Politics & Economics of non-physician primary care providers: Opposition by Organized Medicine ~ part II

by faithgibson on February 23, 2013

in Physician Supervision Issues

Part II

Non-physician primary care providers seen as a threat to Organized Medicine (OM): 

In November of 2004 the AMA launched an aggressive, well-organized and well funded campaign to further restrict the legal ability of non-physician practitioners to provide primary care and be fairly compensated for these services.

Non-physician practitioners who exercise critical judgments similar to physicians include pharmacists, podiatrists, optometrists, physician assistants, nurse practitioners, nurse anesthetists and professional midwives. However, the AMA’s policy opposes anything that: “alters the traditional pattern of practice in which the physician directs and supervises the care”. Of course, this is 19th century thinking and totally irrelevant to the health needs and economic realities of a 21st century population.

Nonetheless, the AMA has particularly targeted the area of reimbursement to concentrate its political influence.  It’s official ruling body — the AMA’s House of Delegates — has passed a number of policy resolutions to prohibit physician assistants, nurse practitioners, nurse anesthetists and other non-physician primary caregivers from being directly reimbursed by government programs such as Medicare and Medicaid.

What that means is that MDs can continue to bill and get reimbursed at MD rates for care provided by the salaried non-physician practitioners in their employ or providing care under legally mandated physician supervision.

The AMA and its role in the Scope of Practice Partnership: 

The AMA created the Scope of Practice Partnership (SOPP) in 2004 as a coalition comprised of itself (the AMA) and the Federation of State Medical Boards, plus six national medical specialty societies and six state medical associations. These include the California Medical Association, Colorado Medical Society, Maine Medical Association, Massachusetts Medical Society, New Mexico Medical Society, and Texas Medical Association.

The perspective of the Scope of Practice Partnership characterizes all non-physician practitioners as ‘physician extenders’. The phrase “physician extender” perfectly conveys its MD-centric perspective, one that sees the proper role of all other healthcare professionals as support staff whose job is to carry out the orders of the allopathically-trained medical profession, while these non-physician practitioners (NPPs) are expected to silently allow their physician-employors be directly compensated for the care they provided.

Physicians profits from the labors of non-physician practitioners in their employ by billing a third party at MD rates. Licensing laws in 28 states already reflect this MD-centric philosophy by legally restricting non-physician practitioners to the subordinate status of a physician-extender, thus prohibiting any form of independent practice or reimbursement.

According to statements published by the SOPP’s Steering Committee, this group intends to use its political, financial and legal resources to turn back the clock and sweep back the ocean – or as they put it, to end what they characterize as “the illegal practice of medicine by non-physician practitioners”.

In the 22 states and District of Columbia that already license non-physician practitioners as independent professionals, SOPP members plan to introduce legislation to repeal these laws. In the 28 states that have restrictive laws on the books already, the SOPP will vigorously fight any effort by nurse practitioners and other non-physician practitioners (NPP) to lift these restrictions.

At the national level, SOPP members are working to get federal legislation passed which will permanently block direct reimbursement of non-physician practitioners (NPP). Last but not least is a strategic plan to elect or appoint physicians sympathetic to SOPP’s policies to state medial boards and subsequently force all non-physicians practitioners under the control of the medical board in each state. {Note: In Feb  2012 it appears the SOPP succeeded in getting 2 members of its own groups — Dr Bishop, from the Am Society of Anesthesiologists, and Dr. GnanaDev, recent past president of the CMA — appointed to a 4-year term on California’s Medical Board.}

The SOPP wants to usurp the regulatory authority of the professional boards that currently license and regulate the practice nurse practitioners, midwives, pharmacists, naturopaths, chiropractors, etc. Instead they want state medical boards to take control of all non-physician practitioners (NPPs), based on the spurious notion that their current professional  boards (BRN, etc) are illegally authorizing such licentiates to practice of medicine without a license, thus depriving the medical profession of its legitimate income.

The AMA has so far maintained an iron grip on its MD-centric system for the last hundred years. The AMA’s Partnership continues to fixate on eliminating alternative forms of health care and the independent practice of non-physician practitioners, which also means that the hub of the health care wheel – high-quality primary care – will continue to be disabled or dysfunctional.

How organized medicine developed its iron grip:

The tap root of our medicalized health care system traces directly back to the lack of a scientific foundation for the medicalized system of an all-alllopathic model of sickness care invented by the AMA in 1904. Plans by influential leaders in the AMA to close half of all medical schools and make medical care exclusive allopathic were based on a political and economical agenda, and not on established scientific principles.

