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 AMA Interim Meeting - November 2007

Report of Hand Society/Association Delegates

Charles Day, MD, MBA
ASSH Delegate to AMA-YPS

Peter C. Amadio, MD
AAHS Delegate

David Lichtman, MD
ASSH Delegate

Hand surgeons who attend the AMA meeting participate in the Hand Surgery Caucus as well as the activities of the House of Delegates (HOD). The Hand Caucus meets at every AMA meeting to discuss topics of interest to hand surgeons, and provides an opportunity for fellowship for the dozen or so hand surgeons (numbers vary from meeting to meeting) who serve as delegates to the AMA from various specialty and state delegations.  Current Hand Caucus members include four past state medical society presidents, three past specialty society presidents, one current specialty society president-elect and the current AMA Vice Speaker.  The caucus allows this group of hand surgeons to “divide and conquer” by assigning individuals to monitor and participate in many other caucuses, including the orthopaedic, plastic surgery and surgery caucuses, and the specialty and service society group, which represents roughly 40% of all AMA members. Through these other groups, hand surgeons can engage a far broader AMA constituency.

The AMA Interim meeting is always focused on advocacy issues. The AMA advocacy agenda for 2007 includes:

* Expand coverage for the uninsured: 1) AMA is a Major supporter of SCHIP reform.   2) AMA is spending $16 million to promote national healthcare reform. Major features: tax credits to help citizens purchase insurance; tort reform; freedom of choice for patients to choose doctors and insurance plan; freedom of choice for doctors regarding billing and practice environment.
* Ensure that physicians—not others—set quality standards (critical for pay for performance reform). Provides major support to state societies to oppose economic credentialing by insurance companies. (Feature story on how AMA helped stop economic credentialing of ASSH and AAHS member Ron Stark in AMA Voice, Nov. 2007). AMA also is the main force pushing consideration of disparities in quality measures.
* Reform the Medicare physician payment system (change SGR formula). AMA is leader of coalition of specialty societies.
* Improve patient safety. AMA a leader; through Joint Commission (AMA appoints 1/3 of members) influences standards.
* Reform the medical liability system; AMA synergizes with specialty societies.
* Promote healthier lifestyles.

I. HOD resolutions of interest:
1) Conflicts of Interest: Health Facility Ownership by a Physician - Resolution from the AMA Council on Ethical and Judicial Affairs (CEJA) proposing the introduction of ethical guidelines for physicians that have ownership interests in healthcare facilities to which they refer patients. These address the issue of when physicians may invest in health care facilities and when they may refer patients to health care facilities in which they have an ownership interest so as to minimize any actual or perceived conflicts of interest and to maintain patients’ trust in physicians.
Relevance to Hand Surgeons: Many hand surgeons have ownership interest in an ambulatory surgical center.  These ethical guidelines can have impact on those that already have ownership or are thinking about ownership.
AMA-YPS Position: Monitor, parts of the resolution call for specific referrals by the physician to alternative arrangements; thus, this would force all physicians to have privileges in multiple centers in order to accommodate this clause.
AMA Orthopedic Caucus Position: Support, even though all the clauses of this resolution may not be ideal, the public sentiment requires that we physicians adhere to some ethical codes with respect to conflicts of interest, i.e., the full disclosures being mandated by FDA from all the pharmaceutical companies.
ASPS/ACS Position: Support
Outcome at AMA: Referred to Ethics Council for revision of language.

2) Impact of Primary Care Reimbursement on Medical Career Choice – Resolution to explore the impact of primary care reimbursement on medical student career choice, and thus its impact on the profession of medicine and access to health care in the United States.
Relevance to Hand Surgeons:  Assumes that reimbursement drives career choice, and that “cognitive” specialties are underpaid. As reimbursements for Medicare are fixed, then any increase in reimbursements for PCPs will be from a decrease in reimbursements from some other specialty in the healthcare system.
AMA-YPS Position: Monitor, see above.
AMA Orthopedic Caucus Position: Support, see above.
ASPS/ACS Position: Oppose as written; support if not focused on differences in reimbursement but rather on general barriers to career choice. Note data that total number of new PCP providers each year up 30% over past decade while surgical specialties are flat, contradicting premise of resolution that fewer people are choosing primary care over surgical specialties.
Outcome at AMA: Passed as modified by ACS. Consider similar resolution focused on surgical specialties next year.

3) Presidential Candidates’ Views on Health System Reform – Resolution from the AMA to host the leading US presidential candidates from all major parties at a candidate forum at the 2008 Annual Meeting of the House of Delegates (HOD) with adequate time for questions and answers directly from the delegates to the AMA.
Relevance to Hand Surgeons:  Healthcare one of the swing issues of the upcoming presidential election.  Hand surgery is an important subspecialty of healthcare.
AMA-YPS Position: Actively support.
AMA Orthopedic Caucus Position: Actively support.
ASPS/ACS Position: No position
Outcome at AMA: Referred to Board for decision.  Issue is whether security and other administrative arrangements are feasible.

