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Back to the Future

AMA Annual Meeting
Hyatt Regency
Chicago
Saturday, June 6, 2015

Robert M. Wah, MD
President
American Medical Association

Mr. Speaker. Members of the Board. Delegates and friends, colleagues and guests – and our international visitors:  I'm honored to speak with you as I complete my term as your president. About what we've achieved, where we progressed, and what yet needs to be done.

Through AMA's work and your leadership:

  • We're reimagining medical education. Easing chronic disease. And ensuring physicians can still put patients first amid disruptive change.
  • Innovative care models are enhancing quality and reducing costs.
  • Millions of previously uninsured Americans are going online to compare prices and buy coverage.
  • We're fighting to make digital health a useful clinical tool instead of an exercise in meeting regulations.
  • And we're moving ahead with innovation in new and exciting ways.

These reasons and more may be why our membership is up four years in a row. I like how this movie is going.

In my talks with this House, I've drawn metaphors from the movies to describe our challenges and progress.

This is my third speech. Last June, I talked about a simple country doctor on a 23rd century starship. In November, I shared how I became "O.B. Wah Kenobi," the intern in a galaxy far, far away.

Many of you offered suggestions on how to complete the trilogy. Bewildered by a maze of regulations? "The Matrix." A noble quest? "Lord of the Rings." Our relentless pursuit of regulatory victories? "The Terminator."

I decided I like the future – it brings out the optimist in me. So come with me…Back to the Future!

There's been lots of internet traffic lately about the vision of 2015 found in the 1989 sequel to the hit movie "Back to the Future." We see an imagined version of our present day from the vantage point of the past. It hints at what's to come – and what's already here. Roads?  Where we're going, we don't need roads!

In "Back to the Future 2," Marty McFly, assisted by mad scientist Doc Brown, travels decades into the future to save his son from some serious trouble.

We arrive with them in a 2015 that looks almost familiar, despite the traffic jams of flying cars. It promises hoverboards. They're actually being developed today by a company using magnetic repulsion. I want one. Of course in the real 2015, people ask me if I have to check my Blackberry out of the museum every morning.

The movie predicted smart phones, flat-screen TVs, and digital glasses, all now a reality. And of interest to many in this room, in the movie, the Chicago Cubs are World Series champions for the first time since 1908. It is, remember, a science fiction fantasy.

In Back to the Future's 2015, devices are voice-activated. Like Siri. And, you can pay for everything with a thumbprint.

In the film, interactive video conversations are commonplace, as is widespread use of tablets.  All true today, more or less.

In looking at what "Back to the Future 2" got right and got wrong about 2015, its biggest blunder might be the widespread use of fax machines. In one scene, Marty and Doc pass a Post Office mailbox that includes a computer terminal that says "Fax here."

This gets a laugh – unless you work in a practice that's still faxing paper records back and forth because their electronic records can't interact – can't interoperate – with outside systems.

Regulatory Relief/MU/EHR:

While AMA and the broader physician community strongly support the use of technology and innovation to improve the health of our patients, the "Meaningful Use" requirements for electronic records are a heavy burden and a prison for innovation. For a better future, EHRs need to be inter-operable, encourage physician-patient interaction, streamline workload and payment and promote team care and coordination.

We've made progress. We asked the federal government to cut the reporting period from a year to 90 days. They did it. One troubling performance measure, the patient view-download-and transmit requirement, will be eased significantly – for now.

It's a start, but I've said it before: Harness technology to improve care – don't let it harness us.  The same goes for those who write regulations. Learn from mistakes and act accordingly. If something isn't working – fix it.

Shaping Regulation to Work for Patients and Physicians

And if you know something won't work – don't do it. One example is our efforts to shut down the Independent Payment Advisory Board – IPAB. An appointed body of alleged "experts" charged with recommending Medicare provider payment cuts whenever spending exceeds preset targets. Sounds like the SGR on steroids. A visit back to the future we'd like to avoid.

That's why the AMA has criticized IPAB ever since it was created by Congress. That's why we want to end IPAB's future – before it happens. The AMA and more than 500 organizations called on Congress to repeal the IPAB and we rallied bipartisan support in Congress to get it done.  

