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Major Actions of the 2017 American Medical Association Interim Meeting
Honolulu, Hawaii, November 10-15, 2017
By Michael A Zimmer MD FACP
- Health Insurance Affordability. The House of Delegates (HOD) adopted policy that opposed the removal of categories from the essential health benefits (EHB) package and their protections as well as opposition to annual and lifetime limits and out of pocket expenses. The report was drafted by the Council of Medical Services who stressed that protecting EHB was essential to ensure that patients have meaningful insurance benefits and need to be protected against annual and lifetime limits.
Further, federal legislation introduced this year considered reduction in EHB for patients with pre-existing conditions to be placed in high-risk pools. There is ample evidence that high-risk pools have not been affordable. States have been more successful maintaining enrollment of these patients with lowered costs through reinsurance.
- On-call and Emergency Service Compensation. Physicians recognize that hospitals have the obligation to provide 24 hour care to patients. Nevertheless, physicians must sacrifice their time and suspend their elective surgical and office work to provide this service. Consequently, the AMA felt that requesting “adequate” compensation for covering doctors was fair and equitable.
- Opposition to Reduced Payment for the 25 modifier. Physicians have experienced 50% reduction in pay when an E/M code is used when a procedure is performed the same day. This practice is employed by at least 5 insurance companies. The alternative is to have the patient return on a subsequent day, which is both inconvenient and distressing. This resolution asks the AMA to collect data and to work with third party payors. Strong language was employed that compels the AMA to aggressively and immediately advocate to ensure that E/M and 25 modifier codes are paid at the non-reduced, allowable payment rate. It further instructs the AMA to employ any means possible including direct payer negotiations, regulation and legislative remedies.
- Mandate Transparency by Pharmacy Benefit Managers; Drug Affordability; Unconscionable Drug Pricing. Perhaps no other issue drew as much emotional repugnance as increased drug costs experienced by patients because of pharmacy benefit schemes. The HOD drafted and passed no fewer than 7 resolve clauses to deal with what appears to be manipulation on the part of pharmacy managers. These resolves ask for greater formulary transparency, oppose provisions in the managers’ contracts THAT PROHIBIT PHARMACIST INFORMING PATIENTS THAT THE CASH PRICE IS OFTEN LOWER THAN THE CO-PAY. Further, the AMA is asked develop model state legislation, advocate for policies to prevent price gouging, and continue the AMA’s TruthinRx program.
- Site of Service Differential. The rising gap between independent practice expenses and Medicare reimbursement continues to increase, usually to the disadvantage of private practitioners. This resolution asks that the AMA study the site of service differential acknowledging that hospitals are required to provide uncompensated care. However, independent practitioners have also sustained increased expenditures with EHR, software and uncompensated care. The Medicare Payment Advisory Committee (MedPAC) recommended that payments should be “site-neutral.” Recognizing that this is a complex issue with the need to achieve fairness on all sides, the resolution was referred to the Council of Medical Services for study and recommendations.
- Expansion of Network Adequacy Program. Termination without Cause. Physicians who are terminated without cause generally have little time to prepare a response and notify patients. The HOD felt very strongly that the amount of time needed to respond to this action should be increased. Physicians should be notified 90 days prior to their termination and 60 days prior to the patients being notified. Providers should have at least 30 to respond, alert patients, or attempt to negotiate a new contract.
- Improving the Affordability of Insulin. Primary physicians are besieged daily by patients who complain that they cannot afford their insulin. As a result, patients cut back on their insulin and some are admitted to the Emergency Departments for ketoacidosis. This resolution asked the AMA to work with relevant medical societies to convene a summit to participate with patients, care givers, manufactures, pharmacy benefit managers to lower the cost of insulin.
Insulin’s cost has risen, 240%, Truvada increased from $8,977 (in 2006) to over $16,000 in 2015. Even lowly doxycycline increased 1,244% and Wellbutrin went up 1,185%. Initially, the Reference committee felt that insulin was just one of a number of drugs whose price has escalated rapidly. But the will of the House prevailed, and insulin’s increase was felt to so dramatic and so fundamental to care that its inflation deserved special attention.
