Political Hardball With An 800 Pound Direct Access Gorilla

It has become a reality in the political arena, regardless of the issue – be it the environment, immigration, or health care. There is always an 800 pound gorilla in the room that nobody wants to talk about for any number of reasons. Taking a hard line with the gorilla - “playing hardball”, if you will – can be a perilous task indeed.

It is pretty tough to play hardball with that 800 pound gorilla in the room. The gorilla has a strong fastball, throws a great curve, and has lots of power behind it. It has a cute smile, that gorilla, just before it decides to tear your head off.

The health care system has historically had physicians in the role of “gatekeepers”, in which the physician directs all care for the patient. But the health care world is changing. Patients want access to care, and they want to do so with any number of providers. They want direct access to chiropractors, advanced nurse practitioners, and physical therapists, among others.

Enter the 800 pound Direct Access gorilla, known as the American Medical Association, and it’s Scope Of Practice Partnership. George Orwell would be proud: if you are a non-physician health care provider, Big Brother is watching your every move.

The American Medical Association is, simply, a professional association for physicians. In 2008, the AMA had 236,000 members, or approximately 29% of the doctors in the US. In a 2009 article in Forbes Magazine, Shikha Dalmia noted that the American Medical Association is

“a doctors' cartel that has controlled the medical labor market in the U.S. like its personal fiefdom for a century.”

Rahul Parikh, MD noted that

“… to it’s critics, the AMA is nothing more than a guild that protects its own at all costs.  For example, it successfully marginalized non-physician health care providers (osteopaths and nurse midwives, for example). By doing this, critics state the AMA was able to control the price of health care through controlling the supply of the nation’s doctors.”

How does it control the medical labor market? How does it successfully marginalize non-physician health care providers?

The gatekeeper model is the foundation of the problem. Direct Access is the new battleground – and this is where the AMA “Scope Of Practice Partnership” (SOPP) comes in.

What is this Scope of Practice Partnership? It is a committee formed by the AMA to monitor the scope of practice of many health care professions, including physical therapists, chiropractors, and nurse practitioners. And oral and maxillofacial surgeons. And naturopaths. And – well, if you are providing health care in any way, shape, or form, they are monitoring your scope of practice. They have produced a “Scope Of Practice Data Series” – one module for each profession – that are intended to provide “data” regarding the education, training, and capacity of the profession in question to partake in patient direct access within their scope of practice. These are then used as “advocacy tools” for legislators who may be faced with upcoming legislation that addresses scope of practice issues in their respective states.

“Patient Protection”. The AMA (and all of the other state medical associations) is particularly fond of using the excuse that direct access to care involves a patient safety issue. They continue to proclaim that the education and training of the providers in question isn’t the same as a physician, that patients need a medical diagnosis from a physician, and that other providers should stop trying to expand their scope of practice because they just want to “be like doctors”. Of course, they are also quick to add that physicians are doing what is right for the safety of the patient, protecting the sanctity of the physician-patient relationship, etc. It is all under the presumed premise of “protecting patients”.

The sermon sure does sound impressive, and it’s pretty good at swaying legislators, especially when the AMA (and its state associations) have millions of dollars at the federal and state level to pour into lobbyist efforts and legislators’ campaigns. How does $1.1 million in Texas and California alone in 2009 sound? That’s not even considering the other 48 states and the federal lobby as well.

That is quite the 800 pound gorilla, isn’t it?

Reality: Turf Protection. For all intents and purposes, the AMA’s goal is to protect the physician’s turf and their corporate interests, whether that is of benefit to the patient (and to the health care system) or not.

Enter the Coalition For Patients Rights: Just ask the Coalition For Patients Rights, who in 2010 sent a letter to the AMA urging them to withdraw the Scope Of Practice Data Series. In it, they noted that

“Inaccuracies, omissions and innuendos within these documents seriously limit their credibility, objectivity and usefulness. Infused with bias more than credible facts or research, the modules call into question the safety and quality of the care provided by virtually all health care professionals, other than MDs and DOs.

“The modules fail to provide empirical evidence supporting the assumptions within them – that MDs and DOs provide superior care to all other types of health care providers or that the scopes of practice of our members are unsafe, problematic, or warrant special scrutiny or study. Our member organizations follow the highest standards for patient safety, and numerous studies demonstrate that our members provide safe, high quality, and cost-effective care.

“These modules are unnecessary, contain misstatements, and are extremely subjective and misleading. Accurate and complete information about the education and credentialing of health care professionals other than MDs and DOs can be obtained directly from the entities charged with the responsibility for those professions, such as the organizations comprising the Coalition.

“Further, it is reasonable to expect that policymakers who have questions about the qualifications of a particular group of health care professionals will go to the primary source for the most accurate and up-to-date information. The laws and regulations adopted by state legislators and regulators ensure that health care professionals practice within the scope of their education and training. AMA’s modules needlessly question this already-substantiated work”.

Their press release summary noted five major areas of concern: conflict of interest, inaccuracies, patient access, redundancies with existing resources and mechanisms, and divisive spirit.

Need I say more?

Chiropractors, Physicians, And Anti-Trust: A fine real-world example of the battleground that exists is that waged between the AMA and the chiropractic profession. This sordid tale went as far as an anti-trust lawsuit filed by chiropractors against the AMA (Wilk v. American Medical Association). The 1987 ruling was against the AMA. The New York Times reported that

“Judge Susan Getzendanner described the conspiracy as ''systematic, long-term wrongdoing and the long-term intent to destroy a licensed profession'' in a ruling late Thursday in an antitrust lawsuit filed in 1976. The decision said the nation's largest physicians' group led a boycott by doctors intended ''to contain and eliminate the chiropractic profession.''

Further to this, Judge Getzendanner ruled that the American Medical Association had violated the Sherman Antitrust Laws of the United States and were found to “engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country”.

Attorney George P. McAndrews, who represented the group of chiropractors in the anti-trust suit, noted that "The AMA has built a fortress around medical care in this country. They have achieved their fortress illegally. They're in the position of power in the health-care system."

A massive disinformation campaign. Discredit. Destabilize. Medical physician monopoly. Any of this sound vaguely familiar?

A Legalized Monopoly: The Scope Of Practice Partnership (as a committee of the AMA) is a virulent entity in the health care arena, actively lobbying against other professions and seeking, at all costs, to maintain control over them. They are seeking to maintain the gate keeper role of physicians and with it the legalized monopoly over the health care industry that comes with this role.

In an era of evidence-based practice, the burden of proof is on the AMA to provide just that - evidence – and not just virulent diatribe espoused by the Scope Of Practice Data Series that make the rounds to legislators nationwide. They have yet to be able to provide any evidence that scope of practice issues like direct access have ever (or will ever) be a true, real-life patient safety issue. Until this happens, the verdict in most access to patient care legislative issues should be in favor of any number of health care providers simply seeking to work within their current scope of practice and training.

It all comes down to dollars and cents - whether anyone wants to talk about it or not, 800 pound gorilla or otherwise. Make the legislator accountable - not to the AMA, TMA or any-other-MA, but to the constituent.

Maybe legislators should ask constituents what they think of this. What is more important to the patient – access to care, or turf protection?

Photo credits: jefka