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In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger is joined by the AMA’s newly inaugurated president, Jack Resneck, Jr., MD, a practicing dermatologist and health care policy expert in San Francisco. Dr. Resneck share his thoughts about the priorities and challenges for his upcoming term as president.
- Jack Resneck, Jr., MD, president, AMA
Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today we're joined by the AMA's newly inaugurated president, Dr. Jack Resneck, Jr., a practicing dermatologist in health care policy expert in San Francisco. We'll share his thoughts about the priorities and challenges for his upcoming term as president. I'm Todd Unger, AMA's chief experience officer in Chicago.
First off, congratulations. Dr. Resneck, your inauguration was last night. So today, day one of your new presidency. I know this is a very busy time for you, so we appreciate you taking time to talk with us today. You are taking the helm at a confusing time in the pandemic. We're definitely not out of it but we do have vaccines and new treatments that have strengthened our ability at least to avoid serious disease and hopefully large-scale deaths that we've seen over the past two and a half years. Given where we are in this context, what do you see as your biggest priority right now?
Dr. Resneck: Thanks, Todd. It's great to be here, and I agree, it does seem like we're in a new phase. I think rates of deaths and hospitalizations, fortunately, are well below their earlier peaks. But with this latest surge, the virus seems to be everywhere and there is so much we still don't know about long COVID and other aspects of treatment. It's really been, I think, a tough last two-plus years for the nation and for doctors and the profession in particular. But I have to say, I've never been prouder to be a physician. Who can forget those early images from the first few months of the pandemic of doctors sleeping in tents and in their garages to protect their families.
In the two years, we've had of physicians combating misinformation, whether locally in their own communities or nationally on television, patiently explaining the benefits of vaccination to their patients and doctors even facing some patients as we know in ICUs and emergency departments who were denying the realities of this virus, even as those patients were being intubated. Doctors have really put their lives on the line and they've been holding together a health care system that has been stretched far too thin. Sometimes I say with duct tape, basically. So one of my top priorities is really ensuring that our nation recognizes it's time to renew its commitment to physicians. I want to ensure that we have a profession that future generations will really want to join and I think we can achieve this through the AMA's Recovery Plan for America's Physicians.
Unger: We're going to talk a lot more about the AMA Recovery Plan for America's Physicians in the coming weeks but on this segment, talk about a few of the pillars of that particular plan. One of those is obviously built around supporting physicians and relieving challenges they face every day in caring for patients. It's this kind of load of burden, among which on the list is this issue called prior authorization. Talk to us a little bit about how prior authorization has affected you and your patients and why it's so important right now for the AMA to take the lead in fixing it?
Dr. Resneck: We really do have to get these burdens out of the way that distract physicians from what brought us all to medicine in the first place, right? Taking, taking care of our patients and prior auth doesn't only SAP, just countless hours of physician time. It delays care and disrupts care for our patients. Todd, I've only been in practice for about 20 years but I remember even in the early years of my own being a physician, when prior auth was focused on a few brand new, really expensive drugs and procedures where the evidence wasn't entirely clear yet. Now we've gotten to a place where the majority of drugs I prescribe are sometimes subject to prior auth and the average physician around the country, our data shows is doing 41 of these prior auths every week. It's an outrageous number.
I'm a dermatologist and I knew we'd hit a new low, when in my own practice I started having to do prior auths for generic topical cortisone, like triamcinolone. That have been around since the 1960s. I don't really know what the health insurer wants me to do in those instances. The system is so opaque. I think patients don't even realize that as a physician, when we're sitting at our computer and talking to them about their treatment, we often don't even know when we're prescribing what things are going to be on formulary, what things are going to require prior auth. So the patients first learn that they have a problem with their medication getting covered when they show up to the pharmacy and the pharmacist looks at them and says, "Hey, your doctor's going to have to work on this for a while to get your health plan to cover it."
So begins this arcane crazy process that involves faxes. What other industries still use faxes? What insurance companies then call, after rejection and an appeal, a peer-to-peer review, where you end up on the phone as a physician with somebody at the health plan. They say peer-to-peer but it's almost certainly not a physician of the same. Especially, I find myself explaining to somebody who's never even heard of the disease that I'm treating, what the condition is and why the prescription I've written for is appropriate. We know that patients sometimes just give up and abandon treatment in the midst of all this. It also really affects continuity of care. For example, I had a patient with really severe head-to-toe eczema, life upside down for years, no longer able to work, struggling to function as a parent.
