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COVERAGE OF THE 65TH AMA INTERIM MEETING

The doctors are in the house

News from the 65th Interim Meeting of the American Medical Association House of Delegates, held Nov. 12-15 in New Orleans.

» App Challenge: AMA announces winners
» Opening session: Medicare physician pay cut must be stopped now, AMA president tells doctors
» Slideshow: Scenes from New Orleans

Legislation (Committee B)

Delegates approve new scope-of-practice policies

Updated Nov. 15, 2011: Delegates adopted several scope-of-practice policies to ensure patient safety at medical spas and during invasive procedures and anesthesia services.

Delegates approved a resolution to ensure that cosmetic medical procedures performed at medical spas -- and in traditional care settings -- have the same safeguards as medically necessary services. The AMA also will advocate that cosmetic medical procedures, such as botulinum toxin injections and laser and intense pulsed light procedures, be considered within the practice of medicine.

House testimony was overwhelmingly in support of a new AMA Board of Trustees report that addressed physician scope-of-practice issues regarding invasive procedures. Delegates adopted policy calling for the AMA to advocate that interventional chronic pain management employing radiation, such as fluoroscopy, is within in the scope of practice of medicine and should be performed only by physicians.

Delegates instructed the Association to create model legislation prohibiting nonphysicians from performing fluoroscopy. Delegates also adopted policy calling on the AMA to convene a task force to develop guidelines for advocacy efforts regarding the appropriate level of supervision, education, training and provision of other invasive procedures employing radiologic imaging by nonphysicians.

The house also directed the AMA to identify and review states whose governor has opted out of the federal Medicare physician supervision requirements for anesthesia services. The Association would analyze data to determine if there has been an increase in patient access to services in those states.

In other action A national transition to a new diagnosis coding set would cause administrative and other problems for physician practices attempting to meet mandates forced upon them by federal health agencies, delegates said.

Delegates adopted policy to work to stop implementation of the new diagnosis coding set ICD-10, which would be used in place of the current ICD-9 standard for billing medical services. The Centers for Medicare & Medicaid Services will require all health professionals and facilities to transition to ICD-10 by October 2013.

The change would force practices to learn 69,000 new codes for billing purposes. ICD-10 is viewed as being more nuanced and providing a greater level of detail for what had led to an injury or illness. ICD-9 has 14,000 codes.

Alabama and Mississippi delegations, the American Assn. of Clinical Urologists and the American Urological Assn. introduced the resolution to stop ICD-10 implementation.

"The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients' care," said AMA President Peter W. Carmel, MD. "At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions. The timing could not be worse, as many physicians are working to implement electronic health records into their practices. We will continue working to help physicians keep their focus where it should be -- on their patients."

Delegates also voted to oppose any attempt to legally prohibit male infant circumcision.

"There is strong evidence documenting the health benefits of male circumcision, and it is a low-risk procedure," Dr. Carmel said. "Today the AMA again made it clear that it will oppose any attempts to intrude into legitimate medical practice and the informed choices of patients."

AMA Finance and Governance (Committee F)

AMA reaches out to physicians in growing segments of practice

Updated Nov. 15, 2011: The House of Delegates directed the American Medical Association to change a group practice advisory committee to a section in the AMA house representing physicians in integrated practices.

A report by the Council on Long Range Planning and Development examined a proposal from the Advisory Committee on Group Practice Physicians to transition to the Integrated Physician Practice Section. The report said physicians in integrated practices -- those organized in multispecialty or large single-specialty group practice -- represent a growing segment of doctors.

The proposed change stirred much debate on the house floor. Some delegates said integrated physician-led practices are the future of medical practice and that the AMA needs to be at the forefront, providing educational materials and representation to these doctors. But others said creating a new section would dilute existing sections and could disenfranchise individual members.

Delegates approved a resolution that calls for the AMA to work to become the lead organization for physicians employed by hospitals and health systems.

As a benefit of membership, the AMA will provide employed physicians with information and advice on matters related to their relationships with hospitals, health systems and other entities. The AMA will work through the Organized Medical Staff Section and other sections to address the unique needs of employed doctors.