- Advanced Register Nurse Practitioners and Physician Assistant’s Expansion of their Scope of Practice. There were two resolutions offered to bring attention to this vexing problem. It is the AMA’s deeply felt opinion that these two groups lack training to practice independently. Out of 7 physician assistant groups, only one is requesting independent practice. Previously, MDs/DOs/PA s have collaborated quite well. The AMA was asked to create a national strategy (consensus of opinions, agreements and solutions) and mount a national and state public relations campaign. Further, this campaign educate the public and seek legislation.
Patients likely don’t appreciate the thinness of mid-level providers’ diagnostic and therapeutic training; organized medicine feels this is our foremost responsibility to protect patients.
- Preserving the Tax deductibility of Student Loans. The Republican Tax Reform act currently before both Houses of Congress threatens to financially destabilize our youngest doctors by increasing their financial tax burden. American is the only country whose government does not pay for medical school tuition. As such, new doctors graduate with hundred of thousand s of dollars in debt. Rescission of the medical school tuition deduction would add a significant burden to residents at a time when they are financially vulnverable.
- Protection of Physician Freedom of Speech. Physicians are increasingly being sued, or publically challenged when giving “good faith” opinion on medical issues such as marijuana, opiods, chronic pain and other issues confronting the profession. The drafters of the resolution asked the AMA to use its Litigation Center to support constituents and component medical societies. Recognizing the complexity of the issue, the House of Delegates remanded the resolution to the Board of Trustees to investigate the optimal language needed to accomplish this goal.
A second resolution involved physicians who have been disciplined or terminated by their employers for expressing their personal viewpoint on social media. The resolution requests the Council on Ethical and Judicial Affairs (CEJA)to amend Ethical Opinion 1.2.10 (Political Actions by Physicians) to add language that physicians have a constitutional right to express their points of view even when it differed from their employers. To achieve the most effective result and given the complexity of the issue, the Board of Trustees/CEJA will recommend solutions.
- Physician Burnout and Wellness Challenges, Safety Net, and Reduction of Physician Demoralization. These challenges are becoming increasingly evident as is physician and resident suicide. A national hotline was proposed, and also a request that hospitals confidentially survey physicians. Hospitals should develop guidelines and strategies to reduce the source of demoralization. Further, a comprehensive task force should be considered to develop wellness programs and identify all factors that lead to physician demoralization. The issue was referred with a report back in June, 2018. (Of note, the Broward County Medical Association has already established a operational task force that is available to its members.)
- Maintenance of Certification (MOC) Fees. A resolution on this topic was again introduced and adopted that would to be reflective of the cost of development and administration of the MOC components. The AMA would work with national medical societies to advocate for physicians to receive value for the enormous expense of physician’ time and effort. There exists a extensive amount of policy dealing with this problematic issue. The AMA has always embraced life-long learning and practice improvement. The tests and training modules should reflect and examine those factor that truly demonstrate a physicians’ capability. Experience suggests that many boards remain expensive, elusive, and fail to meet these fundamental goals.
An excellent, well-attended convocation was organized at this meeting by Dr. Charles Cutler and James Goodyear of the Pennsylvania Medical Society indicated that progress was made by about half of the American Board of Medical Specialties (ABMS) component boards. But several boards (Internal medicine and Pediatrics) remain recalcitrant with large treasuries hidden from scrutiny.
Dr. John Moore, Chair of the Board of the ABMS, stated that his organization is listening and are trying to make the boards better.
There will be a national meeting on December 4 and 5, 2017, with all interested parties attending to address this issue and suggest improvement. Dr. Moore and representatives from the AMA’s Board of Trustees will be in attendance.
(These issues were summarized for clarity. Any errors are entirely the responsibility of the author.)
Revised November 16, 2017
MAZ MD FACP