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Progress, Partnerships and Promise

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

American Medical Association
Interim Meeting
National Harbor, Maryland
November 16, 2013

Mister Speaker, Madam President, members of the Board, delegates, guests: It's been just five months since we last gathered; but I'm delighted to report substantial progress in our work to improve outcomes for America's physicians, patients, and medical students.

This whirlwind of activity can be summed up in three words: progress, partnerships and promise.

But before an update, let me offer both a question and a confession.

My question: Have you hugged an AMA member lately?

My confession?

I did. About three months ago.

I'll explain.

Last summer, I met with the leadership of the Heart, Lung and Blood Institute on the NIH campus. They wanted to hear about our improving health outcomes initiative.

I outlined the AMA's Strategic Plan emphasizing potential intersections of our work with theirs.  One of the most senior NIH officials in the room who had been sitting quietly, suddenly spoke up, saying:  "Excuse me. I don't mean to interrupt, but I just have to say I've never thought of the AMA quite like this. I've never been a member, but I going to join today right after this meeting."

Well, I was a little caught off guard and found myself spontaneously getting up, walking across the room and giving the guy a great, big hug. A technique I learned from our former President – Peter Carmel.

Everyone in the room thought the hug was hilarious.  And while it was a funny moment – I meant it.  It is heartening that our ambitious work strikes a chord with such respected senior thought leaders.

This new-found appreciation for the AMA is not an isolated incident.

This past September, the AMA hosted one of the leading authorities on social determinants of health – Sir Michael Marmot.  Many of you are familiar with his work. 

During a spirited, hour-long presentation Sir Michael applauded the AMA's decision to work toward improving health outcomes. At one point, he paused, then said this: "A few years ago, I could not have conceived of engaging the AMA, but the work you're doing in health outcomes is so important that I must engage and am simply delighted to do so."

Later that same week, Chicago Mayor Rahm Emanuel stopped by the AMA to help dedicate our new headquarters. He used the occasion to recognize the AMA's work and our commitment to improving the health of our Nation and thus, by extension, the health of the 2.7 million citizens of Chicago.

All three of these episodes – and I could recite many more - offer telling snapshots of how others are viewing the AMA and our important work.

They see the AMA's commitment to impact through focus as new and exciting . . . they see our willingness to reposition the AMA as bold and compelling . . . and they see our developing partnerships with others as smart and strategic.

Furthermore – and this is very important - this work brings additional power to our Advocacy efforts in Washington and nationally. 

In fact, our Advocacy team is convinced that our work on the strategic plan greatly strengthens our stature on Capitol Hill and with the public.

With that in mind, let me update you on the progress we're making toward improving outcomes for physicians, patients, and medical students.  All work that, as you know, is based on the policies of this House.

Physician Satisfaction and Practice Sustainability

I'll start with our work to enhance physician satisfaction and to ensure practice sustainability.

Just last month, we released the initial findings from our collaboration with Rand Health.  I hope you saw it – it appeared in more than 200 media reports across the country.

As you'll recall, our study examined over 50 sites from 30 diverse practices across 6 states to better understand the drivers and detractors of physician satisfaction. Let me thank our state medical societies who helped with this: Colorado, Massachusetts, North Carolina, Texas, Washington and Wisconsin.

 

The 150-page Rand report provides a wealth of information on the challenges physicians are facing in the current environment. Most of which, could have been articulated by this House.

So why an external study?

In short: hospitals, payers, regulators – need an empiric body of rigorously conducted, on the ground, social science research to be convinced – to be moved on this topic. This work now is not only in hand, but has the imprimatur of Rand – a respected third party. Very important.

So let me touch on two critical factors influencing professional satisfaction: quality of care and electronic health records. 

In regard to quality of care – the study showed physicians want desperately to be able to deliver high quality care to their patients. Indeed this is our greatest satisfier.  When able to provide such care – physicians are fulfilled.

Unfortunately, obstacles too often get in the way. Physicians are frustrated by the increasing number of clerical and administrative tasks that detract them from their calling: patient care.

A second major finding – just a little surprising for how stunningly dramatic it was – the effect of electronic health records on satisfaction. 

Physicians in the study recognized the potential of EHRs to improve patient care, and did not want to go back to paper; however, if I described the effect of the current state of EHRs on professional satisfaction as dismal, I'd fear I might be insulting dismal.

