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The AMA 2014 and Beyond: A New Hope

Presidential Address to the House of Delegates

AMA Interim Meeting
Dallas, Texas
November 8, 2014

Robert M. Wah, MD
President
American Medical Association

Mister speaker, members of the Board of Trustees, distinguished delegates, friends:

At my inaugural, I spoke of tradition versus convention. The link between preparation and innovation. Health IT. Advances in military medicine. Women’s health. My Chinese heritage. And a couple of sentences about “Star Trek.”

So the press coverage surprised me. One headline said “New AMA President beams in to office” Another quoted the Prime Directive.

Today, I’ll talk about the view of health care from my vantage point as AMA president – and about the great things the AMA is doing on behalf of patients and physicians. And let’s get this out of the way – I’m going to talk about “Star Wars.”

In my travels, I’ve had attentive audiences eager to hear our message. I thank you all for your warm hospitality during my visits. I’ve spoken about AMA’s traditions – and their impact today. 

I want to tell you now about how we’re mobilizing that tradition – and putting it to work in Washington and in the states. In the process, perhaps uncover a few – cosmic truths.

You know I like “Star Trek.” I’m also a big “Star Wars” fan. A movie with its own mythology. In fact, in 2001, “Jedi” was reported as the fourth most popular religion in Great Britain.

“Star Wars” is also the source of a nickname when I first started in medicine. As an OB-GYN intern, I frequently got the call from the emergency department when a woman came in. So often, in fact, that the staff started calling me “Obi-WAH-Kenobi.”

I’d like to think it was for my mystical medical skills – or that I could at least cloud their thinking with a Jedi mind trick. I knew I’d arrived when I was summoned to see a woman with abdominal pain – and the chart was marked “Obi-Wah called.” Left unspoken was the phrase “You’re our only hope.”

So I became “Obi-Wah.” It could be worse: Jabba the Hut. Chewie the Wookie.

“Star Wars” also reminds me of our own struggles at the AMA against the dark sides of the Force – public and private bureaucracies, red tape, predatory lawsuits, broken, busted and constricting formulas. In this high stakes environment, Master Yoda offers a simple but powerful directive for our work: “Do. Or do not. There is no try.”

SGR

“Do” we have, to end the sustainable growth rate – developed a long time ago, in a reality far, far away.

Last spring we made another run through the trenches, firing proton torpedoes to destroy this Death Star. We did come away with a viable alternative to the SGR. And achieved what we didn’t have before – a framework to end the SGR, with bipartisan and bicameral support, backed by more than 600 physician groups.

We’re now delivering this message: Congress must eliminate the SGR in the lame duck session. Why? Because it’s essential to sustainable practice and preserving access. And because it makes perfect sense. Together, we have an opportunity to show the American people that Congress can work together to pass meaningful legislation to strengthen Medicare.

We will work with you – and we will work on our legislators – as we push to end the SGR. Check www.FixMedicareNow.org for the latest on these efforts. We’re doing everything we can. It might not happen during this lame duck session, but the end of SGR is not a matter of if – but when.

ICD-10

Here’s an interesting fact:  Each of the six Star Wars films has this line: “I have a bad feeling about this.” That’s a common reaction to ICD-10.  If it was a droid ICD-10 would serve Darth Vader.

We’d see 13,000 diagnosis codes balloon into 68,000 – a five-fold increase. Sucked into a jet engine?  Burned by flaming water skis? Yes, there are codes for that. We all know ICD-10 is expensive to implement. We don't know if it will improve care.

For more than a decade, the AMA kept ICD-10 at bay – and we want to freeze it in carbonite!

Sunshine Act

Speaking of implementation problems – that brings me to the Sunshine Act.  

Many of us shared the same reaction: “I have a bad feeling about this.” Again, those instincts were correct. Financial interactions with drug and medical device manufacturers are now reported online to the public.

The AMA did get some provisions to give physicians a chance to review and correct data before it’s posted. Unfortunately the Sunshine Act has already burned some of us.

The review website was supposed to go online in January. That didn’t happen until August. Remember the Healthcare dot gov fiasco? The same contractor designed this one. It has a 300-page instruction manual – longer than the blueprints of the Death Star! Then there’s the incomplete or inaccurate physician data.

For instance, one Baltimore surgeon was surprised to learn that, according to the database, health care companies had lavished him $78,000 in food and beverages. It was actually for consulting work but was misclassified. Of the 550,000 physicians affected by the Sunshine Act only 26,000 had a chance to review their data and correct any inaccuracies.

Let me be clear -- the AMA wants transparency. It helps patients make informed decisions about their medical care. But a glitchy website, no time for review and revision, and CMS’ own admission of problems with fully one-third of the data – all cast doubt on ALL the information on the site.

MIS-information leads to misinterpretations, harms reputations and undermines patient trust.  And it discourages the delivery improvements that benefit those very patients. Most relationships with industry drive innovation and advance professional medical education. It makes for better physicians – and more effective treatments.

We’re making an impact. Last week, CMS came around to the AMA’s view that speakers contributing to independent continuing medical education are not subject to reporting. This will encourage the exchange of information. We led the way on this.

We will continue to work with CMS to make sure the Sunshine Act enhances transparency – by using data that is accurate and in context.

