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Shaping the Future of Health Care in America

James L. Madara, MD
Executive Vice President and CEO
American Medical Association

American Medical Association
Annual Meeting
Hyatt Regency, Chicago
June 15, 2013

Mister Speaker, Mister President, members of the Board, delegates, guests: Just a year ago, I outlined at this meeting a bold, ambitious long-range strategic plan.

Since then, I’ve had several opportunities to share our plan with physicians and health care leaders across the spectrum. The result:  the AMA has been uniformly praised for its boldness and vision.

As one distinguished leader put it, “Everyone needs to hear about this work, Jim. Spread yourself thin.” 

Just three weeks ago at the annual meeting of the Society of Surgeons of the Alimentary Tract. After outlining our plan, Chairs of Surgery from three different medical schools told me they were joining the AMA as soon as they returned home.

As you know our plan tracks to a large number of policies developed by the House and was also shaped by the work and reports of our Councils, Sections and Special Groups. This plan doesn’t tip-toe around the edges of what’s wrong; rather it aggressively addresses the core issues which ail us most. 

Our plan focuses on three vital strategic areas:

  • Improving health outcomes
  • Accelerating Change in Medical education
  • Enhancing physician satisfaction and practice sustainability

Progress now exists in each of these three areas, let me update you.

Improving Health Outcomes for Patients

First up, improving health outcomes for our patients. Two months ago, our President, Dr. Lazarus, announced the first two conditions targeted in this initiative: cardiovascular disease and Type 2 diabetes.

We all know how these two conditions devastate our country; affect both our nation’s finances and public health. But most of all, how they adversely affect our patients.    

Currently, more than 100 million people in the U.S. have diabetes or pre-diabetes.  As many as 1 in 3 adults could have diabetes by 2050 unless we do something.

Meanwhile, one in every three deaths in the US is attributed to cardiovascular disease. And almost 70 million Americans have high blood pressure, and this is the number one risk factor worldwide for both disability and death.

The combined cost of these diseases exceeds $500-billion each year. Or, put another way, $5 trillion over the next decade. Something has to be done.

As the sole physician organization whose reach and depth extends beyond our members and includes policy makers, thought leaders, universities, and community organizations, we must intervene. 

Here is what other physician leaders had to say following our public announcement at the National Summit on Health Disparities just a few weeks ago.

(Short clip of docs talking about important of AMA participation in this area)

So, you see what these physician leaders think about our work. They’re excited, enthusiastic, motivated – they want us to succeed.

We’re now establishing the partnerships needed to tackle the three major indicators for developing these conditions: high blood pressure, high blood glucose and high cholesterol.

Our initial efforts to combat cardiovascular disease centers on patients with hypertension, who have not been able to meet their blood pressure goal. Believe it or not, that comes to more than 30 million people.

We’ve now established multiple partnerships in this effort. Let me just give you a flavor of this. For example, we are partnering with the Armstrong Institute for Quality and Safety at Johns Hopkins.

Our combined goal is eliminating preventable harm due to these factors while achieving the best patient outcomes at the lowest cost. And how could we have a better focus than one with 30 million citizens at risk?

In the area of type 2 diabetes, our initial focus will be pre-diabetes – specifically, increasing referrals of patients at risk for diabetes, to evidence-based diabetes prevention programs.

To that end, we’ve already begun working with the YMCAs of the America. We’re entering pilots of clinical-community linkages with local Y’s that offer the diabetes prevention program in three of our major cities.

This relationship with the Y is a sign of our being out in the community, on the ground, not simply theoretical.  It is deemed so important that it is being funded by the CMS Innovation Center.  We are also connecting with societies of the federation around this work.

Participating Y’s will deliver this CDC-developed Program that preliminary studies show to effective in reducing the incidence of diabetes. Some of these affected people do not have links to physicians and this offers an opportunity to link these folks to our profession.

When we approached CDC officials to discuss our interest in working with the Y, they were excited.  Dr. Tom Frieden the Director of the CDC has personally conveyed his delight with the actions of the AMA and let me know our entry in this domain is exceedingly important to public health in his opinion.

