2010 AMA Interim Meeting — California Delegation Highlights

AMA PEOPLE AND ELECTIONS
Stanford medical student Malini Daniel was elected Region I delegate from the Medical Student Section, and Stanford medical student Raymond Tsai and UCLA medical student Erik Madden were elected Region I alternate delegates.

CALIFORNIA RESOLUTIONS

1. Confidentiality Protections in Peer Review Sharing: Referred a California resolution that asks AMA to: (1) support the concept that confidentiality is an important component of effective peer review; (2) support the concept that non-discoverable confidentiality protections are necessary to ensure physician participation in peer review; and (3) advocate for non-discoverable confidentiality protections in any proposed legislation that impacts peer review. (Res. 004)
2. Healthcare Coverage for Children of Military Families: Adopted as amended a California resolution that asks AMA to support legislation that would provide coverage for military children under TRICARE, consistent with coverage afforded to children under non-grandfathered private health plans. (Res. 218)
3. Hospital EHR Systems and Physician Quality Measures: Reaffirmed existing policy in lieu of a California resolution that asked AMA to support the development of hospital electronic health records systems with comprehensive quality measures reporting capabilities, including physician quality measures reported with the consent of the treating physician pursuant to, but not limited to, government incentive programs and regulations. (Res. 820)
4. Helmet Use by Snow Skiers and Snowboarders: Adopted a substitute resolution in lieu of a California resolution that asks AMA to: (1) support legislation requiring the use of helmets by children ages 17 and younger while snow skiing or snowboarding; (2) encourage the use of helmets in adults while snow skiing or snowboarding; (3) encourage physicians to educate their patients about the importance of helmet use while skiing and snowboarding; and (4) encourage the availability of rental helmets at all commercial skiing and snowboarding areas. The substitute resolution also asked that Policy H-10.973 be rescinded. Policy H-10.973, Helmets for Recreational Skiing and Other Winter Sports in Children and Adolescents states: AMA supports the voluntary use of helmets and protective headgear for children and adolescents during recreational skiing and snowboarding. As of September 1997, there is insufficient scientific evidence to support a policy of mandatory helmet use. AMA encourages further research into the epidemiology and outcome of head injuries to children and adolescents from recreational skiing and snowboarding and research on the development of helmets to prevent or reduce the severity of these injuries. AMA encourages the American Society for Testing and Materials to finalize standards for ski helmets and study the effectiveness of ski helmets in preventing serious brain trauma. (CSA Rep. 1, I-97; Reaffirmed: CSAPH Rep. 3, A-07). (Res. 911)
5. Accountable Care Organization (ACO) Principles: Adopted as amended a California resolution which asks AMA to adopt the following accountable care organization (ACO) principles:
   1. Guiding Principle: The goal of an accountable care organization (ACO) is to increase access to care, improve the quality of care, and ensure the efficient delivery of care. Within an ACO, a physician’s primary ethical and professional obligation is the wellbeing and safety of the patient.
   2. ACO Governance: ACOs must be physician-led and encourage an environment of collaboration among physicians. ACOs must be physician-led to ensure that a physician’s medical decisions are not based on commercial interests but rather on professional medical judgment that puts patients’ interests first.
      • Medical decisions should be made by physicians. ACOs must be operationally structured and governed by an appropriate number of physicians to ensure that medical decisions are made by physicians (rather than lay entities) and place patients’ interests first. Physicians are the medical professionals best qualified by training, education, and experience to provide diagnosis and treatment of patients. Clinical decisions must be made by the physician or physician-controlled entity. AMA supports true collaborative efforts between physicians, hospitals, and other qualified providers to form ACOs as long as the governance of those arrangements ensure that physicians control medical issues.
      • The ACO should be governed by a board of directors that is elected by the ACO professionals. Any physician-entity [e.g., Independent Physician Association (IPA), medical group, etc.] that contracts with, or is otherwise part of, the ACO should be physician-controlled and governed by an elected board of directors.
      • The ACO’s physician leaders should be licensed in the state in which the ACO operates and in the active practice of medicine in the ACO’s service area.
      • Where a hospital is part of an ACO, the governing board of the ACO should be separate and independent from the hospital governing board.
