In preparation for this presentation, I took the opportunity to review the remarks made to the House by past presidents Drs. Hank Carter, Beth Purdy, and Gary Figge. Dr. Carter focused on the burden of government regulation on health care, and on the economic costs of the American tort system. Dr. Purdy discussed the interests of the patient, and how they are well-served by the intelligence, training, and ethics of physicians. Dr. Figge developed this theme further, referencing the noble history of the medical profession, and observing that it is the physician who is the expert in “determining the minimum needs and standards for providing patient care and in determining what best environment to provide that care.” All of our past presidents, in different ways, touched on the role of the Arizona Medical Association in supporting our core principles and in advocating for physicians and their patients with our elected officials, the media, the public, and our colleagues. Today I would like to take a broader view of health care and medicine in the United States and Arizona, in an effort to consider how we as physicians and we as an organization can influence its development in the future.

I’d like to start by saying that things are not what they seem. Dr. Figge’s remarks about Osler reminded me about a conversation I had a few years ago with Dr. Ed Benz, President of the Dana Farber Cancer Institute. He had visited the Osler library at my alma mater, McGill University in Montreal, a lovely library devoted to the history of medicine, and saw someone kneeling in front of the portrait of Osler, head almost touching the ground. My God, he thought, they worship Osler here. Then as he moved closer, he noticed that it was a housekeeper cleaning the floorboard beneath the portrait. Things were not what they seemed to be in that situation, and they are not always what they seem to be in health care.

Where does the US rate internationally in health statistics? If you ask the average person on the street, you are likely to hear “The United States is number one.” But this is far from the truth. The Organization for Economic Cooperation and Development, OECD, ranks health care systems every year. The United States does indeed rank first for prostate cancer survival, and is second only to Cuba in survival rates for breast cancer, two diseases which have received considerable public attention and which have gotten significant funding in recent years, but if you look at the fundamental measures of a nation’s health - infant mortality, death rate from childhood diseases, and life expectancy for example - the US ranks very poorly indeed, at or close to the bottom of the OECD list. And it may get worse before it gets better.

We have known for more than forty years that, next to public health measures such as promoting clean water, clean air, sanitation, and vaccination, the primary determinant of morbidity and mortality is individual behavior. The US has done well in controlling tobacco use, but we are failing miserably in areas such as obesity, exercise, and substance abuse. John Kenneth Galbraith, the Canadian economist, once said that “more people in the Unites States die from too much food than too little.” We can certainly all agree that there is an evolving epidemic of diabetes, arthritis, cardiovascular and other diseases that is worsening and is increasingly becoming apparent to us as physicians, to the public and to our legislators. Our young people are vulnerable to the ravages of substance abuse, and to the increase in violence in our society. These are difficult times for all of us, as health care professionals working in a challenging health care system, as citizens in a large complex society, and as members of a workplace and of a family of individual human beings with whom we live and interact daily.

Public health is important, and I have had a long and abiding interest in that area. Part of the mission of our 119-year old Arizona Medical Association is to improve the health of all the people in Arizona. So as physicians in organized medicine, we all have had a long and well-established role in public health. We need to do what we can to protect the public from hazards and to promote the betterment of their health. In Arizona, our ArMA Public Health Committee meets several times per year to discuss public health issues. They, and we, have an important role to play for improving public health.

However, as a medical organization, our mission goes beyond promoting the art and science of medicine and the public health. Our mission includes two additional components, namely to represent the physician and the profession in the public forum, and to defend the freedom and ability of the physician to practice medicine in the best interests of the patient. We must do that in a profession that is becoming ever more diverse, with an increasing number of employed physicians, academic physician researchers and educators, and growing numbers of specialties and specialty societies. We must do that in a profession whose members have been selected for their intelligence, confidence, and drive, and from their earliest years in medical school have been schooled in the primacy of the physician. We must do this in the face of declining public and political esteem, and with the encroachment of paramedical professions who simply lack the knowledge and skills that we have as physicians. To summarize those three points in simple terms, first, organizing doctors is like herding cats; second, divisiveness is damaging our profession; and third, we are under attack.

So how will medicine respond to these challenges? Where does medicine, where do you, want to go with your profession? First, I would like to thank all of you who are here for attending the 2011 meeting of the ArMA House of Delegates. You are what makes our association strong. But being strong is not enough. As an example, I will cite the SGR, the sustained growth rate formula that the federal government uses to determine how much it will pay physicians each year for treating their Medicare patients. To me, the SGR is like a carrot on a stick in front of a donkey. We keep pulling and pulling, but we never get any closer to the carrot. The donkey is beginning to realize that the carrot is an illusion. The next option for the federal government may be to beat the donkey, which it can do through tools like the recovery audit contractors, or RACs, or to get another donkey, by creating programs and incentives to bring more and more paraprofessionals into the health care field. Resisting the government through brute force is not going to work well. We will never get to where we need to go as a profession through brute force alone.

Medicine needs to get smarter. Smarter in the way we practice, smarter in the way we deal with politicians and the public, and smarter in the way we handle the money we receive, as individuals, as groups of physicians, and as organized medicine. We may be tempted to grieve for the loss of what we might think of as the golden age of medicine, when doctors such as Dr. Welby and Dr. Kildare were respected, well paid, and handsome. Using Elizabeth Kubler Ross’s brilliant analysis of the stages of grief, we can predict what we will do as a profession if we begin to grieve. We will go through the stages of denial, anger, bargaining, depression, and acceptance. I think we may have already started down that path. It is the wrong path. We need to recognize the reality of where we are, and be a part of changing it for the better, for physicians and for society.