This is the kind of broad-multiparty collaboration that is needed to get to our result – success in improving health outcomes. Just a flavor, much more to come.

Accelerating Medical Education

In the second of the three strategic focus areas, we will accelerate the pace of change in medical education. Most important, we must match the current education and training of our medical students, who are the future delegates of this House, to the environments in which they’ll practice.

A year ago, some questioned why the AMA felt compelled to drive change in medical education. I think some had forgotten the AMA’s historic contributions.

Last week I was scanning through a new textbook titled “Medical Neurobiology” by Peggy Mason. The second sentence of the Preface in her book began “In 1905, the AMA boldly recommended broad changes in medical education ….”

Peggy then went on to give examples of the changes we proposed that ultimately led to the Flexner Report. By the way, I sent Peggy a follow-up note to let her know her book was excellent and that she had me at that second sentence.

As Peggy recognized in her book – improving medical education was the AMA’s job at the beginning of the 20th Century – and it’s again our job here at the start of the 21st Century.

So what IS the work?  

Well, a clear gap has emerged between physician training and the day-to-day realities of our health care system.

Today medical education focuses primarily on the individual, yet physicians increasingly practice in teams. Today medical students get much of their clinical training through in-patient settings, yet for every person admitted to the hospital there are 300 out-patient visits.

Leaders of health care systems see need for educational improvements. Dr. Glenn Steele, CEO of Geisinger tells us that it can take up to 2 years to bring medical school grads up the level he feels they should be when they leave medical school. Physician leaders at Scott & White, Virginia Mason and Mayo say the same.

Here again, the AMA’s leadership will coalesce others eager to eliminate these gaps, and ensure medical school grads are prepared to meet the challenges of today’s health care system.

Underpinning this effort is an $11 million grant initiative. We invited the nation’s medical schools to submit proposals for enhancing education. We were blown away by the enthusiastic response: 82 percent of accredited US medical schools responded.

This tremendous response is a clear sign these schools had been considering structural change for some time, they simply needed someone to lift the gate and give support to make it happen.

We are lifting that gate and also providing support.  The AMA will make this happen   just as we did 100 years ago. 

Last night, at a great event held at the Chicago Cultural Center, the AMA announced the 11 schools selected to establish this ground-breaking consortium. Here are the schools that were selected.

(Recipient schools shown: Indiana University School of Medicine, Mayo Medical School, NYU School of Medicine, Oregon Health & Science University School of Medicine, Penn State College of Medicine, The Brody School of Medicine at East Carolina University, The Warren Alpert Medical School of Brown University, University of California, Davis School of Medicine; University of California, San Francisco School of Medicine; University of Michigan Medical School, and Vanderbilt University School of Medicine.)

While the AMA and these 11 schools will do the heavy lifting over the next five years, the lessons learned will be shared throughout the medical school community and we will once again be the root of a structural reformation of medical education in our country.

Enhancing Physician Satisfaction and Practice Sustainability

The third strategic focus area is a most critical one – our ambitious plan to create a better health care system for the country. And to do so with the underlying assumption that a better health system will only emerge if the critical providers – the physicians – have a more satisfying and sustainable practice environment.

Thus, we will identify, support and disseminate the models of care delivery and payment that promote the long-term sustainability of -- and satisfaction with -- medical practice.

Now, when we first announced our intention to focus on physician satisfaction and practice sustainability, we heard concerns from outside this body that perhaps ­­we were being a little self-serving. That it wouldn’t resonate with anyone other than physicians.

I was told by two leaders in other sectors that “no one cares if physicians are satisfied.”

This I found shocking.

I asked whether they thought physicians were important in health care delivery.  They said “of course, physicians are central.”

I asked if they measured and cared about patient satisfaction, the answer was “yes.”

I asked if they cared about nursing satisfaction, the answer was “yes.”

I asked if they worried about the satisfaction of non-physician staff….again “yes.”

