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Better Outcomes, Better Systems, Better Education

Nov. 10, 2012

2012 Interim Meeting
Honolulu, Hawaii

Jeremy A. Lazarus, MD
American Medical Association

Mister Speaker, members of the Board of Trustees, delegates, friends:

My thanks to this House. In these last eventful months, our partnerships and cooperation have never been more crucial. Or more welcome.

At my inauguration, I promised to run and not grow weary.

Since then, I’ve spoken to more than 30 state, county, ethnic and international medical organizations, from Alaska to Florida – California to New York – New Orleans to Minnesota – the Northwest Territories of Canada to Montreal – Bangkok, Thailand to Bournemouth, England.

The word “run” has new meaning for me.  And I mean “run” literally. More than once, Debbie and I heard the final boarding call even as we were racing past the Starbucks and the gift shops to the gate.

And at least once we found ourselves on the wrong plane to the wrong country, with a crew that didn’t speak English.

That flight nearly ended with us attempting a personal record for a free fall through the atmosphere.

I can say that – while my feet might be a bit sore – my sneakers are still tied, I’m still on the course and we’re making progress – together – toward the finish line.

Throughout, I’ve been witness to the ongoing evolution of health system reform. Some of it historic.

In June, the Supreme Court voted 5-4 to uphold the individual responsibility to obtain health insurance.

It means millions will get the coverage they need to get healthy and stay that way – and take a stake in the system.

Yet the AMA has noted time and again that the Affordable Care Act was just a first step toward reform.

Some physicians said we went too far in support of the ACA. Others, not far enough.

Fair enough. Two diametrically opposed views – but contained within, a common ground the AMA is big enough to embrace.

And strong enough to advance.

So let me tell you some exciting news of what we’ve accomplished.

We persuaded CMS to revise its ACO rules, so that relevant quality measures are used, and financial risks reduced.

We secured physician representation on insurance exchanges, and that health plans comply with state scope of practice laws.  On this, we’ve got your back.

The AMA won a delay in the implementation of ICD-10 – needed relief from competing Medicare incentive and penalty deadlines.

We eliminated unrealistic lab test order requirements, got multiple extensions on E-prescribing penalties, and protection from unreasonable audits.

Working with state societies, the AMA achieved more than 100 legislative victories in 2011-12  – on Truth-in-Advertising, preserving existing medical liability reforms and protecting the patient-physician relationship.

We’ve got your back.

With 10 other specialty socieites, the AMA is working to help overturn a Florida law that prohibits physicians from asking patients and families about guns in their home and from noting a patient's gun ownership in the medical record.

Lawmakers cannot insert the state into the patient-physician relationship by dictating, prohibiting or threatening the open communication between patient and physician.

It’s shown that patients who get physician counseling on firearm safety were more likely to adopt one or more safe gun-storage practices. We want to reduce firearm-related accidents and suicides.

And last month, the Litigation Center joined the Medical Association of Georgia to fight an insurance industry push to overturn state law that requires physician bills be paid on time.

It has national implications for holding third-party administrators accountable for late payments.

The AMA has also joined 25 other organizations to urge the Supreme Court to maintain race as a factor in medical school admissions.

The AMA and others don’t want to limit opportunities for minorities who want to enter medicine, which could limit care for an increasingly diverse population.

So, you see in all these ways, for students, independent physicians, or those in a group, or those employed – we’ve got your back. The AMA will continue to fight for you.

So will I.

And of course, we’d like even more physicians to fight for – and with.  The good news:  membership is up in all dues-paying segments – so please continue to help us bring more doctors into the fold.

It makes us even more effective in shaping the rules for our evolving health system.

For example, the AMA’s Payment and Delivery Reform Leadership Group is ensuring physicians have what they need to go forward.

I’m especially proud of the AMA-convened Innovators Committee, 12 physicians from across the federation, on the front lines.

In June, they went to the White House to discuss payment and delivery models and the administrative burdens that hamper participation. Giving voice to physicians. And watching your back.

The AMA has also taken our case to Congress.

In September I joined a Senate roundtable on the Sunshine Act provisions of the ACA, to voice AMA support for increased transparency.

