Letters to the Editor  |   December 2009
Protecting Patients and Maintaining Professional Sovereignty in the Midst of Intrusive Government Change
Author Affiliations
  • Todd R. Fredricks, DO
    Ohio University College of Osteopathic Medicine, Athens
    Assistant Professor of Family Medicine
Article Information
Pain Management/Palliative Care / Practice Management / Professional Issues / Psychiatry / Headache
Letters to the Editor   |   December 2009
Protecting Patients and Maintaining Professional Sovereignty in the Midst of Intrusive Government Change
The Journal of the American Osteopathic Association, December 2009, Vol. 109, 622-651. doi:
The Journal of the American Osteopathic Association, December 2009, Vol. 109, 622-651. doi:
To the Editor:  
While reading the summer 2009 issue of California DO,1 I was confronted with an article written by Richard Pitts, DO, and originally published online in 2006, that posed the question, “Healthcare: What Should It Cost?” Indeed, in the midst of the battle being fought over “healthcare reform” in Washington, DC—a battle being waged around legislation created by a Congress made up of few physicians and more than 40% attorneys2,3—I have yet to see anyone survey physicians and ask, “What should healthcare cost?” 
Physicians wait every year to learn what the government will grant us in terms of Medicare and Medicaid reimbursements. We also have to negotiate with insurance companies over reimbursements. I know of no other profession that has as schizophrenic a method for reimbursements as does the medical profession. Certainly, the grocer is paid at time of service. The plumber gets paid or doesn't come out to fix your toilet. Lawyers have hourly rates that they establish as they see fit. It is a mystery why, as one of the most highly educated groups of people in the United States, physicians seem to be so impotent at simply telling society, “This is the fee. Period.” 
Physicians are seemingly the only professionals who are uncomfortable with the concept of cash flow, so we accept the system that we have. No sane businessman or businesswoman would ever take part in an enterprise in which routine reimbursements take months to receive and frequently involve multiple inquiries that demand proof of need. 
We are now facing a massive intrusion by the federal government into our professional lives. Having practiced military medicine, which is a “single-payer” system, I am quite certain that most civilian physicians lack the marshal discipline to simply tell themselves—as is often said in the military—“suck it up and deal with it” without experiencing intolerable frustration. Yet that is exactly what we will be forced to do should we find ourselves solely dependent on the government for our livelihoods. 
Does anyone believe that prior authorizations for medications and other treatments will get better under a government-run, single-payer healthcare system? I am here to tell you that they only get worse. Under a government-run system, the treating physician gets the formulary decided on by a handful of lawyers, accountants, and nonpracticing physicians, and it is almost uniformly based on costs rather than efficacy. Several years ago, Americans were discussing government waste in the form of hammers and toilet seats costing hundreds of dollars,4 and just a few years ago, Americans were upset by the flawed federal and state response to Hurricane Katrina.5 Are we now suddenly satisfied that those efforts were optimal and more efficient than those of the American Red Cross? How quickly we forget. 
Current comprehensive medical insurance plans emerged from relatively affordable, high-deductible plans that were designed to give the purchaser a fall-back option to deal with something catastrophic that might arise6—similar to modern home insurance. No homeowner would ever think to file a claim with his or her home insurance policy to be reimbursed for costs of landscaping and painting. These are routine maintenance issues that are rightfully expected to be the responsibility of the homeowner. Yet, medical insurance has evolved to the point where many otherwise intelligent people believe that they cannot access any care at all—not even routine checkups—if they pay out-of-pocket instead of by using insurance. This way of thinking is a travesty for a “free” people. 
As a profession, physicians should have had enough self-respect to demand that we be compensated for our time and expertise. Notice that I did not say how much that compensation should be, because each practitioner should have the right to determine what he or she is worth and charge accordingly. 
As a former small business owner who operated a private medical consultation service for 10 years, I was very much aware of how competition forced my pricing to a “reasonable” level. When customers pay cash for a product, they pay attention to costs—allowing the business owner to know directly what price is “fair.” It is interesting to note that you become very aggressive with your own overhead when you understand what things cost. 
