Moving Medicine
How the AMA is fighting for physicians and patients in Washington, Part I
Mar 21, 2023
Featured topic and speakers
In part one of this conversation, you'll hear from AMA President Jack Resneck Jr., MD, and Jason Marino, director of AMA Congressional Affairs, about AMA’s advocacy on Capitol Hill and the issues discussed as part of the AMA National Advocacy Conference earlier this year. The conversation is lead by Sandra Adamson Fryhofer, MD, chair of the AMA Board of Trustees.
Moderator
- Sandra Adamson Fryhofer, MD, chair, AMA Board of Trustees
Speakers
- Jack Resneck Jr., MD, AMA president, about his experience being a physician leader pushing for change
- Jason Marino, director, Congressional Affairs, AMA, about the power of physician voices at the AMA National Advocacy Conference
Host
- Todd Unger, chief experience officer, American Medical Association
Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.
Transcript
Unger: In today’s episode of Moving Medicine, we’ll hear from Dr. Resneck and Jason Marino, director of AMA Congressional Affairs, about AMA’s advocacy on Capitol Hill and the issues discussed as part of the AMA National Advocacy Conference.
At this annual conference, physicians connect with industry experts, political insiders and members of Congress on current federal efforts to improve health care. There, they can advocate on crucial health care issues affecting their patients. Dr. Sandra Fryhofer, chair of the AMA Board of Trustees, leads the conversation in this two-part series. Here’s Dr. Fryhofer.
Dr. Fryhofer: I'm Dr. Sandra Fryhofer, AMA Board chair, and I'll be your host for today's session. We're going to take a closer look at important advocacy issues AMA and others in organized medicine are working on at the federal level and solutions that may be on the horizon. The 2022 Omnibus bill included some positive developments for physicians, one of which is on telehealth. The bill extends telehealth payment and regulatory flexibilities for two years. It extends the bonus for APMs—Alternative Payment Models—at 3.5%. It also delays the scheduled increase in the revenue threshold, and as a reminder, for the first few years, in order to receive an APM bonus, physicians had to get at least 50% of their revenue from patients enrolled in APMs in order to qualify. That revenue threshold was supposed to go up to 75% this year, but since no current APMs would qualify, Congress kept the threshold at 50%.
For physician mental health, there also is some progress. This new law adds an exception to Stark. Hospitals and other entities are now allowed to provide evidence-based programs to boost physician resiliency in mental health and to help prevent suicide among physicians. The bill also has an additional and welcome benefit for pregnant people covered by Medicaid. The new law provides a permanent option for states to extend Medicaid coverage for 12 months postpartum. But for many and probably for most physicians, Medicare payment reform is top of the mind as we welcome a new Congress in 2023.
AMA was instrumental in spurring Congress to act at the end of 2022. We were able to alleviate more drastic pay cuts scheduled to kick in, but physicians now still face a 2% cut for 2023, delivering yet another financial blow for physicians, especially for independent practices already stretched thin by staffing shortages and high inflation. Physicians continue to bear the brunt of our nation's flawed and unsustainable Medicare payment model. Adjusted for inflation, Medicare physician pay dropped 22% between 2001 and 2021. This downward trajectory has already forced some practices to reduce their hours and lay off support staff, while pushing others to the brink of closure.
The fact that losses could have been worse this year misses the point. Physicians shouldn't have to face these annual financial cliffhangers year after year. We shouldn't have to worry if our practices will survive another year because of payment cuts that are beyond our control. As with all other issues in health care, it's our patients who suffer the most. Patients lose access to vital care when a physician practice closes or has to reduce its hours.
We’ll discuss these and other issues in greater depth and will also highlight next steps in our advocacy work for this year. Joining today are AMA experts as we talk about advocacy and the macro and micro, from what it's like to be a physician leader at this difficult time for medicine, to what our on-the-ground activities look like as we seek to inform and educate lawmakers on issues, and ultimately influence their policy positions.
Our first panelist is our AMA President Dr. Jack Resneck, the public face and the voice of our AMA on these issues and so many more. Dr. Resneck has been an AMA trustee since 2014. He's a nationally recognized leader in health policy and also in dermatology. Dr. Resneck, if it's OK with you, we're going to go by first names today. So welcome, Jack.
Dr. Resneck: Thanks, Sandy. And you can definitely call me Jack.
