PRESIDENT'S COLUMN THE AFRICAN-AMERICAN PHYSICIAN AND COMMUNITY INTERACTION Richard 0. Butcher, MD President, National Medical Association San Diego, California
There is a new climate in this country-a climate that has been dominated by years of neglect, particularly neglect of the social infrastructure; a climate that has been altered by a decade of searching for the mythical "truly needy"-as if all of us don't need food, clothing, shelter, and access to health care; a climate that has been jarred by the riots in Los Angeles. There are serious challenges that lie ahead. Public education continues to search for the right paradigm to motivate black children-and is failing thousands in the process. The jails are filled with bright young black men who saw little future except in crime and drugs, men who could envision no opportunity for higher education and, if lucky enough to get educated, only face unemployment again. Frustration and stress, lack of economic opportunity, and hopelessness-these are the seeds of violence that dominate the causes of death among our young. These changing times require a reorientation of physicians' roles in the community. At one time, we could focus solely on the specific health-care needs of our patients. Expenses were much less. There wasn't as much technology. Patients trusted their physicians, and the patient-physician relationship was sacred. Those were the good old days, and they, like house calls, are gone forever. Malpractice premiums have risen so high that some physicians have been driven out of practice. The practice of medicine has become much more technologically dependent, and the physician-patient relationship Presented as the keynote address to the National Medical Association/California Black Health Network Joint General Session, May 30, 1992, San Diego, California. Requests for reprints should be addressed to Dr Richard 0. Butcher, National Medical Association, 1012 10th St, NW, Washington, DC 20001. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
has now got a third-party payer and a fourth-party regulator-a so-called advocate who tries to approve certain tests and procedures and deny others. As difficult as it may be to believe, some of our colleagues' practices are so filled with uninsured patients that their offices are not self-sustaining. From my vantage point, physicians will have to come out of their offices and become more actively involved in the economic development of our communities. We will have to become active in the local and state politics of our communities. How many of us have made political contributions to the campaigns of our elected representatives? How many of us have scheduled meetings with these people to come to our communities and help them understand the health-care access and financing problems that we face? How many of us routinely get notices of potential health-care contracts from the county or the state, which could result in new services for our communities and employment opportunities for our own health-care workers? In some cases, we have been like ostriches, with our heads in the proverbial sand, about what is going on around us. This will have to end, and we are the ones who have the opportunity to make a difference. Physicians are typically respected by politicians and trusted by our constituencies. As such, we can and should be a stabilizing factor during these chaotic times. We have been the healers, the entrepreneurs, and the leaders-the mentors for our youth. It is important for each of us to extend ourselves, 3 or 4 hours each month, if not more, to make sure that the political will and economic attention on the health of our people are not lost. At the very core of the social policy debate in this country, we find health care-and the denied access to 745
PRESIDENT'S COLUMN
millions of Americans. No community in this country is immune from this problem. And the debate rages everywhere. In Minnesota, a new proposal to charge a 2% tax on all hospital discharges was adopted last month to raise funds to pay for indigent care. In California, AB336 was signed by the governor and became law last year. It will require Medi-Cal patients to be placed into managed-care systems, such as health maintenance organizations (HMOs), if they do not choose a physician when they are granted eligibility. Clearly, the state is making drastic decisions. Finances are reshaping health care and how it is delivered in this country. Fee for service, as it has been known, looks like it is being pushed out the proverbial window, and something called managed care is being inserted in its place. But what is managed care? How is it being defined? It seems like the early stages of prepaid health plans in Los Angeles, which were being brought to us by ill-informed, but probably wellintentioned bureaucrats, were insensitive to the true dynamics of health-care and physician practices. One disturbing feature, however, is that these managed-care entities have not sought AfricanAmerican physicians, and the concept and its inevitability has not been well supported (or well understood) by our members. Once considered an "alternate delivery system," managed care has become a major force to be addressed. In 1980, pure HMO enrollment in the United States was 9.1 million persons. By 1990, it had risen to 33.6 million members, an increase of 270%. Much of this increase has been in private insured systems; however, within the last 3 years, the federal Medicaid program has discovered managed care. As you all know, the