In other action Delegates approved an AMA Board of Trustees report that provides an update on the alternative membership models project. The report stated that it will be necessary to improve alignment of member benefits, implement a more focused set of activities across the Association, and create a beneficial and transparent partnership with state and specialty societies.

Delegates say increasing AMA membership is crucial and that they are looking forward to hearing a final report on alternative membership models at the house in 2012.

"The fact this has been on the table off and on since 1994 tells us that we are still struggling [with] what sort [of] membership model works best for us," Chicago psychiatrist Shastri Swaminathan, MD, said in online reference committee testimony. He is an alternate delegate for the Illinois State Medical Society.

Medical Service, Practice, and Insurance (Committee J)

AMA supports new payment models to cover the uninsured

Updated Nov. 15, 2011: States must have the freedom to develop and test different pay models for covering the uninsured, the AMA House of Delegates said.

Delegates adopted policy advocating that state governments should be able to develop new models as long as alternatives meet or exceed coverage under an individual responsibility requirement and ensure patient choice to select a physician or private health plan.

The measure enhances existing AMA policy that advocates innovative pay models to cover low-income individuals, said Lisa Egbert, MD, an obstetrician-gynecologist from Kettering, Ohio, and a delegate for the Ohio State Medical Assn. The only difference was removing the distinction for low-income patients, which would broaden the policy.

"I think we all should have that option," Dr. Egbert said.

As states explore new ways to cover Medicaid patients and the uninsured, delegates also adopted recommendations supporting state efforts to develop payment models that provide quality and efficient care.

In other action Delegates adopted recommendations in a Council on Medical Service report advocating for new standards and safeguards to guide states as they develop and introduce health insurance exchanges. The report calls for the AMA to support new insurance exchanges. The AMA will advocate for physicians to be included in governing boards overseeing exchanges.

It's important for physicians to get involved on the state level, said Wichita, Kan., internist Donna Sweet, MD, chair-elect for the AMA Council on Medical Service. The Dept. of Health and Human Services would implement a federal insurance exchange in states that don't have exchanges in place by 2014. "State exchanges need to be in place; if not, the feds will be much more involved," she said.

Health insurance exchanges also should address patient churning among health plans by developing systems that allow for real-time patient eligibility information for medical practices.

Meanwhile, delegates discussed the option of using block grants for Medicaid programs. Block grants are not supported by some specialty societies, such as the American Academy of Family Physicians, said Douglas Henley, MD, an alternate delegate from Leawood, Kan., speaking on behalf of the AAFP. States would stop providing care once a block grant runs out of money.

"We do support reforms and innovation that takes care of the most underserved in our population," Dr. Henley said. "There are many ways to do that, that do not involve block grants."

Samantha Rosman, MD, a pediatrician from Jamaica Plain, Mass., said she doubted that the AMA would support block grants. She is an alternate delegate for the American Academy of Pediatrics.

These grants simply would not work in many states, such as Texas, because of large numbers of Medicaid beneficiaries and uninsured residents, said Bohn Allen, MD, a general surgeon in Arlington, Texas, and a delegate for the Texas Medical Assn.

In the end, the house voted to have the AMA make comments submitted to the Council on Medical Service about Medicaid financing available to AMA members.

Medical Education, Science, and Public Health (Committee K)

Drug shortages declared a "public health emergency"

Updated November 14, 2011: The American Medical Association House of Delegates called for speedy action to address the rising number of critical drug shortages that have affected medicines used in anesthesiology, oncology and many other areas of care. The problem is a "national public health emergency," according to language adopted by the delegates.

So far this year, 230 shortages have been identified, three times as many as in all of 2005, said Lee R. Morisy, MD, chair of the AMA Council on Science and Public Health.

The house adopted the council's report, which supports the 19 recommendations of a 2010 drug shortage summit convened by organizations representing pharmacists, oncologists and medication safety experts. These include offering tax credits for makers of critical drugs and requiring firms to have multiple plants making the same drug to forestall disruptions caused by quality or manufacturing problems.