And to caution that physicians need to review their information and challenge errors.

We don’t need witch hunts against innocent physicians based on inaccurate reports.

Such testimony is crucial to making sure the powers that be hear physician concerns loud and clear.

We’re proud of these victories. We also know the work ahead.

To confront what conflicts with our interests.

Like the Independent Payment Advisory Board, which should be scrapped outright.

And to raise urgent issues that weren’t addressed – like the flawed, costly medical liability system.

The ability to contract privately with Medicare patients, as outlined in the Medicare Patient Empowerment Act.

And the broken Medicare physician payment formula.

Last month, the AMA and 110 state and specialty societies fired a joint letter to Congressional leaders demanding a fix to the broken SGR.

It was a unified message only the AMA could deliver – and because of that unity, it got the attention of Congress and the White House.

We told them delivery reform is needed to offer patient choice and options.

That Medicare must support the infrastructure – that reform demands.

And that payment reflect the costs of providing services as well as progress on quality and cost.

The power behind the message was clear – the AMA, state societies and specialties, working together in the interests of our patients and profession. 

When I spoke in June, we were on the eve of a global event that brings the world closer – the Olympics.

And now, we’re just past a national election. It was contentious – again – and again demonstrated a deep national divide.

For our part, the AMA will continue its work with the White House and the new Congress to implement health system reform and defend the interests of physicians and patients. In the last four years we’ve built key relationships to help us continue our progress.

In the wake of elections, throughout our history, we’ve hoped the better angels of our nature would set aside what is partisan, ideological or just plain self-interested – and come together to act in the best interests of the people.

And while we as a people sometimes fall short of this civic optimism – and fall prey to cynicism – the goal is still worthy.

We saw that in the days before the election – when Superstorm Sandy battered the Jersey Shore and New York City.

In its wake were loss of life, destruction of property, thousands without homes – and an estimated 50 billion dollars in damage.

But instead of finger-pointing and blame, second-guessing and shame, we saw federal, state and local authorities working together, along with  non-profit aid groups like the Red Cross.

Joined by those who helped rescue and protect the victims, and who restored power and communications.

Working together – to ease the pain of a shared catastrophe. And start a return to normalcy.

For years, the AMA has urged America’s physicians to speak with one voice – that together we are stronger – and that we help doctors help patients

But to turn words into deeds takes a certain strength in ourselves– to give just a bit more – to push ourselves just a bit further.

To confront and overcome the crucial issues at hand, it is to us as physicians to pursue less fragmentation, and cultivate more cooperation.

To move from divisiveness  to diplomacy, from conflict to collaboration, from the narrow self interest of personal gain to the national interest of mutual goals.

Now, I’ve seen firsthand how many of you who have disagreed with AMA actions are also those who work the hardest to bring new members into the AMA family.  And I thank you for that.

I understand full well the conflicts we face.  As leaders in state and specialty societies, we advance the priorities of those organizations.

But when we meet at the AMA, it may be difficult to step back from those  priorities.

So today I ask your help. In these pivotal months ahead, I ask all of you to take a long look at the bigger picture.

Let’s follow the rules this House reaffirmed today – to look first at what is best for the physicians and patients of this nation.

And to be ambassadors for the AMA to our states and specialties.

Be part of a community – with your neighbors, your patients and as a team with your colleagues.

Big aspirations – big goals.  But the AMA can help make them happen.

Working through the democratic process of this House of Delegates, we enact policies that affect the entire health care system and every patient.

With our partners, we work to implement through the Board what this body has decided.

This unity of purpose makes us a powerful force.

As such, we need to be mindful of the impact on our credibility and our future if we don’t all pull in the same direction once a policy is accepted. 

There are acts of principle – which are debated in this House of Delegates – and then there are acts of sabotage – outside this House of Delegates.

I know I’m speaking here of ideals. Noble, worthy of pursuit, perfect when they synchronize with achievement – but difficult to fulfill for new physicians who leave med school 160,000 dollars in debt.

Or for those encountering unavoidable conflicts among specialties, states, cultures, ideology and geography.