Dr. Fryhofer: And Jason Marino, AMA's director of Congressional affairs. In this role, Jason's responsible for lobbying Congress on AMA's federal advocacy priorities. Jason's a strong and passionate advocate of AMA policy, and I'd love to hear his story, so welcome back, Jason.
Marino: Thank you. I'm happy to be here.
Dr. Fryhofer: Let's get started and here's the plan. I'll begin with some questions for each of you to set the stage, then we'll move to questions. But before we take a deeper dive into some of these issues, let's begin with some words of wisdom from our AMA president. So Jack, we'll start with you. Please explain why our physician voices are so critical in advocacy. We'd also love to hear about some of your experiences as AMA's top position leader.
Dr. Resneck: Well, Sandy, thanks for the question, and thank you for your leadership as board chair. I also really appreciate your mentioning in your opening remarks critical issues like Medicare payment reform, which are under the umbrella of our Recovery Plan for America's Physicians. These are issues which are such enormous threats to physicians and our patients, and issues on which AMA is really so focused in partnership of course with state medical societies across the country and national specialty societies, as well.
You asked about individual voices, and they really are critical to humanize our priorities and to add stories that can be more than just statistics as we talk with lawmakers. I know we probably have a variety of experience levels in terms of people coming to Capitol Hill and talking to their lawmakers and also doing the same in their districts. I just think that's even more true right now in terms of the importance of our own voices.
This year, one of the things that has me deeply worried and that I've really used as an organizing principle for a lot of my thinking around what needs to happen, is this issue of physician burnout. And we know the stats about the soaring numbers. You've probably all heard that burnout symptoms among physicians jumped from about 38% to 63% in the last couple of years, that one-in-five physicians are seriously considering retirement in the next two years and that does leave me worried.
We know what drives these statistics. We know that there's fallout from the pandemic. We know that there are growing administrative burdens like prior auth. We know that there are states trying to interfere in the doctor-patient relationship. We know that there are threats to practices, like falling Medicare payment, at this time of major inflation. And the answer really doesn't lie in just telling physicians to buck up and be more resilient or do more yoga. Wellness is important, but the real answers lie in getting those systemic burdens out of the way so we can get back to what drew us all to medicine in the first place.
So as I said at Interim, we need to fix what's broken in health care and it's not the doctor. So when I'm talking with a policymaker, whether it's about Medicare payment or prior auth or scope creep or anything else, I keep coming back to that framing, and largely, they get it. They know physicians have put their lives on the line these last three years, they understand inflation, and frankly, most of them have been the victims themselves of some out-of-control prior auth thing from a health plan. So I think it is really helpful to bring our stories.
Dr. Fryhofer: I think all that is so true, Jack. And as a follow-up, I want to ask you this. With the political divides across our country, what are some unifying themes that you've had success with on your various visits on the Hill?
Dr. Resneck: That's a good question. The last several years have, no doubt, been a somewhat politically fractured time in our nation. And as I think about our work, as American Medical Association, it used to be such a small percentage of what we worked on got politicized or viewed through partisan lenses. And as we saw with COVID prevention or vaccines now, such a big percentage of what we do ends up seen through those lenses and no doubt, that does present a challenge as we try to message our policies and our priorities.
But we're not a partisan organization. And I work hard to hammer that point home whenever I'm with policymakers. We're here to advance the health of the nation. And I'm going to work with anybody any time of any party, if there's an opportunity to align with our AMA policy and help physicians and help patients.
So sure, any individual policymaker, you're going to run into―just as you would with any physician―some individual policy of AMA that maybe they don't agree with. But I really try to focus on our policymaking process and make sure they understand that and why we speak for the profession. And that our policy is not just made up by me or you or our board or our management team. I talk about that House of Delegates, where we really gather physicians representing every state medical association, every national specialty society, from urban areas and rural areas, and docs in tiny independent practices and employed in huge settings, and across the political spectrum―and then we have open, science-based debate. And that really clears the air and I think allows me, in a meeting with a member of Congress or anybody else, to focus on our policy priorities and the shared goals that we might have with that lawmaker.
Dr. Fryhofer: Jack, thank you so much for sharing those experiences and your insight. And you've worked so hard for us this year and are continuing to work hard, as well. There's many more months to go before we're going to let you off the hook as being our AMA president.