4) Strategies to Strengthen the Medicare Program – Resolution from the Council on Medical Service (CMS) stating that the AMA (1) support combining the Medicare Trust Funds (Part A and Part B/ Part D) into a single program that offers an integrated set of services that facilitate efficient and appropriate use of care, and (2) encourage the Centers for Medicare and Medicaid Services (CMS) to explore the use of value-based, targeted benefit design to facilitate more efficient cost-sharing structure that will align incentives for patients to seek appropriate and effective care.
Relevance to Hand Surgeons:  The separation of Part A and Part B of the Medicare Trust fund reimburses the surgeon and the hospital facility from independent sources.  While combining the 2 would have benefits of shifting resources to address specific needs in our healthcare system, there is a risk of pitting the surgeons against the hospitals in seeking reimbursements from one fund only.
AMA-YPS Position: Monitor/Support
AMA Orthopedic Caucus Position: Oppose
ASPS/ACS Position: Support
Outcome at AMA: Referred to Board for study.

5) Health Care as a Fundamental Societal Obligation – Resolution from the AMA House of Delegates (HOD) stating that the AMA recognize that every member of society deserves an adequate level of protection from “illness and avoidable pain and suffering related to health problems” and that providing access to quality and affordable health care is a fundamental societal obligation.
Relevance to Hand Surgeons: Nothing specific to hand surgeons but healthcare access and coverage in general.  There’s no mention of how the “societal obligation” should be distributed.  While the general principle of the resolution sounds good, it is primarily the physicians and hospitals that are providing the “societal obligation” currently.
AMA-YPS Position: Monitor
AMA Orthopedic Caucus Position: Monitor
ASPS/ACS Position: Monitor. Concern about unfunded mandate.
Outcome at AMA: Referred for study.

6) Medicare Reimbursement – Resolution from the AMA House of Delegates (HOD) that calls for the AMA to include review and revision (equalization) of the Geographic Practice Cost Indices (GPCI) as a component of overall Medicare reform (i.e. going to a single GPCI index for each state).
Relevance to Hand Surgeons:  The reimbursement rates in the US differ from state and state and even region to region based on the GPCI calculations.  It’s unclear whether going to a single for each state is right.  There’s also discussion that the GPCI is actually fine the way it is distributed now, however, it just hasn’t been updated in decades.
AMA-YPS Position: Monitor
AMA Orthopedic Caucus Position: Monitor
ASPS/ACS Position: Oppose. Effect varies by state.
Outcome at AMA: Resolution not different from current AMA policy; policy reaffirmed.

7) Sustainable Growth Rate and Medicare – The AMA continues to express its extreme disappointment in the failure of the of the US congress to correct flaws in this formula, which basically reward hospitals and punish doctors when services move from the inpatient to outpatient environment.
Relevance to Hand Surgeons:  Medicare is the largest single payer in the US for healthcare.  How Medicare is being recalculated impacts hand surgeons directly.  The US congress has threatened to freeze Medicare increases through multiple sessions now.  There has been last minute political lobbying that has allowed for a minimal amount of increase with each congressional session.  This resolution authorizes the AMA to come up with a solution that can be presented to congress as a way to “solve” the SGR problem.
AMA-YPS Position: Support
AMA Orthopedic Caucus Position: Support
ASPS/ACS Position: Support
Outcome at AMA: Adopted

8) Acceptance of TRICARE Health Insurance – Resolution that calls for the AMA to work with TRICARE to decrease complexities associated with the contracting process and work to increase the level of reimbursement to physicians.
Relevance to Hand Surgeons: Tricare is the primary insurance to all military personnel.  Hand injuries are one of the more common ailments afflicting our military personnel right now.  However, the reimbursement rates are well below Medicare.
AMA-YPS Position: Support
AMA Orthopedic Caucus Position: Support
ASPS/ACS Position: Support
Outcome at AMA: Passed

9) Same Day Procedures – Resolution that the AMA advocate that health plan discounts for second and subsequent procedures on the same day be based on relative resources required for providing the additional services.
Relevance to Hand Surgeons:  Many hand surgery procedures include multiple codes.  On the one hand, this resolution seems to support a higher reimbursement rates than the current 100/50/25/… formula.  However, there was discussion that any further discussion to this 100/50/25/... formula can change it back to the historical one where it was a 100/50/0/… formula.
AMA-YPS Position: Monitor/Support
AMA Orthopedic Caucus Position: Oppose. AAOS lobbied to change old formula to current one based on Abt report around 15 years ago.
ASPS/ACS Position: Monitor
Outcome at AMA: Existing AMA policy (Abt study) reaffirmed.

