Attacking the Dysfunction in Health Care
Barbara L. McAneny, MD, President, American Medical Association
AMA Interim Meeting, Saturday, November 10, 2018
Madame Speaker, officers, delegates, physician colleagues, distinguished guests: it is an honor to address you again as your president.
First, let me thank our veterans, our military members currently on active duty, their spouses and family members who are here with us on Veterans Day weekend: We are very proud of you, and grateful for your service.
I want to tell you a story about a patient I saw recently in my Gallup practice. This man has metastatic prostate cancer to his bones, and he is doing well on his chemotherapy, so he will live for many years.
But metastatic prostate cancer in your bones hurts, and one day he called me to say that his pain regimen wasn't holding him. So, I increased the dosage of his opioids from two per day to three . . . and of course he ran out early.
In Gallup we cannot e-prescribe. Patients must carry a paper prescription to the pharmacy, and my patient lives an hour away from the Gallup clinic. So, I called his primary care physician who agreed to write a prescription for his very large amount of time-release morphine.
The patient picked up the prescription and took it to his pharmacy. The pharmacist then called for the prior authorization but was denied by the health plan.
Then, he checked the PDMP and learned that my patient had multiple prescriptions over the years, some written by me, and some written by my partners. (After all, we practice team based care!)
The pharmacist suspected my patient was a drug seeker, and did not alert me that his prescription was denied.
My patient, a very proud man, felt shamed and didn't know what to do. So, he went home to be as tough as he felt he could be.
That worked for about three days ... and then he tried to kill himself.
Fortunately, his family found him in time, and the Emergency Medicine physician was able to save his life. He spent a week in the hospital and finally we got his pain back under control, on the exact regimen I had prescribed him as an outpatient.
The insurance company paid the ambulance and the hospital bill without any prior authorization.
Like you, I share the nation's concern that more than 100 people a day die of an overdose. But my patient nearly died of an under-dose.
This story illustrates the problems we all confront every day . . . in our current dysfunctional health care system.
First, the health plan made a medical decision without knowing the patient. The health plan does not have the chart, doesn't know the patient, and basically countermanded my orders without even telling me ... using the prior authorization process.
How have we let health plans determine the course of care? They call this quality?
The health plan bears no liability for the patient's outcome, but they do carry the responsibility because prior authorization does not require that the "trained denial personnel" call the doctor and let them know that they changed the plan. The denials are immediate ... and even in cases where we know the drug is denied, it may take days to appeal it, and in the meantime patients suffer.
Ninety percent of physicians surveyed by the AMA report that the prior auth process has led to delays in care and decreased quality of care. This is unacceptable.
Fixing prior auth is a huge priority for the AMA as we fight against the dysfunction in our system.
We need to reduce the intensity of prior auth, ensure that it is evidenced based and stream-lined through automation that doesn't create another physician work flow problem.
The AMA is leading a coalition to standardize and streamline requirements in prior authorization to minimize care delays. We are fighting alongside our state and specialty medical societies to eliminate burdensome prior authorization and fail-first requirements.
I invite you to join our FixPriorAuth campaign. Share your stories on FixPriorAuth.org. Or better yet, stop by the Grassroots Booth to share your story on video, as I will do tomorrow.
My patient suffered, in part, because of the crackdown on opioids. The pendulum swung too far when pain was designated a vital sign, and now we are in danger of it swinging back so far that patients are being harmed.
We need to use our expertise in patient care to change the dialogue to appropriate pain control through a selection of possible therapies ... and to treat opioid use disorder as the relapsing chronic disease that it is.
We must press policymakers to expand coverage and access to treatment programs.
We applaud Pennsylvania in their recent victory to remove prior authorizations from Medication Assisted Therapy.
This is a great example of rational insurance design. We don't want to lose the teachable moment for patients motivated to treat their addiction.
We have made progress in addressing the Opioid Epidemic through the work of our Opioid Task Force and those efforts will continue. Congress recently passed, and the president signed, bipartisan opioid legislation with many provisions supported by the AMA that will enhance treatment and prevention.
When I visited my patient in the hospital as he was recovering from his suicide attempt, I apologized for not knowing his medication was denied. I felt I had failed him. This is what leads to burnout, the frustration of knowing what the patient needs and having the health care system get in the way and prevent that care.
My experience is not unique. As I travel around the country and listen to doctors, I have come to realize that physician burnout is so often about frustration and feeling that we've lost control ... which makes it very difficult to go home at the end of the day and feel good about what we accomplished for our patients.
Too often the health care system gets in the way of actual health care.
I hear from hospital-employed doctors as their contracts come up for renewal, wondering why they are being told to see more patients in less time and for less money.
At the same time, we see hospitals merging, health plans merging, and pharmacy benefit managers acquiring health plans. These systems get more profitable, while choices for patients and doctors diminish.
Yoga at lunch isn't going to fix this one.
I feel a sense of urgency as we are witness to greater concentration of wealth and power in the hands of ever-larger corporations, with more and more middlemen pulling down large salaries while our patients go broke and physician practices struggle to survive.
Concern about increased consolidation and what it means for patients is why the AMA opposed, and helped to defeat, the mergers of Anthem and Cigna, and Aetna and Humana, last year.
This year, we fought a similar battle: the acquisition of Aetna by CVS Health Corporation.
Again, we lobbied hard and urged the Department of Justice to block the merger. So, we were disappointed last month when they decided to let it proceed.
