Federal Advocacy

AMA Annual Meeting 2024: Advocacy progress on Medicare payment reform, prior authorization and more


AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

AMA Senior Vice President of Advocacy, Todd Askew, provides an update at the AMA Annual Meeting on the advocacy efforts of the AMA so far this year on the top priorities for physicians. AMA Chief Experience Officer Todd Unger hosts.


  • Todd Askew, senior vice president, Advocacy, AMA

Your Powerful Ally

The AMA helps physicians build a better future for medicine, advocating in the courts and on the Hill to remove obstacles to patient care and confront today’s greatest health crises.

Unger: Hello and welcome to the AMA Update video and podcast. Today we're coming to you from the floor of the AMA annual meeting in Chicago, where we'll get an Update on the AMA's advocacy priorities from our Senior Vice President of Advocacy Todd Askew. I'm Todd Unger, AMA's chief experience officer. Todd, welcome.

Askew: Good to be here.

Unger: Well, we're sitting in a big empty room. But in a day or so, we're going to see over a thousand physicians, students, all coming together to talk about health policy. Why is it so Important what goes on here in this room?

Askew: Todd this is, in my mind, two opportunities a year with that meeting of the AMA House of Delegates, where all of medicine can come together, build consensus on some of the most important issues, talk about solutions and kind of, quite frankly, give us our charge, and give us direction, information, feedback as well to keep us on track and to really set the agenda for the coming year for the AMA, but also working across all of medicine with our partners in the federation. It gives us that direction. So it's really, really important.

Unger: And we've heard loud and clear from the House and from physicians out there about the issues that they really care about. Let's start with a big one, and that is Medicare—continues to be a top priority for our advocacy work. Tell us a little bit more about what's happening there.

Askew: So just over two years ago, you'll recall, we came together 124 states and specialty associations around a consensus document on the direction Medicare payment reform should go. At the time, policymakers essentially were dismissive. We're not going to deal with doctors anymore. We're not—you guys are fine.

But through a lot of hard work, a lot of meeting with policymakers, a lot of grassroots communications by physicians, the attitude on Capitol Hill has changed completely. There is now a broad consensus in Washington that this is one of the most important issues that needs to be tended to in all of health care. And consensus is building around the solutions as well. I think we know it's not going to be easy. There's some very difficult decisions that will have to be made, some tradeoffs that will have to be made. But I think for the first time, really we've seen this in the last few months even, that across the board there is agreement.

We just saw in the last few weeks the Senate Finance Committee, which is the main committee of jurisdiction in the Senate, released a white paper on options for Medicare physician payment reform. That very much follows the outline of what we have been talking about for the last two years. The chairman of the Senate Finance Committee said in releasing the white paper, if the system is not working for doctors, it's not working for patients. And it needs to be fixed.

And so it can be frustrating. We have a bill. Why isn't the bill passed? Unfortunately, that's just not the way things work. But I think we're on a very—we're on a very good path to tackling this very difficult problem. And we really look forward to the rest of this year, continuing to build that momentum and probably into 2025 looking for some real solutions.

Unger: Todd, were you surprised by how fast it went from we don't want to talk about it, to the progress that you've made right now? And how does that happen?

Askew: So I think in Washington time, it was fast. I think for most people observing from the outside, it's been excruciatingly slow. But over two years, a complete change in attitude, I'm not terribly surprised. A lot of effort went into this by a lot of people, not only all the physicians here in the House of Delegates operating through their grassroots system, with their states, with their specialties, through the AMA systems. A lot of earned media, a lot of paid media, a lot of other resources have been invested into this.

And so, no, not terribly surprised. Really pleased, though, because this is really the first of several big hurdles. And to get over this one, to change attitudes, and to get everybody kind of agreeing on the problem is really the most important first step you can take to getting to a solution.

Unger: Now, when we talked at last annual meeting, one of the things that you spoke about was the need for changes with the MIPS program, Has there been any progress on that front?

Askew: So there has been. This has been—it's a very complicated program, unnecessarily so. That's what happens when it's born of the bureaucracy, essentially, with just a little bit of guidance from Congress. But through a Medicare working group that we've run with multiple states, multiple specialties, we have finally built consensus and drafted a draft piece of legislation that we're talking with members of Congress now that would make some fundamental changes to the program.

There's three really ones that I guess I would highlight. One is we get rid of this tournament model. Right now, the way it works is all the people that get penalties, pay bonuses, the money goes to pay bonuses to people. And so you eat your own. You have to have losers to have winners. That's a huge problem.