What is our reality then, the reality of AZ physicians? First, we have to understand our demographics. Our population is aging, and in a time when we require more physician services, the ratio of physicians to population is decreasing. We need to reduce the restrictions on residency training, and we need to create and to bring more physicians into the state of Arizona. The University of Arizona graduated its first class of Phoenix-based students this year, and Mayo Clinic continues to broaden its relationship with Arizona State University with the goal of furthering their mutual commitment to medical and educational innovation. We also need to support primary care. These doctors are hurting, especially in our rural communities. We need to work with government to establish ways and means to keep them there and to build their numbers.

Second, more doctors are becoming employed. Medicine used to be like the corner store. I’m afraid to say that Walmart is moving in and the corner store can’t compete. We must work together as a profession to promote and maintain physician leadership in these emerging health care organizations, whether they are national entities like Mayo, Cleveland Clinic and Kaiser or local health systems such as Banner, Scottsdale Healthcare and Catholic Healthcare West, St. Joseph’s. Organizations such as these may have the best interests of both their patients and their physicians at heart. But we can’t count on it. Once physicians enter into an employment relationship they are, by default, putting their employment, and perhaps their patients, at risk. He who has the gold makes the rules.

We need to understand the overwhelming involvement and importance of government in the health care arena. Government got into health care almost fifty years ago, and despite the efforts of some of our politicians and some members of the public, it is not going to go away. ArMA has an outstanding record of advocacy with our state legislature, and we have strong relationships with our federal legislators as well through the efforts of our Government and Legislative Affairs Committee and of our ArMA management team -  Chic Older, David Landrith and Carol Wagner in particular. We have developed a set of principles, which I have asked Chic to include in your packages this morning. We are using those principles to guide our actions as we work with the public and their elected representatives.

Another important challenge that needs to be addressed is the deteriorating infrastructure and condition of our public health system. The Maricopa and Pima County Public Health Departments, for example, are among the lowest in the country with respect to investment of public dollars per capita. We need to try to better understand and help change this reality.

As a medical association, we have a noble history and a solid foundation. But as Dr. Carter said three years ago, “it is unconscionable that four out of five practicing physicians, whether sole proprietor, group practice, employed, administrative, or perhaps even retired, do not count themselves as members of the Arizona Medical Association. To remain recognized and function as professionals we must retain control of our profession.” It is up to me as your new president, to our Executive Committee and Board of Directors, and to all of you in this room, to find creative ways to expand our relevance and our membership. In preparation for doing so, Chic has engaged a consultant, Archie Simons, whom Chic refers to as “Mr. Fresh Eyes.” He will work with management, the Executive Committee and the Board in the coming months to develop a growth strategy. We will need your ideas and support in that process.

I’d like to conclude with some provocative thoughts on the future of medicine in the United States over the next 25 years. In my view, there are three options, only one of which is likely to happen. You may have other ideas, and if so I would like to hear them, because my plan is to develop this into an essay for publication in Arizona Medicine early next year. The first option is a single payer system. That is how the Canadian system works. It is like Medicare in this country, but everyone who has lived in Canada for more than three months, not just the elderly, is eligible for medical services and hospital care. Most Canadian physicians charge on a fee for service basis, just as we do in the US. Their fees are set by negotiation between the provincial medical association and the provincial government each year. The provincial government in each of the ten provinces of Canada is the single payer. The system generally works well, it is hugely popular among Canadians, and it is a viable option for the United States, but for political and cultural reasons, I don’t think it will happen here.

The second option is a split public-private model such as that which exists in Germany, to a lesser extent in Great Britain, and in some other countries. Everyone is eligible for medical services, which are covered by taxation, but the list of covered services is not all inclusive, the scope of the medical evaluation may be limited, the facility where the services are provided may be mediocre, and it may take several weeks or months before they can get in for an appointment for non-emergency services. We have this system in the United States already for our primary and secondary public education system. A variant of this might be some form of voucher system. However, I don’t think either a voucher system or a simple public/private model of health care will be developed here.

The third option is what I call the corporatization of health care. Corporatization is the modern American way. Henry Ford started it, Walmart and others have advanced it, and the healthcare system will be its next target. We are seeing a very rapid increase in the number of employed physicians; physicians employed by large groups, physicians employed by hospitals, and physicians beginning to be employed directly by insurers, such as Cigna and Humana. Hospitals are being bought by other hospitals. Hospital chains already exist and will become larger and more powerful. Alliances between hospitals and insurers may begin to develop, and insurers may begin to buy hospital chains or vice versa. There will be a consolidation in healthcare similar to what happens when you add more and more drops of oil to water or vinegar. This has happened in the travel industry for air travel, rental cars, and hotels. It has happened in accounting. I think it will happen in medicine. Between 2009 and 2010 alone, the number of hospital mergers and acquisitions increased by 28%.  In twenty five years, perhaps less, we may have four or five very large healthcare systems nationwide. Government will set the reimbursement rates for Medicare and Medicaid. Health insurance as we know it now may cease to exist. Each corporation will determine how it will provide services to its clients. Individual practices will continue to exist, but will represent the minority of practitioners. I think that there are overwhelming forces in this country that are driving health care toward corporatization. Most of us just don’t realize it yet.

Whichever healthcare model ultimately evolves, state medical associations will have a role to play. The nature of that role will, however, be quite different in each case. Arizona Medical Association will need to follow social and political developments closely over the coming years, and be ready to contribute in a positive way to developing a system that will be best for our patients and our profession. We have a key role to play, and we have an opportunity to provide guidance and leadership for our state and our country.

I’d like to end with one of my favorite quotes, by anthropologist Dr. Margaret Mead. “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”

Thank you.