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Address to the House of Delegates

AMA 2013 Interim Meeting
Gaylord National Resort and Convention Center
National Harbor, Maryland
Saturday, November 16, 2013

Ardis D. Hoven, MD
American Medical Association

Mister Speaker, members of the Board of Trustees, delegates, friends. It is an honor to address you today.

Five months ago I spoke to you about the importance of leadership. Of collaborating, innovating and coming together to drive productive change. I'm happy to say that since then, I have seen countless examples of just such leadership.

I have seen collaboration between the AMA and state and specialty societies yield more than 85 legislative victories. I have seen medical students lead a campaign to save GME – meeting with more than 40 legislators and sending more than 7,000 letters to Congress.

 I have seen significant progress on medical liability reform in states like Florida, Oklahoma and Pennsylvania. I have seen national advocacy efforts yield more than 200 cosponsors for a bill to repeal IPAB. I have seen Maine become the fourth state to enact AMA truth-in-advertising legislation this year alone.

I have seen more than 50 state and specialty medical societies collaborate with the AMA to confront prescription drug abuse – to advocate for a nuanced approach that includes public health, incentives to promote awareness, point-of-care decision support for physicians, addiction treatment, and enforcement.

I have seen membership in the AMA increase.  For the third year in a row.

I have seen our AMA Litigation Center engage in seven cases this year that were argued before – and decided by – the US Supreme Court. Proof that the AMA is not only fighting for physicians – but doing so at the very highest levels.

I have seen the AMA strategic plan begin to take shape, from the innovative proposals unveiled at the first meeting of the medical education consortium…

To novel partnerships that will help improve outcomes for Type 2 diabetes and cardiovascular disease… To a Rand report that provides the statistical backing we need to convince Congress of something you and I already know…

Clumsy EMR technology…rigid quotas…and a sea of regulations don't help us serve patients – they get in the way of serving patients. In short, I have seen that when America's physicians stand together -- united in vision and commitment – we can shape the health care system this country needs. 

Now while these victories have inspired me, in the past five months I have also seen some disturbing developments in the halls of government.

I have seen an attempt to help uninsured individuals enroll in affordable, competitive health care become thwarted by a flawed federal website. And I have seen ongoing division over the Affordable Care Act lead to the unthinkable . . . a full-blown government shutdown.

In my mind, these missteps are examples of what happens when people fail to communicate. When two opposing sides get so caught up in being "right" that productive conversation becomes impossible.

The point I want to make today is that productive conversation is always possible. And it's not just possible, but incredibly necessary.  In fact, over the next few days I hope to hear a great deal of it. And I encourage it. Because today we've arrived at a crossroads on a familiar issue…

An issue that has consumed innumerable hours and even more dollars over the past decade: the broken Medicare system.

As I'm sure you're aware, right now a discussion draft is circulating in Congress that would repeal the irrational Sustainable Growth Rate formula once and for all.

No more annual threats. No more patches. No more Sword of Damocles dangling over our heads.

At first glance, it seems like a cause for celebration.

But let us not be so hasty. Because as with almost everything on Capitol Hill these days, the proposal before us is a mixed bag

I'm not going to sugar coat it. There are things I really don't like about the proposal – chief among them, the idea of a 10-year payment freeze.

I don't need to explain to anyone in this room why freezing Medicare payment where it is right now – a full 20 percent below the actual costs of providing care – just doesn't make sense.

It makes you want to throw up your hands and scream.

But after my emotions settled I took a long, reasoned look at the options before us. And I realized that walking away right now would be a colossal mistake.

Now, more than ever, America's physicians need to maintain the pressure. And here are five reasons why.

Number one.  We must all recognize that this is a draft document.

It is not legislative language. And it is not written in stone. To walk away now, before we know what modifications may be made, and before we have seen the final details, would be ill-advised.

I understand the urge to put a stake in the ground. But if we walk away at this critical time, decisions about the future of Medicare will be made without us.