The current Senate bill already has 40 co-sponsors, the House bill 232, including 20 Democrats – well on the way to pass in a bipartisan way. And good news - the House Ways & Means Committee approved the bill this week.

ICD-10

We face another challenge – sort of like Biff the bully. The transition to ICD-10 codes. It's going to take more than fancy skateboarding to deal with this.

We believe ICD-10 will further disrupt physician practices when we're already facing headaches like Meaningful Use. Nonetheless, Congress and the Administration seems intent on implementing them October 1st. 

The AMA and 99 state and specialty societies have urged CMS to put safeguards in place.

End-to-end testing showed claims acceptance rates would fall from 97 percent to 81 percent if ICD-10 was implemented today. That's 20 percent failure. And this was among the doctors who volunteered – the ones at the front of the classroom, waving their hands to volunteer!

HHS contends ICD-10 isn't to blame – but this may be the "best case scenario!" If Medicare rejects nearly one in five of the millions of claims in the system each day, we'd see a catastrophic disruption to physician practices.

We'll continue to press for more comprehensive testing, a grace period to reduce potential claims denials, hardship exemptions and advanced payment authority to head off cash flow problems.

We've been able to focus even more on these issues because of what the AMA – what all of us – accomplished this spring. Like the plot of a good movie, I've been building up to this.

Eliminating the SGR

And that's the epic improvement to Medicare by eliminating the SGR– Led by the American Medical Association. Led by physicians. Led by … you.

Most of this century we've worked to rid ourselves of the flawed sustainable growth rate – and its fickle, capricious hold over Medicare payments. We all know how the SGR's threats of deep cuts created instability in our practices – and sowed uncertainty about access among our Medicare and TRICARE patients.

Last year, the message got traction. This year it broke through. On April 14th, the Senate followed the lead of the U.S. House and repealed the SGR!

I was in Norway for the World Medical Association, and watched it unfold at 4 a.m. local time on C-SPAN. A friend of mine, a big fan of military jargon, immediately sent me an email with the subject line: "On your watch!" Well, I'm proud to say the elimination of the SGR happened on our watch!

When the president signed it into law, a cheer went up throughout the land. Organized medicine won a big victory.  The Senate passed it 92 to 8. Before that, it was approved by 392 members of the House. That's what's known in Washington as overwhelming, bipartisan, bicameral support – not seen much these days.

Working together, we finally ended an era of uncertainty for Medicare patients and their physicians – and opened new avenues to provide better care at a lower cost. It wasn't a "doc fix." As I wrote in an article for Forbes, it was Medicare that needed fixing - not doctors!

How we did it – together

More than 700 state and specialty medical associations and other partners rallied with the AMA banner. In the month before the vote, physicians made more than 60,000 calls and fired off nearly a quarter-million emails to their elected officials.

We lit up social media – and set it ablaze. Our action alerts on Facebook, Instagram, and Twitter reached more than 3.5 million online users.

There were questions and doubts. Serious ones. About whether this effort would get off the ground. Members of Congress told us it would just be patched again for 6 months to a year.

A lot of moving parts had to act together at just the right time – and in just the right way. Think of Congress as the "flux capacitor." They were "fluxing."

We revved up the DeLorean to 88 miles per hour – punched in the coordinates – and fueled it with the 1.21 gigawatts of energy put forth by the AMA and America's physicians in a lightning bolt striking at just the right time. We burned rubber and we smashed through the barriers to success.

Other provisions in the new law

There are other things for us to cheer in the new law.

  • Annual payment increases through 2019.
  • Streamlined quality reporting programs.
  • Physicians who privately contract with Medicare patients won't have to "opt out" every two years—once you're out, you're out – until you say you're in.
  • Medical liability lawyers can't use Medicare quality program standards and measures in lawsuits.
  • And we stopped the CMS proposal to eliminate the 10- and 90-day global surgical services bundles.
  • Incentives to use alternative models or the new fee-for-service program. Participation is entirely voluntary.
  •  And did I mention annual payment increases through 2019?

