Bruce A. Scott, MD, still recalls with crystal clarity the first time he stood before the AMA House of Delegates (HOD).
Back then, Dr. Scott was a medical student, and he rose to make a brief statement on that day in 1987.
He took his place at the microphone before the hundreds gathered for the meeting and spoke on behalf of the National Student Research Forum to thank the AMA Educational and Research Foundation (now the AMA Foundation) for providing a grant for the annual meeting at the University of Texas Medical Branch (UTMB) in Galveston where students can discuss student research papers in a scientific atmosphere. Soon enough, his 30-second time at the mic was up.
When Dr. Scott wasn’t speaking, he observed delegates from all over the nation, from a myriad of specialties, debate and discuss medicine’s most pressing issues. He saw them compromise, call for studies, reach conclusions and call for action on items in a way that would impact physicians and patients nationwide.
Dr. Scott was hooked.
Sworn in as the speaker of the AMA House of Delegates in June, Dr. Scott hasn’t missed an AMA Annual or Interim meeting since attending that first one as a guest three decades ago. He’s also the president of the Kentucky Medical Association (KMA).
Over the years, he’s chaired the AMA Resident Physicians Section (now the AMA Resident and Fellow Section). He’s served as the AMA Young Physicians Section’s delegate to the HOD and was the young physician representative on the AMA Board of Trustees. He has been president and a board member of the AMA Foundation. He’s been a member of the Kentucky delegation to the HOD for the past 17 years and has been involved in countless ways in the KMA, his specialty society and his county society over his career.
“I tell people I caught a disease 30 years ago, and I haven’t been cured since,” jokes Dr. Scott, an otolaryngologist who practices in his hometown of Louisville, Kentucky. He’s also a clinical assistant professor at the University of Louisville School of Medicine and the medical director of a multispecialty ambulatory surgery center.
Joking aside, Dr. Scott says organized medicine is his hobby—a hobby he wouldn’t have been able to do at this level without the support of his college sweetheart to whom he’s been married for more than 30 years or the partners at his five-member independent private practice.
“I enjoy it. I don’t play golf and I don’t watch much television,” he says. “It’s a way to impact our profession and patients beyond taking care of an individual patient’s needs in my office. Through organizations like the AMA and the KMA, you are able to take care of needs of all the physicians and all of the patients in the nation or the state. Together we can have an impact on the health care system.”
Dr. Scott has played a part in numerous AMA efforts to make health care better for the nation’s physicians and patients.
Over the years, he has been part of the AMA’s effort to sound the alarm to the dangers of health insurance company megamergers. Dr. Scott has helped ensure that physicians’ voices were heard as the government restructured the way Medicare paid medical professionals for the care they provide.
He has been vocal about the importance of the government continuing to fund Children’s Health Insurance Program, which provides insurance to children whose families make too much money to be covered by Medicaid but not enough money to buy insurance on the open market. And Dr. Scott has championed the AMA effort to make clear that the Affordable Care Act can be improved, but it shouldn’t be outright repealed without improvements being made.
“On a national level, we’ve been able to protect access to care and to protect the safety net programs,” Dr. Scott says.
He’s championed causes to improve health care at the state level as well.
In Kentucky this year, the KMA scored a big win with a prior authorization bill that, among other things, requires health insurers to give patients an answer about authorization within 24 hours in urgent situations and five days in nonurgent scenarios. Previously, patients could be in limbo for weeks to find out whether an insurer would approve a life-saving treatment.
And when it comes to maintenance drugs, authorization will now be valid for one year even if the dosage changes during that time, thanks to the law that takes effect Jan. 1, 2020.
“Now, physicians sometimes have to get authorization every month, or once a quarter, for medications that patients have been on and are working for them. They have to get prior authorization even if the dosage changed to a lower dose,” Dr. Scott explains. The law improves upon a system that “was harmful to patients and a burden to doctors.”
Nationally, health insurers and benefit managers have increasingly required physicians and other health professionals to obtain prior authorization before prescribing medication or providing medical services, and the KMA was able to draw upon prior authorization reform resources the AMA has gathered to help physicians make changes in the states. Model legislation, surveys and reports detailing the harm and burdens prior authorization causes and the need for reform, and a chart detailing laws states have passed are among the resources available at the AMA website and at FixPriorAuth.org.
Kentucky pushed for the prior authorization for a year and a half before convincing lawmakers that the bill was necessary to improve patient health.
When doctors first went before the General Assembly, lawmakers said physicians and insurance companies should work together outside of the legislative body. When nothing came of six months’ worth of talks, physicians went back to the General Assembly.
Dr. Scott relied on AMA research to educate legislators about the importance of a prior authorization bill, noting that a 2018 AMA survey of 1,000 physicians showed that 91% believed prior authorization negatively affected patients’ clinical outcomes and 75% believed prior authorization requirements can lead patients to abandon treatments. Physicians also reported they and their staff spend 15 hours a week on prior authorization. That’s nearly two business days a week on a task that takes time away from patient care.
“And a key to us getting the legislation was the impact on patients,” Dr. Scott says. “Two members of the Senate committee had personal experience of not being able to get refills because of prior authorization.”
Prior authorization is one example of how the AMA and KMA have been on parallel paths, Dr. Scott notes. Billing, tobacco, access to care, and obesity and diabetes also have been top priorities for both organizations. AMA surveys on these issues, along with model legislation, strengthen what the KMA’s working on. And the AMA has supported tort reforms as they’ve been challenged in the courts, including in Kentucky courts.
