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Bridging the Gap

June 13, 2009

AMA Annual Meeting
Hyatt Regency Hotel
Chicago, Ill.

Nancy H. Nielsen, MD, PhD
American Medical Association

Good afternoon, friends.

There's an empty chair here on the dais where our immediate past president, Ron Davis, would have been. We left it empty, to honor him.

Ron would have enjoyed this past week. He would have reveled in the controversy of a newspaper article that got all the facts right, but created a false impression about the AMA's commitment to health reform.

Ron would have written the correction himself, editing it until it was just right. He would have explained in a cerebral and dispassionate way the difference between "not the best way to achieve the goal,” which is what we said – and "we oppose,” which is what we didn't say.

Let's be clear – our organization's entire proud history is based on helping our nation receive the highest quality health care possible. Just because we think there is a better way to get to that goal – that doesn't mean we oppose health system reform. Far from it.

This is a battle for affordable health insurance and quality health care for all Americans. It's also a battle for our right to make medical decisions with our patients. And it's a battle for our profession's rightful place on the battlefield itself – on the front lines.

Tomorrow morning, Rich Deem and I will go over details of our engagement in this monumental effort to achieve a better health care system. And on Monday, President Obama will be here to address this House of Delegates. The decisions that we make in the next four days will have a profound impact, and the country is watching.

Last Saturday was the 65th anniversary of D-Day, one of the greatest battles in our nation's history. Maybe you've seen documentaries of the Allied forces landing in Normandy by air and by sea.

The battles were bloody. The risks unimaginable. The courage remarkable. And the ultimate outcome was freedom for the citizens of France and Europe, and the beginning of the end of the war fought by our country's greatest generation.

As I watched it all on the military channel last Saturday, I was struck by something I hadn't noticed before — I was struck by the intensity of the fight for control of the bridges near Utah and Omaha beaches. And it is both battles and bridges that we need to speak of today, because we are heavily engaged in both.

First, the battles.

We've won some big ones, and we did it together. When the U.S. Senate failed to stop the SGR-mandated cut, we took matters into our own hands. We had the courage to stand up to senators in their home districts.

With your help, and with the help of every state and specialty society in this House of Delegates, with the help of tens of thousands of physicians, medical students and patients across the country – that battle was won.

But now we we're in a battle to get Congress to repeal the SGR once and for all. It is time to pour concrete into that hole and walk away from it. The President's budget showed the way, and the House agreed. In the Senate – not so much.

Let's fight this battle to completion. No more short term fixes. No more waiting. No more promises. Because now is the time to fight to get this thing done. Once and for all.

And we've battled big health plans. We helped the Pennsylvania Medical Society block the merger of Highmark and Independence Blue Cross. Insurer dominence and monopsony power is always bad for physicians, and for patients.

We won a very long battle that exposed how physicians were systematically underpaid for years by insurers for out-of-network services. We sued in 2000, and a settlement with United Healthcare was finally agreed upon through efforts brokered by the New York State Attorney General, Andrew Cuomo.

Other national insurers, as well as regional plans, also settled with Attorney General Cuomo, but only United has agreed to fund $350 million to a reparation fund.

Since Aetna, CIGNA and Wellpoint have not yet arrived at an understanding of what they need to do to repair relationships with physicians, we recently filed suit against them. We will do battle when necessary.

At the state level, there is so much good that has come from our work together. Battles won include private payer reforms passed in Utah, Georgia and Maryland. And our work to enact regulation of rental network PPOs is gaining momentum, with battles ongoing in five other states.

On medical liability, we have to continue to fight to protect the reforms we've achieved. In Colorado, we helped the Colorado Medical Society defeat a bill that would have chipped away at their cap on non-economic damages. We helped the Utah Medical Society successfully change the standard of evidence for emergency physicians from "preponderance of the evidence” to "clear and convincing.” It's one of those "devil is in the details” changes that will help, but it underscores why meaningful liability reform nationwide is needed.