However, we won a very important concession: the Justice Department is requiring divestiture of Aetna's Medicare Part D prescription drug business as a condition of the merger ... a move that we hope will help protect competition in those important markets.
And we will be watching drug pricing in this merged system, because another issue that is interfering with patient care is the skyrocketing cost of prescription drugs.
We get frustrated when our patients cannot afford the medicine they need. No one should have to suffer because they cannot afford pain medicine, just as we cannot let high drug prices prevent someone from managing their chronic disease.
The AMA is fighting for drug price and cost transparency at both the state and federal levels. We are also activating our grassroots network through TruthinRx.org, a website for physicians and patients to tell their stories and lobby Congress directly.
We all know that health care costs in this country are unsustainable. We spend three and a half trillion dollars yearly now, and if nothing changes we will spend $5.7 trillion in 2026. That means no money for schools or fire departments or bridges that don't fall down. We know that cannot happen.
It has to change ...and it will. But who will lead that change?
Hospital systems? Health plans? PhRMA? PBMs?
Are doctors positioned to make a difference? We are!
Health care runs on our licenses, so we have the power to fix it. When doctors work together, for the good of patients, we are unstoppable.
The AMA is our voice to create a health care system that provides health for patients, not profits for middlemen.
How will we do that? The best way to keep health care bills down is to intervene early in the chronic diseases that account for 90 cents of every dollar we spend on health care.
Our Improving Health Outcomes program is reaching more prediabetics and giving doctors the tools to help patients to control their disease, stay healthy and avoid the expensive complications that are breaking the bank.
But we know when diabetics live in food deserts, when there are limited options for fresh food and few safe places to exercise, their outcomes will suffer.
If we are going to keep our patients with chronic diseases healthy and working instead of making them permanent customers of the health care system, we must reach all people.
We must be able to intervene to address and improve the social determinants of health.
That includes childhood traumas, which is why we protested the separation of children from their mothers at the border, why we continue to advocate for mental health parity, and why we must take women seriously when they tell us they are sexually harassed.
And that includes those being harassed in our own profession!
I was disappointed to read the recent study indicating large numbers of our female colleagues are still being harassed. We cannot point fingers at others if our own house is not in order.
It must stop now. Time's up!
The AMA stands for equality - whether you are my patient or my colleague!
Our Code of Ethics commits us to treat all patients - and one another -- ethically and professionally. We've got this. We can do it.
In the United States, we know that health care costs rise when behavioral health is neglected ... and that access to care is about having insurance that actually covers the cost of your care.
We all know that people without insurance live sicker and die younger than those who have it. That is why we have fought efforts in Washington DC and at the state level to strip away patient protections gained through the Affordable Care Act.
We don't want to see children tossed off their parent's plans. I am a cancer doctor. All of my patients have pre-existing conditions that would make them uninsurable forever, and I don't want to go back to those bad old days.
We don't want insurance companies spending large sums of our patients' premiums on wasteful administrative overhead. We know as doctors that paperwork wastes money and we are pleased that the Administration and HHS is taking action to put patients before paperwork.
We did have some concerns about the recent proposal on E and M codes to pay physicians the same for a visit for a modest problem as for highly complex care.
We worked with CMS in a collaborative way and achieved a two-year breathing space for an AMA-led workgroup to develop potential E and M coding changes to support the level of care we all want for patients.
We will continue, as we always have, to work with all branches of government to make it easier for doctors to take care of patients. We will work with the private payers for rational health policy.
We are working to end EHR abuse as well. Doctors are spending excessive time on data entry, contributing to physician burnout, with implications for quality of care. Much of the EHR technology is dysfunctional; it grew out of the billing software, so it doesn't give us the decision support or the information we need.
The vendors of these systems like to paint doctors as Luddites who don't like technology. They need to understand that we love technology; we just want technology that works.
The AMA has convened health plan vendors and doctors to address the problems, and we are working on interoperability. Health plans and hospitals use data blocking or inconvenience to keep patients trapped in their systems. Doctors just want the results of the tests.
Hey Siri, what was the result of Mr. Smith's CT done in the ED last night?
We will not let dysfunction infect the "internet of things" that will be a part of the health care system of the future. Dr. Madara will tell you about our efforts there, and he deserves credit for having the vision to move the AMA forward in that space.
We will continue to help physicians figure out better ways to structure their practices, and then adapt the payment system so that they can deliver the care that they know patients need, and be fairly paid for it!
This is how we will lower the price tag on health care. Physicians know what would work in their specialty and their community, and the AMA is trying to give them the support and opportunity to make those changes.
So, the AMA steps in where others fear to tread, and it will take time but we will get there.
Gun violence is another area where many "fear to tread." Just in the last two weeks we have mourned still more senseless deaths from the mass shootings in Pittsburgh, and in Thousand Oaks.
Meanwhile, the CDC reported yesterday that both firearm homicides and suicides are at their highest levels in more than a decade.
Friends, these deaths - from mass shootings, from suicide, from children gaining access to a parent's firearm - are preventable.
Thoughts and prayers just won't cut it anymore. Policymakers at the state and federal level must act on common-sense, data-driven measures to prevent yet more carnage.
We must also continue to speak out. We are the AMA.
Sooner or later, we are all patients, and patients need doctors.
It is our job ... our calling ... and our mission ... to create a health care system that recognizes and supports the efforts of dedicated medical professionals.
We need to create a system that values health over money, power and politics.
We can do this, and we must do this.
We are the AMA!