For the past several years, the medical
profession has been undergoing a disturbing transformation. The
process was begun by the Centers for Medicare and Medicaid Services
(CMS) in an effort to control exploding Medicare costs, and was
accelerated by the passage of the Patient Protection and Affordable
Care Act of 2010. As a surgeon in practice for over 30 years, I
have witnessed this transformation firsthand. I fear that my
profession will soon abandon its traditional code of ethics and
adopt one more suited to veterinarians.

For centuries, my predecessors and I have been inculcated with
what has come to be called the “Hippocratic Ethic.” This tradition
holds that I am ethically required to use the best of my knowledge
to recommend to my patient what I consider to be in my patient’s
best interests—without regard to the interests of the third-party
payer, or the government, or anyone else.

But gradually the medical profession has been forced to give up
this approach for what I like to call a “veterinary ethic,” one
that places the interests of the payer (or owner) ahead of the
patient. For example, when a pet owner is told by a veterinarian
that the pet has a very serious medical condition requiring
extremely costly surgery or other therapy, the veterinarian
presents the pet’s owner with one or more options—from attempt at
cure, to palliation, to euthanasia—with the associated costs, and
then follows the wishes of the owner.

Several factors in combination are bringing this ethical
approach to my profession.

Since the mid-1980s, Medicare has imposed price controls on
health care providers. Over the years, in order to accommodate
increasing Medicare utilization, physician payments have steadily
dropped.

Meanwhile, the regulatory burden on physicians has increased. In
the last few years, CMS required all providers to adopt electronic
health records or face economic sanctions from Medicare. It is the
ultimate goal that every health care provider, including
pharmacies, will have electronic databases that will be accessible
to the U.S. Department of Health and Human Services (HHS).

In 2009, as part of the so-called stimulus bill, the Federal
Commission for the Coordination of Comparative Effectiveness
Research (FCCCER) was created. Its mission is to collect the data
culled from all electronic health records and make recommendations
regarding the comparative effectiveness of drugs, procedures, and
therapies. In rendering advice, the FCCCER will essentially answer
the following question: What is the most cost-effective way of
allocating a fixed amount of resources among a population of
roughly 310 million people?

With this same question in mind, the U.S. Preventive Services
Task Force, a committee that reports to HHS, concluded in 2009 that
mammogram screenings should not be recommended to women under age
50. This caused an uproar among both private health care providers
and breast cancer advocacy groups, and the task force soon backed
down. Similarly, in the fall of 2011, the task force recommended
the abandonment of certain routine prostate cancer screenings. Once
again, health care providers and cancer advocacy groups protested,
and the task force rescinded its recommendation.

In 2010 the Patient Protection and Affordable Care Act
established an Independent Payment Advisory Board (IPAB). Beginning
in 2014, the 15 presidential appointees on this board will
determine what therapies, procedures, tests, and medications will
be covered by Medicare, using advice provided by the FCCCER. Such
determinations will then be used to design the coverage packages
for the non-Medicare insurance offered through the government–run
exchanges. The decisions of the IPAB are not subject to
Congressional oversight or judicial review.

Meanwhile, in an effort to control costs now, CMS has developed
practice guidelines and protocols for physicians to follow.
Committees of health care academics and statisticians developed
these guidelines, using data from large population samples.

These protocols govern the therapeutic decisions made by the
health care practitioner—right down to the pre-operative
antibiotics a surgeon may order. Despite the fact that several
recent peer-reviewed studies concluded that the protocols have had
no positive effect—in fact, one study showed post-op skin
infections increased since the protocols were instituted—CMS
imposes financial penalties on hospitals that fail to get protocol
compliance from their medical staff.

Medical students and residents are now being trained to follow
federally-derived protocols and guidelines as a normal part of
medical practice. As a result, this new generation of doctors will
be less inclined to challenge the recommendations of federal task
forces and agencies. Some academics also worry that “teaching to
the protocol” might discourage independent thinking and the use of
intuitive knowledge, two traits essential to the practice of good
medicine.

In addition, decreased reimbursements and increased regulatory
demands on physicians have led many to sell their practices to
hospitals. As of this writing, the American Medical Association
estimates that 50 percent of the nation’s doctors are now hospital
employees. As private medical practice becomes more economically
untenable, look for the overwhelming majority of doctors to become
salaried hospital employees—many working in shifts—in the next few
years. Virtually every doctor now graduating a residency program is
taking a position as a salaried hospital employee.

Ten thousand people will turn 65 every day for the next 19
years, placing an even greater fiscal burden on the Medicare
program.

One way CMS is trying to deal with this is by penalizing
hospitals and doctors who treat patients with resistant problems.
Effective this year, any patient readmitted to a hospital within 30
days of discharge for the same or a related problem will be treated
by the hospital without compensation. The plan is to implement the
same policy with respect to the original treating physician in the
near future.