The American Medical Association's House of Delegates recently wrapped up a busy agenda that included resolutions on drug prices, mental health and LGBTQ inclusion in the medical field. There were also some firsts during the gathering in Chicago. The AMA took aggressive steps to address gun violence as a public health issue, calling for support on an assault-weapons ban, mandatory registration of all firearms, laws that would keep guns out of the hands of those convicted of domestic violence, and raising the legal age to buy guns to 21. It's also the first time women will serve as president and president-elect. Dr. Patrice Harris, a psychiatrist from Atlanta, will become president after Dr. Barbara McAneny, a practicing oncologist from Albuquerque, serves a year in the top office. McAneny also built and manages the New Mexico Cancer Center. The Modern Healthcare editorial team recently sat down with McAneny to talk about the AMA's goals and challenges in the next year. The following is an edited transcript.
MH: What are the priorities for your presidency?
McAneny: I want to see us target underserved areas. It's rare for me to see a patient who's not diabetic in my health clinic on the Navajo Nation. So I plan to push the AMA to get into the communities.
I'm also worried about the well-being of physicians because they spend a lot of time begging and playing "Mother, may I?" with the insurance companies. I have to prior-authorize every chemotherapy I give, even though everybody agrees it's right. So by the end of the day you feel like, "I'm just trying to do my best here." And doctors feel that all across the country. It's alarming to me because for the first time we're starting to see doctors wanting to leave the field to go do something else. Where it used to be that you had to sort of push them out the door at 75 and say, "Retire already."
Now we're struggling at the same time when we have a significant physician shortage. So that's a big priority.
I have purchased three electronic health record systems for my practice over the 20 years I've been managing partner. If I purchased another, I'd have to go into the witness protection program because my partners would kill me. And I have an EHR that's reasonable, but it's reasonable for seeing a patient, one patient, at a time. EHRs should be more than glorified billing machines. We're looking at precision medicine and genomics. There is no way I'm going to keep in my head all the genetic mutations that occur with cancer, and there's a new drug every week. I need an EHR that gives me that decision support. And we are so far from that.
One thing I'm really excited about at the AMA is this thing we call our Integrated Health Model Initiative. We can look at not just interoperability but have the ability to slice and dice the information we get so that I'm not looking up stuff that's irrelevant. I can focus on what I need to take care of that one patient.
MH: Following up on your concern over physician burnout, how well is this being addressed?
McAneny: We told large institutions, "This is how you can determine whether the physicians that you employ are burned out." And their first reaction was, "Well, who cares? Just do your job." We could show them that it costs between $500,000 and $1 million to replace a physician who quits because they're burned out. We've taken away too much control from physicians in how they practice. And we need to give it back.
If I have somebody in my private practice who isn't nice to my patients, they don't work for me very long. I have control over that part of my environment. And we've taken that control away from a lot of physicians, particularly in the employed environment, where they can't get somebody who's not doing their job out of their practice.
MH: As you think about patient populations that are hard to reach, how can the healthcare system build more access points to reach them?
McAneny: One of the things we advocate for is team-based care, recognizing that as the doctor I need to manage the team, but I can't do everything. In small towns, I worry about losing physician practices because most of the hospital systems that employ an increasing number of physicians tend to be in more urban areas. I think we have to make it so it is economically feasible for primary-care doctors to live in the communities they want to live in and provide services there.
There was a great Health Affairs article that looked at the fact that the average three-doctor practices were able to do a great job of keeping people out of the emergency department, lower hospitalization rates, lower readmission rates because they actually know those people, and they're out in the community taking care of them.
I am very concerned about our primary-care infrastructure across the country. We are seeing a lot of universities trying to train people. Fewer people want to go into primary care. Those who do become hospitalists at a time when we need people out in the trenches managing people before they get sick enough to be in the hospital.
MH: You've testified against the big insurance company mergers and most recently the CVS purchase of Aetna. Do you think those efforts are going to be more difficult now that a judge has approved the Time Warner-AT&T merger?
McAneny: The short answer is probably yes, if they think having bigger and bigger corporations is a better thing. In my town, a DaVita practice is becoming Optum medical group. We don't know what that is going to affect in our market. If I were getting my care from a physician whose paycheck was being signed by an insurance company, are they truly working for me as a patient or are they working for the insurance company? Why are we putting physicians in an ethical bind? We should protect physicians from that.
MH: What are your thoughts about the proposed CMS Innovation Center demonstration on direct practice arrangements?
McAneny: It is a difficult question. The underlying problem is that Medicare pays about 80% of the cost of doing business. For example, in my clinic on the Navajo Nation, 70% of my payers are governmental—Indian Health Service, Medicare and Medicaid. And I struggle to keep that practice breaking even. It's because the shortfall of managing patients who are on Medicare is a major stressor. And remember we have an aging population. The prediction is that by 2030, 70% of the country will be on Medicare.
People don't know where the money's going to come from for me to patch up those holes. If we could have more transparency in healthcare payments so we could understand where all the cost-shifting occurs, we might be able to come up with a more rational system.
MH: What is the AMA doing policy-wise to address payment issues?
McAneny: We have a coalition with insurers, hospital associations, the Medical Group Management Association and other entities that are interested in trying to say, "Let's have more of a rational, perhaps electronic prior-authorization process." We're faxing things in 2018. I can't believe it. So we're working from that end to say, "This has gotten out of control. We need to look at whether or not it's truly useful."
The other thing is the litigation where (20 state attorneys general) want to declare unconstitutional what's left of the Affordable Care Act. The things that are left are things that people actually really like—getting rid of pre-existing condition blocks, having insurance companies have a medical-loss-ratio limit. So we're saying, "This has to be defended." Every patient I take care of will not be insurable because they have a pre-existing condition of a cancer. That's crazy. You can't do that.
So we have filed an amicus brief saying that we support what's left of the ACA. And I think that's one way to work on all these issues that are frustrating physicians. I can tell you that there's nothing more frustrating than to see a patient's insurance company yank their coverage halfway through a course of treatment. That puts me in the moral bind of, do I continue the treatment knowing I'm to not going to get paid and I have to buy another $30,000 worth of chemotherapy out of my practice's pocket, or do I abandon that patient and not complete their therapy? What do they want us to do? If I do the first one, pretty soon my practice is gone. If I do the other, I can't live with myself. Why do we put physicians in those binds?
When Anthem comes up with a policy that says if you go to the emergency room and it wasn't a heart attack, we're not paying for it—basically you have to be able to figure out ahead of time whether it's a true emergency according to Anthem's determination of an emergency. We were all over that in terms of saying, "This is not acceptable. We have a reasonable person policy for what you think might be an emergency."
We will continue to work with the payers. And actually, Anthem came around on that and a couple of other in-the-weeds payment issues where they were willing to work with us and even put out a statement saying that they want to work with us to come up with a more rational policy. So we'll try to support doctors from the grassroots up, but there's a lot of work to do.
