Dr. James Madara has served as executive vice president and CEO of the American Medical Association since 2011. Madara, a pathologist and gastroenterologist, previously served as dean of the University of Chicago Pritzker School of Medicine and CEO of the University of Chicago Medical Center. He has been named three times to Modern Healthcare's list of the 100 Most Influential People in Healthcare and twice to the 50 Most Influential Physician Executives and Leaders ranking. Modern Healthcare reporter Andis Robeznieks recently talked with Madara about re-engineering physician practices, the regulation of telemedicine practice and why the AMA opposes the ICD-10 coding system. This is an edited transcript.
Modern Healthcare: Why do so many physicians say they wouldn't recommend medicine to their children as a career?
Dr. James Madara: We are going through an evolution in healthcare, where many things are being layered onto physicians. Some of those things are needed to improve the healthcare system, while others interrupt the interface between the physician and the patient. As the time is taken away from seeing patients, it seeds dissatisfaction.
Part of the AMA's work is around re-establishing joy in practice. We looked at some of the things that were dissatisfiers for physicians, and some were internal to the practices. If a practice had better pre-visit planning in the physician's office, one could then have a more collaborative space between the patient and the physician and get work done rather than just tests. Another improvement is systematic prescriptions, so that prescriptions are written for all the various drugs that someone is taking and they're written for 13 months, so it's a once-a-year exercise. That alone will save an hour or an hour and a half of physician time a day. We have constructed modules for physicians and practice administrators about embedding these processes so doctors have more time with their patients.
Then there are things outside the practice, and one of the largest is the electronic health record. EHRs were built to optimize claims and billing and risk mitigation, but not the efficient entry and extraction of clinical data at the point of care. We're working with vendors and regulators on this.
MH: Why is the AMA opposed to implementing the new ICD-10 diagnostic and procedural coding system?
Madara: It's sometimes said that ICD-10 would bring us up to a standard that's being used in other countries. What's not realized is ICD-10 in the U.S. is not the same as ICD-10 in Canada. It has a complexity in the U.S. that you don't see in other countries' ICD-10s. Secondly, we have multiple things rolling out on physicians simultaneously from the federal government. They all utilize practice time and resources. If there's going to be any electronic rollout of ICD-10, shouldn't there be at least end-to-end testing in real practices to know that this is not going to disrupt care and that it will give the efficiencies that are asked for?
MH: What is the AMA's policy on the Federation of State Medical Boards' interstate compact concerning telemedicine?
Madara: The AMA House of Delegates supported the compact proposal from the federation's proposal to open the capabilities of telemedicine to the population but at the same time make sure that quality and safety protections were in place. The compact would permit telemedicine and provide a structure in which state medical boards would have expedited review of out-of-state physicians for quality and training. Each state legislature would have to vote to participate. There is a widespread sense that this will be important in the future of medicine, particularly in rural areas.
MH: Can you explain the reason for the need for multiple licenses based on the idea that the practice of medicine in telemedicine occurs at the patient's location and not the physician's location?
Madara: That's so the state boards can ensure accountability for medical care that's given in their states. If a physician with a state license from another state is weighing in on a patient's care, that state board needs to weigh in to ensure the accountability of all physicians who practice in that state.
MH: So if the patient is in Nevada, the doctor in Florida has to have a Nevada license.
Madara: Yes. And the Nevada board would have to be comfortable with that fellow in Florida in terms of training. We want to look at histories of actions and all the things that the state boards do to make sure the physicians are held accountable for quality and safety.
MH: The CMS recently released a massive amount of data about individual physicians' Medicare payments. What has been the impact, and what are the AMA's suggestions for improving transparency?
Madara: The outcome has been the release of flawed information that didn't provide insights, and it's exactly what was predicted. The AMA is all for transparency, but it's also for accuracy. As you know, there were extreme examples of inaccuracy, for example, a Michigan primary-care physician having a large CMS innovation grant that crossed many providers and then being publicly reported for the total payments of all providers in that network.
MH: What's the AMA's legislative advocacy agenda in Congress, and are you adjusting that agenda to reflect the Republican victories in the midterm elections?
Madara: The agenda isn't adjusted based on elections because our agenda is always bipartisan and it's always focused on two things—the art and science of medicine and the betterment of public health.
Obviously, the Medicare sustainable growth-rate formula is an important piece of our agenda. It's really about payment and delivery reform. We currently have these EHR meaningful-use requirements, and it's clear that this was another program rolled out without a lot of testing. Physicians are having to do things around meaningful use that really have no bearing to their individual practice. The payment and delivery reforms that came along with the SGR repeal bill would normalize meaningful use but actually shift more emphasis to interoperability because interoperability is the big problem right now. Why aren't EHR vendors spending more attention on interoperability? It's because their R&D budgets are swamped by the meaningful-use requirements. So SGR repeal was part of something much larger and even more important.
MH: Any predictions of whether the new Republican control of Congress will help or hurt chances for SGR repeal?
Madara: We probably have something like 35 legislative days until the next deadline at the end of March. Congress already decided on an SGR bill; it's just that they couldn't figure out the details to get the thing passed. So they have to be successful with the decisions they've already made.
MH: What AMA project are you particularly excited about?
Madara: We're working with the Centers for Disease Control and YMCAs around the country on addressing pre-diabetes. There has to be a way of connecting community assets with sustainable business plans to the needs of that patient population, then tie that back into the medical system in an information loop. If we can get this right and get it scaled in the area of pre-diabetes, it will apply to many chronic diseases. To me this is the golden goose in dealing with the chronic disease burden in the U.S. That is incredibly important.
