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Saturday July 22, 2017
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July 2017 - Volume 14 - Issue 1

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Summary of Major Actions of the Annual American Medical Association House of Delegates, June 10-14, Chicago, Illinois

By: Arthur E, Palamara, MD
 
1. Model Medical Staff Code of Conduct and Application to Employed Physicians
The AMA advocate for the separation of terms of employment contracts and medical staff privileges. There is the right to review for all physicians regardless of employment status. This includes the right to review and may include a physician whose conduct has been characterized as “disruptive, intimidating, or inappropriate.”  (Submitted in part by  the Broward County Medical Association. Also FMA policy)
 
2. Revision of Research Certification and Institutional Review Board Protocols (IRB.)
To do even minimal research, the “researcher must obtain CITI researcher certification. This takes about 6-10 hours and costs $3,500-$4,000. Physicians who are engaged in research must have IRB approval before initiating the research. This includes research derived from retrospective patient files (off the shelf research) which exposes the patient to negligible risk. IRBs should grant a “Category 5” exemption but often don’t. Cost to publish this research are between $500 and $4,000. These problems are a burden to the infrequent researcher without institutional support and stifle investigation. The AMA has agreed to examine this problem. (Submitted by Broward County Medical Association.)
 
3. Supervised injection facilities.
This is a controversial issue. The municipality or state would create supervised areas where drug addicts could “shoot up” with illegally purchased drugs in the presence of medical personnel who could provide sterile needles and have Narcan available. They could also enroll drug addicts in drug treatment programs. There are currently 92 such facilities in the world. New York State and Massachusetts are currently studying the advisability of creating these facilities. The benefits are apparent with 99 persons
losing their lives daily in the United States. The contrary argument is that the state is facilitating malignant and illegal behavior. This was referred for study.  
 
4. Health Care as a Human Right.
The World Health Organization and the World Medical Association recognize a human right to a basic level of health care. It also asks the AMA to support the United Nations Universal Declaration of Human Rights. Testimony on this resolution was ideologically rich but robustly divided. Referred for Study. 
 
5. Expansion of United States Veterans’ Health Care Choices
Our American Medical Association would encourage the Veterans Administration and physicians caring for veterans outside the VA to exchange medical records in a timely manner and include HER interoperability to insure prompt care. It also included additional funding for the Veterans Choice programs.
 
6. Caps on Federal Medicaid Funding
The House of Delegates voted overwhelmingly to oppose caps on the Medicaid program.
 
A second complicated resolution concerning coverage for children, amount of funding for each state, potential downside of cost-saving mechanisms, should not decrease patient access to quality care or physician payment . To continue, federal funding should be based on the cost to each state and should continue to be funded based at current Medicaid expansion levels. Also, the government would continue to monitor the impact on services. (This section was referred for study.)
 
The final resolution, advocated that Congress and the Department of HHS should take input from the AMA, State Societies, and other interested groups. (adopted.)
 
7. Repeal and Replace Outdated Refundable Advanceable Tax Credits - Public Option
The AMA is currently looking at Tax Credits. The Congressional Budget Office concluded in May, 2017, that in many areas, tax credits and supplements were working to provide patients - even those with low expenditures -  the ability to purchase insurance. This stabilized the market in most areas. 
 
The House of Delegates decided that the AMA should conduct an in-depth study to examine marketplace stability. Testimony from the floor of the House requested that a “Public Option” be included as an alternative to Tax Credits to ascertain if the “Public Option” would increase competition to the insurance marketplace.
 
8. Out-of-Network Care
The House passed a resolution to protect both patients and doctors when out of network care is given:
- Patients would not be penalized when they receive out of network care
- Insurers must provide network adequacy
- Insurers must be transparent
- Patients protected using the “prudent layperson” criteria
- Physicians would be compensated with the criteria of regional “usual and customary”
fees as reported by a benchmarking database.
- The AMA would develop model legislation.
 
9. Physician and Medical Staff Members Bill of Rights (originated by the Broward County Medical Association)
- The right to be self-governed
- The right to advocate for its members
- The right to share in the decision making of the organization
- The right to engage the healthcare organization’s administration and governing body on
professional matters 
 
(Note: in North Carolina, 8 hospitals have de-credentialed their medical staffs and stripped them of their authority: A violation of Joint Commission policy.)
This Board of Trustees report was adopted with minimal modification on the floor of the House of Delegates.
 