federal Medicaid budget is increasing by leaps and bounds. Within the next 5-year period between 1990 and 1995, it is expected to double. It is probably the fastest growing component of the entire California budget. Even though the beneficiaries have not significantly increased over the 15-year period from 1975 through 1990, the budget increased five times during that period, an increase from $12 billion to $66 billion. Premium increases skyrocketed after plan consolidations of the late 1980s. This is the primary reason why Gail Wilenski, the previous administrator of the Health Care Financing Administration and now health advisor to President Bush, has said that'managed care is the wave of the future for all Medicaid programs in this country. It is a mechanism to cut spiraling increases. The problem is that oftentimes, Medicaid reimbursement doesn't cover 746
the cost of providing services. More importantly, we have concluded that all insured and government-funded patients are being shifted into managed-care systems within this decade. From the provider perspective, the question of whether an independent hospital or private practice physician shall decide to participate in managed care during the next 10 years is not the issue. Based on the enrollment data, either we'll all become involved in managed care in some fashion or we'll be looking for alternative means of employment. By all available data, managed care is not a fad or a trend-it is here to stay. This year, we must all get acquainted with the system so that we can stay in the mainstream. Cost is a major factor in the switch to managed-care facilities and, in particular, the reason why the government is looking so favorably in this direction. The issue for the National Medical Association is how all this affects indigent communities of color and physician-patient relationships. As you may well know, African Americans disproportionately rely on Medicaid to obtain access to health care. About 6.6 million individuals, one third of Medicaid beneficiaries, are of African-American descent. Medicaid is the sole medical coverage for one out of every five African Americans under the age of 65. This high ratio is directly connected to the numbers of African Americans who live in poverty in the United States. Data suggest that African-American patients overwhelmingly seek and visit African-American physicians when they have a choice. A managed-care mandate could jeopardize that choice, especially if we, the physicians, remain estranged from the facilities and the structure. The assumption is that large multispecialty group practices have not sought out African-American physicians for balanced multicultural staffing patterns. In addition, we find that more African-American physicians work as sole practitioners than any other group of
physicians. Traditionally, African-American physicians have been somewhat opposed to managed care. This year, we will be examining in detail the managed-care system: the advantages and disadvantages as well as the overall effect it will have on us as individuals in our communities and on the greater public. There are the same corporate issues of institutionalized racism, including a separate level of treatment standards for patients of color, as well as fees for doctors and health-care professionals. Unless we become actively aware of the needs and development in this area in our cities, states, and nation, we may be left out-once again on the outside looking in. We must JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
PRESIDENrS COLUMN
YOHIMBINE HOI change the perceptions and responses among AfricanAmerican physicians. If we don't, the plans to link large numbers of Medicaid patients to HMOs, multiinstitutional groups, and other managed-care structures will result in a shift of significant numbers of patients out of African-American practices, leaving few, if any, alternatives for African-American physicians other than employment with governmental or corporate structures. So let's get educated quickly. The managed-care issue is a large and important one. When we look at the disproportionate manner in which the African American has access to health care, we can understand the devastating effect that managed-care institutions will have. We must participate to ensure that facilities are located near our communities, that our patients will have the opportunities to choose AfricanAmerican physicians, and that the issues of service and support are applied to the existing and new managedcare facilities. We again will be the advocates for justice and equity in health care. Educating our patients will be necessary. Whenever possible, we will need to empower our patients, apprise them of the possible changes, and challenge them to insist on fair and equitable treatment. If enough patients complain about the lack of African-American physicians, then facilities will be pressed to look at the infrastructure and fix it. A total interaction is needed between health-care physicians and community. Now is the time to complete the link between us, the community, the lawmakers, and the civic leaders. Together we can look at managed care from a different perspective; we can help implement the structure for our Medicaid and indigent-care patients. I urge you to keep informed and maintain open dialogue among other professionals, to share articles of information with each other. Together, we can adjust to the new system and begin to work on the inside for our futures and for the well-being of our patients.