“It’s a symbiotic relationship,” Dr. Scott says.
Being part of organized medicine isn’t always about dealing with lawmakers and working to get legislation passed. As KMA president, Dr. Scott has also been part of initiatives to take messages directly to patients.
One visible effort was a “Focus on Flu” campaign in Kentucky in the fall of 2018 to get more of the commonwealth’s residents to immunized against influenza. Local TV news anchors were vaccinated on air during morning and midday news programs.
Kentucky's Commissioner for Public Health Jeffrey D. Howard Jr., MD, and Secretary of the Cabinet for Health and Family Services Adam Meier got their flu shots during the campaign’s kickoff press conference. More than 5,000 Focus on Flu adhesive bandages were distributed at community events and a website allowed patients to enter their ZIP codes and find the closest clinic offering vaccinations.
In the end, 54% of Kentuckians got flu vaccinations, up from 41% the previous year, according to a poll of adults in the state that was jointly funded by the two health-focused nonprofit organizations. “It’s not entirely because of the campaign, but it did help make a difference,” Dr. Scott says.
While the prior authorization bill is a huge win for physicians and their patients, Dr. Scott and the KMA will be back before the Kentucky General Assembly in 2020 to push for the passage of a bill that would prohibit insurers from requiring prior authorization for prescription drugs used to treat opioid-use disorder.
The Kentucky House advanced the bill this year, but the Senate failed pass it.
Kentucky has the eighth-highest opioid-overdose death rate in the nation. Any delay in access to medication-assisted treatment—even the 24 hour-limit set to go into effect next year—can mean the difference between life and death for a patient with opioid-use disorder.
“The biggest hurdle for treating opioid disorders is patients seeking help. If a patient comes in and a doctor says, ‘We have the medication to help you, but you have to wait a few days or even 24 hours,’ that patient may never come back in for the treatment or may overdose during that waiting period,” Dr. Scott explains. “The last thing these patients need is a roadblock.”
Dr. Scott is confident that the legislation can pass with more education and time next year.
From a practical standpoint, lawmakers will have more time to pass legislation. In odd-numbered years such as 2019, the Kentucky General Assembly only meets for 30 days. In even-numbered years, the Assembly meets for a full session. And as other states have passed similar bills, there is concrete evidence to demonstrate these laws save lives.
“I think we will get this passed next year,” Dr. Scott says. “This is a problem that crosses all economic, race and gender lines. These are people who go to your church. There is a need in the community, and we will have more time next year to take the message to lawmakers.”
At the national level, care remains too far out of reach for too many. “Every day we see patients who can’t afford care because of high deductibles,” Dr. Scott says. “For many patients with a $6,000 deductible, it may as well be $1 million because either way they can’t afford it.”
He says outreach should improve to help raise patient awareness of the safety-net options available to them and that pharmacy pricing needs to be more transparent. Also, Dr. Scott adds, there is more work to be done on the tobacco front, including state and national legislation that would raise the buying age for cigarettes and e-cigarettes to 21.
“And,” he says, “as the prior authorization law goes into effect in Kentucky in 2020, we need to remain vigilant about making sure it is enforced.”
Juggling it all can be wearying. Dr. Scott concedes there are days where he comes home after a long day of surgery, and it can be challenging to think about the editorial he needs to write, or the news media interview for which he needs to prepare. But he knows it is that effort that will help improve patients’ and physicians’ lives.
“When we move the needle on an issue—that’s what keeps me going,” he says. “It’s knowing that it is going to result in a change that makes a difference.”
For example, when he first got involved in organized medicine, Joe Camel billboards still flanked high-school campuses. The first medical resident contracted HIV after a needlestick incident. Resident work hours had not been reformed. There was no guaranteed health insurance or disability insurance for residents.
“We made a difference on those issues,” Dr. Scott says. “Rather than each of us pushing one institution to change, we could make a change at the national or state level to impact all those physicians and patients.”
And he encourages other physicians—especially young physicians—to get involved to make their impact felt beyond the exam room.
He recognizes that it is a challenge to do so early in your career—you are trying to get a practice established, likely have a young family and are in a new community. As a father of three young adults, Dr. Scott hasn’t forgotten what it was like to manage those demands.
“Sign up. Show up. Step up and you will move up,” he advises. “Organized medicine is hungry for young leaders. If you show up and are willing to get involved, we will mentor you.”
It can be at the local, county, state or national level, Dr. Scott says.
“Find your passion and get involved. Physicians are looked to as leaders in the community. They need to get out of the exam room and be a visible part of the community,” he says. “You can’t just sit in the dark and complain. You need to get out there and be part of the solution.”
At that 1987 House of Delegates meeting as a wide-eyed medical student from UTMB, Dr. Scott knew he wanted to be HOD speaker one day.
He watched AMA House Speaker John Lee Clowe, MD, and Vice-speaker Daniel ("Stormy") H. Johnson, Jr., MD, preside over the powerful, evidence-driven body that advocates for patients and physicians.
“I remember watching them up there leading the charge and knowing when they were finished they would make sure there was follow-through on what was passed,” Dr. Scott says.
Now Dr. Scott is the one with the gavel, presiding over 640 physicians and medical students who comprise the policymaking body that convenes 190-plus state and specialty medical societies and other critical stakeholders.
“I can’t think of a better position,” he says.