That's a battle we have to fight, and we have asked the Obama Administration and Congress to join us and help enact medical liability reforms

At the National Advocacy Conference the past two years, the AMA urged attendees to get their representatives to co-sponsor legislation on balance billing, authored this year by our own – Dr., delegate and U.S. Congressman Tom Price. Part of the problem is that to date, only 6 representatives have signed onto HR 1384. So this battle is ongoing.
We continue to press for the right to privately contract. In the late 1990s, in response to AMA lobbying, Senator Jon Kyl introduced a sound private contracting provision that passed the Senate. Unfortunately, it was watered down in Conference Committee which is how we ended up with current law. AMA leaders continue to advocate for private contracting on Capitol Hill.

Now you may say, if we've pressed for private contracting, balance billing and liability reforms, where are the victories? Well, you know how to count – count the votes. Sometimes it's who's in control, sometimes it's timing.

We've fought hospital challenges to physician autonomy in Arkansas and Florida. And we've won two important cases that are well-described in the Litigation Center brochure you'll find in the bag at your seat today. Please read about them. The one in Arkansas involved economic credentialing. The one in Florida involved a hospital administration that wanted to change medical staff bylaws – unilaterally. acceptable. When the practice of medicine was jeopardized, we stood together, we did battle, and we won.

We are using new tools to protect against unwarranted scope of practice expansions. We're helping the Hawaii Medical Association to oppose a bill that would allow advance practice nurses to call themselves primary care providers. This issue is only going to get more intense.

In science, public health, medical education and many other areas – the AMA has worked hard and earned wins for the house of medicine. Perhaps none was more satisfying than finally winning the ability of the FDA to regulate tobacco. Ron Davis would be extremely pleased.

We should all be proud of these and many other wins. I there were time to list them all, it would be an impressive list. But the House of Medicine has shown there are also other ways to achieve our objectives – to do what's necessary for our patients without donning full metal jacket or drawing bright lines in the sand.

Sometimes we need to build bridges. But it takes courage to build bridges with unlikely partners. Sometimes, the bridges only come after we have demonstrated our resolve.

That's the story of our National Health Insurer Report Card, which rolled out a year ago and has turned into a win-win between the AMA and the national payers to simplify and improve claims payment. And just to be sure that we keep the insurers' attention, and we continue to improve our relationship with them.

We'll also continue to use the AMA Heal the Claims Process to help insurers make significant improvements to their claims adjudication process. Aetna, CIGNA, Humana and UnitedHealthcare all participated in regular, productive discussions that have led to real improvements. Our Private Sector Advocacy staff said this has been more successful than they had hoped for.

As our recent lawsuits against several large insurers demonstrate, the AMA is not going to tolerate abusive behavior. We will always advocate for fair payment for our services. We can always go to court. We can crank up the volume, spend tremendous energy and resources banging heads with our adversaries, but when the right opportunity presents itself, why not try to resolve some things by talking it through?

Consider this — payers have data and other resources which, if properly deployed, could help us improve patient care. They have data that, quite frankly, can help us become better at what we do.

We don't trust their "report cards.” With good reason. But we are committed to taking advantage of their data and resources to the extent that health plans are willing to partner with us.

A year ago, in my inaugural address, I called for a bridge to be built between physicians and other stakeholders, especially health plans. I urged health plans to provide us with data, information, and tools that could help us improve patient care.

Today, I'm pleased to share news of three initiatives that could help us all.

First, the AMA,the Colorado Medical Society and United Health Group arelaunching an innovative, collaborative Physician Quality Improvement Program in Colorado. This represents the first collaboration of its kind between a state medical society, a national physician association and a national insurer. This collaboration will work with specialty societies and Colorado physicians who want to participate.

They will look at areas of overuse and misuse in a few high-cost, high-variation conditions. It will examine data from Colorado physicians through the lens of the Physician Consortium for Performance Improvement — the PCPI — the organization that the AMA convenes and staffs, and in which virtually all specialties and many states participate.

That means the quality measures they use will be evidence-based, reflect the current state of our scientific knowledge, and are those that our profession has developed. Data will be analyzed to identify best practices and then promote adoption of those best practices, with the goal of improving both quality and value. Any savings that result will be shared with participating physicians.

This program will be strictly voluntary, and the goal is to improve patient care. At no time will any of this data be used to publicly rank or rate individual physicians. No public report cards — just a sincere desire to improve the care we provide.