10) Medicare Payment Reform – Resolution that AMA devote the necessary political and financial resources to protect patient access to care by advocating for national legislation or litigation designed to pre-empt state laws that prohibit balance billing and inappropriate inclusion of balance billing bans in insurance-physician contracts. Additionally, resolution calls for AMA to develop model language for physicians to incorporate into any insurance contracts that attempt to restrict a physician’s right to balance bill any insured patient.
Relevance to Hand Surgeons:  Hand surgeons currently have the option of balance billing for Medicare patients. There is discussion that to change the SGR formula for Medicare, the AMA needs the support of organizations such as the AARP to get it passed in congress.  However, it is unlikely that an organization such as the AARP will sponsor this bill allowing physicians to balance bill Medicare patients.  The orthopedic caucus initially was against support of this resolution.  However, due to the voice of the YPS delegate who expressed that balance billing is one way for physicians to offset low reimbursement rates, the orthopedic caucus changed its position from opposed to support.
AMA-YPS Position: Active support
AMA Orthopedic Caucus Position: Support
ASPS/ACS Position: Monitor
Outcome at AMA: Reaffirmed existing AMA policy.

11) Prohibition of the Use of FDA-Approved Drugs and Medical Devices Off-Label – Resolution that AMA advance and foster regulatory and legislative initiates to support appropriate off-label use and reimbursement of US Food and Drug Administration (FDA)-approved drugs and devices.
Relevance to Hand Surgeons:  This resolution allows for this to occur and more importantly allows for reimbursement for these uses.
AMA-YPS Position: Monitor/Support
AMA-OSC Position: Support
ASPS Position: No Position
Outcome at AMA: The existing AMA policy supporting off label use was reaffirmed.

II. Other Issues of Interest to Hand Surgeons at the AMA:
1) Andrew Gurman, MD, is an Orthopaedic Hand Surgeon and AMA delegate from Pennsylvania. He is a member of AAOS and ASSH. He is also now the Vice-Speaker of the AMA HOD. This is a very influential position within AMA. He ran with the official endorsement of the AAOS, ASSH, and AAHS.  He will be invited to give a talk to the 2008 ASSH Young Members Forum on the topic of relevant healthcare issues for the young physician. Dr. Gurman has been active in the Hand Surgery Caucus at AMA and attended this year’s meetings of the Caucus as well. Dr. Gurman has also agreed to meet with the ASSH Council in May 2008 to explore issues of mutual interest between ASSH and the AMA.  Other senior AMA officials are expected to participate.
2) The “freeze” on HOD membership ends 12/31/07. This freeze is the result of two problems: the difficulty in apportioning members to the larger specialty societies (who get one delegate for every 1000 AMA members in that society), and the minimum requirements for specialty society membership in the AMA HOD (either 1000 AMA members with any percent participation or at least 250 members AND at least 35% of society members in the AMA).  The fundamental problem in the former is that most AMA members live and practice in just one state (making assignment of members by state fairly automatic) while many belong to multiple specialty societies. The policy has been that each member is assigned to the state in which they practice and must choose a specialty society by election. Unfortunately, very few members actually elect a specialty society to represent them, resulting in an underrepresentation of the larger specialty societies in the HOD. In the latter, many smaller societies were grandfathered in, and the percentage was set at a time when 35% of US doctors were AMA members as well. The corresponding figure today is 26%. While the AMA debated the issue, the current composition of the HOD was frozen. Now basically the status quo has been reaffirmed, and once again the above rules will be applied. It is likely that some states and specialties will lose delegates; some smaller societies may lose their place in the HOD.

III. Suggested Action Item:
Increase AMA awareness by hand surgeons by including on ASSH and AAHS dues notices a copy of the AMA advocacy agenda (see attachments) and possibly even a line item where members can sign up for AMA membership.
Please feel free to contact us if there are any questions:

Charles S. Day, M.D., M.B.A.
Assistant Professor in Orthopedic Surgery
Director, Orthopedic Curriculum
Harvard Medical School
Chief, Orthopedic Hand & Upper Extremity Surgery
Beth Israel Deaconess Medical Center

Peter C. Amadio, MD
Mayo Clinic
200 First Street SW
Rochester, MN 55905
507 284 2806
Fax 507 284 5539

David M. Lichtman, MD
Department of Orthopaedic Surgery
John Peter Smith Hospital
Fort Worth, Texas 76109
817 920 6903
Fax 817 927 3955