In the late 1990’s I gave a lecture entitled “Post-Hippocratic Medicine in the Shadow of Nietzsche” in response to Peter Singer, the chair of bioethics at Princeton University. Singer had proposed we not consider humans “fully human” until they reached five weeks of age (after birth). During the first four weeks, he argued, we should allow the overt killing of infants with disabilities. This was “cost-effective.” It served the “greater good” by controlling the skyrocketing cost of healthcare.

For a decade I studied the question ”How did America reach a place in her history where we could seriously consider resurrecting the ancient practice of infanticide?” What I discovered changed my life.

For the past 2,500 years physicians served only one of two roles in Western culture. They either followed Hippocrates and served the wellbeing of their patients, or they followed Plato and served the greater welfare of the State. The philosophy of Peter Singer is not new—it has been with us for millennia. We once again stand at these same fated crossroads of Plato and Hippocrates as we debate the future of American healthcare.

Based on my study of history, philosophy, and current events, I feared we were rapidly returning to the world of Plato; a world where physicians worked at the behest of government, not solely for the patient. To help Americans understand what was about to transpire, I launched  Physicians for Reform in 2006.

The challenges facing American healthcare are real. The cost of healthcare is rising at twice the rate of inflation. Driven by the high cost of care, 28% of the patients visiting the emergency room where I work do not have coverage. Change will come; the only uncertainty is where that change will lead. Will the patient remain at the center of American healthcare? Or will the needs of the State reign supreme?

During the spring of 2008, the Barbara Wagner story confirmed my fears. After two years in remission, Barbara’s lung cancer returned. Her oncologist recommended treatment with Tarceva, a new chemotherapy. However, Barbara was a patient under the state-run Oregon Health Plan. Based of the “greater good” the State, Oregon denied her chemotherapy, instead offering to pay for physician-assisted suicide.

When asked about denying Barbara’s treatment, Dr. Walter Shaffer, a spokesman for Oregon’s Division of Medical Assistance Programs, explained the State’s policy this way, “We can’t cover everything for everyone. Taxpayer dollars are limited for publicly funded programs. We try to come up with policies that provide the most good for the most people.” (Learn details of the story here.)

In this context, Medicare is Already Rationing Care takes on an entirely new perspective. The fundamental issue is not physician reimbursement. The issue paramount for every American is access to care. Mayo just closed the doors of one of its clinics to new Medicare patients. Others will certainly follow if we continue down the road Washington is hell-bent to travel.

We must find fiscally responsible, patient-centered solutions to the challenges facing American healthcare. If we do not, financial pressures will drive us once again into the arms of Plato. Physicians for Reform is dedicated to finding these solutions so physicians can tread once again the ancient path of Hippocrates.

Visit Physicians For Reform to learn more about the history of Western medicine and the efforts of this grassroots movement. Only by working together will the patient remain at the center of American healthcare.

Medicare has already begun the process of backdoor rationing. Facing overwhelming budget shortfalls, Medicare needs to trim its books. Washington found a clever solution: eliminate the billing code for “physician consults.”

As a hospital physician, I often admit Medicare patients with chest pain or shortness of breath. If my patient needs urgent help from a cardiologist, I call a colleague for assistance.

Until December 31, 2009 the cardiologist could charge a “physician consult” fee for getting out of bed, coming to the hospital, and evaluating a patient with a potentially life threatening problem. Medicare paid $195.76 for this middle-of-the-night work (the same rate as when done during the day).

By eliminating the “physician consult” billing code, Medicare now advises the specialist to charge for a “hospital admission.” For two more months, Medicare will pay $175.67 for this service. However, without a change in current law, the physician’s reimbursement for a “hospital admission” will drop to $141.63 on March 1. This is why the “Doc Fix” is so important for working physicians and their Medicare patients.

Other recent and obscure changes in Medicare guidelines are potentially even worse.

As of January 1, Medicare will not pay the consultant at all unless the admitting physician uses an “HI modifier” when billing Medicare for the initial admission. This means in order to get paid, the consulting physician must rely on another physician’s billing practice. Many physicians remain unaware of this obscure change (Medicare guidelines were altered as recently as December 17). The result? Many consultants will be denied payment altogether—yet another way to “save” Medicare dollars.

Most physicians function as small business owners. Consider what becomes of this $141 per consultation (assuming they are lucky enough to receive that):

Interventional cardiologists pay approximately $50,000 a year for malpractice insurance. If they work 40 hours a week, 50 weeks a year this means they pay $25 an hour for malpractice coverage. If they spend two hours in middle of the night coming in to see my patient, this effectively cuts their salary by $50. Earning $91 for middle of the night work simply does not cover the rent, utilities, and salaries for office staff that must be paid each month to keep the office doors open.

Why should seniors care?

Even before these cuts, Medicare already underpaid physicians by 15 to 25 percent compared to traditional insurance companies. No business can survive when expenses exceed revenue—no matter how well intentioned the physician.

When the pending $500 billion cut to Medicare (used pay for healthcare reform) is added to the cuts outlined above, physicians will be forced to limit their exposure to patients on Medicare. They will shift their work to younger, healthier patients who are less complex, require less time, and have traditional insurance. This kind of “reform,” even as millions of baby boomers enter the system, will only exacerbate the physician shortage for Medicare patients.

There are ways to “bend the curve” without sacrificing our seniors. But sadly, Washington chose another path. Politicians chose to reward political allies and pay off key Senators rather than protect American seniors.

Several common sense reforms would “bend the curve” without backdoor rationing. But Washington continues to ignore these ideas. These solutions include:

1. End abusive medical litigation by passing patient-centered tort reform.
2. Let businesses purchase insurance across state lines.
3. Give younger, healthier Americans tax incentives to purchase low cost/high deductible plans and let them put pre-tax dollars into a healthcare savings accounts.

If Washington continues to protect political allies and buy Senate votes rather than pursue patient-centered reform, then let backdoor rationing begin. This is not overheated rhetoric. This is reality. Mayo Family Clinic in Glendale Arizona just announced it will stop accepting Medicare as of January 1.