Decisions that impact our livelihoods…decisions that impact the future of health care delivery…decisions that impact the welfare of our patients.  That's not an option.

Right now we have an opportunity to negotiate. Right now we have an opportunity to advocate for the elements we like, and change the elements we don't. And that's why we need to keep pushing.

Number two: the support for this draft is not only bicameral, but bi-partisan.

Think about that for a moment. We're talking about a Congress that actually closed its doors – for 16 days – rather than sit down and reach a compromise.

The fact that this Congress has come to agree on anything – let alone something as important as SGR repeal – is itself an incredible accomplishment. Proof of the widespread recognition that SGR has to go.

Unlike passage of the Affordable Care Act, which split conspicuously along party lines, SGR repeal enjoys support from Republicans and Democrats alike. In the House, and in the Senate.

The desire is there. The timing is right. And that's why we need to keep pushing.

Number three. By Congressional standards, SGR repeal is "on sale" right now.

At this time last year, the cost for repeal was projected at $297 billion. Today, it's $138 billion.  That's a savings of more than fifty percent.

We may never see a number like this again. We may never get this opportunity again. And that's why we need to keep pushing.

Number four. The status quo, as dysfunctional as it may be, is itself under threat. What do I mean by that? For a number of years, the status quo has gone something like this…

The SGR formula mandates a 20 – 30 percent cut. Physicians and patients express outrage. Congress institutes a temporary patch. And on occasion – when we're lucky – we might get an update. Half a percent here…one percent there.

It's less than ideal, but when you consider the prospect of a 10-year freeze, suddenly a 1 or 2 percent increase starts to look pretty good. Right?

Well I hate to say it, but after countless meetings on Capitol Hill I've come to realize that the status quo may not be around much longer.

Today, many rank-and-file members of Congress and their staffs are questioning why physician cuts have been off the table in budget discussions. And they're hearing a chorus of calls from other health care providers that physicians should bear the pain of absorbing the cost of a temporary SGR patch.

The fact is, today a one-year SGR patch costs $18 billion dollars. Given the current fiscal environment, there's a real possibility that next time the cut comes around, Congress will choose to save the $18 billion – and replace it with a cut for physicians.

That's the reality of the situation. It is ugly. And that's why we need to keep pushing.

Lastly. Most importantly. We cannot forget the chaos SGR has created for physicians and our patients over the past decade.

We cannot forget the five patches in 2010 alone.  How physicians had to take out bridge loans to keep their practices afloat. How practices had to let employees go. How physicians had to stop taking new Medicare patients.

And how some patients were forced to delay critical procedures.

Walking away from the single greatest opportunity we've had to remove this scourge once and for all… walking away before we even have legislative language before us…would be a colossal mistake.

And that's why we need to keep pushing – until we push through.

In my experience, meaningful change – truly groundbreaking change – does not come overnight. As much as we wish it were otherwise, change takes time.

Five months ago I told you a bit about my experiences treating patients in the early days of the AIDS epidemic.

One of my patients during those days was a talented young photographer named John Kelly Cooper.

Well one day he came to the office and gave me a framed photo he'd taken. In the center was a wine glass full of pills. Behind them, forming a semi-circle, was a sea of bottles. At least 15, maybe 20. And to the right there was an IV bag – a vital part of treatment back then.

The title of the photo was: "my daily dose."

During the early days of the AIDS epidemic, this depressing picture was simply the best we could do. Our patients' immune systems were so compromised that their bodies had become fertile ground for a host of diseases – lung infections, meningitis, brain malignancies. The best we could do was tackle the symptoms. Try to bring down that 105 degree fever. Try to stop the patient from shivering. Try different combinations of antibiotics and hope one would work.

We made the most of what we had on hand. Sometimes it helped relieve the patient's pain. Sometimes it did not. At that time, the concept of a cure for HIV didn't even seem within the realm of possibility.