However, medical ‘science’ as we know it today (i.e. evidenced-based) did not yet exist and instead, the determination of medical efficacy was legally based on the authority of state-licensed physicians as “expert opinions”. Just as the opinion of the US Supreme Court is “supreme” — that is, its findings are accorded the status of a ‘fact’, so too is the ‘expert opinion’ of an MD as to whether a medical action (or omission of medical intervention) is therapeutically-effective (i.e. ‘competent’) or isn’t (i.e. medical mal-practice) based entirely on the statement/professional opinion of an MD.

Case law actually rejects any opinion about a medical topic if the speaker is not him or herself a medical doctor. This often gives rise to an exchange in a court of law in which a witness makes a definitive statement about some medical procedure or drug being unnecessary or incorrectly performed. Then the attorney from the other side cross-examines the witness and says: “Oh yeah, and just what medical school did YOU graduate from?”. At this point the jury is instructed by the judge to disregard the statement as irrelevant, since non-MDs have right to express such opinions about the practice of medicine simply because they are not MDs.

It was the opinion of MDs that the bio-scientific foundation for allopathic medicine was already (or soon would be) so effective against all diseases states and all mental and physical conditions, and under all circumstances of the human condition, that all other forms of ‘health-related care would become unnecessary. But they went even further by representing all non-allopathic disciplines and practitioners as a form of ‘quackery’ perpetrated by ‘charlatans’ — snake-oil salesmen, herbalists, naturopaths, midwives, Chinese medicine, etc.

However, the above opinions must also be seen in the historical context of the time. In the last 1800s and early 1900s,  the naturally multi-disciplinary  system of the time had produced a  glut of healthcare providers — MDs as well as drugless practitioners, midwives, and the like. As a result,  the average income of an MD had been driven down to little more than the “weekly wage of a mechanic” (to quote documents of that era).

In an effort to address this and other problems, the AMA’s Council of Eduction (CME) published a report in 1905 on medical schools in the US and Canada which was essentially a ‘hit list’ to force the closing of schools that did not ‘measure up’ to the AMA’s idea of a proper ‘scientific’ curriculum or other factors that ran counter to the AMA’s agenda. This was a nebulous idea defined as schools that taught courses in any non-allopathic topic such as naturopathy or acupuncture. It  resulted in the disproportionately loss of schools that admitted women, blacks and other ethnic minorities, immigrants and those of limited financial means.

In 1908 the AMA directly solicited the help of President Henry Pritchett of the Carnegie Foundation to rework the findings of the 1905 CME report and publish it under aegis of  Carnegie Foundation. The following is a brief summary of the motives and actions of the parties as recorded in AMA’s Minutes of its December 1908 meeting, Dr. Arthur Dean Bevan (chairman of the Council from 1904 to 1928) as published in JAMA and recorded in other historical documents:

“Recognizing the need for overall public support of its efforts, the Council approached the Carnegie Foundation … to enlist its aid as a neutral party.”

“… it occurred to some of the members of the Council that, if we could obtain the publication and approval of our work by the Carnegie Foundation .. , it would assist materially in securing the results we were attempting to bring about.”

With this in mind we approached President Henry S. Pritchett of the Carnegie Foundation, presented to him the evidence we had accumulated and asked him to make it the subject of a special report on medical education to be published by the Carnegie Foundation. He enthusiastically agreed to this proposition.”

Minutes of the December 1908 meeting of the AMA’s Council (New York):

“At one o’clock an informal conference was held with President Pritchett and Mr. Abraham Flexner of the Carnegie Foundation. Mr. Pritchett had already expressed, by correspondence, the willingness of the Foundation to cooperate with the Council in investigating the medical schools.

He agreed with the opinion previously expressed by the members of the Council that while the Foundation would be guided very largely by the Council’s investigation, to avoid the usual claims of partiality no more mention should be made in the report of the Council than any other source of information.

The report would therefore be, and have the weight of an independent report of a disinterested body, which would then be published far and wide. It would do much to develop public opinion.”

“The Council and the Carnegie Foundation believed that the observations and recommendations in the report would be more widely accepted if they came from a neutral educational foundation of high standing

“Although the Foundation would be directed fundamentally by the Council’s previous investigations, it was decided that to guarantee the objectivity and partiality of the final report, the Council would be mentioned only as a source of information.”

“The Foundation responded enthusiastically and appointed Abraham Flexner, MA, to conduct a continuing investigation of the medical schools.

In 1909 the AMA loaned Dr. N. P. Colwell, a very influential member of its Council on Medical Education, to the Carnegie Foundation to assist Mr Flexner in his efforts to incorporate the Council’s recommendations into a new document attributed to the Foundation.

After reading the CME’s 1904 report and other materials provided by the Council, he and Dr. Colwell concluded that there were too many medical schools in the USA, and too many doctors were being trained. Their goal was cut the number of MD-granting institutions from 160 to just 31.  This reduction of medical schools was to be promoted was a public safety campaign and good faith effort to modernize medical education.

