consider a country that would allow monopolistic companies to also lower their payments to these workers, just like the government. Consider a country that threatens to drive these workers out of business because their costs could not be covered. Consider the plight of the workers that would lose their jobs because of this ruthless government behavior. Consider the unfortunate consumers of the services that these highly skilled workers would normally provide --- consumers who would find the lines long and the services denied because of the government's policies.
Does this sound like tyranny or, perhaps, a third world dictatorship? The country is the United States. The workers are health care workers --- physicians, nurses, therapists, hospitals, and their employees.
We are losing the greatest health care system in the world because of unrealistic cuts in payments to health care providers at all levels. This is health care tyranny in the "land of the free." Bargain basement medical care will soon be worth less than what we pay for it. Urge your representatives to turn this short-sighted policy around in the name of quality. Discuss this issue with those who know.... We and our patients deserve better.
Ward S. DeWitt, MD
I heartily appreciated the editorial by Dr. James Weaver entitled, "Physicians Hear This: Say Goodbye to Third-Party Payment or Die" [Medical Sentinel 1998;3(1):26-28].
To address one point in this article, i.e., that fee-for-service engenders a conflict to overtreat patients, I think that this conflict will be removed if the third-party payer is in fact removed from the patient examination room. That is, if the relationship between the payer and the third-party payer does not include the physician, or if in fact there is no third-party payer, the patient himself will understand the cost of medical care and begin to make informed decisions. This, in fact, will lead to patients seeking physicians, who are known to practice quality care and not overutilize unnecessary medical resources or overtreat.
Again, however, I agree with the main thrust by the author that the intrusion of the third-party payer into the examination room has unfortunately left us in the medical profession prey to their manipulation. Thus, it is imperative for the future of medicine that we rid ourselves of this intrusion.
Charles P. Prezzia, MD, MPH
Medicare Investigator Jailes
Dear Dr. Orient,
I have so many articles piled up on my desk that I want to share with you and other AAPS members, it's becoming more and more difficult to get to them all.
In the event that I end up in jail, however, for participating in the non-violent march to the local IRS office with other members of the Independent Citizens Committee for the Fair Treatment of the Lapp Family, I just had to get this one last piece off. It's a real gem!
Last month, I wrote to the Gerry Town Court to find out what happened to the Medicare investigator who was arrested and jailed on April 8, 1997 for making sexually harassing phone calls from his hotel room while he was in Jamestown, New York to conduct a "Medicare investigation" at the hospital. Here is the reply that I got. I think it's from the Gerry Town Justice.
The Medicare investigator plead guilty and was fined only $250 plus court costs. He did, of course, spend some time in the Chautauqua County Jail prior to appearing in court.
I see something terribly wrong with our system of justice when a Medicare investigator is fined a mere $250 for making multiple obscene phone calls to multiple people (a clear pattern of abuse), intentionally harassing them, and a physician can be fined 40 times as much ($10,000!) for coding errors on Medicare claims which may be unintentional.
In any event, there is no longer any doubt about the guilt of this particular Medicare investigator. He did, in fact, commit the crime he was accused of committing.
Lawrence R. Huntoon, MD, PhD
Transformation of Medical Ethics Through Time
October 7, 1997
Dear Dr. Annis:
[Regarding "The Transformation of Medical Ethics Through Time" (Medical Sentinel, Vol. 3, # 1-2, 1997) which I gave in part as a speech to the American Society of Dermatology (ASD) last year in San Antonio, Texas]... I admit I was highly critical of the AMA and organized medicine. Unfortunately, it is all true and I wish I did not have to say it. Sadly, I have it all well documented. In fact, most of it is quite detailed in my new book, Medical Warrior: Fighting Corporate Socialized Medicine.
One only has to see where we stand today in medicine, the demoralization of physicians, the deterioration in the quality of care with managed care, the general devastation that government in "partnership" with the medical politicians of organized medicine "in the new era of cooperation rather than confrontation" have wrought on the profession to realize that, in recent years, the AMA has not served us well.