Five or six years later, researchers had not only begun to understand the disease, but also develop a host of drugs that could help slow it down. Zerit. Crixivan.

Unfortunately, these medications came with horrible side effects. Kidney stones, pancreatitis. Some even caused a patient's fat cells to redistribute, so patients developed humps on their necks, or distended abdomens.

We were making progress, but it was slow-going, and it wasn't without a price.

It wasn't until the ‘90s that things really started to get better. Not just the medications, but also our understanding of how to prevent complications from developing. Our patients began to not only live longer, but also live better.

And today – today I tell my patients that the biggest threat to their health isn't necessarily HIV, but the poor habits so many of us in this country are battling – poor diet, lack of exercise, smoking.

Today, instead of taking 15 or 20 medications like John Kelly Cooper did, my HIV patients can take just 3 medicines – bundled into one pill. With minimal side effects.

When I look back at the progress we've made toward treating HIV I'm struck by just how long the journey has been. Some 30 years and counting.

Sometimes the resources on hand were woefully insufficient. But we seized on every improvement as it emerged. We took it one step at a time, always with our eye on the long-term goal – a cure. Needless to say, we haven't gotten there yet. But that doesn't make our end goal any less important. And we're a lot closer today than we were 30 years ago.

So what is our goal for health care in this country today? When it comes down to it, what do we ultimately want?

We want America's physicians to be able to do what we do best – serve America's patients. We want to serve young and old. We want to serve rich and poor. We want to provide them with the highest level of care possible, regardless of whether they have insurance.

We want the ability to treat patients when and where it counts. In the office, before that lump in a woman's breast has turned into untreatable cancer. Instead of in the nation's emergency departments, when it is too late.

We want people with chronic conditions to get the care they need. Better yet, we want to help them prevent those conditions from developing in the first place.

We want more autonomy. Less bureaucracy. More time with the patient. Less hassles getting in our way. In short, we want to do the job we went to medical school for.

We want to cure. We want to comfort. We want to save lives. And if there's one thing we don't want… It's the prospect of a 24 percent cut, threatening our ability to do that job.

Threatening care for the nation's seniors. Threatening care for the nation's disabled. And threatening care for the nation's veterans.

Colleagues, a few weeks ago I had the pleasure of attending the meeting of the Pennsylvania Medical Society. During an afternoon with a few hours to spare, I was able to visit the National Civil War museum in Harrisburg.

I don't think any of us who never fought in battle can really comprehend the trauma of war. But having walked through that museum and seen the personal accounts – from the manuscripts to the photos to the personal effects of the many men and women who died – I now view the war in a different light. I am now keenly aware of the human cost that went into forging this great nation.

I also view those 272 words Abraham Lincoln delivered in Gettysburg in a different light. Words delivered on a battlefield where more than 50,000 people lost life or limb.  

On a gloomy day in 1863, Lincoln stepped up to the podium at the dedication of National Soldier's Cemetery and said:

"(T)hat we here highly resolve that these dead shall not have died in vain… that this nation, under God, shall have a new birth of freedom… and that government of the people… by the people… for the people… shall not perish from the earth."

Lincoln delivered those words in the face of uncertainty. He could not know that the Civil War would rage for another 18 months. He could not know about the challenges of Reconstruction. He could not know the ultimate fate of the nation nor the triumphs it would achieve in the years ahead. That the United States would not just survive, but become a world superpower. Those were the victories that awaited. But they did not come easily. And they did not come quickly.

Why am I telling you this?

Because two days from now, we will celebrate the 150th anniversary of the Gettysburg address. And two days from now, many of us will find ourselves on Capitol Hill, exercising our rights as Americans.

So as we meet with our elected officials let's draw some inspiration from one of our greatest presidents.

Let's be vigilant. Let's hold on to our vision for a better future. And let's remember our long-term goal: To do right by America's physicians. And above all… to do right by America's patients. Thank you.

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AMA President Ardis Dee Hoven, MD