But between ideals and reality are the immutable principles of our ethics. 

To listen to our heart and be driven by science – and not the latest fad or the biggest pile of cash. Knowing in our heart that a medical school diploma is not a treasure map.

It seems to me the stars have aligned in such a way that our loftiest aspirations are exactly what’s needed now to transform our health care system.

And to embrace a new set of core values – ones better suited to integrated care.

For years, physicians have cherished autonomy.

The physician Atul Gawende put it this way:

 “The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves.”

But this was before the red tape of big insurance – and big government.

Before physician shortages, aging populations, and chronic conditions.

And before we had 6,000 drugs and 4,000 clinical procedures at our disposal.

It once made sense for physicians to value autonomy, independence, and self-sufficiency. But the game has changed.

Integrated care asks us to cultivate mutual trust. To recognize that each team member offers unique skills and knowledge. To support this trust with open and timely communication.

It requires us to recognize that the general practitioner has different skills to offer the Alzheimer’s patient than the neurologist.

Or the psychiatrist who treats their depression. Or the caregiver who administers their medications. But all have something to offer.

And finally, we must go all-in to improve the quality of health care for our patients and the country.

That means collecting, sharing, and analyzing data, leveraged to care for patients.

And while team-based care is just one aspect of our medical world, it’s a big one – and its evolution depends on how well it keeps patients healthy, and how well it functions for physician members.

For that reason, I’m pleased that a new Integrated Physician Practice Section is joining the House of Delegates, which will address issues facing physicians in group and integrated practices.

Of course, during my travels on behalf of the AMA, I’ve met physicians who resist this concept of collaborative care.

Perhaps they are trying to ride out a wave they fear will become a tsunami, or believe that these changes hamper their ability to think, create or do good by patients.

I understand their concerns.

In fact, if their approach can match the quality goals of these new, evolving systems – I support what they are doing. The AMA does not subscribe to one-size-fits-all solutions – and welcomes all ideas.

Nonetheless, for most physicians, these new systems can bring better results.

A great example is the Southcentral Foundation in Anchorage, which I learned about firsthand when addressing the Association of American Indian Physicians in August.

Run by and for Alaska Natives, they’ve earned national attention for reducing health disparities and improving outcomes.

      Patients are assigned to a health care team – say, a physician, a nurse, medical assistants, even traditional healers.

      In the last decade, Southcentral Foundation has seen a decrease of 40 percent in ER visits, 75 percent in hospitalizations, and 30 percent in routine doctor visits.

      And they’ve made inroads in curbing disparities. Today, binge drinking, strokes, heart disease and cancer rates for natives are about the national average, a major victory for the demographic.

      And in August, I saw another example at the University of Florida.

      My host was David Paulus, MD, an AMA member and member of this House, who works at the university’s academic health center. 

      I thought I was in pretty good shape, but chasing Dave around campus is an extreme workout in and of itself.

      On rounds, I watched him administer anesthesia to a patient. The scene was buzzing with activity.

      A team of professionals working together, from the nurses to the staff operating sophisticated technology. In all, I counted eight people assisting in the patient’s care.

      All under physician leadership, each executing their roles according to their training, experience and licensure. Each crucial to treating this patient.   

Our ethical imperative requires us take on even bigger challenges, however.

We need to have a difficult but necessary conversation with the public and our leaders about the tough choices ahead.

In June, the AMA passed ethics policy that calls on physicians to be  stewards of the resources society entrusts to us. To follow policies on issues such as:

Cost versus value. End of life care. The responsibility of patients to own  their own health. The need for more public health investment.  The very unsustainability of the system itself – absent fundamental change.

The fact is, a big chunk of health care – as much as 30 percent – is redundant or unnecessary.

As we try to reign-in costs, physicians can be part of the solution.  At the same time, we can’t do it alone.

Patients need to guard their own health. Eat better, don’t smoke, or drink to excess – hit the gym or walk around the block. Be positive. Take medications as ordered. Follow-up with their doctor.

And we need to remind elected officials and policy makers that even the most skilled physician can’t cure social determinants of health like poverty, unemployment, and limited or no access to transportation, exercise resources or healthy food.

