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Presidential Address

June 12, 2010

AMA Annual Meeting
Hyatt Hotel
Chicago, Illinois

J. James Rohack, MD
President
American Medical Association

As I reflected on this, my last official address to this House of Delegates as your President, I remembered what it was like sitting out there as a young resident physician.

It was 1984, and I'd just been elected as an alternate delegate to the Texas Delegation.

I was so excited to be part of an organization that fought for the medical profession and represented its values.

This professional association — our AMA — was born from the need to reassure a skeptical public. Our AMA was a promise to our patients that America's physicians were bound by common educational standards and guided by a common set of ethics.

That we were a profession — not a trade, not an occupation, not just a job.

I'll ask you to look back — and remember your college years and applying to medical school. Your hopes and dreams and aspirations.

Why did you want to be a physician?

Did you write on your application that you wanted to help others? To be a healer or a teacher of health? For most of us, I suspect it was because you wanted to serve those who suffer — and touch lives.

Being in this House of Delegates the last 26 years, I have listened to many individuals. In the Reference Committees, on the floor of this body — and out in the hallway in small groups, or one-on-one conversations.

Yes, I have heard those who say the AMA does nothing with the policies adopted by the House. Or does the wrong thing with those policies.

I have heard those who say that the AMA represents just the solo practitioner. And the complaints that the AMA represents just group practices.

Indeed, I have heard those who say the AMA represents just the private practice of medicine as well as those that say it just represents academic medicine.

Then there are those who say that the AMA represents just primary care physicians and those who say the representation is just for non-primary care specialists — and each claim it's to their own detriment.

And then there's the ultimate dissonance: Electing known and respected individuals from the House of Delegates to the Board of Trustees — who then continue to practice medicine — only to hear soon afterwards that he or she no longer really represents the practicing physician?

John F. Kennedy noted this: "The great enemy of truth is very often not the lie — deliberate, contrived and dishonest — but the myth — persistent, persuasive and unrealistic. Too often we hold to the clichés of our forbears...

We enjoy the comfort of opinion without the discomfort of thought."

The truth is, for decades, our AMA has struggled internally on issues of governance and policy.

One big difference now is the instant communication of the internet, and emails, and text messages and Tweets. Cutting-edge technology that can shift emotions into overdrive and consume dispassionate reflection.

Instant communication can be a help and a curse. The meaning is in the message — is it a myth, a lie or the truth?

Over these last 26 years, I have read the reports from numerous outside consultants about what our AMA is, or should be.

We've been told our AMA agenda is at times a mile wide and an inch deep — if we try to cover everything, we can't accomplish anything.

I listened. And when you elected me to our Board of Trustees, I promised to work for a more focused agenda. And, my friends, we have done that.

During the last two years of serious discussion about health system reform, our AMA focused on a few critical principles.

For instance, the goal of getting more of Americans insured so that fewer risk living sicker, and dying younger.

Facing the ugly truth about health care disparities.

And reforming an insurance system that was too often an adversary in patient care — and not a partner.

This new law does maintain a pluralistic American health system.

Thanks in large part to AMA influence, it makes needed changes to a private insurance market that had consolidated into a handful of dominant companies.

One in which a profitable business model was to avoid covering those who needed health insurance the most.

Thanks to AMA influence, we returned choice and competition back in the private market through health insurance exchanges.

And to implement a long standing AMA policy of individually owned health insurance through a mandate that individuals get health insurance.

Those who live at four times the poverty line are eligible for advanceable tax credits inversely related to income.

Once implemented in 2014, the infrastructure will be in place to federalize payments for the medical care portion of Medicaid to help those patients take responsibility for their own health insurance policies — and take responsibility for their own health.

The Patient Protection and Affordable Care Act also broadens Medicaid to cover the home care cost for an elderly loved one to live with their adult children and not be forced financially to put them in a nursing home.

These steps may help ease the burden on state Medicaid budgets.

Thanks to AMA influence, the new law reduces administrative waste, which will lower office overheads and raise our office practice bottom lines.

And no more rejections for pre-existing conditions, or lifetime caps that bankrupt families fighting catastrophic illnesses.

While we did not get medical liability caps on non-economic damages in this legislation, we did secure AMA policy to test alternatives with a 50 million dollar investment annually for at least the next 5 years.

Passed by a Democratic Congress and signed by a Democratic president who happens to be an attorney. Conventional wisdom — and some past history — would not have predicted that.

Also in this new law were other provisions that were important, but not as heavily covered by the media and bloggers.

Our AMA successfully encouraged incentives for innovation in basic and clinical science, such as the Cares Acceleration Networks and health delivery research.

Our AMA successfully called for more funding for medical student loan repayment programs and increased payment for primary care, rural general surgeons and improving geographic disparities in payment for physicians in 42 states.

In the new law, our AMA successfully called for payment rates for primary care services for Medicaid patients to be at least equal to those for treating Medicare patients — a significant plus for pediatricians and others who provide primary care services.

But we know we need to continue to work for payments to cover costs for all specialists — and to make this policy permanent.