   3. Physician and Patient Participation in an ACO Should Be Voluntary: Patient participation in an ACO should be voluntary rather than a mandatory assignment to an ACO by Medicare. Any physician organization (including an organization that bills on behalf of physicians under a single tax identification number) or any other entity that creates an ACO must obtain the written affirmative consent of each physician to participate in the ACO. Physicians should not be required to join an ACO as a condition of contracting with Medicare, Medicaid, or a private payer or being admitted to a hospital medical staff.
   4. The Savings and Revenues of an ACO Should Be Retained for Patient Care Services and Distributed to the ACO Participants.
   5. Flexibility in Patient Referral and Antitrust Laws: The federal and state anti-kickback and self-referral laws and the federal Civil Monetary Penalties (CMP) statute (which prohibits payments by hospitals to physicians to reduce or limit care) should be sufficiently flexible to allow physicians to collaborate with hospitals in forming ACOs without being employed by the hospitals or ACOs. This is particularly important for physicians in small- and medium-sized practices who may want to remain independent but otherwise integrate and collaborate with other physicians (i.e., so-called virtual integration) for purposes of participating in the ACO. The ACA explicitly authorizes the secretary to waive requirements under the Civil Monetary Penalties statute, the Anti-Kickback statute, and the Ethics in Patient Referrals (Stark) law. The secretary should establish a full range of waivers and safe harbors that will enable independent physicians to use existing or new organizational structures to participate as ACOs. In addition, the secretary should work with the Federal Trade Commission to provide explicit exceptions to the antitrust laws for ACO participants. Physicians cannot completely transform their practices only for their Medicare patients, and antitrust enforcement could prevent them from creating clinical integration structures involving their privately insured patients. These waivers and safe harbors should be allowed where appropriate to exist beyond the end of the initial agreement between the ACO and CMS so that any new organizational structures that are created to participate in the program do not suddenly become illegal simply because the shared savings program does not continue.
   6. Additional Resources Should Be Provided Up-front in Order to Encourage ACO Development: CMS’s Center for Medicare and Medicaid Innovation (CMI) should provide grants to physicians in order to finance up-front costs of creating an ACO. ACO incentives must be aligned with the physician or physician group’s risks (e.g., start-up costs, systems investments, culture changes, and financial uncertainty). Developing this capacity for physicians practicing in rural communities and solo-small group practices requires time and resources and the outcome is unknown. Providing additional resources for the up-front costs will encourage the development of ACOs since the “shared savings” model only provides for potential savings at the back-end, which may discourage the creation of ACOs (particularly among independent physicians and in rural communities).
   7. The ACO Spending Benchmark Should Be Adjusted for Differences in Geographic Practice Costs and Risk Adjusted for Individual Patient Risk Factors.
      • The ACO spending benchmark, which will be based on historical spending patterns in the ACO’s service area and negotiated between Medicare and the ACO, must be risk-adjusted in order to incentivize physicians with sicker patients to participate in ACOs and incentivize ACOs to accept and treat sicker patients, such as the chronically ill.
      • The ACO benchmark should be risk-adjusted for the socioeconomic and health status of the patients that are assigned to each ACO, such as income/poverty level, insurance status prior to Medicare enrollment, race, and ethnicity and health status. Studies show that patients with these factors have experienced barriers to care and are more costly and difficult to treat once they reach Medicare eligibility.
      • The ACO benchmark must be adjusted for differences in geographic practice costs, such as physician office expenses related to rent, wages paid to office staff and nurses, hospital operating cost factors (i.e., hospital wage index), and physician HIT costs.
      • The ACO benchmark should include a reasonable spending growth rate based on the growth in physician and hospital practice expenses as well as the patient socioeconomic and health status factors.
      • In addition to the shared savings earned by ACOs, ACOs that spend less than the national average per Medicare beneficiary should be provided an additional bonus payment. Many physicians and physician groups have worked hard over the years to establish systems and practices to lower their costs below the national per Medicare beneficiary expenditures. Accordingly, these practices may not be able to achieve significant additional shared savings to incentivize them to create or join ACOs. A bonus payment for spending below the national average would encourage these practices to create ACOs and continue to use resources appropriately and efficiently.