Let's be frank: EHRs as they exist today are constructed to optimize two things: claims billing and risk mitigation. They are not optimized for efficient entry and extraction of clinical data needed by physicians to help their patients.

This needs to change. EHRs must serve and enhance the physician-patient interface . . . other functions should be retrofitted and subservient to this higher clinical need.

So how do we proceed?

The AMA is launching both short-term and long-term strategies to help physicians navigate some of the frustrations documented, now with undeniable rigor, by this study.

Short-term: we have identified a list of a dozen or so practice flow and practice architecture issues that we can address to help physicians, regardless of practice mode or care model.  These resources will begin rolling out by the coming summer. 

For our longer-term strategic approach – the AMA will pursue four initiatives to help physicians in their practices. These include:

  • Developing tools to address intrusions on physician practice.
  • Engaging both EHR vendors and regulators to improve EHR usability.
  • Enhancing understanding of emerging payment models and their impact on the physician practice to detect obstacles and nip them in the bud.
  • And, promoting shared management and physician engagement with hospitals that employ physicians.

Just last month – something occurred that hadn't happened since 1975 – the AMA and the American Hospital Association convened a multi-day joint meeting in DC to discuss some of the important issues that are emerging in this new landscape.

A critical take-away – for all participants – was that high functioning hospital-physician models depend upon physicians having a real shared partnership in leading the enterprise. The key isn't so called physician "alignment," the key is shared leadership with physicians. 

We are also hard-wiring this work in physician satisfaction to our Advocacy efforts. Because improvements which make things better for physicians while improving both quality and the patient experience need to be embedded in our national policies.

The AMA is committed to this goal – and our work -- now built on a strong fact base, is well underway. In short, if you can't get no satisfaction – that needs to change. And the AMA is ready to help.

Improving Health Outcomes

Second, let me update you on our next strategic objective: improving health outcomes.

As you know, our initial focus is on two of the most pervasive, devastating, and costly conditions in the country – cardiovascular disease, and Type 2 diabetes.

No matter what your specialty, every single day – each of us interfaces with patients, neighbors or loved ones who have at least one of these conditions – or risk developing them in the future.

So how will the AMA help?

First, diabetes. As physicians with a full panel of patients, it can be hard to find enough time to address our patients' acute conditions – let alone the ones they risk developing in the future.

But the need to do so is critical; because while 26 million Americans have diabetes, nearly 80 million have prediabetes.

Surprisingly, a model community asset with a large national foot-print is available to help: the YMCA.

If you're like me, you probably view the Y as a place to swim in the pool, or workout in the gym. But as Neil Nicoll -- CEO of the Y -- told me recently – the Y has changed its long-term strategy to one of community health and wellness.

What an asset for our patients!

We need help in promoting simple – but proven – disease prevention strategies such as exercise and dietary improvement. And by linking this help to physicians' offices, we accomplish two major things.

First, we gain a needed ally in supporting our treatment plans. Second, individuals at risk who do not have a physician, now have a community resource that can establish one if we shape this correctly. A win-win.

The AMA has a new pilot program, now active, focused on increasing physician referrals of people with prediabetes to local YMCA's Diabetes Prevention Program sites in three cities. Our pilot will establish a communication channels between clinical practices and these sites.

The Y Program is based on the CDC's successfully piloted, evidence-based National Diabetes Prevention Program.  Initial experience has shown this program can reduce the number of new cases of type 2 diabetes by 58 percent among adults, and 71 percent in adults over the age of 60.  71 percent!!


Our first step is working with physician practices and Ys in our pilot sites in Indianapolis, Minneapolis and Wilmington. Our joint work is under an innovation grant from CMS - thus qualifying seniors who have prediabetes can participate in this program at no cost.   Preliminary conversations with private payers show potential to broaden the payer base.

As we learn from these pilot sites, we will expand our efforts to engage more physicians and Y's in other communities. Our novel approach is attracting attention from the likes of CDC and is a new way of thinking about the physician's link to the community. This is critical.

Over the last quarter century, we have converted acute disease to chronic manageable disease – we did so with heart disease and stroke, and it appears we will do the same with cancer in the coming decade. But converting disease from acute to chronic – compels us to identify community resources and link these to physician practices.

Public Health is underfunded and we need to find new sites like the "Y"s – that offer huge national footprints and sustainable business plans to add a new and more fiscally stable public health strategy, by pulling in private sector elements. 

