The 159th annual meeting of the American Medical Association's House of Delegates, held last month in Chicago, featured attempts to build bridges between those who sought to punish AMA leadership for supporting healthcare reform and the leaders themselves, who continue to defend the association's support for the law.
At AMA annual meeting, action but no clear consensus
In addition to its continued discussion of the Patient Protection and Affordable Care Act, the AMA voted to push for legislation that would let physicians negotiate extra payments from Medicare patients and discussed emerging problems related to nurses and their scope of practice.
But reform was at the center of much of the debate. One delegate referred to the reform law as the "eventual care act," and board of trustees candidate Joe Gutierrez, M.D., a surgeon and past president of the Medical Society of the District of Columbia, said it doesn't protect all patients, isn't affordable, doesn't give physicians private contracting rights and doesn't offer meaningful liability reform. Additionally, he noted, it doesn't fix the Medicare physician-payment formula, which now has doctors facing a 21.2% payment cut in December.
Another one of the eight trustee candidates vying for four contested seats, Richard Frankenstein, M.D., echoed the sentiments voiced by Gutierrez. “I am dissatisfied with the work product,” said Frankenstein, the former president of the California Medical Association. “I want to be part of the team that gets it right.”
In contrast were the three candidates competing for the office of president-elect, all of whom were sitting trustees and supporters of the reform law. “This bill has more of our policy in it than any bill I've seen since I've been in the House (of Delegates) since 1986,” said Joseph Heyman, M.D., a president-elect candidate and former AMA board chairman. “On balance, we did the right thing.”
Although agreeing that the reform law benefits patients, the president-elect candidates acknowledged that provisions meant to benefit doctors—such as a Medicare payment fix—were stripped out late in the process. This led the eventual winning candidate, New Jersey neurosurgeon Peter Carmel, M.D., to note that doctors are at a disadvantage when negotiating with Washington politicians because “we are hard-wired to be honest; they are not.”
“Why are so many angry? Because we failed to get physician items in the bill,” Carmel said. “We wound up with a bill that had none of our major items for physicians. Let's go back and get them.”
Frankenstein, Gutierrez and other harsh reform critics failed to win election to the board, but after much long debate they won a prize they had sought for years: a commitment by the AMA to craft legislation that would allow physicians “private contracting” rights with Medicare patients, which would allow doctors to charge fees that exceed Medicare rates, with patients paying the balance out of their own pockets or with supplementary insurance making up the difference.
“Resolved, that our American Medical Association immediately formulate legislation for an additional payment option in Medicare fee-for-service that allows patients and physicians to freely contract, without penalty to either party, for a fee that differs from the Medicare payment schedule and in a manner that does not forfeit benefits otherwise available to the patient,” stated the final version of resolution 204. “This legislative language shall be available to our AMA members no later than Sept. 30, 2010.”
For those trying to push the AMA to take a more free-market approach, such as St. Petersburg, Fla.-based neurosurgeon David McKalip, M.D., the passage of the resolution appeared to make up for the losses incurred at the ballot box. McKalip, who attended the meeting as an AMA member and not a delegate, lost his bid to gain a seat on the AMA Council on Medical Service—which studies the social and economic aspects of medical care—but was happy with the overall result of the meeting. "I thought it was a great meeting, it was a historic meeting,” McKalip said. "The House of Delegates is a body that changes direction slowly. It took five years to get 204 passed.”
But the resolution had its detractors, including Richard Corlin, M.D., who served as AMA president in 2001-02. "I'm sorry to swim upstream on this, but there is language in this that will get us laughed out of the room," Corlin said during the debate. “It will cause us to not be taken seriously by people who want to be our allies."
Officially, the AMA painted the vote as a reaction to the Senate's inability to revamp the Medicare payment formula and stave off the 21.2% payment cut. "Seniors deserve a Medicare benefit that allows them access to and choice of physicians," AMA trustee David Barbe, M.D., said in a news release. “Low Medicare payments, continued payment uncertainty, and a steep 21% payment cut have put access and choice in jeopardy. A new patient-centered category of Medicare payment will allow seniors to use their Medicare benefit fully for the healthcare they need."
Scope-of-practice issues, often seen as a turf issue in which doctors try to limit the services physician assistants and nurse practitioners can offer, were also discussed. On the topic of nonphysicians offering pain-management services, most delegates appeared willing to set the issue aside for further study, but doctors from Iowa, Nebraska and South Dakota pushed for more immediate action and it was decided to refer the related motion to the board to rule on a course of action in the near future.
In an interview after the meeting, Iowa Medical Society President Timothy Kresowik, M.D., said the issue is coming to a head at critical-access hospitals where certified registered nurse anesthetists are providing spinal injections requiring fluoroscopic guidance without, he said, specific training in pain management or radiology—thereby exposing patients to the risk of injury and overexposure to radiation.
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