10. Reimbursement for Translation Services
The AMA would work to reduce the burden of the costs associated with translation services as implemented under Section 1557 of the Affordable Care Act.
 
11. Eliminate Requirement for History and Physical Update - Board of Trustee Report.
Testimony was mostly negative on their report which found reasons for the status quo. This means that failing to update the H & P on the day of the procedure/surgery would be a violation of conventional risk management practices. Testimony did not agree.  The Board of Trustees Report was referred back for further “discussion.”
 
12. Oppose Direct to Consumer Advertising of  the American Board of Medical
Specialties (ABMS) “Product”.
Presently, the American Board of Internal Medicine (ABIM) and ABMS post the names of doctors who fail to maintain their board certification in the form of print media, social media, apps, and websites. The ABMS makes unsubstantiated claims that maintenance of certification (MOC) equates to better outcomes. The ABIM has spent $500,000 advertising the importance of board certification. Testimony strongly opposed ABMS and ABIM advertising. This was referred to the Board of Trustees for further study.
 
13. Action Steps Regarding Maintenance of Certification (MOC)
Perhaps the most contentious issue discussed at the 2017 House of Delegates was MOC. This resolution stated that the AMA recognized lifelong learning for a physician is best achieved by on going participation in a program of high quality continuing medical education appropriate to that physician's medical practice as determined by the relevant specialty society. This principle is strongly supported.  However, many Boards exceed this standard and appear interested in their own financial benefit. The resolution was referred to the Board of Trustees for further study.
 
The AMA has a vast policy involving the issue of MOC. Most delegates feel that the Boards have not done a good job evaluating physician performance. The current MOC process is overly expensive, time-consuming and potentially injurious to physicians, hospital credentialing, and their careers.
 
The Medical Society of Pennsylvania had a 90 minute panel discussion that documented the blatant unfairness of ABIM and ABMS practices. Testimony suggested that the Boards are more interested in their own financial inurnment. Their conduct has been scandalous including obtaining a federal injunction against a doctor who had started a review course.  The ABIM went so far as invading his house and confiscating his computers.
 
Another doctor (pediatrician) who had complied with all of modules and passed the written MOC was dropped from Board status and lost her Blue Cross contract because she refused to pay an additional $1,600. (Her status was restored when she paid.)
Many state societies are disappointed that AMA leadership AMA has not taken a more aggressive stance to redress this injustice.
 
14. Regulation of Physician Assistants
This resolution would oppose Physician Assistants from establishing their own licensing Board. Further, it would ask the AMA to develop policy to would place ARNPs under the jurisdiction of state licensing boards and develop model legislation.  Since ARNPs desire to practice independently, logic would suggest that they operate with the same level of skill as physicians and be held to the same medical legal standard.
 
15 Reduce Physician Administrative Burden of MACRA
This resolution encourages the Centers for Medicare and Medicaid Service and Congress to revise the Merit Based Incentive Payment System (now called QPP) and advocate for scoring adjustments for physicians treating high risk beneficiaries.
It should be noted that the AMA has already been successful in limiting MIPS reporting to only one benchmark in one patient.  A physician who complies with this simplified mandate would not be subject to penalty and reduction in Medicare Compensation.
 
16. Sale of Insurance Across State Lines
Sale of a health insurance product across state line would require that the policy would be
consistent with standards and laws of the state. The patient would have the right to bring the claim in the state where the care was provided. Also, the insurer would have to ensure network adequacy.
 
17. Medicare’s Appropriate Use Criteria (AUC)
Many doctors are unaware that Medicare’s AUC program has already been developed to decrease the number of potentially unnecessary and expensive tests: especially imaging. This resolution asks the AMA to advocate to delay the effective date of the Medicare AUC program. Until CMS can adequately assess how the QPP affects the use of advanced diagnostic imaging, implementation would be delayed.  The AMA is afraid that AUC will place another time consuming burden on already stressed physicians and lead to physician burnout. Moreover, compliance may not be very difficult on physicians with HER.  Small practices, lacking EHR will find this particularly burdensome.
 
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