As far as my comments about Representative "Pete" Stark and political contributions, it is also all quite true. As I wrote in my book, Medical Warrior, "To add insult to injury, Rep. Fortney 'Pete' Stark (D-CA) charged, 'The AMA is trying to take control of health care reform....Basically, the AMA would like to be the principle negotiating agent, the big muckety-muck. That is not going to happen.' Pete Stark, it should be noted, ranked No. 1 in political contributions, collecting $497,250 for the decade ending June 30, 1991. Common Cause reports that of that amount, he amassed $203,200 from medical political action committees (PACs) placing him in the No. 2 position in contributions from our ranks."(This verified information was gleaned from Common Cause and published by Physician's Weekly in 1992.) In fact, citing figures from 1975 to 1992, Wolinsky and Brune (The Serpent on the Staff --- The Unhealthy Politics of the American Medical Association, G.P. Putnam's Sons, New York, 1994) used figures of the Federal Elections Commission compiled by the National Library on Money & Politics and honoraria listing by the Nexis database service to show Representative "Pete" Stark as receiving $6,100 in direct contributions from the AMA. Moreover, in the AAPS News legislative supplement, December 1993, we reported, "The medical industries huge expenditure of political action committee funds looks like a massive exercise in pathetic groveling and professional self-abasement. Medical industry PACs contributed $5.9 million to the members of the Ways and Means Committee from January to June 1993. The biggest winners: Pete Stark (D-CA), $646,150; Charles Rangel (D-NY), $416,082; Dan Rostenkowski (D-IL), $384,777."
I was incorrect about one thing, AMPAC's biggest investment was not in Henry Waxman, as I thought, but it was in another [liberal] Democrat from California, Vic Fazio, then chairman of the fund-raising Democratic Congressional Campaign Committee! (See Serpent on the Staff, page 92.)
The truth is, to help obfuscate the facts, the AMA leadership has repeatedly stated that the reason Rep. Stark has been an enemy of medicine is because of the money that was raised against him by the doctors in California. The fact is that all this time he was receiving huge amounts of money funneled to him from organized medicine and medical political actions committees, and despite all of this "financial assistance," he continued to be an enemy of the medical profession, pursuing aggressively Stark I, Stark II, and Stark III legislation in the late 1980s and through the 1990s. Since "Pete" Stark's anti-kickback statutes began before 1989, it is obvious that he was receiving money from organized medicine while he was already proposing legislation that went contrary to the interests of physicians.
If you now feel a tinge of betrayal, you can begin to realize how I felt in the early 1990s when I learned about the wheelings and dealings in organized medicine and came across this type of information. And, in fact, I still feel betrayed! When I brought this up with a former Speaker of the AMA House of Delegates, he told me: "Miguel, it's just politics!" A couple of years later, as you will find out in Medical Warrior, I was sacrificed --- with the opposite of the intended effect.
If you have any specific information, facts, and/or figures that dispute any of these findings, I will be happy to see them.
I recommend that you not only read my book, but also Dr. Jane Orient's book, Your Doctor Is Not In (if you have not already), and definitely, Wolinsky and Brune's The Serpent on the Staff ---The Unhealthy Politics of the American Medical Association, which I think you can now obtain in paperback at bookstores. Neither of us will agree with everything in this book, but the information they have gleaned is quite damning to the AMA and embarrassing to principled physicians such as us.
Miguel A. Faria, Jr., M.D.
January 22, 1998
Two reactions followed my receipt of your letter of October 7, 1997. First, I knew that it reflected your honest appraisal and opinion based upon sources which you quoted and, second, I also knew that some of the sources quoted were at least misinformed on many points of fact.
To obtain a clear and documented record, I wrote to my friend, Jim White, who is chairman of the AMPAC Board, requesting a careful review of all activities for or against Pete Stark.
My request coincided in time with a major move of the offices of AMPAC and all past records were buried in the moving process. I received apologies for lack of available documentation, but, a promise to assign personnel for a complete study when all records could be retrieved from the archives.
That response has just been received and I enclose it for your information. The second page gives a summary of what I had vaguely remembered when I questioned your sources during the meeting in San Antonio.
The Medical Sentinel continues to be a valuable source of information for AAPS members, and I salute you for its immediate success.
Edward R. Annis, MD
January 13, 1998
Dear Dr. Annis,
Thank you for being so patient. I was finally able to get access to our archived files and now have the information you requested regarding AMPAC contributions to Congressman Pete Stark.