So – many, many thanks to all of you who participated in this overwhelming – and overwhelmingly successful grassroots campaign. Medicine's united voice was loud, it was heard, and it was persuasive. Now it calls out for continued physician leadership as change goes forward.

We're already working to shape how this law is implemented to protect physician and patient interests. And America's physicians and the AMA are also sharpening our focus and energy toward improving this nation's health, while enhancing the patient-physician partnership.

So I hope you'll understand my wish, one last time, to do a victory lap. Maybe just once around the ballroom. Is there a DeLorean in the House? … a Hoverboard, maybe?

RX: Putting Physicians in Positive Light

I've mentioned "Back to the Future 2" and its predictions, from 1989, of what 2015 might look like. This year – 2015 – also saw the release of a movie that reveals some of the new realities of our health care system. In specifics or in spirit – it reflects much of the AMA's strategic work.

The PBS documentary "Rx: The Quiet Revolution," sponsored by the AMA, looked for challenges and opportunities in our health care system. It found doctors, nurses and others at work in teams to lower costs, improve outcomes and enhance quality. A transformation of the way America delivers – and receives – medical care.

Its stories align with our mission to promote health, prevent sickness and help people live longer, more productive lives.

For instance, in one scene, a diabetic woman in rural Mississippi tests her blood sugar and enters the number on a tablet. Its software sends it to her care team in Jackson. The number's been high lately. The nurse calls the patient and offers to help to lower her blood sugar.

And, most hopeful of all, this patient is getting consistently better results. She's lost weight. And sharing her experience with family, her friends and her community. Like her care team, she's invested.

Prevent Diabetes STAT

This type of interaction among patients and the physician-care team is crucial to AMA efforts to improve outcomes – and prevent Type 2 diabetes and cardiovascular disease.

Our work is getting results, most recently with our new partnership with the Centers for Disease Control and Prevention: Prevent Diabetes STAT: Screen, Test, Act—Today™.

It helps physicians tap prevention programs in their communities or online – and drew from our pilot with 11 practice sites in four states in Delaware, Florida, Indiana and Minnesota.

In the 2015 of Back to the Future, Doc got a new spleen and a rebuilt colon at a rejuvenation clinic. We're addressing a reality today where our efforts can prevent deadly outcomes from diabetes and cardiovascular disease. And that means a better, healthier future.

Change in medical education

We know as well that tomorrow's physicians need to be better equipped to confront that future. That informs our Accelerating Change in Medical Education consortium of 11 medical schools. These projects will help transform med-ed – largely unchanged since the Flexner Report a century ago.

We're investigating new core science to give them skills to navigate an ever more complex health care system and to harness new technology to improve patient care. Designing the medical school of the future is not the stuff of science fiction, but becoming fact, thanks to the AMA and our partners.

The "Rx" documentary and our other strategic work with partners across the country is showing Americans what we already know: High-quality, affordable care is our priority – now and in the decades to come. When our stories are shared, our work is advanced – and our patients win.

Conclusion

I'm proud of the exciting work in innovation we're doing at the AMA. For instance, we're developing initiatives to address technology challenges and opportunities facing physicians – like our partnership with the high-tech incubator – Matter.

This health IT hub brings doctors to the technology table – and gives them the tools to apply it today for a better future.

Imagine if Nathan Davis, riding in a DeLorean, arrived here in Chicago this week. I think he'd be overwhelmed by the changes in medicine and the advances we've made – but I think he'd also be pleased and reassured that our mission and goals at the AMA remain true to the course set back in 1847.

We've worked "for the betterment of public health" in everything from medical ethics, education, vaccinations, treating epidemics and attacking tobacco. Now, AMA and America's physicians are leading the way toward a new era of better health – and a better health care system.

Thoughts about the future can be clouded by our daily challenges in the here and now. But meeting those challenges today means a better tomorrow. Each victory takes us back to the future – one with an ever-strengthening bond between physician and patient. Our work to achieve this may never end, but our results will be real, and lasting. The reward: Healthier patients and a healthier world.

The challenge of change swirls all around us – we need to see it as an opportunity to maximize those opportunities. It will take hard work – imagination – and creativity. I look forward to joining you – working with you – and I'll see you in the future!

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Robert M. Wah, MD