The medical profession is long overdue for a correction regarding insurance and compensation. I understand that many physicians are convinced that a nationalized healthcare insurance system will cure the ills with which we all struggle. Sadly, this belief is utter foolishness. Under a government-run, single-payer system, physicians will be forced to accept whatever compensation we are given and to practice in whatever geographic location is deemed to be in greatest need—just as is done in the military. As I write this letter, the state of California has its employees on mandatory furlough. The state workers had no choice in the matter. The government came in and simply told them that they would not be paid for the furloughed days and that they had to take the days off. End of story. 
Do we really want to put ourselves in such a position? Currently, Medicare and Medicaid provide enough of a contrast for us to compare the effectiveness of fee-for-service and third-party coverage against government-managed healthcare. This useful contrast would vanish under a single-payer system. 
I believe it is time for the medical profession to seriously consider a return to a fee-for-service healthcare system. Physicians need to set rates—individually—and then inform the insurance companies and the state and federal governments that we will no longer accept assignment for noncatastrophic services. Of course, hospitalizations, surgeries, and other “big-ticket” items are another story. These are the types of services that medical insurance was originally and appropriately designed to cover. 
A number of actions can be taken to help consumers pay for healthcare within a new fee-for-service system, including establishing health savings accounts and requiring providers to list menus of their prices for common procedures to allow consumers to “shop” accordingly. In addition, competitive restrictions, such as those on sales of health insurance across state lines, should be eliminated—as should restrictive covenants and networks. 
Returning to a fee-for-service system will be difficult. Physicians will initially have to adjust their fees downward and reduce their overhead costs through staff cuts. They might see a reduction in patient volume as people “shop the market,” but this downturn will level out as physicians learn how to respond to compete fairly with other providers. Benefits gained from fee-for-service would be simplicity of billing and a clearer idea of cash flow over time—reducing the need for the armies of staffers who do nothing more than try to get payments for physicians. 
Would a new fee-for-service system work? Surely. If more than 100,000 family physicians stop providing routine care for assignment, all 535 members of Congress, the 50 governors, and countless state representatives and insurance company executives will take notice and have no choice but to listen. Physicians simply need to speak with a unified voice, emphasizing that our patients deserve the dignity of care based on a relationship with their physicians, and physicians deserve to be compensated on their own terms. This relationship has no room for third parties or bureaucrats who, as noncontributing middlemen, provide nothing more than headaches and vastly increased costs. 
To readers who doubt the potential for a return to a fee-for-service system, I would point out that until the World War II era, this system was standard for physicians and patients and it worked just fine.6 Why should we continue to be the only profession that lacks the inherent self-respect to work on a fee-for-service basis? 
Some readers may find the ideas expressed in this letter to be radical. If so, that is a sad commentary on our current state of thought and discourse in the United States, as well as on our understanding of our own professional history. Our patients deserve our best advice. We simply cannot provide that advice if we are dependent on some third party for our livelihoods. We have an ethical obligation to give objective and clear recommendations to our patients. However, once we are forced into a highly controlled and centralized system, we will cease to be autonomous and we will often find ourselves powerless to positively affect the people who trust us with their lives. 
The majority of us did not enter medicine to relinquish our duties to our patients. Thus, we must take a stand and make our position clear to those who would attempt to usurp our professional sovereignty. 
Pitts R. Healthcare: what should it cost? The American healthcare paradox. California DO. Summer 2009:15,25. Accessed October 13, 2009.
110th Congress lawyer-legislators: US Senate. American Bar Association Web site. Accessed October 13, 2009.
110th Congress lawyer-legislators: US House of Representatives. American Bar Association Web site. Accessed October 13, 2009.
Case study: a simple tool—hammer time. CNET News Web site. Accessed October 13, 2009.
Roberts J. Poll: Katrina response inadequate. September 8, 2005. CBS News Web site. Accessed October 13, 2009.
A brief history of health care in America. Associated Content Web site. Accessed October 20, 2009.