In their case, they actually did need a newer biologic medication because they failed everything else and it was working great. This is a patient who they were a productive working citizen, again, paying taxes, their family would come in and give me hugs because it had really transformed their life and I had gotten it approved. A year later, the health plan said, "Oh, well, you need to do another prior auth because it's been a year." So I dutifully filled out pages and pages of paperwork explaining how great the patient was doing. It got rejected and their reason for the rejection was, "Patient no longer meets severity criteria."
So it becomes this Kafkaesque mess, and so we've put a lot of efforts into this and despite all this, the insurers haven't only ignored widespread calls for reform but they've actually opposed them. So we now have right-sizing prior auth at the AMA as a major legislative priority. We are supporting a bill in Congress to fix this for Medicare Advantage plans. We're working with states around the country on some innovative bills to try to get this under control. Prior auth is ... It's overused. It's costly. It's inefficient. It's opaque and it harms patients.
Unger: Listening to your stories. It triggered a memory of my first experience with prior auth, which was trying to get access to Accutane when I was in college and working with my dermatologist to do that. So what an important problem, an obstacle for the AMA to work on. One of the other things that you've been really vocal about is telehealth, really coming out of a slower growth period into the front burner here in the course of the pandemic and a really key part to keep what's been so great about that expanding and in process. And your specialty dermatology has really benefited from innovation in this area, which people may not have thought about at first blush. Tell us a little bit more about your experience with telehealth adoption and why you find it so important to advocate for its continued use for all physicians?
Dr. Resneck: Yeah. I agree with you. Telehealth has really been a success story in these otherwise very difficult pandemic years. We saw just rapid expansion early on in insurance coverage and real widespread uptake, not just in dermatology but across specialties. So before the pandemic, a typical patient who I would see, you mentioned Accutane, so a patient who was coming in on Accutane for their acne or a patient who has a complex autoimmune disease who might live two or three hours away. I might see them in person to get the diagnosis down and really talk through things with the patient the first time. But they were not allowed to do their follow-up with me where it would really make sense to do a telehealth follow-up to fine-tune their medications. Meanwhile, their insurer might cover them, going to some large web-based corporate telehealth provider for their follow-up. But at that time they wouldn't cover the patient following up with the health care team who actually knew them well.
So now patients can use telehealth with their existing health care teams and patients have really seen benefits, access, convenience, transportation time, as I mentioned, less missed work, not having to deal with childcare issues around coming to the doctor's office. On the physician side, we've really gained experience in every specialty in terms of figuring out, "Hey, these are the kind of situations where telehealth is really useful, like those medication follow-ups I mentioned and here are other instances where maybe it's not the best and it's better to see a patient in person." If I've got a melanoma patient who's coming in for a full-body check to make sure they don't have new skin cancers, not as easy a thing to do via telehealth.
We've still got work to do. Some of that expanded coverage is at risk and could go away. So we have to make sure that gets maintained. We have some treat tweaks and regulations to do around making sure, for example, if you've got an established relationship with a patient in your state and they go away, they travel for work or college or vacation, that you can continue to provide telehealth for them. And the FSMB, the Federation of State Medical Boards, has just released some great new proposals around that. I really want to make sure we deploy telehealth where it's most needed. Where do we have big gaps? I think that's around chronic disease, hypertension, diabetes, mental health care, as opposed to, again, what we were seeing years ago, which was just an expansion of quick, easy access, maybe through some of those corporate providers, when a patient wanted antibiotics, they didn't need or something.
Finally, I would say, I want to make sure we deploy telehealth with an equity lens from the beginning. I learned a lot in my practice these last two years during the pandemic offering telehealth about not just rural but a lot of other, even urban and suburban marginalized populations who didn't have broadband access or the devices to use telehealth as easily and in that case, being able to do just audio-only telehealth was really helpful. So we're working to maintain that.