A decade ago, our AMA created the Physician Consortium for Performance Improvement to assure that the medical profession remains fully engaged in quality definitions and measure development.

In the new law, our AMA along with many others successfully advocated for needed funding for parts of the quality development and measurement infrastructure to work as it should.

You know them by their initials — NQF, AQA, HQA, QASC — all examples of the infrastructure our AMA has helped build.

I want to take a moment to personally and publicly thank the person who has been the most effective voice for our AMA policies in this quality arena.

I ask this House to help me express our deepest appreciation now for the dedication and wisdom she has shown representing us and our medical profession: Thank you, Dr Nancy Nielsen.

These were just some of the elements our AMA considered important, if not crucial, for any health care legislation.

We also blocked several provisions we believed would harm patients and physicians.

Taxes on cosmetic surgery. Expanding Medicare to persons at age 55. Stopping Medicare payment cuts for physicians if they order many tests or imaging — a real threat to those who treat sicker patients.

So our AMA helped get some provisions in — and keep some out.

In all, under the new law, our AMA has new avenues to work toward our goals in ways you may not have heard about, or thought about.

But some goals we did not achieve. And this led to a lot of disappointment, frustration and at times, fury.

One, the Medicare physician payment formula has not been permanently repealed.

Current payment is still 20 percent less than the real cost of providing care, based on what the Medicare Economic index would pay.

And this fatally flawed formula penalizes physicians for doing the right thing for patients — by keeping them healthy and out of the hospital.

Congress created this problem, still doesn't understand it, and continues to make it worse through temporary fixes, not permanent solutions.

This problem will only get worse next year, and the years to come with the Baby Boomers becoming eligible for Medicare.

Once face-to-face with this oncoming train, perhaps Congress then will finally allow balance billing and private contracting without penalty to help solve the financing problem.

I can assure you I have delivered this message time and again in Washington, DC, as AMA president — and have been met by resistance that is both bipartisan and bicameral.

Last week, we kicked it up a notch with an ad campaign using print, television and radio to hold the feet of Congress to the fire. It is critical that we increase the engagement of patients in this battle..

But we also need — all of you.

Our AMA is not some abstract idea or faceless entity. It's made up of people. It is you.

If we are to ask our patients to take responsibility for their own health — then it's up to us to take responsibility for the health of our profession.

Hold your members of Congress accountable for his or her votes — on issues such as repealing the SGR and making Medicare sound for our seniors. Step up your pressure on your Representatives and Senators. The AMA doesn't vote — our AMA doesn't have an individual member of Congress.

But you do. They represent you. They represent your patients. They will listen. You have their ear — so, if need be — give them an earful.

Not all of our challenges — are in Washington.

Our AMA has also been actively influencing issues that affect physicians outside of Congress, and unconnected to the publicized — and polarizing — arena of health system reform legislation.

Our AMA is quietly influencing the shape of health care in America through efforts such as the Healthier Life Steps program.

This patient-physician partnership helps physicians help patients eat better, be more physically active, avoid tobacco use and alcohol misuse.

We all know these behaviors are the leading causes of preventable illness and mortality among our patients. They also contribute heavily to the problem of spiraling health care costs.

The Healthier Life Steps is available online, free of charge, to both health care practioners and patients.

I was delighted to see our Medical Student Section choose it as their National Service Project. And last month, I was able to help kick off the co-branded program at the Texas Medical Association's annual meeting.

Take advantage of it. It might help save the life of someone you love.

A year ago in my inaugural address I noted that evolution occurs whenever systems are stressed.

Well, it's hard to describe our American health system as anything but stressed.

Demographic challenges, disease burdens, flawed payment mechanisms, liability fears, health delivery barriers.

All seeming to conspire to disrupt the system at a thousand places.

Now, we live under a new law. A new system.

The Patient Protection and Affordable Care Act — which includes AMA policies adopted by this House of Delegates over many decades — is a first step.

But it's not the last.

Our goal is to help make American health care perform at its peak for everyone involved — in every level of the system.

The last year has been interesting times for me, and for organized medicine.

And I emerge more excited and confident than ever

that the next 90 years — the balance of the 21st century — will continue to produce innovations in medical science and delivery that would boggle the minds of our forebears.

Since 1847, our AMA has played an important role in the art and science of medicine and the betterment of public health . And since then, it has evolved time and again. That will not change.

With Dr. Cecil Wilson well-prepared to pick up the torch on Tuesday, my time to help lead is passing.

But I know that the future leaders in this hall — our medical students, residents and young physicians — are more than equal to the challenge of steering us toward their own golden age of medicine.

The future is bright — if you accept that challenge with open hearts and open minds — and a spirit of doing what's right for medicine, our profession and our patients.

This annual meeting will be an historic one in the history of our AMA. We have new policies to discuss and a record number of candidates for president-elect and the Board of Trustees.

Most of all, I know these next four days will again demonstrate to the world the passion we all have for our medical profession.

It has been a humbling honor to represent you these last 12 months. And as I close, I ask you to always remember that the art of caring for patients — is caring for patients. Because from caring, comes courage. Be courageous.

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