Likewise, we are dealing with the problem of cardiovascular disease. Our initial efforts are focused on the common precursor: hypertension.  Today there are 30 million patients who have high blood pressure and a source of healthcare, and yet still suffer from unmanaged hypertension. 

The AMA has recently created a partnership with The Armstrong Institute at Johns Hopkins in this effort.  During a year-long pilot phase, launched just recently, we're partnering with physician practices in Chicago and Baltimore to develop a set of evidence-based recommendations.  We're also exploring how to engage community resources to help control blood pressure – using the same logic I outlined just a while ago. 

Our work is very consistent with the highly regarded Million Hearts initiative and – in fact – Million Hearts has indicated that it is willing to work with us to spread our findings.

We'll refine these programs based on our initial findings, and then expand them in practices just as in our diabetes work. 

Accelerating Change in Medical Education

Finally, let me update you on our work to accelerate change in medical education.

As you know, the AMA awarded $11 million in grants to 11 medical schools across the country this past June to enhance how we train the next generation of physicians.

Just last month, these 11 schools returned to Chicago for the first meeting of our Consortium. Joining our grant recipients were other medical education leaders, including representatives from groups such as AAMC and ACGME

The Consortium meeting was followed by a two-day AMA Medical Education Conference. It was inspiring to see leaders from diverse schools coming together – each with their own slice of innovation. Each committed to working together to craft the essential components of the Medical School of the Future. 

Let me highlight some of the themes.

Two consortium schools - Indiana and NYU - are using new technologies to create virtual patients and medical records from actual de-identified cases. Such new innovation offer advanced teaching tools to enhance clinical decision-making.

Meanwhile, other schools are testing new models of earlier clinical immersion and more realistic outpatient exposures – both Penn State and Vanderbilt have innovative and complementary approaches in this area.

East Carolina is planning new core curriculum in patient safety, while University of California, San Francisco aims to evaluate students based on their progress on quality improvement and team-based care.   Michigan is creating a program that shapes training uniquely to each individual student.

All the schools are adopting competency-based assessments, offering faster-moving students the opportunity to graduate in less than the traditional four years.

Lastly, within this consortium, three schools – Brown, UC Davis, and East Carolina – will work together to explore different innovative angles in education focused on health disparities and underserved populations.

These are all innovative ideas but more powerful than any one, is the consortium itself bringing together several divergent innovations into one view, one construct –  that construct being the medical school of the future.

Our AMA is driving this once in a century structural transformation.

Protecting the Patient/Physician Relationship

As you can see, we are making significant progress on all fronts. 

This important work – built upon the policies of this House – not only provides a pathway for improving outcomes for patients, physicians, and medical students, but – importantly - it strengthens the platform from which we launch our critically important advocacy and policy efforts.

Our work is just beginning, but already we have an exciting story to share. And I do so every chance I get – with individuals as well as large groups.

For example, I recently found myself sitting next to a physician on an airplane.

Like many physicians, he had a compellingly unique story. After doing his medical training here in the states, he worked for several years in a remote African village.  After returning home, he decided to earn his divinity degree. He now serves as both physician AND pastor to a small community in the Pacific Northwest. What a commitment to community – talk about 24/7!

Well, I began speaking with him started to share the AMA's work in some detail, but he politely interrupted and said – "But listen, can you tell me what the AMA's new work means to someone like me."

Here's how I answered:

"For more than 165 years the AMA has been focused on protecting and enhancing the physician-patient relationship.   Let's consider the components of that. 

Patients want us to protect that relationship because they value their health – they want good health outcomes.

Physicians obviously want us to protect that relationship – but it can only be protected if it occurs in a practice environment that is sustainable and satisfies their desire to provide quality care.

And society needs us to protect that relationship by ensuring future physicians are optimally trained for the healthcare systems of tomorrow.

In a nutshell ", I said , "that is what we are doing – improving health outcomes, enhancing physician satisfaction, and training the next generation of physicians to meet the demands of tomorrow."

After I said that, he looked at me, thought for a bit then replied:  "Well I didn't know all of that, but I'm a little isolated.  It makes sense to me. It sounds important and like the right thing.  You know, how can I join the AMA?"

I told him…….but in retrospect, I should have given him a big hug.

Thank you.

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James L. Madara, MD, CEO and EVP