The way the rest of quality reporting and other health care sectors goes, you get an update each year. And then if there's a penalty for quality, you get a tiny bit less, but you're still getting a positive update. So if we get to a point where we have regular positive updates for physicians and Medicare, you can impose quality incentives on top or underneath that update but still not having people fall further and further behind, still not making sure that you have to have losers to have winners. So that's a critical change.

Another critical change in the MIPS program that's needed that we've kind of worked on is data. Right now, physicians need data to be able to assess their quality, to assess if they're making improvements. The lag for data is almost two years. So you're getting data for stuff you did two years ago and you can't use that to improve your quality. CMS is supposed to be providing timely and actionable data. And so this would kind of put the screws to them and tell them, you've got to provide this data, or you can't penalize physicians at all if you're not giving them the tools that they need.

And the third is the measures themselves. Most physicians that I've talked to just they don't see any clinical relevance in the measures that they're reporting. And we know from the studies that the program does zero to improve quality, that it is essentially the same as the random sample in terms of quality improvement. There's no impact. And so more relevant actionable measures that make sense to physicians that actually you can say, if I do this, this is how care is going to improve. Those are kind of the three main components of what we're hoping to move forward in MIPS.

We're getting some very good reception on Capitol Hill, because the changes just make sense. But that is a big piece of going forward. There are some that would say eliminate the MIPS program altogether. It's unlikely, however, that Congress is going to eliminate it and have nothing in its place. They're going to try and create something else. And I think it's much better if medicine builds consensus and says, this is what quality should look like, as opposed to leaving it to Congress or the bureaucracy.

Unger: That sounds like a good plan. Well, let's switch gears and move to a topic that is near and dear to the hearts of physicians, and that is prior authorization. We had a big win back in January with the CMS final rule. What's been happening since then?

Askew: So this drumbeat over years has produced what we saw in regulation. Again, you define the problem, you build consensus, and eventually things start to fall in place. That's what happened when this final rule came out. There was a broad recognition that, at least as far as CMS can regulate, the plans that the government regulates, they were going to take some important steps. Is it the full solution? No, it's an important step forward, absolutely.

The next thing we're working on right now, there's two things really. One, codify those wins, because, if you move to another administration or further down the road, they could come back and change it and take all that away. So let's codify those wins, put them in statute. We expect literally in a couple of weeks, we'll have that bill reintroduced and are very hopeful that we can get it with a very low score this time. And we'll be able to make progress, get that bill, get those things written into law, not just in regulation.

The second thing we're seeing is a lot of work in states. We've had more than 10 states this year that have passed prior authorization regulations and laws of their own. And their reach is even broader, in a lot of cases, than the federal government can. in terms of the employer sponsored plans, a lot of them that they can regulate at the state level. So that is where a lot of this action is going to happen. And there's been a lot of enthusiasm for some of these reforms like gold carding programs in the states. And so we are continuing to work with them to help advance those priorities as well.

Unger: All right. One of the other key areas of focus is around technology. No shortage of discussion about that, with the real focus being how do we make technology work for doctors, not vice versa, and how do we make it an asset, not a burden. Tell us more about your efforts there.

Askew: Well, it's kind of a—there's a broad range of efforts. One I would highlight, though, is telehealth. So telehealth has really changed the way a lot of folks practice or has the potential to. But there's a lot of uncertainty because the statute that allows it to be provided for in most cases under Medicare is temporary. It's not a permanent part of the law. And it needs to be extended every few years.

Right now, and we're working very hard to convince them otherwise, but the congressional budget office says it is extremely expensive to do it for a lot of reasons that we think they're just wrong on. But regardless, that is what it is. So just recently, we had a House committee report out a two year extension for telehealth, along with a five-year extension for the hospital at-home program, which uses a lot of these modalities to. Care for patients in the home instead of instead of the hospital.

We think both of those things will get done at the end of the year. They're very likely to be in a year-end health care package. And so I think we'll see that stability, and we'll just continue to work with the folks and with everybody across the federation to provide permanent authority for the provision of telehealth services under Medicare, which is really critical. Because if you're really going to lean into this and make this part of your practice, you're going to need some certainty before you make the investments. And so temporary extensions, good, that care keeps flowing. But really permanency is what's needed to allow physicians the certainty that they can make this part of their practice and make the investments that are necessary.