Jason, this next question's for you. Can you give us a sense of the congressional landscape, where it stands now and what we can expect in the year to come?
Marino: Sure. Well, at the beginning of every new Congress, who controls C-SPAN’s staff gets to control where the cameras go, not the speaker. Until you get a speaker, C-SPAN staff gets to control it because usually, when there's a speaker, they make it focus on whoever's speaking at the time and they want to keep it boring. But when this Congress started, we had a historic 15 votes to get a new speaker, and you could see all the side conversations and whoever thought that a C-SPAN 2 viewing would have higher ratings than a Georgia football game. But that's kind of what the country saw and that's how we've begun the 118th Congress. It's taken about a month to get the Senate organized just with committees, et cetera, so it's a slow start.
And I'll say big picture, the zeitgeist of the moment has changed. The 117th Congress was COVID, was trillion-dollar bipartisan bills on infrastructure, on COVID-related and then a series of partisan bills, a trillion dollars apiece on some of the ruling party's priorities. And now, here we are, 118th Congress with now divided government and the conversation has changed to we're in a time of historic inflation and we have a debt limit that we're now under extraordinary measures—we're under extraordinary measures because of the debt limit, which is $31.4 trillion, and it's got to get increased. And the extraordinary measures may last until June and then it's the moment of truth where, what happens?
And the divide is, on the Republican majority side, we've got to do something about this debt. We've got to try and balance the government in 10 years, the budget in 10 years. We have to stop the $2.4 trillion deficits. On the Democratic side, it's well, we already spent this money and we just got to pay our obligations, and we shouldn't be cutting Social Security and Medicare to do any of this stuff. And then you have the counter, but we're not going to touch Medicare and Social Security.
And it's high stakes and it reflects the divide in this country. We're a very divided country and the constituents are telling their members—and you've got to hold the line here on both sides. And so the members are in this dance where they're trying to negotiate or not on the debt limit and the deficit. And so in this environment, a divided government and people have staked some lines out here now, things that need to get done are appropriation bills, usually towards the end of the year.
And there's been shutdowns in the past when there’s divided government, and you had these big debt limit debates. Sometimes, the funding bills for the federal government don't work out by the October 1 deadline each year and there's sometimes a temporary delay or not. We don't know if we're headed to that. There's always the defense bill that has to get done. It's always gotten done for 50-plus years. There's a farm bill that's usually bipartisan that needs to get done, and now with the China balloon, there's probably something on China, so that's out there. And then where does everyone else fit in, other priorities, especially priorities that spend money? And so you always hear about it's the worst climate ever in Congress. Well, this really is one of the worst climates ever, and it's not an exaggeration.
Dr. Fryhofer: Wow. Thanks for setting the stage as to what you're dealing with on the Hill right now, but I've got one more question for you, Jason, before I let you go. Can you talk about some of the issues that will be addressed and why they're so important?
Marino: The three big issues we're going to talk about are Medicare physician payment reform. We're going to talk about the scope of practice issue and as Dr. Resneck mentioned, scope creep. And then we're going to talk about physician workforce issues. But I want to spend most of my time right now on the real big one—the real big issue—and it's the Medicare physician payment reform and where we go in this new 118th Congress.
I just painted a picture of how difficult it is, and we do have—I'm going to lay out a four-point plan to reform the Medicare physician payment system and it starts with diagnosing the problem of what is wrong with Medicare payment system, with MACRA—that's the bill that governs the program for Medicare payment system. And you don't need ChatGPT or A.I. to tell you what's wrong with the problem, it's there's no inflationary update―at all.
The last 20 years, because of that, it's been a 22% real dollar decline when you adjust for inflation. We're in a time of historic inflation and going forward, it's going to be 0.25, not 2.5%, 0.25%. That's laughable. That's not … how do you pay your staff? How do you innovate? How do you go forward with that? So that's a big issue right there. Other providers all have it in statute, they have an update. So we've got to get that fixed.
The second part is alternative payment models. They have a lot of promise. In the new innovative models for care, there was incentive payments to help these come online. Unfortunately, in 2015, when MACRA passed, the promise of all these APMs would come online for all different specialties, all different types, and they were going to be promising and save money, and that would be a win-win. It didn't really happen. It happened somewhat in the ACO—Accountable Care Organizations—that came online that have had some success. It just hasn't been as broad as we'd like. And all of those bonuses are all going away—these incentive payments—and we've got to get those incentive payments continued and find a way to keep the pipeline going so there's new APMs for every physician of all types. That's important.