"Our patients are suffering, unable to receive the vital medicines that they need," said Leah S. Mc Cormack, MD, a Forest Hills, N.Y., dermatologist who spoke on behalf of the Medical Society of the State of New York in reference committee testimony. "The patients of America need to hear from the physicians of America that this is an emergency. We really need the concrete steps on how to solve this problem."

On Oct. 31, President Obama issued an executive order to the Food and Drug Administration to widen mandatory reporting of critical drug shortages, give information to the Justice Dept. about potential price gouging, and speed up approval of applications to make the products. The AMA commended the president for taking action and will report progress on the drug-shortage problem at the 2012 Annual Meeting.

The house rejected a proposal made on the floor to call for eliminating Medicare's average sales price formula that some experts argue is to blame for the shortage problem. Delegates also voted down a measure that would have sought to penalize drug manufacturers that fail to remedy a shortage within 30 days.

In other action Amid news that Florida and other states have seen a large jump in the number of babies born addicted to prescription painkillers in recent years, the house directed the AMA to support physician education on the proper use of controlled substances.

"Prescription drug abuse is a problem for our patients," said alternate delegate David Welsh, MD, a Batesville, Ind., general surgeon who spoke on behalf of the Indiana State Medical Assn. in reference committee testimony. "It's of high cost to our patients, families and society. We're trying to combat that."

The number of deaths related to prescription opioids rose nearly fourfold between 1999 and 2008, the Centers for Disease Control and Prevention reported in the Nov. 4 Morbidity and Mortality Weekly Report.

The AMA will promote physician training and competence on prescribing opioids and other controlled substances, help doctors identify patients likely to misuse medications and encourage physicians to use the prescription-drug monitoring programs that are operational in 36 states.

The Council on Science and Public Health will issue a comprehensive report at the June 2012 Annual Meeting on how to prevent fraudulent prescriptions and improve prescription monitoring programs by making them functional across state lines and easily accessible at the point of care.

The house also took action to address the dangers of overradiation, calling for minimum educational and training standards for personnel operating medical equipment using ionizing radiation. The AMA signed on to the American College of Radiology's "Image Wisely" and "Image Gently" campaigns, which encourage ordering tests involving ionizing radiation only when necessary and using the minimum amount of radiation necessary when conducting such imaging studies.

Meanwhile, the house directed the Association to make expanding federal funding for graduate medical education a priority. President Obama's budget proposal called for steep cuts in that area, even as the Assn. of American Medical Colleges predicts that current funding levels will make it difficult for the nation to forestall a shortage of more than 90,000 physicians by 2020.

Constitution and Bylaws

AMA calls for research on organ donations for HIV patients

Updated Nov. 14, 2011: The House of Delegates adopted policy to support amending the federal National Organ Transplant Act to allow clinical research to evaluate the clinical risks and benefits of HIV-infected organ donation to HIV patients.

The Infectious Diseases Society of America introduced the proposal, noting that HIV patients are living longer and that transplantation with HIV-infected organs may be the best option for many patients with end-stage organ failure. Delegates said allowing these organ donations would increase the organ supply to such patients.

Meanwhile, delegates adopted policy that encourages each state medical society to develop a standardized form for advance directives. The form would be used by physicians and other health professionals as a template to talk about end-of-life care with patients.

In other action Delegates referred proposed ethics policy that would have given guidance on the role that physician treatment decisions play in overall health care costs. The Council on Ethical and Judicial Affairs report examined physician obligations to manage health care resources while meeting the needs of patients.

The report said a doctor's main ethical obligation is to promote the well-being of individual patients. But physician responsibilities also call for doctors to be prudent stewards of resources. To be good stewards, doctors should base recommendations and decisions on patients' medical needs and, when available, use scientifically based evidence to inform decisions, among other things, the report said.

"It puts physicians in no real danger or undue burden," alternate delegate Stephen Schwartz, MD, said in support of the report in reference committee testimony. The Warrington, Pa., psychiatrist spoke for the Pennsylvania Medical Society.

But several delegates said the report should be referred over concerns about the practical limitations of doctors making treatment decisions based on stewardship when they often are unaware of the costs of procedures.