Highlights of AMA’s Annual Meeting

Highlights:

• Tort Reform
• Medicare Payment Reform
• Access to Care / Health System Reform
• Palliative Care and End-of-Life Care
• Modes of Participation in Medicare and Their Impact on the Patient, the
• Direct-to-Consumer Advertising of Prescription Drugs
• Addressing Inadequate Influenza Vaccine Supply and Distribution
• Centers of Excellence Designation
• Pending Litigation Regarding Medical Errors

Our American Medical Association House of Delegates met last month from June 10 through June 14. A key highlight was the installation of Los Angeles cardiovascular surgeon and CMA Past President William Plested, MD, as the new AMA president.

As per both the custom and intent of meetings such as this, there were discussions, debates, and decisions surrounding literally hundreds of specific policy issues. But before elaborating on any of those, it is useful to be reminded of what AMA is already doing in advocacy — because of existing policy — relative to two key issues.

Tort Reform

With approximately 20 states still in crisis, this remains a top-tier issue for medicine that need not be debated. For years there has been a political impasse, with the House of Representatives passing legislation that was MICRA and much more, extending significant protections to multibillion-dollar corporate entities such as health plans and pharmaceutical companies, while the Senate was routinely filibustering if not flat-out defeating comparable legislation.

The new wrinkle is that at the behest of CMA, AMA, and others, the U.S. Senate is finally considering legislation (S.22) that is “provider-only,” as in it only applies to physicians, hospitals, clinics, and the like, not Aetna or Merck. This is obviously a good thing from a policy perspective, but so far it has not brought any Democratic senators on board. The current political environment just makes it all but impossible to get what would need to be a sizable number of Democratic senators (9–12) to step up and support a top priority of President Bush.

As an aside, it is worth noting that S.22 also uses a different “cap” model than the classic $250,000 MICRA cap on non-economic damages. Instead, it uses the $750,000 “stacked cap” model recently passed by voters in Texas, wherein the physicians in a medical malpractice case would still have non-economic damages capped at $250,000, but there would be a separate $250,000 cap for hospitals, and a third $250,000 for a possible third healthcare entity (clinic, nursing home, etc.). If passed, this would actually represent a setback from our MICRA standard, but it would be a godsend in at least 20 other states.

Finally, AMA continues to be a leader in evaluating alternatives to the tort system, including various forms of arbitration, mediation, and specialized medical courts.

Medicare Payment Reform

This is as big an issue as it was when I wrote about it in the July 2005 issue of San Diego Physician (“Will the Last Physician in San Diego County Accepting Medicare Patients Please Turn Out the Light?”).

Again, there is no need for any “new” policy here. The failed Sustainable Growth Rate (SGR) formula must be scrapped, a new formula that honestly accounts for escalating costs of practice must be developed, and a new and enhanced mechanism of funding Medicare must be approved before most of the baby boomers retire (hint: means-testing). The only problem is that the ten-year Congressional Budget Office cost estimates for these three recommendations are $150 billion, $100 billion, and $1 trillion respectively. And, if and when means-testing is proposed in a serious fashion, seniors will riot.

But despite all of these obstacles, for five years running, AMA and CMA have actually succeeded in convincing the powers-that-be in DC not to impose any of the cuts that physicians were in line to receive under the SGR. And the elimination of the SGR, high cost and all, may actually happen in the next year or two. It may not seem like much, but with the backdrop of a physician population that continues to provide ready access to care to Medicare patients in 2006 while being paid at 2000 rates, AMA’s accomplishments have been nothing less than Herculean.

Access to Care / Health System Reform

As to the meeting itself, the most important thing that happened related to a third key policy area: Access to Care / Health System Reform. This has been an area in which AMA has had keen interest but little real policy. And, frankly, in 2006, with healthcare costs continuing to escalate to the point where employers are dropping coverage for employees, dependents, and retirees, the various modest incentives supported by AMA to encourage people to become insured just won’t make enough of a difference. Some sort of mandate is necessary.

That all changed on June 13. After two years of study, prompted exclusively by CMA, AMA leadership recommended, and the AMA House of Delegates overwhelmingly passed, an individual mandate policy modeled almost exactly along the lines of a similar proposal adopted by the CMA BOT back in September 2004. The plan calls for a mandate to purchase insurance covering catastrophic as well as evidence-based preventive care. The mandate would apply without subsidy to upper income individuals and families earning > 500 percent of the Federal Poverty Line (about $48,000 for an individual and $95,000 for a family of four). And, as subsidies become available, the mandate would be applied to more and more people, eventually providing critical assistance to a clear majority of the uninsured.

Notably, this individual mandate proposal differs considerably from the one passed in Massachusetts, which mandates much more comprehensive policies, yet is supported by billions of dollars from prior pre-existing state taxation to support the uninsured.