Then the third is the MIPS program. Right now, because of COVID, it's kind of been on pause, but it's like a Hunger Games in that you get a MIPS score, and then if you don't—if you get a good score, you might get a little bit of bump up. If you get a bad score, you get cut and it's a zero-sum game. And there's winners and losers, and it's not always the fairest system. It's been on pause, so physicians haven't felt it fully yet.
And then there's quality metrics that―are they really, the right metrics? Are you checking boxes or are you really innovating? And the CMS, do they have a right? There's a lot of questions there and a lot of room to reform that and make it work better.
And then, finally, why do we have these cliffhangers every year? What's going on? You probably wonder. And it's every year the physician payment rule that comes out and they can modify payment. They increased payments for E&M services, but every time you increase it somewhere, you do an across-the-board cut to every service to pay for it because it has to be done in what's called a budget-neutral way. And this has been happening, and it's been triggering significant cuts for non-E&M services.
And we've been trying—and we've gotten some success the last few years to get some amelioration to get those cuts addressed, but we're hearing from Congress, “No, that's it―we're not in the business of dealing with this every year.” And we're saying, “Well, let's fix it, then. Let's fix the budget neutrality problem. Let's go from $20 million that was written in 1989, probably at some late-night deal for the OBRA bill—some big bill they put together in the '80s—and this $20 million never got updated to inflation. It should be $100 million. Let's make it $100 million.”
Things like dental—new codes maybe that deal with dental or things that are non-vision related―why is that triggering budget neutrality for physician services? That doesn't make any sense. Let's stop that.
And then let's find a way—historically, CMS, when they estimate a new service, they tend to overestimate and then it triggers bigger cuts than are necessary, and they never look back. It's just ... the cut is built in and, oh, well, everyone moves on except those who got cut, they have to live with that cut. We can fix that in a way that doesn't cost a lot of money.
So those four things that could be done to fix, and we have the template. We've written—in the last Congress, we respond to RFIs and a lot of—we work all the specialty groups and all the states to develop feedback. We have the template for everything I just said to fix MACRA. So that's the first point is just diagnosing the problem and getting people to realize this is a problem.
The second is, how do you get 60 senators and these 218 members of the House to pass a bill to fix it? How do you make that happen? It's not so simple. And it starts with, as you talked earlier, about educating members of Congress.
And one big mistake I think a lot of people make when they first come to the Hill that don't do this every day because you're too busy saving lives and you focus on the Hill, and you come to the Hill and you think that everyone knows more than they really do.
I mean, my own personal history, I'm 25 years old and I'm studying romantic love at Yale with a professor who's a famous love theorist. And then, I fell in love with someone and I didn't want to research anymore. And a year later—a year later—I'm working as a top health advisor for the chairman of the Senate Appropriations Committee and I'm dealing with NIH budget. I'm dealing with AMA meetings. My boss says, "I don't like health care, it's complicated, I trust you." And I think I know it all. And I got some real power and I don't know anything about what I don't know.
And that's how a lot of the Hill is. It's people that are from all walks, a lot are in their 20s. They think they know it all. They're smart folks, but they have a lot of power that you wouldn't realize, and they don't understand things like what's budget neutrality. What's MACRA from 2015? I was still in elementary school. I mean—and they turn over a lot, they switch offices. And so they don't know a lot and that's why you have to keep coming. So you coming and you talk about it, and you go to the Hill and you educate members and the staff over and over and over again, and don't assume their knowledge.
And then the third point part of the plan is we've got to have some committee hearings. We asked the last Congress for hearings that never happened. This Congress, we need hearings where you have the key committees and they focus and do a deep dive and you have people like us that testify and say, "Hey, this is where it's broken." You have real world examples―”This is how it hurts patient care”―and you get the messaging out. And you get the committee staff, who write some of the bills, to really focus on it.
