When medical groups circle the wagons: Always shoot outwards

This article is part of an ongoing series from the American Association of Clinical Urologists (AACU), based on a partnership between the AACU and Urology Times. In this special installment, the American Association of Clinical Urologists’ delegate to the AMA, Jeffrey E. Kaufman, MD, shares his perspective on the role of general medical associations when issues divide physicians. We welcome your comments and suggestions about topics for future articles. Contact Ross Weber, state affairs manager, or Joe Arite, government relations manager, at 847-517-1050 or info@aacuweb.org.

General medical membership organizations such as the American Medical Association, American College of Surgeons, and state medical societies represent the interests of a variety of medical practitioners. To be fair and serve the general need, it is important that they tread carefully to avoid getting caught up in turf battles or give the appearance of favoring one interest group over another. As all health care providers deal with escalating costs, decreasing reimbursement levels, and increasing regulatory burdens, there are ever-greater pressures to expand their practice range and focus. Unfortunately, these expansions may stray into services historically provided by other specialties. Inevitably, the encroached-upon group seeks to maintain its position and the status quo.

Arguments between medical specialties (and even subspecialties) existed long before our modern era of board specialization. The ancient Hippocratic Oath includes the phrase, "I will not cut for stone, even for the patients in whom the disease is manifest; I will leave this operation to be performed by practitioners." This grew out of the historic divide among "physicians" who practiced a crude form of medicine with a few herbs and early medicines, "surgeon/barbers" who had few tools available to them for surgery and were primarily confined to repairing battlefield wounds or performing amputations, and "lithotomists" who only treated stones, which were removed with a very quick cut to the perineum using techniques passed down from father to son. These three medical "specialties" were distinct, and practitioners tried to stay off the others’ turf.

Today, we see boundaries overlapping between orthopedic surgeons and podiatrists, between gynecologists and urologists, between board-certified plastic surgeons and a whole host of other practitioners. When legislative and regulatory initiatives pit one physician group against another, organizations such as the AMA or various state medical societies recognize they cannot win if they get involved in these battles. Attempts to resolve arguments in a Solomon-like fashion by splitting the baby often end up seriously hurting one group, the other, or everyone involved. At best, they will upset one faction and risk losing support from that group. At worst, the exposure alerts payers and regulators to a weakening of the ranks that would allow them to clamp down on everyone involved.

A good recent example occurred when the American College of Radiology complained there was indiscriminate overutilization by various specialists of major imaging techniques. The Centers for Medicare & Medicaid Services, the Medicare Payment Advisory Commission, and others pounced and recommended that fees for all imaging studies be reduced. Sure, this hurt those specialties identified by the ACR, but it had a significant negative impact on all radiologists, as well, and hurt their members more. A similar situation occurred with pathology. As the College of American Pathologists brought attention to specialty labs via direct billing legislation, payers learned how overpaid the pathologists have been for some procedures and reduced reimbursements for all providers.

Almost 2 years ago, urology was blindsided at the AMA House of Delegates when radiation oncologists sought approval of a resolution declaring that radiation oncology services were not to be defined as an "ancillary service." They claimed this phrase diminished the standing of their independent specialty. The problem was that "ancillary service" is a legal term and if AMA policy stated that radiation treatment was not an "ancillary service," the Stark exemptions against self referral would cease to apply and all non-radiation oncologists would have been prevented from any ownership position in a radiation treatment center. Obviously, that was their goal. But it could have had other unintended consequences, especially if it had then been interpreted that a radiation oncologist who saw a patient and recommended radiation would not have been allowed to refer treatment back to himself. Clearly, that would not have worked out well for them.

Fortunately, the AMA House of Delegates’ Urology Caucus, under the leadership of Bill Gee, MD, the senior AUA delegate to the AMA, convinced the AMA Board of Trustees that the radiation oncologists’ initiative was nothing more than a turf battle, and they backed away from changing previous policy. Similar attitudes prevailed when pathology, radiology, and other groups tried to secure policy statements favoring them over other groups (eg, orthopedics, neurosurgery, OB-GYN, dermatology, urology). This position of neutrality has been generally true at the AMA level, the American College of Surgeons, and most state medical associations.

The best example is Medicare itself. CMS has historically avoided crafting policies that would limit authorization to an exclusive group of physicians practicing a particular area of medicine. CMS will rarely address credentialing when determining a coverage policy. They will instead list criteria that the patient must meet, but rarely specify which specialty would be given exclusive right to provide care.

While it is important that our umbrella medical organizations continue to adhere to a neutral policy regarding which specialty physician group has favored or exclusive rights to any given area of health care, a different situation exists with respect to the question of non-physician practitioners getting into the independent practice of medicine. Such efforts have historically been met by a unified response from medical organizations even if they are made up of doctors from a variety of specialties and backgrounds. To have a strong voice, however, physicians must be unified and consistent in their advocacy efforts. Sadly, this is not always the case. Whether the Florida Medical Association’s recent abandonment of ophthalmologists in their optometrist scope of practice fight is a sign of things to come will be played out in the coming months. Will your state medical association or the AMA decide how strong to stand based on the political clout of your specialty? Such decisions may impact your membership in those general medical associations, but it will not diminish their influence in the Halls of Power, where rightly or wrongly they are seen as the arbiter of all positions related to physicians and health care providers.

It continues to be important that we remind all health care providers that, when circling the wagons, it’s important to only shoot outward.

Jeffrey E. Kaufman, MD, practices urology in Orange County, CA. In addition to his role as the AACU delegate to the AMA, Dr. Kaufman serves as Western Section of the AUA Representative to the AUA Board of Directors. The opinions expressed in this column are his alone and do not represent those of the AUA or the AUA Board of Directors.

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