To consider this when taking actions that affect physicians, and to do their fair share in building a better, more equitable system.

And it’s for us to consider as we work together towards achieving the AMA’s new strategic plan and realizing the mission of the AMA.

As you know, we’re shifting focus to three areas critical to our health care future, which must take shape through physician leadership:

One: Improve patients’ health outcomes and reduce costs

Two: Accelerate change in medical education to align physician training and education with the evolving health care system; and

Three: Enhance professional satisfaction and practice sustainability by helping physicians adopt delivery and payment models that make sense for their practices.

These are big, ambitious goals, and Dr. Madara will share the details with you.

But they build on the AMA legacy of guiding physician professionalism, setting standards for medical education, and advancing medical science.

They articulate the policies of this House of Delegates, and define the AMA’s role in shaping 21st century health care.

I support it. The Board of Trustees supports it. Now we need you – to help achieve it.

This strategic plan re-affirms the AMA as the spearhead to help physicians succeed in health care’s brave new world dawning.

And it means a better and healthier future – not just for patients and physicians, but for the country as a whole.

When I spoke to you in June, I mentioned a passion beyond medicine, and that is competing in triathlons.

I’ve competed in 13 to date, and my favorite is the one on the big island of Hawaii.

Competitors come from around the world, and the buzz at the start is contagious. Everyone races into the water, a crowd cheering you on.

Once out of the water and onto the bicycle, you still feel pretty good after those first 10 or 20 miles. But by the time you get to mile 30, it’s not the same as when you began.

You’re biking through lava fields. The temperature has shot up to 100 degrees. Crowds have dwindled.  A sharp uphill turn at the midway point forces you to lean into the pedals with everything you’ve got.

At the same time, the wind is blasting you with all it’s got. And the thing about the wind – it doesn’t get winded.

At mile 40 you wonder why you’re not going faster. Was there a hole in your training?

By mile 50 you realize that when you signed up for this event,  the hole was apparently in your head.

Still, you push on. You focus on getting to the summit. And coming back down.

Finally, you get there. You turn around.  And you’re greeted by a blast of wind in your face.  In my experience, the wind in Kona is always blowing in your face.

And as bad as it’s been, the return trip is worse.

By mile 112 of the bike ride you’re exhausted.  But still you start the marathon. Your legs are jelly. The jokes are over. You contemplate quitting. Head for the beach and a drink with a tiny umbrella.

But then, suddenly, you’re transformed.

You spot a mile marker and realize you’re near the next rest station. So you focus all your energy on this one small goal, nothing more.

Get there, drink some fluids, take a breather, and discover you have enough energy to push for the next one.

When things really get bad, you seek other options. Slow down and walk. Talk to the other athletes. Commiserate. Encourage one another. And before you know it, you’re running again.

And when you cross that finish line, it’s an experience like no other.

To me, in so many ways, competitions like this remind me so much of the long path to health system reform – and the AMA’s response.

It’s a long, sometimes torturous process. But the pride in accomplishment – pushing ourselves past our limits in pursuit of a worthy goal – to overcome terrain, conditions and our own fears and discomfort…

It adds up to a victory that goes beyond the personal into something greater than ourselves. Shared with our patients, our profession and this nation.

I’ve talked today about how the AMA has your back, what we’ve accomplished, and how our destiny is on track to re-shape healthcare.

Now, I ask for your help. To have the AMA’s back in this effort. To support our new strategic plan, and help it fulfill its bright promise to improve our health care system for physicians and patients.

To put the AMA out front of the inevitable and necessary transformations wrought by a new century.

It’s said that there is a moment in every race where you reach a decision – to either quit, or ease up, or tell yourself “I can do this.”

Well -- We can do this. We trained all of our adult lives to be the best physicians we can be. 

We can launch into this work before us – and be on the course, for our patients and ourselves. 

It has always been within each one of us to exceed even our own expectations.  That’s what persistence teaches us.

It’s a definition of dedication, and that’s why – as members of America’s premier medical association – each one of you will cross the finish line and feel the joy of the great thing you have accomplished. Together. Thank you.