I asked that, since they thought physicians were central to health care and since they thought the satisfaction of all other non-physician people in the system was critical, didn’t they think they had missed something in logic? 

The answer that came back was, thankfully, but slowly: yes. But, coupled with the comment that there were insufficient data to demonstrate in a variety of working environments how to satisfy physicians.

It is not self-serving to say physician satisfaction is important.  It is self-evident to say so;   and anyone who denies this is simply being foolish. Physician satisfaction does matter.

A preliminary study by Rand reveals that patients of satisfied physicians better adhere to their care recommendations.

Another Harvard Study of over 16,000 practicing U.S physicians found that dissatisfied physicians were 2-3 times more likely to leave medical practice than their more satisfied colleagues.

This is not what we need in the face of 30-million newly insured patients seeking care in this coming year.

As I mentioned, healthcare executives will often eventually confide that satisfied physicians would be good for patients and good for healthcare. But they just don’t know how to get there.

What healthcare systems need – and what physicians yearn for – are proven strategies that can enhance physician satisfaction, while improving patient outcomes across practice settings.

Here again, the AMA’s leadership on this critical issue is not only needed, it is our responsibility to you . . . to every physician . . . to our patients and to the health care system overall. 

We have now partnered with Rand to conduct in-depth research on 30 diverse physician practices in six states which were selected in collaboration with state medical societies.  

Yesterday, those of you who attended the inaugural IPPS meeting heard some of the early indicators emerging from this work.

As this work is completed and its findings published later this year, we will begin to create tools and resources you can use to improve these critical indicators of physician satisfaction and practice sustainability

We will promote successful models, and these models are emerging, in both the public and private sectors.

And we will work with hospitals and health plans to fight and shape government policy and legislation that enables these models.

In short, we will do everything in our power to restore joy in medicine; to ensure that every physician, in every practice environment, can thrive in our evolving health care system. 

We will provide the data, analytics and tools; and repeat this process cycle-by-cycle for sequential improvement. Boot strap to a more satisfying and sustainable environment for practice.

In concluding let me say that, at our Interim Meeting last November, I acknowledged that advancing these three strategic areas will be a challenge. In fact, I referred to them as our “AMA moonshots.” Because that is exactly what they are: highly aspirational, unapologetically bold, and fully worthy of our attention.

The AMA, through all the work you do here in this proud body, has a long and distinguished history of tackling this country’s most difficult health-related challenges.

Just two examples: We did it in the 1800s by establishing the first code of medical ethics; we chased the then wide-spread quackery out of our nation.

And we did it when JAMA published statements from tobacco companies’ own files, proving they had known the dangers of smoking for more than 30 years;  thus forcing that industry to own up to the health problems created by the products it sold. 

But despite all we have accomplished, there are those who still doubt our physician resolve.

Teddy Roosevelt – a president of great resolve – had this to say about naysayers in his famous 1910 “man in the arena” speech.

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena. Whose face is marred by dust and sweat and blood. Who errs. Who comes up short again and again – because there is not effort without error and shortcoming. But who does actually strive to do the deeds.”

You are the men and women in the arena. You stand at the pro and con microphones here in this House and fiercely defend your points of view.

You, representing more than 185 medical societies – from every state, specialty and practice setting – bare the dust and sweat of lending your voices and your insights in shaping medicine’s future.

You vote on policy and you emerge as one, a single House united behind shared positions.

You give AMA’s voice. Power in communities across the nation and in our nation’s capital.

You, along with our members across the country, our Advocacy efforts, the practice tools we offer, and the research and education we provide – the five components that comprise the AMA Equation – give us the resolve to continue to lead, now into our 166th year.

And now, through this strategic plan, you will once again move our mission forward: to promote the art and science of medicine and the betterment of public health.

This mission – our mission – is compelling and the path to achieving it is clear.

Our work is not easy, but I am confident America’s physicians are up to the challenge. The AMA is right where it should be – right where it must be. We have – once again – entered the arena.  Thank you.


James L. Madara, MD, CEO and EVP