Physician Advocacy: The AMA Interim Meeting 2019

The Interim Meeting of the American Medical Association (AMA) House of Delegates (HOD) in San Diego, California, November 15–16, was focused on legislation and public advocacy. The purpose of a meeting halfway between the annual June meetings is to allow the organization to respond quickly to time-sensitive issues. The scope of resolutions is reduced, and there are only five reference committees. But there is no shortage of important issues. Issues highlighted on the AMA website include the opioid epidemic, vaping, access to health care, drug pricing, and Medicaid reform. We usually have the meeting somewhere else than Chicago, and since it’s late in the year, somewhere warm. Which is admittedly a fringe benefit.

Patrice Harris, MD, the President of the AMA, spoke of trust. Trust, she said, is scarce today, yet people still trust their physicians. This is rooted in three characteristics: competence, honesty, and compassion. Physicians know their jobs. Few professions carry out such relentless self-examination. We are honest, calling out invalid and unscientific fads and publicity. We are compassionate, fighting for health equity. Compassion leads us to advocate for humane treatment and health care for immigrants at our country’s borders. Because it hurts patients, the AMA opposes “surprise billing”. We want to reform electronic health records (EHR), and to empower technology to improve health care.

James Madara, MD, Executive Vice President, began by citing Elon Musk, who commented that “Excessive automation at Tesla was a mistake. Humans are underrated.” Optimum technology must be blended with human effort. The AMA is working to improve the care of chronic disease by improved technology. To improve the care of hypertension, technology will allow patients to measure blood pressure at home and have the values transmitted directly to the patient’s medical record. A joint effort with the American College of Cardiology aims to include 22 million hypertensive patients. In other initiatives, the AMA is working to improve continuing medical education and to reconfigure undergraduate medical education.

Since 2003, there has been a public member to the Board of Trustees (BOT). In 2020, that will be Harris Pastides, PhD, the retiring president of the University of South Carolina. Besides having a stellar record at USC, he has been a strong leader in civil rights and equal opportunity. In his acceptance speech, he said that he wants to help the AMA lead the reform of American health care. A “first college graduate” in his immigrant family, he is especially concerned about maintaining access to medical education for all. He feels strongly that no student should be turned away because they cannot afford medical education.

For the past four years, the Council on Ethical and Judicial Affairs has been working to craft an acceptable statement of the ethics of maintaining competence in the face of advancing age. It mandates we evaluate our own competence as we progress through the stages of life. All of us need to be concerned, with self-assessment and self-awareness. And not only for ourselves, but for our colleagues. The current policy can be seen at the AMA website.^1,2

The HOD continues to address the high cost of drugs. A Council report and several resolutions proposed such innovations as competitive bidding, international price indices, increased transparency, and mandatory arbitration. Resolutions called for inclusion of co-pay coupons in health plan deductibles and for Sunshine Act disclosures by pharmacists and pharmacy benefit managers. There was a general agreement that this is an issue which needs continued attention, and which will require a multi-faceted approach. Separate but related resolutions advocated identification of the country of origin of all pharmaceuticals.

A resolution was passed to strengthen AMA advocacy for a pass/fail grading system in medical schools. Another resolution reaffirmed AMA policy to lessen the financial and time impact of Step 2 CS examination on medical students. There were resolutions to enhance medical education in the areas of nutrition and in LBGTQ care. A resolution called for IRB training in research protections for LBGTQ individuals. One resolution advocated better treatment of health care coverage for medical students, to include such clinically-related injuries as needle sticks and diseases. A resolution wished to address problems in the National Resident Matching Program (NRMP), and the shortfall of residency program positions. The number of U.S. graduates who are unable to obtain training positions through the match continues to grow. Another resolution called for the Veterans Administration to provide more training positions. These issues will be considered in detail by the BOT.

The Missouri Delegate to the American Medical Association Interim Meeting in San Diego, California, November 15–16, 2020.

There was a report from the Council on Medical Education and a separate resolution, both of which called for increased instruction on healthcare finance for students and residents. This originated in a resolution from Missouri, adopted at the 2018 annual meeting, resulting in the Council report. It’s always good to see an issue from Missouri which has been carried forward into AMA policy.

In July 2019, Hahnemann Hospital of Philadelphia declared bankruptcy, leaving 571 residents and fellows in limbo. Along with other disruptions, their malpractice tail coverage was stopped. This, according to state law, jeopardized their continuing medical licensure. The BOT will consider ways and means to help these unfortunate trainees, as well as to work with the ACGME and CMS to try to ensure such a training catastrophe cannot happen again.

The AMA has, for the past three years, held “Camp AMA”, which provides child care at the AMA meetings. Strongly supported by the Young Physicians’ Section (YPS) and the Medical Students Section (MSS), a resolution called for this to be continued as a permanent part of the AMA meetings, and to be free to participants. This will greatly encourage participation by younger physicians and medical students, something which has been a goal of the AMA for the last decade. Both state sections meet at the MSMA annual meeting, and national sections at both AMA meetings each year.