Congressman Stark was first elected to Congress in 1972. My records on Stark contributions begin in the 1980 election cycle. During the 1980, 1982, and 1984 election cycles, AMPAC did not make any contributions to Congressman Stark. In the 1986 election cycle, AMPAC made an independent expenditure on behalf of Mr. Stark's Republican opponent, Dave Williams, totaling $252,199. Mr. Stark won the election, of course, but filed a complaint about our independent expenditure with the Federal Election Commission (FEC) which the Commission dismissed. Mr. Stark then sued the FEC in federal district court, and that case was also dismissed.
In the 1988 and 1990 election cycles, AMPAC made no contributions to Congressman Stark. In the 1992 election cycle, a total of $6,000 was made in AMPAC contributions to Congressman Stark --- a $3,000 primary contribution, a $500 Washington fundraiser contribution, and a $2,500 in-kind contribution attributed to AMPAC but made by the California Medical Political Action Committee (CALPAC). In the 1994 election cycle, AMPAC contributed $3,500 to Congressman Stark. As I mentioned on the telephone the other day, from 1992 to 1994 we seemed to have reached a measure of détente with Mr. Stark and, although we still disagreed on many issues, he was very helpful to the AMA on a number of issues before the Ways and Means subcommittee on health.
In the 1996 election cycle, AMPAC did not accept the recommendation of CALPAC to contribute to Mr. Stark's campaign and CALPAC contributed $5,000 from their own federal PAC. Finally, no contribution has been made to Congressman Stark in the 1998 election cycle.
In summary, during the past fourteen years AMPAC has contributed a total of $9,500 to Congressman Stark's campaigns and a total of $252,199 to a campaign that opposed Mr. Stark. The problem with the letter you received from Dr. Faria is that he seems to believe that AMPAC either made all of the contributions attributed to "medical industry PACs" or assumes that AMPAC has influence over contribution decisions made by other PACs. Both assumptions are incorrect.
I hope this information is helpful. Please let me know if I can provide any further assistance.
Executive Director and Treasurer, AMPAC
February 17, 1998
Dear Dr. Annis,
Thank you for sending me the results of your inquires regarding Rep. "Pete" Stark (D-CA) and AMA contributions. Suffice to say, the six-digit figure of contributions received by Rep. Stark from political action committees of "the medical industry" and organized medicine placed him second in overall contributions from these entities. The question is how much of this money can we really trace back to the AMA and associated medical societies (organized medicine and its subsidiaries).
I came up with the figure of $6,000. The figure that was mentioned by Kevin Walker, Executive Director and Treasurer of AMPAC, in his letter to you confirms that this figure is in fact higher. The total was actually $14,500!
AMA leaders will say of course that this is "just politics." I hope you now agree with me that this is more a matter of misguided politics, political expediency, and what I have lately called flexible medical ethics.
Miguel A. Faria, Jr., MD
Peer Review Immunity
In an era when corporations are practicing medicine illegally by hiring colleagues who lease their licenses, I have to disagree with the Michigan State Medical Society (MSMS) that broader immunity to peer reviewers will improve the system. The MSMS must oppose the legislative intention to extend immunity to non-governmental entities, as far as peer reviewers are concerned.
A principle behind governmental immunity is that the government acts for the good of all. However, when peer reviewers act, they act in the majority of the cases, on behalf of a business, whether a hospital, an HMO, a group practice, health plan or physician network. They act not for the good of all but for the good of a particular entity that has the resources to hire them and the will to fire peer reviewers when they do not submit to their agendas (as the reviewers for CNA's worker's compensation program/personal communication). They use economic incentives to sway physicians' medical decisions (Miguel Faria, Jr., M.D./Physician's Practice Digest, March/April 1998).
Peer reviewers are under contract and under pressure to make an easy living, leasing their licenses to those businesses to perform quality assurance, sometimes of questionable nature, such as downcoding and underpricing peers' services.
Quality assurance is best served when the peer reviewer has to face a jury for a presumptuously tortuous action. Juries should decide if, in fact, that action was tortuous, intentional, and whether it caused harm. Granting peer immunity by legislative act goes against the pursuit of justice. Accountability for peer review activities is essential.
Wanda Velez-Ruiz, MD
Your Senators and Congressmen are receiving the Medical Sentinel as a courtesy of the Board of Directors of AAPS. Write or call them and ask them if they have read specific articles and what they think of the Medical Sentinel. ---Ed.
Correspondence originally published in the Medical Sentinel 1998;3(4);109-113. Copyright©1998 Association of American Physicians and Surgeons (AAPS).