The next step for AMA will now to be start working on legislation along the lines of their new policy. And once that happens, they will be much more appropriately positioned to engage in the access-to-care debate likely to occur during the upcoming 2008 presidential election season.

Other significant actions that occurred at the meeting included the following:

Palliative Care and End-of-Life Care

Adopted as amended an AMA Board Report asking that: (1) AMA establish policy that recognizes the importance of providing interdisciplinary palliative care as a means of relieving patients’ suffering and improving their quality of life; (2) the Council on Medical Education’s support of palliative medicine as a medical subspecialty recognized by the American Board of Medical Specialties be reaffirmed and that the inclusion of palliative medicine in the undergraduate and graduate curriculum be encouraged; (3) AMA encourage the training of physicians and allied health workers in palliative care and interdisciplinary care; (4) AMA encourage all physicians to become skilled in palliative medicine and familiar with coding for reimbursements of hospice and palliative care services; (5) AMA advocate for reimbursement of Evaluation and Management codes reflecting prolonged time spent on patient care beyond face-to-face encounters; (6) AMA promote research in the field of palliative medicine; (7) AMA continue efforts in developing CME activities on pain management and end-of-life care issues; and (8) AMA encourage physicians to be knowledgeable of patient eligibility criteria for hospice benefits and, realizing that prognostication is inexact, to make referrals based on their best clinical judgment. (Board of Trustees Report 5)

Modes of Participation in Medicare and Their Impact on the Patient, the Physician, and the U.S. Congress:

Adopted as amended the recommendations of Board of Trustees Report 16, with the remainder of the report filed. The report recommends that AMA: (1) continue to work to identify politically viable modifications to the statutory language on private contracting that will make opting out a more reasonable choice for practicing physicians; and (2) educate physicians on the different options for participating in the Medicare program and provide its members with the tools and information necessary to analyze the impact on their patients, their practice, and the U.S. Congress, of their choice of the three modes of relating to the Medicare program by:

• Opting out of Medicare, or
• Caring for Medicare patients in a fee-for-service relationship, making the decision to “accept assignment” on the basis of mutual needs of the patient and the physician, or
• Continuing as a “participating physician” in the Medicare program, understanding that the physician is subject to the continued anticipated reductions in direct reimbursement and the ultimate inability to directly negotiate any fees on behalf of their practice. This may give Congress the wrong impression that there is no problem with continued fee reductions. (BOT Report 16)

Direct-to-Consumer Advertising of Prescription Drugs:

Adopted a series of recommendations from the AMA Board, such that AMA will now consider acceptable only those product-specific DTC advertisements that satisfy an extensive series of guidelines. These guidelines relate to multiple aspects of accuracy and truth, as well as making clear that patients should not self-diagnose, but rather seek the counsel of their physician. They also call for enhanced FDA regulation of all DTC advertisements. (BOT Report 9)

Addressing Inadequate Influenza Vaccine Supply and Distribution:

Adopted a substitute resolution which calls for the AMA to: (1) work with the Centers for Disease Control and Prevention (CDC), appropriate medical specialty societies, and influenza immunization partners to ensure, in future influenza seasons, adequate influenza vaccine distribution and administration to the high-priority populations as recommended by the Advisory Committee on Immunization Practices (ACIP); (2) advocate vigorously that for every influenza season, an adequate number of doses of every manufacturer’s vaccine supply be sold directly to health care providers immunizing patients identified by the ACIP as being high priority for receiving influenza vaccine; (3) urge manufacturers and distributors of influenza vaccine to provide a dedicated ordering system for small- and medium-size medical practices to pre-order vaccine up to an appropriate volume threshold; (4) work with the CDC, through the National Influenza Vaccine Summit, to ensure compliance with the ACIP’s annual recommendations with respect to the immunization of patients prioritized to receive influenza vaccine; and (5) prepare a comprehensive report educating physicians on the complexities of influenza vaccine supply and distribution. (Res. 514)

Centers of Excellence Designation:

Adopted as amended a resolution asking AMA to: (1) work with appropriate organizations such as the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, America’s Health Insurance Plans, the American Hospital Association, and others to assure the development of quality-based criteria that must be met before a program can be designated a “Center of Excellence; and (2) inform and require from all health insurance carriers and companies, including CMS, that any designation of “Center of Excellence” status be based on quality outcomes and not to require that physician insurance participation be part of those requirements. (Res. 528)

Pending Litigation Regarding Medical Errors:

Referred for decision a resolution asking AMA to begin emergency negotiations with the Centers for Medicare and Medicaid Services, the U.S. Congress, and the Administration, to preserve patient access to hospitals, physicians, and other healthcare providers, in light of the pending litigation crisis precipitated by the Wilkes McHugh Law Firm’s recent filings in the U.S. District Court against hospitals with the Catholic Health Initiatives and Triad systems. (Res. 734)