2009 AMA Interim Meeting Highlights: Pacific Rim Delegation (November 10, 2009)

AMA People and Elections

• Gerald Murphy, MD, of Simi Valley was re-elected chair of the California delegation, and Albert Ray, MD, of San Diego was elected vice chair.
• Debra Judelson, MD, of Beverly Hills announced her candidacy for election to the AMA Council on Science and Public Health in June 2010.
• Ryan Riberia (UC Davis) and Erin Schmidt (Loma Linda) were elected Region I delegates from the Medical Student Section, and Malini Daniels (Stanford) and Srihari Namperumal (UC Davis) were elected Region I alternate delegates.
• Lisa James of Berkeley was awarded the Citation for Distinguished Service, the highest honor the House of Delegates presents to a nonphysician. Ms. James is director of health for the Family Violence Prevention Fund, which has worked for more than 20 years to prevent violence in homes and communities and to help victims of violence. She has developed educational materials on domestic violence and has collaborated with healthcare professionals and others in 15 states to develop healthcare responses to domestic violence.

California Resolutions

1. E-prescribing of Scheduled Medications: Adopted a California resolution that asks AMA to support action requiring the U.S. Drug Enforcement Administration to move expeditiously to establish reasonable requirements enabling the use of e-prescribing for controlled substances. (Res. 211)
2. Federal Payment for Emergency Services for Undocumented Immigrants: Adopted a California resolution that asks AMA to support federal legislation to extend Section 1011 of the Medicare Modernization Act (MMA, P.L. 108–173), which provides for federal funding to the states for emergency services provided to undocumented immigrants. (Res. 212)
3. Physician Supervision Over Certified Registered Nurse Anesthetists: Adopted as amended a California resolution that asks AMA to urge the federal government to repeal the opt-out provision of the Medicare Conditions of Participation that eliminated the long-standing requirement that certified registered nurse anesthetists practice under direct physician supervision. (Res. 213)
4. Medicare Coverage of Avastin for Intravitreal Use: Adopted as amended a California resolution that asks AMA to: 1) support the ability of local Medicare carriers to price compounded drugs, including Avastin, using a “non-specific” J-code or other reasonable means where this is medically appropriate and financially beneficial; and 2) urgently and actively lobby the Centers for Medicare and Medicaid Services (CMS) on the issue of Medicare coverage of Avastin for use in ophthalmic treatment, including the need for any intervention to be fully retroactive to prevent breaks in coverage. (Res. 813)
5. Forced Off-label Use of Medications and Step Therapy: Reaffirmed existing policy in lieu of a California resolution that asked AMA to support legislation to bar health plans and insurers from requiring a patient to use a particular non-Food and Drug Administration (FDA)-indicated drug before providing access to FDA-indicated drugs if they cannot demonstrate that the particular non FDA-indicated drug is supported by widely accepted guidelines or clinical literature, and if they cannot show that the particular non FDA-indicated drug is appropriate for the treatment of the medical condition and medically appropriate for the patient. (Res. 814)
6. Government Recovery Programs: Adopted a California resolution that asks AMA to: 1) advocate that all government recovery programs contain complete physician access to any data mining criteria and programs, that there is same-specialty/same-subspecialty physician review prior to denial of claims, and that any denial of claims be based on medical necessity review as determined by that same-specialty/same-subspecialty physician reviewer; and 2) explore options for increased reimbursement of physician costs related to government audits, including remedies available through the Equal Access to Justice Act. (Res. 815)

Other Key Actions:

Ruling Policies With Regard to AMA Health System Reform: Adopted a substitute resolution (Res. 203) regarding health system reform that provides:

That our American Medical Association be committed to working with Congress, the administration, and other stakeholders to achieve enactment of health system reforms that include the following seven critical components of AMA policy:

• health insurance coverage for all Americans
• insurance market reforms that expand choice of affordable coverage and eliminate denials for pre-existing conditions or due to arbitrary caps
• assurance that healthcare decisions will remain in the hands of patients and their physicians, not insurance companies or government officials
• investments and incentives for quality improvement and prevention and wellness initiatives
• repeal of the Medicare physician payment formula that triggers steep cuts and threaten seniors’ access to care
• implementation of medical liability reforms to reduce the cost of defensive medicine
• streamline and standardize insurance claims processing requirements to eliminate unnecessary costs and administrative burdens

That our American Medical Association advocate that elimination of denials due to pre-existing conditions is understood to include rescission of insurance coverage for reasons not related to fraudulent representation.

That our American Medical Association House of Delegates support AMA leadership in their unwavering and bold efforts to promote AMA policies for health system reform in the United States.

That our American Medical Association support health system reform alternatives that are consistent with AMA policies concerning pluralism, freedom of choice, freedom of practice, and universal access for patients.

That it is American Medical Association policy that insurance coverage options offered in a health insurance exchange be self-supporting; have uniform solvency requirements; not receive special advantages from government subsidies; include payment rates established through meaningful negotiations and contracts; not require provider participation; and not restrict enrollees’ access to out-of-network physicians.

That our American Medical Association actively and publicly support the inclusion in health system reform legislation the right of patients and physicians to privately contract, without penalty to patient or physician.

That our American Medical Association actively and publicly oppose the Independent Medicare Commission (or other similar construct), which would take Medicare payment policy out of the hands of Congress and place it under the control of a group of unelected individuals.