   8. The Quality Performance Standards Required to Be Established by the Secretary Must Be Consistent With AMA Policy Regarding Quality. The ACO quality reporting program must meet the AMA principles for quality reporting, including the use of nationally accepted, physician specialty-validated clinical measures developed by the AMA-specialty society quality consortium; the inclusion of a sufficient number of patients to produce statistically valid quality information; appropriate attribution methodology; risk adjustment; and the right for physicians to appeal inaccurate quality reports and have them corrected. There must also be timely notification and feedback provided to physicians regarding the quality measures and results.
   9. An ACO Must Be Afforded Procedural Due Process With Respect to the Secretary’s Discretion to Terminate an Agreement With an ACO for Failure to Meet the Quality Performance Standards.
   10. ACOs Should Be Allowed to Use Different Payment Models. While the ACO shared-savings program is limited to the traditional Medicare fee-for-service reimbursement methodology, the secretary has discretion to establish ACO demonstration projects. ACOs must be given a variety of payment options and allowed to simultaneously employ different payment methods, including fee-for-service, capitation, partial capitation, medical homes, care management fees, and shared savings. Any capitation payments must be risk-adjusted.
   11. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Patient Satisfaction Survey Should Be Used as a Tool to Determine Patient Satisfaction and Whether an ACO Meets the Patient-centeredness Criteria Required by the ACO Law.
   12. Interoperable Health Information Technology and Electronic Health Record Systems Are Key to the Success of ACOs. Medicare must ensure systems are interoperable to allow physicians and institutions to effectively communicate and coordinate care and report on quality.
   13. If an ACO Bears Risk Like a Risk Bearing Organization, the ACO Must Abide by the Financial Solvency Standards Pertaining to Risk-bearing Organizations. The Resolution also asked AMA to: (1) advise physicians to make informed decisions before starting, joining, or affiliating with an ACO; (2) provide information to members regarding AMA vetted legal and financial advisors, and seek discount fees for such services; and (3) develop a toolkit that provides physicians best practices for starting and operating an ACO, such as governance structures, organizational relationships, and quality reporting and payment distribution mechanisms. The toolkit should include legal governance models and financial business models to assist physicians in making decisions about potential physician-hospital alignment strategies. (Res. 819)
6. Use of Ongoing Professional Practice Evaluation Data: Adopted a substitute resolution in lieu of a California resolution that asks AMA to advocate that Ongoing Professional Practice Evaluation (OPPE) data be considered as peer review information and therefore be afforded protections under relevant state and federal law, and not be used for economic credentialing purposes. (Res. 821)

OTHER KEY ACTIONS

1. Work Value, Medicare Economic Index and Transparency (Res. 207) • Practice Expense Accuracy and Survey Cancellation (Res. 211): Referred Resolutions 207 and 211. Resolution 207 asks the AMA to: (1) request the Centers for Medicare and Medicaid Services (CMS) to keep the current relative value of work and the proportion of the Medicare fees in the physician work component of the Medicare Economic Index (MEI) at the current level (i.e., 52.47% and not decrease it to 48.27%); (2) demand CMS make Medicare payment methodology and explanations transparent and simple enough for all to understand, including physicians and politicians; (3) through the use of more surveys, advise CMS in determining the correct inputs into the MEI and continue to educate Congress that Medicare payments are not keeping up with practice costs in every region of the country; and (4) emphasize to CMS that physicians need to be paid more for their increasing practice costs as well as inflationary increases in the payment for their work. Resolution 211 asks AMA to seek to partner with the Medical Group Management Association, American Medical Group Association, and state and specialty societies to encourage fuller participation in a nationwide physician practice expense survey that could be funded from all these entities, or by the Centers for Medicare and Medicaid Services.