Unger: Well, you are clearly very passionate about advocacy and particularly about policy related to some of the issues we talked about prior auth, telehealth. You've testified a lot on Capitol Hill on behalf of patients and physicians, and even before stepping foot in medical school, you got a degree in public policy. I'm curious how you see that kind of background helping you in your new role and thinking about how you frame the work ahead, and why it's so important for other physicians to join you in the AMA and thinking about hearing about these issues beyond the exam room?
Dr. Resneck: Yeah. Well, if you asked any of my friends and family who were in town for the inauguration these last couple of days, they would tell you I've always been a policy nerd and politics was a big part of the family dinner table growing up, and you mentioned my policy training background. But I think more than the content of that training being useful. There's some broader lessons, maybe, that I've taken from that experience. The first of which is people who show up, get to set policy. They're the ones who get to make change and that insider approach, being at the table. It doesn't mean that one has to be meek or apologetic of being at the table. It can be powerful and focused and really infused with purpose.
A second takeaway for me is that it's really important that we bring data and that's what we're really good at, at the American Medical Association. But we also know the power of storytelling and physicians have stories to share, and stories are really powerful. Stories about those things that need to change for us to be able to provide the best care for our patients and part of my job in this role as president is to ensure that those physician stories are amplified and heard.
Finally, I would say being just relentless in our efforts to accomplish those goals, even when we don't get something across the finish line in one given year, going back to Congress and trying again and not giving up, whether it's fixing Medicare payment or expanding patient access to care or keeping politicians from interfering in the exam room or criminalizing evidence-based care, whether it's in the realm of reproductive health or gender-affirming care, stopping the public health crisis of gun violence. There's so much to do and I'm going to be relentless in showing up to get those things done.
Unger: Well, speaking of stories to tell. You grew up in the South in Shreveport, Louisiana, and you've said that experience helped shape and influence your perspective and also your priorities. Tell us a little bit more about that.
Dr. Resneck: Well, I loved growing up in Shreveport, actually. Louisiana has great food, incredible music, beautiful scenery. Last night in my inaugural, I did speak about my deep commitment to our AMA's work in health equity. In my youth, I did also see racism. I saw inequities and certainly those are not unique to the South. I try to approach this topic with a great deal of humility. There are some people in your audience today who have far more health equity experience and expertise than I do and some who bring lived experiences that I do not. So I'm a little hesitant to answer your question and center my own experiences here but you asked, so I'll mention a few aspects.
I think among the many privileges that were afforded to me by birth was a family who really recognized inequities in our community and in some cases spoke up. I have an uncle, one of my dad's brothers named Myron and he started an anti-segregation newspaper with several friends in the 1950s, actually as an undergrad at Ole Miss. He was outed as a contributor after a few of these had been published and endured death threats and people shooting at his car on the highway. So he did actually stop publishing and when he returned as a medical student at Ole Miss, he was failed out for his views. I can't claim I shared his bravery and my understanding, I think of racism as a teen was pretty unsophisticated. It wasn't informed by adequate dialog with minoritized friends, for example.
But I did know enough at age 16 to sense that some things weren't right and I wrote an op-ed in our city's newspaper, for example, about the need to remove Confederate monuments from our courthouse law. That didn't go over so well in 1987. I was also influenced by stories of my great-grandmother. She was widowed, two young kids by actually the last great pandemic a century ago. And she in the 1920s applied to medical school and was accepted. But the misogynistic physicians in her town made their objections pretty darn clear and laid out threats that derailed her plans.
So again, I don't bring the lived experiences of many minoritized and marginalized colleagues but I hope that these narratives prepared me in a way to commit to a lifetime of listening and learning, and to participate in and support and amplify and continue to work towards a more equitable future. We have overwhelming evidence of appalling health inequities and I'm just incredibly proud to be part of an AMA that is reckoning with our past mistakes and deeply committed to achieving health equity.
Unger: Well, Dr. Resneck, I'm so excited about the year ahead of you. I'm going to look forward to talking with you many times over the coming year about how your presidency is going and the work of the AMA. Again, congratulations on your new position and best of luck this year. We'll see you soon. That's it for today's episode. We'll be back with another Moving Medicine segment soon. In the meantime, visit ama-assn.org/podcasts to look at all our videos and podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.