EBOLA

Accurate information – presented in context – can also save lives. As you know, Dallas had the nation’s first Ebola patient. Obviously cause for concern, but misinformation and lack of information led to panic and paranoia.
The AMA is looked to for reliable information – so check out the AMA's online Ebola Resource Center for updated information from the CDC, JAMA and other public health groups. And in addition to our efforts to prepare for and treat Ebola, a sharper focus by the US and the international community is essential to contain the outbreak in West Africa.
As I said on “Face the Nation,” the dynamic nature of this disease requires a dynamic response. We need to talk to – and learn from – each other. I have every confidence in the CDC – and in our team effort. But this fight can’t be won by one person or one entity. We have to stand together.
So the AMA, hospitals and our partners in nursing put forth a plan to manage care of Ebola patients. We must ensure that all hospital and clinical staff can safely provide quality care. And that nurses, physicians and staff have the proper training, equipment and protocols to stay safe while providing that care. Make this a time for preparation, not panic.

EHRs

Accurate information, transmitted in a usable way is also the promise of Electronic Health Records.  And a challenge for all physicians in the decade to come.

At the AMA, we see the vast potential to improve patient care and safety through EHRs, telemedicine and the exchange of data. We also know change can be difficult. Faced with this monumental task of transition, a lot of physicians have thought: “I’ve got a bad feeling about this.”

EHRs are difficult to use, eat up hours in data entry, interfere with face-to-face patient care and degrade documentation. Meaningful Use exacerbates these issues. So we want changes in how the government regulates EHRs so vendors focus less on federal mandates and more on the needs of their customers – physicians.

We’re calling for a more flexible approach to meaningful use, expanded hardship exemptions, improved quality reporting and solutions to usability issues.
We cannot let the technology rule us – we must rule the technology. Like a Jedi warrior – be not averse to technology, but don’t rely on it alone, at the expense of our own senses, training and clinical acumen.

MU, PQRS, VBM

Some issues transcend both the SGR and EHRs, and pose new threats to Medicare’s stability. And once again, a lot of physicians are saying: “I’ve got a bad feeling about this.”

Physicians providing care to Medicare patients could be swamped by a tsunami of penalties. Adding up to more than 13 percent by the end of the decade. This atop the 21 percent cut physicians already face if SGR isn’t stopped.

It’s not just the sequester. It’s the patchwork of laws and regulations such as the Meaningful Use program, the Physician Quality Reporting System, the Value-based Modifier Program. It sounds confusing. It is. Enough to stump even the protocol droid C3PO.

This hodgepodge cuts physicians’ time with patients, wastes energy and resources and fuels professional dissatisfaction. And, ironically, discourages the very investment in new technology and new approaches to the delivery of care it’s supposed to promote.

They aren’t aligned, forcing physicians to register and report their information over and over again, over many formats. The AMA wants it streamlined.  Doctors should be able to make a one-time report to meet requirements for all Medicare physician quality programs. Report once, use many. And they should create the efficiency and improvements in care we were promised.

Beyond reporting problems, you have to meet 100 percent of Meaningful Use requirements. It’s all or nothing. It’s unfair, unrealistic and unworkable. Thanks to heavy pressure from the AMA, CMS did reopen the hardship exception to avoid penalties. The new deadline is November 30th. The AMA encourages all physicians concerned about a penalty to apply.

Telemedicine

A more meaningful technology is telemedicine.
The AMA is at the forefront of this movement – we’ve developed policy to guide lawmakers and we’re driving it forward. We’re showing how telemedicine can deliver the right care at the right time in the right place for patients using real-time interaction through online portals, remote monitoring and store-and-forward practices.

Data can be sent from patient to physician – like a follow-up photo of a suspicious mole to their dermatologist. Or a physician can follow results of a patient’s blood pressure or glucose readings. Or patients and physicians interacting through secure video services. Not a hologram of Princess Leia delivering an urgent message – but better – a two-way communication, not a one-way plea.
Patients that use telemedicine are better at managing chronic conditions, which improves outcomes, reduces costs and expands access to care.

To comply with local laws, physicians need to be licensed in the same state as the patient – not on the other side of the globe. This requires a streamlined licensing process to practice telemedicine in multiple states.  We applaud the Federation of State Medical Boards model to expedite licensing. It would help telemedicine flourish and states would keep their authority to protect patients.

We need coverage and reimbursement of telemedicine services and fewer restrictions in Medicare. We want patients to use it if they need it. Lift geographic restrictions. Free up its use in alternative payment models. And cover the dual eligibles so they can use these services.

Telemedicine, SGR, EHR, ICD-10, Sunshine – all part of the vast galaxy of issues the AMA is addressing on behalf of all physicians and patients.

            All in addition to – and supported by – the three strategic goals we share – our “Moonshots” to improve health outcomes for our patients, improve physician satisfaction and improve the education of our future doctors.

            Our hard work is earning the trust and support of more and more physicians. Membership is up for the fourth straight year – kind of like the box office for “Star Wars” and its sequels and prequels.

            Our AMA has accomplished much this year. But none of us can go it alone. We face issues that make us think: “I have a bad feeling about this.”

            But recognizing potential problems – is the first step toward overcoming them. To do, you first must start. We’ve taken that step – and we are fighting that “bad feeling” with positive action on behalf of physicians and our patients.

This year, I traveled across this country and sometimes across the planet. On these long flights, I’d love to make the jump to light speed in the Millennium Falcon. Instead, it’s more like flying the Daily Pigeon in the middle seat. But I’m grateful for the privilege of representing our AMA. I’m seeing how physicians are navigating today’s health care challenges. And how the AMA can help.

Obi-Wan said “The Force is an energy field created by all living things. It surrounds us and permeates us. It binds the Galaxy together.”

            In that way, the House of Medicine – and the power generated and put to purpose by America’s physicians, acting together through the AMA – is a Force to reckon with indeed.

That means all of us, speaking in one voice at the AMA – speaking so loud on behalf of our profession and our patients -- that all can hear. This, as Obi-Wan observed, “Can make us more powerful—than you can possibly imagine.”  May the Force – be with us.

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James L. Madara, MD