.A American Heart Q Association WERE FIGHTING FOR
'YOUR LIFE
747
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PHARACEUICAL, IC _ I l
_ |219 Cenountey Roadie_dt d - enaly Ne Jerseythln[onr 0767
(21 569-8502_ _~~~~~80 237-9083catIn eneoncdsi
There is a new climate in this country-a climate that has been dominated by years of neglect, particularly neglect of the social infrastructure; a climate that has been altered by a decade of searching for the mythical "truly needy"-as if all of us don't need food, clothing, shelter, and access to health care; a climate that has been jarred by the riots in Los Angeles. There are serious challenges that lie ahead. Public education continues to search for the right paradigm to motivate black children-and is failing thousands in the process. The jails are filled with bright young black men who saw little future except in crime and drugs, men who could envision no opportunity for higher education and, if lucky enough to get educated, only face unemployment again. Frustration and stress, lack of economic opportunity, and hopelessness-these are the seeds of violence that dominate the causes of death among our young. These changing times require a reorientation of physicians' roles in the community. At one time, we could focus solely on the specific health-care needs of our patients. Expenses were much less. There wasn't as much technology. Patients trusted their physicians, and the patient-physician relationship was sacred. Those were the good old days, and they, like house calls, are gone forever. Malpractice premiums have risen so high that some physicians have been driven out of practice. The practice of medicine has become much more technologically dependent, and the physician-patient relationship Presented as the keynote address to the National Medical Association/California Black Health Network Joint General Session, May 30, 1992, San Diego, California. Requests for reprints should be addressed to Dr Richard 0. Butcher, National Medical Association, 1012 10th St, NW, Washington, DC 20001. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
has now got a third-party payer and a fourth-party regulator-a so-called advocate who tries to approve certain tests and procedures and deny others. As difficult as it may be to believe, some of our colleagues' practices are so filled with uninsured patients that their offices are not self-sustaining. From my vantage point, physicians will have to come out of their offices and become more actively involved in the economic development of our communities. We will have to become active in the local and state politics of our communities. How many of us have made political contributions to the campaigns of our elected representatives? How many of us have scheduled meetings with these people to come to our communities and help them understand the health-care access and financing problems that we face? How many of us routinely get notices of potential health-care contracts from the county or the state, which could result in new services for our communities and employment opportunities for our own health-care workers? In some cases, we have been like ostriches, with our heads in the proverbial sand, about what is going on around us. This will have to end, and we are the ones who have the opportunity to make a difference. Physicians are typically respected by politicians and trusted by our constituencies. As such, we can and should be a stabilizing factor during these chaotic times. We have been the healers, the entrepreneurs, and the leaders-the mentors for our youth. It is important for each of us to extend ourselves, 3 or 4 hours each month, if not more, to make sure that the political will and economic attention on the health of our people are not lost. At the very core of the social policy debate in this country, we find health care-and the denied access to 745
PRESIDENT'S COLUMN
millions of Americans. No community in this country is immune from this problem. And the debate rages everywhere. In Minnesota, a new proposal to charge a 2% tax on all hospital discharges was adopted last month to raise funds to pay for indigent care. In California, AB336 was signed by the governor and became law last year. It will require Medi-Cal patients to be placed into managed-care systems, such as health maintenance organizations (HMOs), if they do not choose a physician when they are granted eligibility. Clearly, the state is making drastic decisions. Finances are reshaping health care and how it is delivered in this country. Fee for service, as it has been known, looks like it is being pushed out the proverbial window, and something called managed care is being inserted in its place. But what is managed care? How is it being defined? It seems like the early stages of prepaid health plans in Los Angeles, which were being brought to us by ill-informed, but probably wellintentioned bureaucrats, were insensitive to the true dynamics of health-care and physician practices. One disturbing feature, however, is that these managed-care entities have not sought AfricanAmerican physicians, and the concept and its inevitability has not been well supported (or well understood) by our members. Once considered an "alternate delivery system," managed care has become a major force to be addressed. In 1980, pure HMO enrollment in the United States was 9.1 million persons. By 1990, it had risen to 33.6 million members, an increase of 270%. Much of this increase has been in private insured systems; however, within the last 3 years, the federal Medicaid program has discovered managed care. As you all know, the federal Medicaid budget is increasing by leaps and bounds. Within the next 5-year period between 1990 and 1995, it is expected to double. It is probably the fastest growing component of the entire California budget. Even though the beneficiaries have not significantly increased over the 15-year period from 1975 through 1990, the budget increased five times during that period, an increase from $12 billion to $66 billion. Premium increases skyrocketed after plan consolidations of the late 1980s. This is the primary reason why Gail Wilenski, the previous administrator of the Health Care Financing Administration and now health advisor to President Bush, has said that'managed care is the wave of the future for all Medicaid programs in this country. It is a mechanism to cut spiraling increases. The problem is that oftentimes, Medicaid reimbursement doesn't cover 746
