- by Richard Amerling, M.D., New York, NY, April 2009
"When in the Course of human events, it becomes necessary for one Profession to dissolve the Financial Arrangements which have connected them with Medicare, Medicaid, assorted Health Maintenance Organizations, and diverse Third Party Payers and to assume among the other Professions of the Earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of Mankind requires that they should declare the causes which impel them to the separation.
We hold these truths to be self-evident: that the Physician's primary responsibility is toward the Patient; that to assure the sanctity of this relationship, payment for service should be decided between Physician and Patient, and that, as in all transactions in a free society, this payment be mutually agreeable.
Only such a Financial Arrangement will guarantee the highest level of Commitment and Service of the Physician to the Patient, restrain Outside Influence on Decision-Making, and assure that all information be kept strictly confidential.
When a Third Party dictates payment for the Physician's service, it exercises effective control over the Decision-Making of the Physician, which may not always be in the best interest of the Patient. The Third Party then intrudes heavily into the sacred Patient-Physician relationship and demands to inspect the Medical Record in a self-serving attempt to satisfy itself that its money is being spent in accordance with its own pre-ordained accounting principles.
The Financial Arrangements between Physicians and the Third Parties have become so destructive to the Patient-Physician relationship, and to the Medical Profession as a whole, that it is the Right, and Obligation, of the Members of the Profession to abolish them. Prudence will dictate that arrangements long established should not be changed for light and transient causes; and accordingly all experience has shown, that Physicians are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations evinces a design to reduce them under absolute Despotism, it is their Right; it is their Duty, to throw off such arrangements, and to provide new Guards for their future security.
Such has been the patient sufferance of this Profession; and such is now the necessity that constrains them to alter their former Financial Arrangements. The history of the present system is a history of repeated injuries and usurpations, all having in direct effect the establishment of an absolute Tyranny over the Medical Profession. To prove this, let Facts be submitted to a candid world.
The Tyranny began during the Second World War, when Companies, suffering under Wage and Price Controls, were forced to lure workers by offering Health Insurance Benefits. This benefit, in lieu of cash, received favorable tax treatment and was allowed to continue after the War, even with the removal of the Wage and Price Controls. This system created a strong incentive to use Medical Care and set the stage for massive Cost Inflation.
Slowly, insurance changed into payment for all Medical Expenses, minus a small and shrinking Deductible, which led to further Inflation, and a call to control costs.
The Government decreed that Employers must offer Employees the option of a Health Maintenance Organiz-ation. Thus were born the HMOs: Private Insurance Entities designed to ration Medical Care for their Members. These Organizations received Tax-favored treatment that allowed them to survive in spite of their horrendously flawed concept.
The Government, in 1965, in its Infinite Wisdom and going far beyond its Powers as set out in the Constitution, decreed that the Poor and the Elderly should receive Health Benefits funded by the Taxpayer. Thus came into existence Medicaid and Medicare. Medicaid, from the Conception, paid Physicians such a lowly wage that few participated, thereby creating a Two-Tiered System. Medicare payments to Physicians were initially fair and reasonable, and many Physicians participated in Medicare. Both Systems flooded the Medical Marketplace with Money, which fueled Inflation even more.
Alarmed by the Medical Cost Inflation that it had engendered, the Government set out to restrain costs, principally by limiting fees to Physicians. These Price Controls had the effect of increasing Medical Inflation, as Volume of Services went up, and Quality went down.
With each new round of Controls, Regulations and Paperwork multiplied many fold. This caused Physicians great Anguish, and took more time away from the Patients, with attendant loss of Quality and increase in Medical Inflation.
Government policies continued to favor the HMO, in the hope they would tame Inflation. These Organizations skimmed Money off the Premiums as Profit, but which they called "Savings." They spent less on Medical Care by denying or limiting access to Specialists, Procedures, Hospitals, and High Technology. Since this strategy mostly delayed care, it was ultimately more expensive. Thus did the Premiums again start to rise.
The HMOs paid the Physician by Capitation; Physicians could stay profitable by having large numbers of Capitated Patients, which they would see rarely, if at all! There were other Financial Incentives to Physicians to limit their Patients' access to Tertiary Care. These incentives set Patient against Physician, thus destroying this Sacred Trust.
Remuneration for Physician services by the Government and the HMOs has dwindled to the point of Unprofitability and has compelled the Bankruptcy of increasing numbers of Practices, and the search for Other Sources of Income by Physicians. No other Profession in the United States is denied the ability to raise fees to cover increasing costs of doing Business.
The Government, becoming increasingly desperate that all its strategies to control costs had failed (because they themselves were the cause of Cost Inflation!) resorted to Criminal Prosecutions of Individual Physicians and Hospitals for alleged Fraud. The Regulations being so Arcane and Vague, a simple Billing Error could be interpreted as Fraud. Most of those so pursued, being financially unable to defend themselves, simply capitulated and paid Huge Sums to the Government. Some were imprisoned.
The Government passed a Massive Bill called HIPAA, which forced Doctors and Hospitals to spend billions to comply, with absolutely no positive impact on Patient Care.
The Government passed a law called SGR which automatically lowers Physician Payment when total spending and volume increase, virtually assuring a downward spiral in Payments.
The Government and HMOs now conspire to limit fees to Physicians by a diabolical machine known as "Payment for Performance," based on "Practice Guidelines." In addition to insulting our Ethic, this system will close the circle between the Central Payment for Care and the Central Prescription of Care. Thus do we completely lose our Professional Autonomy.
In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A System whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a Free Profession.
We, therefore, the undersigned Physicians of the United States of America, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name of our Patients solemnly publish and declare, that we will withdraw our participation in all above-described Third Party Payment Systems. Henceforth and Forever, we shall agree to provide our services directly to our Patients, and be compensated directly by them, in accordance with the ancient customs of our Profession.
As has always been true of our Profession, our charges will be adjusted to reflect the Patients' ability to render payment. Nothing prevents any patient from purchasing and using Insurance. The Patients' medical interactions with us will remain completely confidential. We pledge the highest level of Service and Dedication to their Well-Being.
And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.
- Richard Amerling, M.D., New York, NY, April 2009
Please sign this declaration on the website of the AAPS! Thank you!