The novel I, Claudius, is a historical fiction written by Robert Graves in 1934. Daily life amidst Rome’s political decay during the despotic regimes of Augustus, Tiberius and Caligula is richly described. Claudius’ grandmother was the sinister Livia who manipulated these figures to secure her own power and aspired to become a goddess. Regretfully for her, Livia never achieved that status but was nevertheless named Queen of Heaven. Since she killed most of her adversaries, the threshold for becoming a celestial queen, back then appears rather low.
Although unwilling to become emperor, Claudius agreed only to save his wife and unborn child. It is no less than a miracle since — as a child — he survived malaria, colitis, rashes, and walked with a limp, from him we derive the word claudication. But this essay is not about the Emperor Claudius nor the politically unsettled time of the darkening Roman Republic, but about a parable contained within the novel: a story that may have bearing on today’s medical dystopia.
In 1988, I wrote an essay for the Broward County Medical Association RECORD describing the insidious deterioration of health care that was slowly enveloping our profession. HMOs were becoming popular as non-medical financiers learned how to enrich themselves at patient/physician’ expense. Then, as now, everything bad in health care has its origins in South Florida. The paramount example is IMC, International Medical Centers, whose CEO Miguel Recarey Jr. swindled Medicare and Medicaid out of $781 million dollars intended to provide care for 197,000 enrollers but failed to pay doctors. Although later indicted by the Department of Justice, he fled to Spain with $300-400 million missing. He was arrested in Spain but was never extradited to the United States. Some very high-level politicians sighed a great sigh of great relief. Without question, Mr. Recarey and others were harbingers of things to come and with it, the dethroning of physicians from our august position as leaders in health care. (Examples are too numerous to site.)
Back to ancient Rome: Phaedro was a rich nobleman who lived in the internecine world of brutal Roman politics in the first century AD. He had a dog, a very faithful, honest, obedient animal representing qualities obviously not shared by leading Romans of his day. The dog was so trusted that his master sent him to the meat market to fetch a package of meat and return it to his master. He had such confidence that the dog would never betray his trust. The master gazed from his window watching in horror as his dog was beset by a pack of mongrels. He realized immediately that his faithful dog never had a chance to protect the meat. As the scuffle ensued, Phaedro observed his dog emerge from the scuffle with a large piece of meat which the dog began to eat and finish on the spot while the pack continued to squabble. When the dog arrived home, Phaedro did not castigate the animal for eating the meat but praised him for his intelligence, successfully dealing with a horrific situation over which he had no control.
On November 17, at the 2025 Interim Meeting of the American Medical Association, delegates had the opportunity to listen to a speech from CMS Administrator Mehmet Oz. Well aware that deeply held feeling concerning the current administration existed, delegates were warned that inappropriate conduct would not be tolerated. Security was tight and guards in dark clothing were positioned around the room. As it turned out, none were needed. The crowd of physicians was polite. Dr. Oz spoke physician to physician, glumly presenting a realistic description of the decomposing status of American health care. Among the highlights:
-Medicaid: CMS estimates that 6.1 million out of 20 million people could work but don’t(?)
-He mentioned (twice!) that South Florida is the capital for Medicare/Insurance fraud in the United States.
-There are too many people on the Affordable Care Act. At least a quarter never use it. (Surprisingly, all of us have automobile insurance but hope never to use it. Perhaps he meant that insureds don’t go in for annual wellness examinations?)
-There are too many codes in ICD-10.
-His solution for the prior-authorizations scourge is to give Gold Cards to 50% of the doctors who deliver medically necessary care/procedures. (The implication suggests that 50% of physicians fail to practice according to the standards of their specialty.)
-Doctors are retiring at age 61. He opined that doctors working an additional 3 years would reduce health care expenditures $1 trillion.
-He mentioned CMS successful negotiations with the pharmaceutical industry bringing the cost of GLP-1 inhibitors down to reasonable levels. “It is wrong that the price of the same medication manufactured and shipped from Europe is four times the price when sold in the United States.” President Trump was congratulated for using his negotiating skills to compel the industry to lower prices.
-He did not mention what was going to happen to the patients in the Affordable Care Act who are going to face stiff increases in their premiums next month. (His speech was given before President Trump floated the idea of continuing the financial supplements/tax credits for another two years.)
-He did not mention the anticipated 6.7% increase in health care insurance premiums anticipated for 2026.
-He did not mention President Trump’s accusing the insurance industry of charging too much and reaping enormous profits. He did offer that the current administration prefers negotiation rather than other forms of pressure.
-His concluding argument is that doctors need to play a more assertive (my word) role in health care as we seek solutions. He felt that we need to create a more “Quality Driven Payment System,” and the MIPS was not working.
-Lastly, he feels that expanding Accountable Care Organizations is a potential solution.
Dr. Oz coming to the American Medical Association suggests that the administration is keenly aware that our current health care system is unsustainable and would have physicians become more engaged in achieving the solution.
Regretfully, health care does not appear to be among the president’s priorities.
Getting back to Phaedo, his intelligent pup slipped out of the pack leaving the remaining cubs to fight among themselves. Since health care cannot exist without doctors, it appears the moment has arrived for us to reassume our leadership role. It has taken 37 years, but a cascade of events exposes our opportunity to reassume our position as stewards of the profession.
It will be challenging, often painful and confrontational, but the rewards great. Nor is it a coincidence that the most successful hospital systems in the country have doctors with major leadership roles. Instead of tinkering around the edges, doctors need to take the helm. Before it is imposed on us by others with less integrity.
We may have to “bark” a little, but it will be worth it.