Unger: Absolutely. Now, on continuing on the technology front, of course, one of the big topics that is hotter than ever is AI. Seems to be moving at just such a rapid clip in terms of discussions in health care. Talk to us a little bit about what physicians need to know in regard to advocacy around this issue of AI.

Askew: It's like you said, it is everything. It touches everything. Every time we sit down to talk about AI, there's another entire issue. Or the algorithms, do they have equity problems? Right. Who's liable? If AI suggest you take one course of treatment for a patient and you do it, but it turns out not to be right, are you liable? Or is the AI liable?

Or what if AI tells you one thing and you use your clinical judgment to say, no, I'm going to go a different way, and you were wrong, but the AI was right. I mean, so there's these all the very difficult questions. And unfortunately, Congress is not a very good venue for figuring out some of these answers. There is a lot of talk, there's a lot of effort to come up with working groups that. The administration has put out executive orders, ordering a lot of reports and studies and recommendations. But nobody really has yet gotten a handle on exactly, exactly where they're going to engage first. It's a little bit of everything right now.

I think probably one of the first areas we'll see some significant regulation in AI is how you apply AI to drug development and the FDA issues. And can you accelerate? How much can we accelerate the development of new drugs using AI, instead of the models we have now? So that'll be a fascinating area to watch, but there's literally no area of health care or life really that I think AI is not going to touch. And right now, Washington is still in the figuring-out phase.

Unger: Lots more to look forward to on that front. Well, the last topic I want to talk to you about is around scope of practice. We've been supporting state medical associations in their advocacy efforts throughout the year. Tell us a little bit more about the AMA's work in this important area.

Askew: Sure. So we've had success in more than 50 different bills over the past year. It's a little quieter than last year. Last year was very busy. You have some states that are not in session this year, so there hasn't been as much opportunity. But when we talk to physicians, this still remains one of the most important issues to them, because what they see is the deterioration of the health care team. And I think most physicians know that that team, right, everybody contributing is critical. That's the best way to deliver health care, with a physician at the head of the team.

And when that starts to break down, you have problems in terms of quality of care, in terms of cost, and it really can also lead to a lot of burnout, too, as we struggle to find the right roles and things like that. So it continues to be such an important issue for so many reasons. And it's a fight that we'll keep—that we're going to keep fighting, because that's where our members, that's where physicians need our voice.

Unger: Had a chance to talk to leaders in Texas and Mississippi just in the last month about scope of practice issues. It's amazing how many scope expansion bills they face just at the state level. Are people aware of like where this action is? And how is the AMA helping there?

Askew: Yeah. We continue to consult. We write letters in support or opposition of different bills we work with. We testify in front of state legislators. We communicate with state legislators in coordination with the state medical associations. Texas last year, I think defeated over 100, just in Texas alone. And so it is not as if there's one battle. It's a constant churn of legislative things.

A lot of them are—they're pretty much the same. A lot of them, the same specialties trying to do the same thing or the same type of providers doing the same thing in different states. And so we have a very good road map. We stay in very close communication with our colleagues in the states on how we can be supportive of their efforts. And in a way, it's a very good formula.

We also have, I'm sure you're aware of the Scope of Practice Partnership grants, where the AMA, I think this year, we have over $600,000 in grants to go to states for very specific purposes. Sometimes they need to hire an extra lobbyist. Sometimes they need a media campaign. Sometimes they need to hire a consultant or somebody to help draft something to help support those efforts. And so that's a very important program where the states especially get together and pool their money. AMA pays for about half of it. The other comes from the federation. And then we give grants out to folks that need it for very specific battles. And it's proven a very successful model.

Unger: And so important. Lots of busy days ahead here in the House of Delegates. Is there any particular policy debate that you're keeping an eye on?

Askew: No, I mean, obviously, we want to hear what the top issues are. We want to hear what physicians are experiencing. We certainly hear a lot about government interference in the practice of medicine and how is that impacting their practice. There's certainly a lot of economic issues. There's a lot of issues around consolidation, unionization, non-compete agreements. So, I mean, there's a lot going on in health care right now.

This is our opportunity to hear and learn from the delegates and for the delegates to come together and build consensus on how we should tackle some of these issues.

Unger: Well, Todd, thank you so much for all of the work you do on these important issues. This kind of advocacy is how we fight to support physicians. And you can support our work by becoming an AMA member at ama-assn.org/join.

That wraps up today's episode, and we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/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.

Subscribe to AMA Update

Get videos with expert opinions from the AMA on the most important health care topics affecting physicians, residents, medical students and patients—delivered to your inbox.

AMA Update podcast logo