Medical Device Daily Executive Editor

FORT LAUDERDALE, Florida – U.S. governmental and reimbursement policies have worked to erode the American public’s trust in medicine and created a “zero-sum” game that works to pit doctors against one another and reduces their traditional role, that of offering societal benefit.

This was the critique of America’s current healthcare dilemma presented by John Mayer Jr., MD, president of the Society of Thoracic Surgeons (STS; Chicago), in his presidential speech on the opening day of the organization’s annual meeting and exhibition in this sun-splashed city.

While such presentations are often pro forma exercises in organizational self-congratulation, with spotty attendance, Mayer’s observations were delivered in a large hall packed with attendees and his message concerning the medical profession was hardly congratulatory.

Mayer, of Boston Children’s Hospital, said that his audience probably was “offended” by the continual bashing of American healthcare as inefficient, error-prone and much too expensive for what is provided, since the society’s members have produced “improved outcomes despite treating an older, sicker population” in the face of reduced reimbursement and additional pressures “imposed from outside.”

But he did not dodge the result: “I do not think there is a very high level of trust in the medical profession as a whole,” he said, “though most [people] say they trust their own doctors.”

Mayer charged that “financial incentives” that serve to guarantee payment and “prospects of financial gain” by treating more patients had “adversely influenced patient care.

“We cannot afford this type of public perception if we are to survive as a profession,” he said.

He frankly acknowledged the “unraveling of the social contract” between physicians and society, and he emphasized the need for “rebuilding the partnership between medicine and society, which is ultimately the basis of the social contract.”

While saying there must be changes in reimbursement “to better align the incentives,” Mayer said this should not be the starting point for the effort.

Rather, he said, “It is critical to focus on rebuilding the partnership between medicine and society,” and he went on to outline how STS members could do this.

For Mayer, the starting point is in the STS’s efforts, in development over the past 20 years, to build a national database tracking outcomes “well before the national focus on quality and patient safety,” thus providing a model for others to follow.

STS’s database, he said, had been able to document $346 million in reduced post-operative care and had encouraged other such efforts, with this work continuing on a variety of fronts.

“We now have over 3 million patients entered, now audited, and there is evidence that the database mechanism is an effective tool for reducing outcomes and complications,” he said, citing a variety of efforts to link up with other databases.

He said that the STS database has “provided essential information that has changed the paradigm of how physician services are valued,” and that “almost no other specialties” have pursued this type of initiative.

Not unexpectedly, he later issued a call for attendees to participate in this effort. And the conference packet includes a 47-page roster of those participating in the STS database.

Turning to the reimbursement issue, Mayer said that rather than pay for performance, he advocated “pay for participation” — participation in “efforts such as the STS database.”

He referred to plans for a Medicare initiative that will provide a 1.5% reimbursement for such participation. And while he called that “not a large amount of money,” he characterized the payment as a way to recognize “professional behavior” and a “move toward gaining societal trust.”

More than recommending only adjustments in payment, Mayer advocated “structural changes” in the reimbursement system, given Medicare’s “fundamental conceptual flaws” in that system.

The primary flaw, he said, is that the “entire pool of resources from which all physician reimbursement is drawn is a fixed pie. It grows only as fast as the Medicare population increases and depends, to some extent, on the growth of the economy.”

The result of that “fixed pie,” he said, is to create “a zero-sum game” in which more payment to one, reduces the payment to another.

“The only economic reward for the physician is to provide more services or higher complexity services. Thus, every other physician’s reimbursement is adversely affected ... In maximizing their own benefits, the participants in the zero-sum game impinge on each other.”

The result, he said, is the need for some restraint, “but no one gains individually from restraint.”

He called the managed care’s system of capitation “a failed concept” and that “no one ever trusted that the physicians’ financial welfare was not impacting patient care.” And he argued that economic incentives “should be focused at a different level, not at the individual practitioner or practice.”

Based on the idea of a more collective approach, Mayer provided a clarion call for breaking out of the zero-sum game via cooperative effort at the “specialty level.”

One mechanism for this, he said, is the creation of “specialty-specific conversion factors” providing an “incentive for the entire specialty to work together,” for self-regulation and track results “from outcomes-focused registries.”

He encouraged the need for self-regulation and he borrowed a term from business writer Adam Brandenburger, to pursue “co-opetition” rather than competition, saying: “You don’t have to blow the other guy’s light out for yours to shine.”

And he concluded with a call for surgeon participation in the political process, referring to the current competition for the U.S. presidency as a critical time to become involved in politics and policy-making.

“Now is the time to influence the development of healthcare reform,” he said, adding that when the Clintons were attempting to do this, they had “four [hundred] or five hundred wonks working on various facets of the plan, but almost no physicians involved ...”