And another thing is no one's just going to drop a bill and fix the whole thing. It's too big and complicated, but you can take pieces. Someone could drop a bill to give an MEI inflationary update. Someone could drop a bill on the APM side to fix that. Someone can fix budget neutrality. You get different bills, then you do a co-sponsorship campaign around those bills. And you drive support throughout the whole Congress and use that as a proxy for where people are―“Why aren't you sponsoring the bill? Jump on in.” So those are things that we hope.
And then the fourth point, final point, is the tortoise and the hare play, in that, it goes back to, you’ve got to keep educating, you've got to play the long game. You've got to stay focused on the issue and try not to divert too much. And you've got to wear them down. This is one of the issues where it might take it the whole Congress, but you've got to wear members down over and over. They keep thinking, “Oh, God, I got to meet with Dr. Resneck, Dr. Fryhofer again, what am I going to say? They met with me six months ago. We haven't done anything.” You've got to hold them accountable, members of Congress. And that race ended well. I mean, the tortoise won because he played the long game. So that's kind of the four points on that.
And then, briefly, I'll just mention the other issues on scope. Scope of practice is one of those where it's the tortoise in the hare in reverse, where we could be the hare in that our allied friends and allied professionals are the tortoise, and they're trying to expand scope in any way they can. And they've dropped several bills. There's a big one they've dropped called the ICAN, and it brings in a lot of different odd specialists in one bill—one big, mega scope bill—called the ICAN—and we're saying, “We can't.”
There's a reason that you went to medical school and the trainings are different. And the physician-led teams are what the patients want so it's for the best for the patients and the outcomes and we'll talk about some of the research that shows that some of our allied professional friends can be more costly and not as effective in delivery of care. So that's something we're going to bring up.
And we're vulnerable on that because now, I mention this environment where they're not going to spend much money. The way it's framed is, look, there's a shortage of access to health care issues, a shortage of physicians, and we need more people and these odd professionals want to come and serve these patients. And you know what? It's just removing red tape. It doesn't cost anything. CBO—Congressional Budget Office—won't score it. It made me a favor. And so this makes sense and you can get bipartisan support for that.
And so we have to counter that. And they only have to get one of the bills passed and they can kind of build from that. That's the game. And a lot of the groups are focused on just scope issues, not our breadth of issues.
And then finally, we do have an answer on scope. It's workforce. It's a bill called the Residency Physician Reduction Act. We need more medical residency slots. This bill would have 14,000. It used to be 15,000 because two years ago, we got 1,000 slots—the most in 25 years, 1,000 new slots. And then last December, we got a bill―200 slots for psychiatry and psychiatric subspecialties. So we're making progress and we want to build on that. We want more slots. We're not going to get all 14,000 at one time, but we'll take them as they come and it's important. And there's a bill out there that would create 1,000 new slots to deal with the opioid and substance abuse disorder training. So that's out there.
And then finally, Conrad 30 is a program that physicians who come—IMG physicians—who do their medical training in the U.S., there's a rule that if they're on a J-1 visa, they have to go back to their home country for two years or if they serve in a rural area for three years, they can be exempt from that requirement to go return to their home country for two years. And it's a win and win―30 slots for each state. There's the ability to increase those slots since it's so popular.
And there's also a provision in that bill that says if you're a physician who serves five years—IMG physician—in an uninsured community, then you can be eligible to be exempt from the green card cap because we all know, the current per country green card cap—many physicians, including some from India, a 40-year plus waitlist, and this would make you exempt. So win-wins. It doesn't cost the government anything. It's a win for the IMG physician, it's a win for their patients, a win for their community.
If there's a larger immigration bill, which we can't control the politics of that, this is ready to go, just a matter of keeping people on the Hill educated. This is a solution. This is one solution to the workforce. And we always love it when the doctors and the physicians come to town to go to the Hill and help us out.
Dr. Fryhofer: Well, Jason, you've had a lot on your plate and it sounds like you're just going at this at so many different angles. Thank you—thank you so much for all of your hard work. And I keep thinking about that graph of physician payment when physician payment goes down and everybody else's payment over the last few years goes up because they do have those inflationary updates, but thanks for that great description of all those different steps that we're taking—the AMA's leading to help physicians and our patients. Thank you and have a great rest of your day. I'm Dr. Sandra Fryhofer.
Unger: Don’t miss part two of this conversation. Subscribe to the Moving Medicine podcast anywhere you listen to yours or visit ama-assn.org/podcasts. Thanks for listening.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