2. Accounting for Bundled Care Payments (Res. 814) • Impact of Accountable Care Organizations and Foundation Models (Res. 818) • Legal Structures for Clinical Integration (Res. 832) • Accountable Care Principles (Res. 833): Referred a series of resolutions regarding ACOs and other integrated models. Included in this referral was a California resolution (Res. 818). Resolution 814 asked AMA to study and provide a detailed report by the 2011 Annual Meeting that describes how a single, global, or “bundled” payment would be divided among primary care physicians, specialists, ambulatory care centers, and hospitals describing in detail what percentage of each “healthcare dollar” goes to each participant. Resolution 818 asked AMA to continue to evaluate accountable care organization (ACOs) and medical foundations and their compliance with existing law, and their impact on the ability of physicians to practice appropriate and quality patient care, and to make available to physician members and local county medical societies existing resources (webinars, issue briefs, noteworthy articles, etc.) related to ACOs and medical foundations. Resolution 832 asked AMA to continuously monitor healthcare laws and regulations to develop and make available to AMA members model organizational information for all physicians, including independent and/or small groups as well as medical staffs, so that AMA can communicate, organize, and participate in care processes for high quality and efficient service delivery of healthcare that will permit independent physician practitioners and/or small groups to clinically integrate and provide accountable care, and make available to AMA members no later than the 2011 Annual Meeting, by electronic means as well as on the AMA website, and in hard copy on request, specific model organizational information to provide accountable care. Resolution 833 asked AMA to develop and propose specific AMA principles concerning ACOs and the provision of accountable care; that these principles place the patient’s best interests before all other considerations and ensure no intrusion into the patient-physician relationship; and that they be made available to members no later than the 2011 Annual Meeting.
3. Study of Interpreter Mandate: Adopted as amended a resolution that asks AMA to evaluate the impact on a physician practice of any federal mandate that requires an interpreter be present for patients who cannot communicate proficiently in English, or are hearing impaired. (Res. 823)
4. Cannabis for Medicinal Use: Amended AMA Policy H-95.952 in lieu of a Hawaii, which called on AMA to recommend the re-scheduling of medical cannabis to a status that is either equal to or less restrictive than the Schedule III status of synthetic THC (Marinol), so as to reduce barriers to needed research and to humanely increase availability of cannabinoid medications to patients who may benefit. AMA Policy H-95.952 Cannabis for Medicinal Use to state: (1) Our AMA calls for further adequate and well-controlled studies of marijuana and related cannabinoids in patients who have serious conditions for which preclinical, anecdotal, or controlled evidence suggests possible efficacy and the application of such results to the understanding and treatment of disease. (2) Our AMA urges that marijuana’s status as a federal Schedule I controlled substance be reviewed with the goal of facilitating the conduct of clinical research and development of cannabinoid-based medicines, and alternate delivery methods. This should not be viewed as an endorsement of state-based medical cannabis programs, the legalization of marijuana, or that scientific evidence on the therapeutic use of cannabis meets the current standards for a prescription drug product. (3) Our AMA urges the National Institutes of Health (NIH), the Drug Enforcement Administration (DEA), and the Food and Drug Administration (FDA) to develop a special schedule and implement administrative procedures to facilitate grant applications and the conduct of well-designed clinical research involving cannabis and its potential medical utility. This effort should include: a) disseminating specific information for researchers on the development of safeguards for cannabis clinical research protocols and the development of a model informed consent forms for institutional review board evaluation; b) sufficient funding to support such clinical research and access for qualified investigators to adequate supplies of cannabis for clinical research purposes; c) confirming that cannabis of various and consistent strengths and/or placebo will be supplied by the National Institute on Drug Abuse to investigators registered with the DEA who are conducting bona fide clinical research studies that receive FDA approval, regardless of whether or not the NIH is the primary source of grant support. (4) Our AMA believes that effective patient care requires the free and unfettered exchange of information on treatment alternatives and that discussion of these alternatives between physicians and patients should not subject either party to criminal sanctions. (CSA Rep. 10, I-97; Modified: CSA Rep. 6, A-01; Modified: CSAPH Rep. 3, I-09). (Res. 902)