The YPS has been particularly concerned about the treatment of immigrants at the border. Joining with Dr. Harris, the YPS will continue to work for improvements in health care in the detention centers. A resolution opposed the mandatory collection of DNA samples from undocumented immigrants. Another asked the AMA to advocate for state legislative bans of “conversion” therapy for sexual orientation or gender identity. Another resolution asked for a ban on child marriage, leaving the definition of ‘child’ to state legislatures.

There were two BOT reports dealing with the opioid crisis. The AMA has called for increased ability for primary care practices to dispense methadone, for creation of Quick Response Teams, and for strengthening of local strategies to address the crisis. In a related issue, a resolution called for national prescribing guidelines for benzodiazepines. This was discussed at some length in reference committee, with little consensus. Some feel opioid guidelines put out by the Centers for Disease Control (CDC) have been a success, while others say they have not been helpful. This issue was basically deferred, but will be brought up again later. A major question is, who will write the guidelines? The CDC has little expertise in psychiatric medications, and the FDA has shown little enthusiasm for writing practice guidelines.

There were several resolutions on cannabis use. A report from the Council on Science and Public Health outlined the complex legal and medical issues. It was strengthened to recommend that hospitals should not allow the use of cannabis within the facility. As this is a recommendation only, hospitals and medical staffs are free to do whatever they wish, but if they wish to ban cannabis, the AMA is supportive. Additionally, the HOD has now called for increased research on the effect of cannabis legalization, greater engagement with the public health system, outreach to the public, and formation of a Cannabis Task Force to engage the public and physicians. There was extensive discussion of state-level initiatives both for medical use and for full legalization. The AMA continues to maintain opposition to so-called “medical” marijuana and to full legalization.

Resolutions dealt with other specialized issues. A resolution called for the AMA to evaluate school resource officers. Two resolutions advocated for the protection of health data under net neutrality, regardless of how that particular debate plays out. A resolution called for action to end the racial pay gap among physicians. A resolution supported extension of DALCA, the legalization of children of immigrants on valid visas. Many such immigrants are physicians.

There was considerable discussion of forced organ harvesting, which is said to be continuing in China. The HOD has asked the AMA to study this issue. The issue has been considered by the World Medical Association, and the practice is against the law in China. But recent studies have documented the continuation of the practice.^2,3

The use of Electronic Nicotine Delivery Systems (ENDS), otherwise known as “vaping,” continues to be of significant concern. There were several resolutions which called for regulation, bans on flavoring, and total bans. The outcome was that the HOD would like to see a ban on vaping at least until the FDA has produced regulations and will continue to support a ban on the use and sale of ENDS to minors.

MIPS (Medicare Incentive Payment System) continues to be non-functional. The system is flawed and has not shown any positive results. A BOT report on MIPS was considered too weak and was sent back for a re-do. While there is existing AMA policy calling for improvement in MIPS, the sense of the House was that the AMA should actively work to have CMS abandon MIPS.

The House passed resolutions to support the use of “veterans’ courts” which have expertise in the treatment of veterans with PTSD and other psychiatric disorders. A different resolution supported the use of “drug courts”, which are specifically constituted to deal with drug-addicted offenders. Both types of courts can divert appropriate individuals from the prison system to treatment facilities. Both have proven effective.

The meeting of the Organization of State Medical Association Presidents (OSMAP) was, as usual, the day before the meeting. Dr. Harris, spoke of the current directions of the AMA, especially the importance of health equity. Gary Price, MD, president of the Physicians’ Foundation, spoke of their work on defining socioeconomic determinants of health, and on their forthcoming physician survey. The Foundation does such a survey every two years, and this year’s survey will inform AMA policy in the 2020 election year. “Surprise medical billing” has been the subject of legislation in New York and California and pending Federal legislation. It was discussed at length. Surprise billing is basically an artifact of the increasing use of narrow networks by insurance companies. Legislation in California allowed insurers to pay at or slightly above Medicare rates, while legislation in New York mandates payment at more realistic charges, with an arbitration mechanism. While both of these would address the problem from a patient’s standpoint, the California approach cuts physician reimbursement, and has adversely affected access to specialty care in California. The New York approach has cut surprise billing by a third, and has saved patients $400 million in emergency care.

Missouri physicians continue in leadership roles. David Barbe, MD, is now President-Elect of the World Medical Association, representing the AMA in that organization. Edmond Cabbabe, MD, serves on the Council for Long Range Planning and Development. David Fleming, MD, serves on the Council on Ethical and Judicial Affairs. Charles Van Way, MD, continues to serve on the Steering Committee of OSMAP.

All of the reports and resolutions adopted in the meeting are available on the AMA website. Highlights from the meeting are at https://www.ama-assn.org/house-delegates/annual-meeting/highlights-2019-ama-interim-meeting.