Every step in the Colorado Collaborative Quality Improvement Project will be designed and approved by physician members of the Colorado Medical Society and our AMA. If successful, this pilot might be a model for expanded use in Colorado and for future programs with other insurers throughout the country.

Again, the goal is to do the best for our patients: the right care at the right time.

The second collaboration includes the PCPI, the Council of Medical Specialty Societies, and United Health Foundation, with input from the American Board of Medical Specialties. Physicians will be supplied with data and tools to help them evaluate their own practice and improve their care — and also help them meet their board requirements for Maintenance of Certification.

And the third collaboration, a big potential boon to our practices, is the work on administrative simplification that was announced at the White House by AHIP. We have been clamoring for this for a long time. AHIP tells us that it's coming to fruition and pilots will begin this fall in Ohio and New Jersey. They are developing a Web-based project to provide physicians with one portal to conduct all business with all insurers; everything from verification of insurance coverage for a patient, to authorizations, to billing and claims management.

If the pilots are successful, this could be incredibly useful and could help reduce our need for office staff to perform some of these functions. Streamlining administrative processes helps everyone.

Don't worry – we haven't drunk the KoolAid put out by health plans. But we can't keep on hating everyone all the time – government, health plans, and sometimes even each other.

It's our responsibility to try some new things and innovate in health care delivery, just as we innovate in science and technology.

Tomorrow, you will hear details of our recent promise at the White House to commit to "bending the curve” of rising health care costs. There was some confusion in the media early on, but never any confusion in our resolve to have our profession take ownership of medical decisions – not the government, and not a health plan.

And President Obama acknowledges that medical decisions must be made between the patient and the physician. That's where medical decisions belong, and we will fight till our last breath for that privilege. But because it's a privilege, with that comes responsibility and accountability. Medical costs are out of control and are crippling our nation. We can't heal the nation's health care system and its economic woes alone.

There are many factors here: Hospital readmissions, poor care coordination, duplicative services, defense medicine, and more. It's patient's lifestyle choices, too. Let's have the discussion tomorrow about the elements that are under debate in Congress. But what's beyond debate is that we must be part of the solution.

Change is always difficult, and it does carry risks. Not changing also carries risks, including leaving our patients and our profession mired in an unacceptable status quo.

You know, we have sometimes drawn lines in the sand that have left our AMA blamed for blocking reforms. It's time for physicians to take charge, to lead, to work with each other, to use technology and goodwill and the professionalism that drives us to solve the problems of of our health care system.

In my final eVoice column this week, I wrote about Atul Gawande's watershed article in the New Yorker. I urge you to read the article, because everyone in Congress, and everyone in the White House has.

We need to address variations ourselves or others will do it, using blunt instruments like cutting our fees. Is that what we want? Of course not. So let's take charge of figuring out the causes of variation and eliminating what's not in patients' best interests.

I think people sometimes forget that this is brutal, hard, complex stuff we do every day. Think about it — there are more than 60,000 diagnoses; 11,000 surgical procedures; and at least 4,000 drugs.

We can work together, and learn from each other as we transition from lonely, dispirited people to energized, empowered, highly skilled professionals who clearly make decisions based on patients needs and can prove it.

And that's why AMA leadership in Washington – and across the country is more important now than ever before. That's why your AMA is being so visible and so engaged.

On a personal note, it has been the greatest honor of my career to represent you in this monumental effort. I thank you for that privilege.

You may wonder why we've been circumspect and respectful in expressing concerns about reform proposals. Where's our fighting spirit? Why haven't we stormed the cliffs, drawn the lines in the sand, blown up the bridge, or at least controlled the bridge, as the brave men did at Normandy?

It's because there isn't any bridge. We have a chasm in health care in this country. We have to help build a bridge across it if there's any hope of creating a better future for our patients and our profession.

America has come close to building such a bridge several times in the past. Each time, for different reasons, it has turned away. We now have the best, and maybe last chance in a generation to build that bridge.

Rabbi Schaalman's invocation said it very well. Our country needs us. How will we respond? This is our profession's D-Day.

Thank you.