5. Physician Health Programs: Referred Council on Science and Public Health Report 1 which provides an historical overview on the development and operation of physician health programs (PHPs), notes relevant AMA Policy, and briefly discusses what is known about the barriers to use of PHPs and the effectiveness of their confidentiality safeguards. Additionally, some key studies demonstrating the effectiveness of PHPs are reviewed in an effort to identify best practice characteristics. The report recommends that AMA: (1) affirm the importance of physician health in its strategic plan and the need for regular and ongoing education of its members as to physician health; (2) assist in furthering the informational and educational aspects of physician health across the continuum of medical education and other relevant organizations for the purpose of expanding awareness regarding the importance of enhance physician health and awareness of programs designed to accomplish that goal; and (3) recognize the following as essential components of a state physician health program: (a) contingency management that includes both positive and negative consequences; (b) random drug testing; (c) linkage with the 12 step programs and with the abstinence standard espoused by these programs; (d) management of relapses by intensified treatment and monitoring; (e) use of a continuing care approach; (f) a focus on lifelong recovery; and (g) the process should protect anonymity. The importance of PHPs and the overall value of this report were consistently emphasized. Recommendation 4 in the report provides an avenue for more explicit development of guidelines and essential features for high quality PHPs. Concern was expressed about the apparent focus of the report on the addicted physician; a need exists to also recognize other conditions (e.g., the disruptive physician, physicians with mental health disorders) as important reasons that physicians are referred to PHPs. The Federation of State Medical Boards noted that it also has guidance on dealing with physician impairment and protecting the public. The concept of developing hospital-based physician health programs also was raised, as was the issue of payment as a covered benefit for urine drug testing within the confines of a PHP administered program. A request also was made for any subsequent developed guidelines to be brought back to the HOD for approval, and that AMA advocate for PHPs to be open to medical students. (CSAPH Report 1)
6. Consistency of AMA Policy on Market Regulation (CMS Report 1) • Withdraw Support for a Federal Mandate for the Individual Purchase of Health Insurance (Res. 816): Referred Council on Medical Service Report 1 and Resolution 816. Council on Medical Service Report 1 provides a summary of legislative and regulatory activity pertaining to market regulation, discusses concerns related to Resolution 204-I-09, outlines relevant AMA policy and advocacy efforts, and presents policy recommendations. Resolution 816 asks AMA to support using tax incentives and other non-compulsory measures to encourage purchase of health insurance, rather than a federal mandate, and rescind policy H-165.848, Individual Responsibility to Obtain Health Insurance. There was extensive testimony on Council on Medical Service Report 1 and Resolution 816. In introducing Council on Medical Service Report 1, a member of the Council on Medical Service noted that long-standing AMA policy supports both direct and indirect methods to provide more choice and access to affordable coverage for all individuals, including those with high-risk conditions. Council testimony reiterated a strong belief that there is still a need for direct risk-based subsidies such as high-risk pools, risk adjustment, and reinsurance. The Council also noted that without an individual mandate, indirect approaches to protect high-risk patients, including the elimination of denials for pre-existing conditions, will not be effective. Additional speakers noted that without requiring individuals to purchase health insurance, other market reforms unravel. Ultimately, speakers in favor of Council on Medical Service 1 and opposed to Resolution 816 noted that without an individual mandate, there would be an increase in “free-riders” in the healthcare system, the pool of insured individuals will be less healthy, premiums for everyone will increase, and the goal of millions of individuals becoming insured will not be achieved. Testimony in favor of Resolution 816 noted that AMA policy on individual responsibility conflicts with AMA policy in support of pluralism and free-market economic principles. Supporters of Resolution 816 noted that there are non-compulsory measures, such as tax incentives and health savings accounts, that could effectively serve as alternatives to a federally imposed requirement that individuals purchase health insurance. However, there was also testimony that stated that evidence was lacking that universal coverage could be accomplished with tax incentives but without an individual mandate. Speakers also spoke to constitutional questions raised by the individual mandate included in ACA.
7. Physician Tax Credits for Uncompensated Care: Adopted as amended the recommendations in Council on Medical Service Report 2, and the remainder of the report filed. The recommendations in CMS Report 2 state: 1. That our American Medical Association (AMA) reaffirm Policy H-165.838, “Health System Reform Legislation,” which states that AMA is committed to achieving the enactment of health system reforms that include health insurance coverage for all Americans, and insurance market reforms that expand choice of affordable coverage, and are consistent with AMA policies concerning pluralism, freedom of choice, freedom of practice, and universal access for patients. 2. That our AMA study methods, including potential tax credits or deductions, to support physicians who provide uncompensated or under-compensated care. (CMS Report 2)