the cost of providing services. More importantly, we have concluded that all insured and government-funded patients are being shifted into managed-care systems within this decade. From the provider perspective, the question of whether an independent hospital or private practice physician shall decide to participate in managed care during the next 10 years is not the issue. Based on the enrollment data, either we'll all become involved in managed care in some fashion or we'll be looking for alternative means of employment. By all available data, managed care is not a fad or a trend-it is here to stay. This year, we must all get acquainted with the system so that we can stay in the mainstream. Cost is a major factor in the switch to managed-care facilities and, in particular, the reason why the government is looking so favorably in this direction. The issue for the National Medical Association is how all this affects indigent communities of color and physician-patient relationships. As you may well know, African Americans disproportionately rely on Medicaid to obtain access to health care. About 6.6 million individuals, one third of Medicaid beneficiaries, are of African-American descent. Medicaid is the sole medical coverage for one out of every five African Americans under the age of 65. This high ratio is directly connected to the numbers of African Americans who live in poverty in the United States. Data suggest that African-American patients overwhelmingly seek and visit African-American physicians when they have a choice. A managed-care mandate could jeopardize that choice, especially if we, the physicians, remain estranged from the facilities and the structure. The assumption is that large multispecialty group practices have not sought out African-American physicians for balanced multicultural staffing patterns. In addition, we find that more African-American physicians work as sole practitioners than any other group of
physicians. Traditionally, African-American physicians have been somewhat opposed to managed care. This year, we will be examining in detail the managed-care system: the advantages and disadvantages as well as the overall effect it will have on us as individuals in our communities and on the greater public. There are the same corporate issues of institutionalized racism, including a separate level of treatment standards for patients of color, as well as fees for doctors and health-care professionals. Unless we become actively aware of the needs and development in this area in our cities, states, and nation, we may be left out-once again on the outside looking in. We must JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
PRESIDENrS COLUMN
YOHIMBINE HOI change the perceptions and responses among AfricanAmerican physicians. If we don't, the plans to link large numbers of Medicaid patients to HMOs, multiinstitutional groups, and other managed-care structures will result in a shift of significant numbers of patients out of African-American practices, leaving few, if any, alternatives for African-American physicians other than employment with governmental or corporate structures. So let's get educated quickly. The managed-care issue is a large and important one. When we look at the disproportionate manner in which the African American has access to health care, we can understand the devastating effect that managed-care institutions will have. We must participate to ensure that facilities are located near our communities, that our patients will have the opportunities to choose AfricanAmerican physicians, and that the issues of service and support are applied to the existing and new managedcare facilities. We again will be the advocates for justice and equity in health care. Educating our patients will be necessary. Whenever possible, we will need to empower our patients, apprise them of the possible changes, and challenge them to insist on fair and equitable treatment. If enough patients complain about the lack of African-American physicians, then facilities will be pressed to look at the infrastructure and fix it. A total interaction is needed between health-care physicians and community. Now is the time to complete the link between us, the community, the lawmakers, and the civic leaders. Together we can look at managed care from a different perspective; we can help implement the structure for our Medicaid and indigent-care patients. I urge you to keep informed and maintain open dialogue among other professionals, to share articles of information with each other. Together, we can adjust to the new system and begin to work on the inside for our futures and for the well-being of our patients.
.A American Heart Q Association WERE FIGHTING FOR
'YOUR LIFE
747
_ * _
togh it is per ~~nervous an ecrease . . Xis tothtc(cholinergic , . _. t nmale xual
,
ret
acin onc ee adeauaitely studie ehigh Yoh lyvi tiuhai
Inificantinfueicn ona
enileh edt
amril ~~~~~~~has
centers an
str
ditdb -adr c recept , itso e dI tol I t; howeve rm ined .. thic : ocon~ is in I a. mydrIat rodiisiac. atvty a .train ions: i and p nt, s to iewoted uatei rm ~~~atsha op can b of ad nS. tra~~in rl, Warn notp ed must du ancy. Neither is t is nal sii with o r pedi l edin l isto it- tbe n,. ctio
rn
e
imbine
pattern of response
PHARACEUICAL, IC _ I l
_ |219 Cenountey Roadie_dt d - enaly Ne Jerseythln[onr 0767
(21 569-8502_ _~~~~~80 237-9083catIn eneoncdsi
