Presidential Message
Michael Seider, MD, Ph.D

Where is Health Care Taking Us?
March 28, 2010

I love to give my opinion on matters that I have no control over. As I am writing this column, Congress (or specifically the Democrats of Congress) is writing my future. Since I have no crystal ball as to what they are going to create, I will just sit and speculate how it will impact my practice, our state and national society and medicine in general. Of course, with millions of words being written every hour on the subject, this will only add to the noise but it may make me feel better to write about it.

In regards to my practice, I have been railing about self-referral and its impact on my practice over the past 5 years. I have gotten up in national meetings of my society (ASTRO) and tried to convince the people who run the organization what was happening at the grass roots level and how it was going to affect everyone as time went on. But, as with most things in life, if it doesn't have a direct impact on "you", then the problem tends to get minimized. This is what happened. And now, five years later, the hammer is hitting all practices, both private and academic and the powers that be don't like it.

Self-referral in radiation oncology is now a number one issue, just as it has been an issue for the radiologists during this time period. So, with the politicians writing the new law, is self-referral going to remain or go away? As far as I can tell, it is not going to change.

The new mantra for management is going to be "cost controls". This is defined as paying less for services and pretending that you really are just making the payments "fair". There are a lot of ways to do this. For radiation therapy, you simply increase the utilization time of a treatment machine from 50% to 90% and voila, you save lots of money on machine costs. Do treatment machines run all the time with patients underneath getting therapy? Nah, but why let reality interfere with a great mechanism for reducing payments.

In my opinion, self-referral will be dealt with by reducing payments so much that it will not be worth it for anyone to own their own machines. So who will own them? Large multi-practice organizations that employ physicians and can spread the cost of therapy over the entire huge practice. These clinics (but not solo practices) may even get a bonus from the government for running all the therapy and diagnostic equipment units just to make sure that individuals do not go out and start their own treatment centers. This will be good for the Mayo Clinics of the world, but it will be bad for me. What really bugs me is that with one small change in a Medicare rule, all of the above would be unnecessary. The House of Medicine (aka the AMA) does not agree and therefore, we all will suffer.

How does the impending legislation affect our state and national society? This may be simple or complex, depending upon how much the government has control over the payment system. If a public option appears, then we will have a one-payer system within the decade. It will be vitally important that radiology and radiation oncology have a large, strong society if that scenario plays out. Why? We will have to fight for every reimbursement penny that the government doles out, and we will be fighting with every other specialty society out there, as well as every other interest group that thinks they have a say in the management of medicine.

Without a powerful local, state and national organization, we will be left out of the discussions and will suffer for it. So it behooves us to bulk up now and start convincing the non-believers that it is time to join up. This includes our academic brethren who until this time thought that they were above the fray. I have a message for my academic colleagues. When you are in the middle of the Coliseum, the lions do not care if you are Christian or Pagan. To them, you're just red meat. We need to actively recruit Residents and Fellows and we have to hone our message, which is: "They are out to get us". Apathy will guarantee us a place in the sand box, but not at the table.

Nationally, we need to decide how we are going to deal with the rest of the house of medicine. Are we always going to be able to own our own equipment? Should other specialties be able to read images? A better question may be: Should other specialties be able to read imaging and get paid for it? Should other specialties be able to own treatment equipment? I think that nationally we need to get our heads together and answer these questions. Will Urologists want to own an IMRT machine if they lose money on every patient they treat? If we continue on our present course, this is where we will be in a few years. We have already seen it in outpatient PET scanning and MRIs. I think that Medicine has played into the hands of the powers that be by being fractious and divided. It needs to stop, but I always did believe in the tooth fairy.

As the president of this organization, I can only try and make an impression on the people I lead. I am committed to increasing the head count of the state society and I am looking for members to be ambassadors for this goal. It means talking to non-members and enduring the usual statements such as: "What has the OSRS ever done for me?" or I belong to (insert specialty society name here) and I don't need to spend any more money on anyone else." We all know that there are physicians who are never going to join. We don't want to spend time with these people. We need to get to the undecideds that may join if given a compelling reason. I cannot think of a more compelling reason than what is happening in Washington DC right now.