The Journal of the American Medical Association will publish in its Dec. 3 edition a manifesto denouncing the profit motive as the source of the ills afflicting medicine in the U.S. today.
The document is causing dismay in the managed-care and for-profit sectors because of what they see as its sanctimonious tone and because it represents to some observers a politicalization of the scientific journal. Several medical directors of large HMOs suggested that its publication in JAMA is the latest example of the journal's progressive demonization of the managed-care industry.
The manifesto, which has been circulating among physicians around the country for months under the title "A Call to Action," originated among a cadre of doctors at Harvard Medical School in Boston, calling themselves the Ad Hoc Committee for the Defense of Health Care. The JAMA version, under the headline, "For our patients, not for profits," will be followed by the names of 2,000 physicians, nurses and students in Massachusetts who signed the piece.
A demonstration led by the committee will be held Dec. 2 at Faneuil Hall in Boston, with other protest activities scheduled around the country. Some adherents of the ad hoc committee are trying to buy a full-page ad in certain editions of the New York Times.
The document, obtained by MODERN HEALTHCARE last spring (May 26, p. 4), describes contemporary medicine in almost Dickensian tones: "Doctors and nurses are being prodded by threats and bribes to abdicate allegiance to patients and to shun the sickest, who may be unprofitable. Some of us risk being fired or `delisted' for giving, or even discussing expensive services, and many are offered bonuses for minimizing care."
The document rarely mentions managed care. There are three references to HMOs made only in passing. Yet high-ranking medical officers of three nationally known HMOs read it as an implicit attack on managed care, as did Jerome Kassirer, M.D., editor of the New England Journal of Medicine.
"A lot of this could have been lifted from my editorials on managed care," Kassirer said. "I think what this piece ignores is some of the benefits that managed care has yielded."
The manifesto is "very clearly an attack on managed care," said one senior medical officer for a national HMO. He and the other medical officers quoted in this article all asked that their names not be printed because they don't want to incur the wrath of JAMA and because some of the doctors who signed the piece may be on their HMO panel.
Thomas Scully, president of the Federation of American Health Systems, correctly guessed that Harvard Medical School teachers Steffie Woolhandler, M.D., and David Himmelstein, M.D., are among the manifesto's authors. Scully described them as "off-the-map, wild single-payer advocates. They're on the extreme liberal fringe." Another main author is Bernard Lown, M.D., a Harvard cardiologist who helped organize doctors opposed to nuclear proliferation.
An HMO medical affairs director from the East Coast said, "This is consistent with the tendency in JAMA to publish politically tendentious articles.
"What worries me about that is it becomes a group of important physicians wrapping themselves in the mantle of objective scientific observers. That fact alone could mislead the public to think that's what all doctors think, or that's what the most authoritative doctors think, all those Harvard doctors. To place this in an objective scientific journal seems to me to be beyond the pale," he said.
George Lundberg, M.D., editor of JAMA, said he didn't see the arguments as radical at all. The basic principles of the piece -- that patients come first, that everybody should have access to medical care, "that ripping off money from the system for excess profit is incompatible with medical professionalism -- I see that as conservative," he said.
"The mere fact that business has taken over medicine in recent years should not cause people to think it has always been such," he said.
He added that JAMA does not oppose managed care in principle. "The journal is in favor of managed care when it is the Dr. Jekyll form and not the Mr. Hyde form," Lundberg said. And he upheld the journal's interest in publishing articles about "political actions necessary to advance the public health."
All the same, the managed-care industry feels it is under attack by organized medicine, and publication of this document in JAMA may confirm that feeling, or at least feeds the industry's paranoia.
The New England Journal, too, lobs salvos against the bulwarks of managed care. It was in the pages of the New England Journal that Himmelstein first argued that clauses in managed-care contracts were preventing physicians from discussing all treatment options with their patients. A subsequent federal investigation turned up little evidence of such "gag clauses," but the damage to the industry's reputation had been done.
Karen Ignagni, president and chief executive officer of the American Association of Health Plans, isn't sure JAMA is as balanced or as upfront in its point of view as the New England Journal. "What is the ethical responsibility of a scientific journal?" Ignagni asked. "What steps, if any, should a journal be required to take to ensure that the political goals of a particular constituency do not affect its scientific standards, the research itself, or the conclusions drawn from it in its pages?"