Report of the American Medical Association Interim Meeting

The 2023 Interim Meeting of the American Medical Association (AMA) House of Delegates (HOD) was at the Gaylord National Hotel, National Harbor, Maryland, near Washington, DC., November 10–14, 2023. The Interim Meeting focuses on advocacy, particularly on current and pending legislation, other urgent issues, and ethics.

Some resolutions offered were not considered at the meeting. Too many resolutions were submitted to permit adequate consideration of all of them. Many resolutions simply restate existing policy. There is a task force charged with finding ways to limit the number of resolutions. In the short term, there seems little alternative to screening resolutions before accepting them for consideration.

Jesse Ehrenfeld, MD, AMA president, addressed the meeting. This is a difficult environment for physicians. He has seen many of the problems for himself: a physician friend overwhelmed by pressures of the COVID pandemic. Another left her practice and her home because of interference by legislative action. More than one hundred million patients have no access to primary care. Payment has been flat relative to inflation and is going to be cut next year. Physician burnout is at 60%. Physicians must advocate for patients and for themselves. No one else can do it as effectively, and no one knows the problems as well as physicians.

Missouri Delegate Betty Drees, MD, and Alternate Delegate Joanne Loethen, MD.

James Madara, MD, Executive Vice President, focused on how we balance the immediate needs of patients and physicians with an effective long-term strategy to improve the health care system. The AMA has a well-shown ability to respond to short-term challenges, such as the COVID pandemic. Starting 10 years ago, the AMA has been pursuing the formation and implementation of a long-range strategic plan. The plan was derived in large part by analyzing and evaluating existing activities. The process remains dynamic, yearly refining a long-term projection. There are three arcs. First, reimagining medical undergraduate education, residency training, and lifelong learning. Second, confronting chronic disease, specifically focusing on hypertension. Third, removing obstacles that interfere with patient care. Examples are reforming Medicare policy and the Physician Recovery Plan. There are three accelerators: equity, advocacy, and innovation.

The Heart of America Caucus with the Missouri and Kansas Delegations.

Willie Underwood, MD, Chair of the Board of Trustees (BOD), read a statement that the AMA is in solidarity with all the physicians caring for patients in Israel and Gaza. The HOD refused to consider a resolution calling for a ceasefire and has avoided involvement in the political issues surrounding the war.

Moving to the core business of the HOD, more than 100 resolutions and reports were considered. The HOD was well attended, drawing 672 of 705 (95%) of delegates.

“Fix Medicare Now” was the major theme of the meeting. First, inflation-adjusted physician payments have been reduced 26% in the last 20 years and will be cut another 3.4% in January 2024. We must convince Congress that these cuts are totally unsustainable. Second, physician payments must be indexed to inflation, like all other participants in Medicare. Third, MIPS has failed, and must be discarded. Go see the website www.fixmedicarenow.org.

Missouri Delegates Joe Corrado, MD, and Ed Cabbabe, MD.

There continues to be issues surrounding medical education. The Council of Medical Education (CME) issued reports advocating personal days for medical students (#1); ensuring equity in interview processes (#3); and advocating unions for residents and fellows (#5). Resolution 208 called for minimizing the impact of training of mid-level providers on medical education. Resolution 301 advocated for additional protection for residents when hospitals close. Resolution 302 expressed concern over the treatment of students with disabilities. Resolution 304 advocated for increased health insurance options for medical students.

Drug use continues to kill people each year. An exponential increase has been caused by fentanyl, often mixed with other opioids or amphetamines. At the meeting of the Organization of State Medical Association Presidents (OSMAP), speakers from four states discussed harm-reduction strategies. These include legalization of fentanyl test strips, and availability of naloxone, drug injection centers, and recovery centers. Mental health resources are terribly inadequate to deal with the problem. As an aside, Resolution 916 advocated for the elimination of artificial dose limits for buprenorphine. Payers often impose such limits even though contradicted by evidence and clinical experience.

Cannabis use, despite legalization in a majority of states, remains a health concern, especially for pregnant women and children. Resolution 205 called for model state legislation for warnings to be placed on cannabis products. Council on Science and Public Health (CASPH) report #6 assessed marketing practices for cannabis, also calling for state legislation and package labeling to warn patients of hazards.

Gun violence is a perennial concern of the HOD. Board of Trustees (BOT) report #14 discussed whether physicians should be funded to provide safe storage devices to patients. Its conclusion was that safe storage devices are a “Good Thing” but did not recommend that physicians distribute them.

Another perennial concern is health system reform. The Council on Medical Service (CMS) reports #6 and #7 addressed payment models and sustainability for rural health systems. CMS #3 addressed adequacy of insurance networks. CMS #5 discussed the problems with unwinding of the broadened Medicaid eligibility introduced during the pandemic.

Resolution 210 advocated for the expansion of Medicaid and CHIP to undocumented immigrants, as has been done in New York and California. This was highly controversial and was referred to the BOT for further study. The cost would be quite high. Resolution 803 advocated legislation to prohibit states from charging co-pays or other fees for Medicaid and CHIP. Pediatric practice has been very severely affected, with pediatric hospital beds closing across the country. Better reimbursement policies are urgently needed. Resolution 817 recommended expanding Medicare reform efforts to include pediatric populations covered under Medicaid and CHIP.