Together Flexner and Colwell set about to create and publish policies that would reduce the number of  medical schools by half between 1910 and 1935. This master plan was distributed in 1910 as Carnegie Foundation Bulletin #4, more commonly referred to as the Flexner Report.

Whatever the actual motives behind these drastic reductions, it resulted in male-only admittance programs to accommodate a smaller admission pool. Another consequences of the AMA/Carnegie/Flexner plan was that medical education became much more expensive, putting such education out of reach of all but upper class white males.

Also a disproportionate number of schools targeted for closure were those that admitted women, blacks and other ethnic minorities, immigrants and others of limited financial means. Since these students could rarely afford six to eight years of university education, they were denied admission to university-affiliated medical schools. In general, the standardization of medical education as promoted by the Flexner Report led to the domination of American medicine by well-off white males.

Another aspect of the AMA’s success in forcing the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced Flexner Report recommendations. Through the combined work of each state chapter of the *AMA, the 1905 recommendations and decisions of the CME came to have the force of law in all 48 states. With no successful opposition to this plan, there were only 66 American medical schools left standing in 1935.

Over that same 25 year period, the AMA also successfully eliminated all non-allopathic practitioners except for chiropractors, who used the ballet initiative system in California and other states to get their own independent practice act.

As the annual number of medical school graduates sharply declined, the availability and affordability of medical care became problematic.  By reducing the number of MDs available to the population, and eliminating the multi-disciplinary nature of health care (often my by charging its practitioners with the illegal practice of medicine), it became dramatically more difficult for people of color, residents of rural areas, and for those of limited means generally to obtain medical care in any form.

**State chapters of the AMA include the California Association of Medicine or CMA.

Click here for more on the Carnegie Foundation’s relationship with the AMA and it’s insider role in creating the Flexner Report :

Politics masquerading as science:

The public and other professionals assumed that the AMA used a scientific method of evaluation (statistical research and comparative studies) to determine the evidenced-based or ‘best practices’ model of health care: would it be multi-discipline or exclusively allopathic, MD-only care? Or would it be a cooperative and complementary model of MDs, non-allopathic physicians and non-physician practitioners, with the type of treatment and category of practitioner determined by the kind of care the patient required or requested? As we know only to well, no rational process was used in 1910, nor has one been applied in the 99 intervening years.

The uncritical acceptance of an unscientific premise:

Without understanding the long-term implications, states began adopting the exclusively allopathic, MD-centric model in 1910. The most immediate consequence of these policies was to eliminate women and minorities from the mainstream practice of medicine and dismantle and eventually discard the multi-discipline tradition of healthcare.

For instance, in 1909 California had a multi-discipline Board of Medical Examiners with 11-members — 5 MDs and 6 non-allopathic physicians. In 1911, the Medical Practice Act was amended to eliminate all 6 non-allopaths and replace them with a 12-member all-MD medical board, which is still in place today.

This same MD-centric, authority-based model provided the platform and push-off point for an exploitive form of corporate medicine that has doubled our troubles with the extremes of non-treatment and over-treatment, excessive cost and increased mortality.

Too long medical politics has masqueraded as medical science and corporate politics has triumph over fiscal responsibility. As we rightly credit medical science with saving lives, so we must credit medical politics for costing lives.

Of course, this returns up to the intro to part 1 ~ questions of why our current healthcare system, which looks much different after reading about how our current problems came about and what to do to repair, rebuild, reform, and rehabilitate by rediscovering our original tradition of multi-disciplinary care providers. Of economic and practical necessity, this must include the retooling of professional education for all health-related disciplines, accompanied by the independent practice non-physician primary-care providers as part of a strategy to replace our sickness care system with pro-active, protective and preventive HEALTH care:

  • doesn’t work for so many of us — answer: because what we have now is a very expensive but ultimately ineffective ‘sickness-care’ system
  • isn’t sustainable — answer: because a ‘sickness-care’ system is too expensive to maintain without millions of uninsured, quotas for care and ultimately, some form of ‘death panels’
  • why America has entrenched such a dysfunctional system — answer: the AMA‘s successful strategy via the Flexner Report in 1910 to eliminate multi-disciplinary HEALTH care and replace it with “chokepoint medicine” — MD-centric, allopathic-only medical care that only comes into play after people become sick
  • why chokepoint medicine doesn’t serve us — answer: because it chokes up the point of entry into the health system by making everyone cools their heels in a doctor’s medical office BEFORE they can get access to non-physician healthcare services
  • what to do to repair the damage and fix the problems — answer: replace chokepoint medicine with a truly multi-discipline healthcare system that includes the independent practice of non-physician primary care practitioners as a normal part of its mainstream services

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