That our American Medical Association actively and publicly oppose, in accordance with AMA policy, inclusion of the following provisions in health system reform legislation:

• Reduced payments to physicians for failing to report quality data when there is evidence that widespread operational problems still have not been corrected by the Centers for Medicare and Medicaid Services;
• Medicare payment rate cuts mandated by a commission that would create a double-jeopardy situation for physicians who are already subject to an expenditure target and potential payment reductions under the Medicare physician payment system;
• Medicare payments cuts for higher utilization with no operational mechanism to assure that the Centers for Medicare and Medicaid Services can report accurate information that is properly attributed and risk-adjusted;
• Redistributed Medicare payments among providers based on outcomes, quality, and risk-adjustment; measurements that are not scientifically valid, verifiable and accurate;
• Medicare payment cuts for all physician services to partially offset bonuses from one specialty to another; and
• Arbitrary restrictions on physicians who refer Medicare patients to high quality facilities in which they have an ownership interest.

That our American Medical Association continue to actively engage grassroots physicians and physicians in training in collaboration with the state medical and national specialty societies to contact their members of Congress, and that the grassroots message communicate our AMA’s position based on AMA policy.

That our American Medical Association use the most effective media event or campaign to outline what physicians and patients need from health system reform.

That national health system reform must include replacing the sustainable growth rate (SGR) with a Medicare physician payment system that automatically keeps pace with the cost of running a practice, and is backed by a fair, stable funding formula, and that AMA initiate a “call to action” with the Federation to advance this goal.

That creation of a new single payer, government-run health care system is not in the best interest of the country and must not be part of national health system reform.

That effective medical liability reform that will significantly lower healthcare costs by reducing defensive medicine and eliminating unnecessary litigation from the system should be part of any national health system reform.

That our American Medical Association reaffirm AMA policy H-460.909 Comparative Effectiveness Research, which states:

H-460.909 Comparative Effectiveness Research

The following principles for creating a centralized comparative effectiveness research entity are the official policy of our AMA:

Principles for Creating a Centralized Comparative Effectiveness Research Entity:

A. Value. Value can be thought of as the best balance between benefits and costs, and better value as improved clinical outcomes, quality, and/or patient satisfaction per dollar spent. Improving value in the U.S. healthcare system will require both clinical and cost information. Quality comparative clinical effectiveness research (CER) will improve healthcare value by enhancing physician clinical judgment and fostering the delivery of patient-centered care.

B. Independence. A federally sponsored CER entity should be an objective, independent authority that produces valid, scientifically rigorous research.

C. Stable Funding. The entity should have secure and sufficient funding in order to maintain the necessary infrastructure and resources to produce quality CER. Funding source(s) must safeguard the independence of a federally sponsored CER entity.

D. Rigorous Scientifically Sound Methodology. CER should be conducted using rigorous scientific methods to ensure that conclusions from such research are evidence-based and valid for the population studied. The primary responsibility for the conduct of CER and selection of CER methodologies must rest with physicians and researchers.

E. Transparent Process. The processes for setting research priorities, establishing accepted methodologies, selecting researchers or research organizations, and disseminating findings must be transparent and provide physicians and researchers a central and significant role.

F. Significant Patient and Physician Oversight Role. The oversight body of the CER entity must provide patients, physicians (MD, DO), including clinical practice physicians, and independent scientific researchers with substantial representation and a central decision-making role(s). Both physicians and patients are uniquely motivated to provide/receive quality care while maximizing value.

G. Conflicts of Interest Disclosed and Minimized. All conflicts of interest must be disclosed and safeguards developed to minimize actual, potential, and perceived conflicts of interest to ensure that stakeholders with such conflicts of interest do not undermine the integrity and legitimacy of the research findings and conclusions.

H. Scope of Research. CER should include long-term and short-term assessments of diagnostic and treatment modalities for a given disease or condition in a defined population of patients. Diagnostic and treatment modalities should include drugs, biologics, imaging and laboratory tests, medical devices, health services, or combinations. It should not be limited to new treatments. In addition, the findings should be re-evaluated periodically, as needed, based on the development of new alternatives and the emergence of new safety or efficacy data. The priority areas of CER should be on high-volume, high-cost diagnosis, treatment, and health services for which there is significant variation in practice. Research priorities and methodology should factor in any systematic variations in disease prevalence or response across groups by race, ethnicity, gender, age, geography, and economic status.

I. Dissemination of Research. The CER entity must work with healthcare professionals and healthcare professional organizations to effectively disseminate the results in a timely manner by significantly expanding dissemination capacity and intensifying efforts to communicate to physicians utilizing a variety of strategies and methods. All research findings must be readily and easily accessible to physicians as well as the public without limits imposed by the federally supported CER entity. The highest priority should be placed on targeting healthcare professionals and their organizations to ensure rapid dissemination to those who develop diagnostic and treatment plans.

J. Coverage and Payment. The CER entity must not have a role in making or recommending coverage or payment decisions for payers.

K. Patient Variation and Physician Discretion. Physician discretion in the treatment of individual patients remains central to the practice of medicine. CER evidence cannot adequately address the wide array of patients with their unique clinical characteristics, co-morbidities and certain genetic characteristics. In addition, patient autonomy and choice may play a significant role in both CER findings and diagnostic/treatment planning in the clinical setting. As a result, sufficient information should be made available on the limitations and exceptions of CER studies so that physicians who are making individualized treatment plans will be able to differentiate patients to whom the study findings apply from those for whom the study is not representative. (CMS Rep. 5, I-08)