Missouri Alternate Delegate and KCU medical student Charlie Adams.

Resolution 224 recommended changes in ERISA to increase accountability of pharmacy benefit managers. Resolution 818 called for the AMA to begin considering a single payer system. Because the AMA has long opposed a single payer system, some newspapers reported this with approval. But it was not accepted and was referred to the BOT for further study.

Obesity remains a serious health problem. Now that anti-obesity drugs are available, insurers are refusing to cover it. Resolution 806 called for the AMA to promote inclusion of anti-obesity drugs as standard insurance benefits.

There was extensive discussion over Resolution 4, which called for the AMA to advocate for decriminalizing physician-assisted suicide. Even the terminology is controversial; other terms are “end of life expanded treatment options” and “medical aid in dying.” This is a perennial ethical problem and was not going to be settled at this meeting. The resolution was referred to the BOT to be studied further.

The Council on Science and Public Health (CSAPH) report #1 analyzed the causes of medication shortages and possible remedies. This remains a severe problem, and these reports are issued each year. Little progress has been made. CASPH report #2 summarized the conflicts between health equity and personalized medicine. Such conflicts are not inherent but are common at our current state of genetic knowledge. Resolution 922 addressed the issue of transferring scarce supplies of drugs among pharmacies to address local shortage issues. CASPH report #5 discussed the use of re-usable devices instead of single-use devices. The movement away from reusable devices and towards single-use devices, especially in the operating room, appears to have gone too far, and is now a major contributor to excessive hospital waste and to the overuse of plastics.

BOT report #12 dealt with restrictions on just where the AMA allows itself to meet. Over the last eight years, the AMA has become increasingly restrictive. Now, California adopted similar restrictions by law in 2016. The state maintains a list of states to which state employees were not allowed to travel. So, the AMA staff adopted the California list. But the list has expanded to 26. All states in the southern tier, favored for late fall meetings, are on the banned list save for New Mexico and California itself. Forget having regional meetings in the South. Florida is off limits (except for the 2024 Interim Meeting, which was arranged some years ago). The AMA, which represents physicians in all states, has engaged in a circular firing squad. The report concludes with a recommendation that the ban on unfavored states be lifted, with the caveat that no hotel or convention center with restrictive policies would be acceptable. There was a furious debate. The report went through two separate revisions before it was even discussed. It was sent back to the BOT for further revision.

Missouri Delegates Betty Drees, MD, and Charles Van Way III, MD.

Regulation and/or legislation was advocated in several areas. Good Samaritan laws vary greatly across the states, creating confusion. BOT report #6 called for developing model legislation to bring order to the situation. Resolution 206 expressed concern about augmented intelligence in health care, which requires oversight and regulation. Scope of practice in emergency departments is a thorny problem. There are many hospitals in which no physician is physically present. Is an emergency department (ED) staffed by nurse practitioners or physician assistants able to provide adequate care? Resolution 207 called for legislation requiring that EDs operate only under direct physician supervision. This is a complex issue, affecting rural hospitals in states like Kansas, and will be further considered by the BOT.

Climate change continues to concern many physicians. BOT report #3 was on AMA policies and actions on climate change. However, it failed to meet the expectations of climate change advocates that the AMA present a plan for dealing with climate change, so it was not adopted and was referred to the BOT to be reconsidered.

As usual, the HOD dealt with a mixture of physician-specific issues, such as Medicare, and societal issues, such as the public health impact of climate change. The AMA sees itself as having an additional role beyond simple physician advocacy. There was a lot of specific action on specific issues. For example, there was a general session on climate change and another on the ethical conflicts involved in working within large health care systems. There was a growing consensus at this meeting that the AMA is most effective when it works on physician-specific issues and other issues affecting the health care system.

Several Missouri physicians continue to serve in leadership roles. Edmond Cabbabe, MD, serves as past chair of the Council for Long Range Planning and Development. Elie Azrak, MD, serves on the board of AMPAC, the AMA Political Action Committee. Jerry Kennett, MD, is on the AMA Foundation board. Kelly Schmidt, MD, is the past Chair of the Resident and Fellows Section. David Fleming, MD, serves on the Council on Ethical and Judicial Affairs. Marc Mendelsohn, MD, serves on the Council on Science and Public Health. Charles Van Way III, MD, is secretary of the Steering Committee of OSMAP, the Organization of State Medical Association Presidents.

Your AMA delegation would very much like to hear from AMA members throughout Missouri about the issues discussed at the meeting, especially Fix Medicare Now. For further information, the business of the meeting is available on the AMA website. Highlights and all of the reports and details are at www.ama-assn.org/house-delegates/interimmeeting/business-ama-house-delegates-interimmeeting. The Annual Meeting of the HOD will be in Chicago, June 12–16, 2024. Meanwhile, the AMA continues to advocate for physicians and their patients across the country.