Informational Reports BOT Report(s) 03 2017 Grants and Donations 05 Update on Corporate Relationships 06 Redefining AMA's Position on ACA and Healthcare Reform 07 AMA Performance, Activities and Status in 2017 08 Annual Update on Activities and Progress in Tobacco Control: March 2017 Through February 2018 21 Ownership of Patient Data 32 Studying Healthcare Institutions that Provide Child Care Services 36 Management of Physician and Medical Student Stress 42 Demographic Report of the House of Delegates and AMA Membership CEJA Opinion(s) 01 Ethical Physician Conduct in the Media CEJA Report(s) 07 Judicial Function of the Council on Ethical and Judicial Affairs - Annual Report CLRPD Report(s) 01 A Primer on Artificial and Augmented Intelligence CME Report(s) 05 Study of Declining Native American Medical Student Enrollment CMS Report(s) 08 Addressing the Site-of-Service Differential Report of the Speakers 01 Recommendations for Policy Reconciliation
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Informational Reports
BOT Report(s)
03 2017 Grants and Donations 05 Update on Corporate Relationships 06 Redefining AMA's Position on ACA and Healthcare Reform 07 AMA Performance, Activities and Status in 2017 08 Annual Update on Activities and Progress in Tobacco Control: March 2017 Through February 2018 21 Ownership of Patient Data 32 Studying Healthcare Institutions that Provide Child Care Services 36 Management of Physician and Medical Student Stress 42 Demographic Report of the House of Delegates and AMA Membership
CEJA Opinion(s)
01 Ethical Physician Conduct in the Media
CEJA Report(s)
07 Judicial Function of the Council on Ethical and Judicial Affairs - Annual Report
CLRPD Report(s)
01 A Primer on Artificial and Augmented Intelligence
CME Report(s)
05 Study of Declining Native American Medical Student Enrollment
CMS Report(s)
08 Addressing the Site-of-Service Differential
Report of the Speakers
01 Recommendations for Policy Reconciliation
© 2018 American Medical Association. All rights reserved.
REPORT OF THE BOARD TRUSTEES
B of T Report 3-A-18 Subject: 2017 Grants and Donations Presented by: Gerald E. Harmon, MD, Chair This informational financial report details all grants or donations received by the American 1 Medical Association during 2017. 2
B of T Rep. 3-A-18 -- page 2 of 2
American Medical Association Grants & Donations received by AMA For the Year Ended December 31, 2017
Amounts in thousands Funding Institution Project Amount Received
Agency for Healthcare Research & Quality (subcontracted through Northwestern University)
Midwest Small Practice Care Transformation Research Alliance
$ 299
Centers for Disease Control and Prevention (subcontracted through National Association of Chronic Disease Directors)
Diabetes Technical Assistance and Support 243
Centers for Disease Control and Prevention (subcontracted through YMCA)
Diabetes Prevention Program 9
Centers for Medicare Medicaid Services Transforming Clinical Practices Initiative — Support and Alignment Networks
453
Centers for Medicare & Medicaid Services (subcontracted through Mathematica Policy Research, Inc.)
Quality Measures for CMS Programs Serving Medicare-Medicaid Enrollees and Medicaid-Only Enrollees
53
Substance Abuse and Mental Health Services Administration (subcontracted through American Academy of Addiction Psychiatry) Providers Clinical Support System for Opioid Therapies 91 Government Funding 1,148
American Association of Colleges of Osteopathic Medicine
Accelerating Change in Medical Education Initiative 13
American College of Physicians International Congress On Peer Review and Scientific Publication
10
American Medical Association Foundation via contributions from Eli Lilly and Company
Accelerating Change in Medical Education Conference 9
American Medical Association Foundation via contributions from Genentech, Inc.
Accelerating Change in Medical Education Conference 45
American Medical Association Foundation via contributions from Pfizer, Inc.
Accelerating Change in Medical Education Conference 23
American Medical Association Foundation via contributions from The Physicians Foundation
Joy in Medicine Research Summit 57
American Osteopathic Association Accelerating Change in Medical Education Initiative 13
Public Library of Science International Congress On Peer Review and Scientific Publication
10
Stanford University International Congress On Peer Review and Scientific Publication
30
The Marcus Foundation, Inc.
Evaluation of a Virtual Interactive Platform in Enhancing Diagnostic Reasoning and Improving Diagnostic Accuracy 788
Nonprofit Contributors 998
BioMed Central International Congress On Peer Review and Scientific Publication
10
Copyright Clearance Center, Inc. International Congress On Peer Review and Scientific Publication
5
Precision Computer Works, Inc. International Congress On Peer Review and Scientific Publication
5
Silverchair Science + Communications, Inc. International Congress On Peer Review and Scientific Publication
10
Wolters Kluwer Health International Congress On Peer Review and Scientific Publication
30
Contributions less than $5,000 International Congress On Peer Review and Scientific Publication
2
Contributions less than $5,000 International Medical Graduates Section Reception 8 Other Contributors 70
Total Grants and Donations $ 2,216
© 2018 American Medical Association. All rights reserved.
REPORT OF THE BOARD OF TRUSTEES
B of T Report 5-A-18 Subject: Update on Corporate Relationships Presented by: Gerald E. Harmon, MD, Chair PURPOSE 1 2 The purpose of this informational report is to update the House of Delegates (HOD) on the results of 3 the Corporate Review process from January 1 through December 31, 2017. Corporate activities that 4 associate the American Medical Association (AMA) name or logo with a company, non-Federation 5 association or foundation, or include commercial support, currently undergo review and 6 recommendations by the Corporate Review Team (CRT) (Appendix A). 7 8 BACKGROUND 9 10 At the 2002 Annual Meeting, the HOD approved revised principles to govern the American Medical 11 Association’s (AMA) corporate relationships, HOD Policy G-630.040, “Principles on Corporate 12 Relationships.” These “Guidelines for American Medical Association Corporate Relationships” were 13 incorporated into the corporate review process, are reviewed regularly, and were reaffirmed at the 14 2012 Annual Meeting. AMA managers are responsible for reviewing AMA projects to ensure they 15 fit within these guidelines. 16 17 YEAR 2017 RESULTS 18 19 In 2017, forty-four new activities were considered and approved through the corporate review 20 process. Of the forty-four projects recommended for approval, thirteen were conferences or events, 21 nine were education, content or grants, nineteen were collaborations or affiliations, and three were 22 member service provider programs (Appendix B). 23 24 CONCLUSION 25 26 The Board of Trustees (BOT) continues to evaluate the CRT review process to balance risk 27 assessment with the need for external collaborations that advance the AMA’s strategic focus. 28
B of T Rep. 5-A-18 -- page 2 of 15
Appendix A
CORPORATE REVIEW PROCESS OVERVIEW The Corporate Review Team (CRT) includes senior managers from the following areas: Strategy, Finance, Health Solutions Group (HSG), Advocacy, Federation Relations, Office of the General Counsel, Medical Education, Publishing, Ethics, Enterprise Communications and Marketing (ECM), Physician Engagement (PE), and Health and Science. The CRT evaluates each project with the following criteria: • Type, purpose and duration of the activity; • Audience; • Company, association, foundation, or academic institution involved (due diligence reviewed); • Source of external funding; • Use of the AMA logo; • Fit or conflict with AMA Corporate Guidelines; • Editorial control/copyright; • Exclusive or non-exclusive nature of the arrangement; • Status of single and multiple supporters; and • Risk assessment for AMA. The CRT reviews and makes recommendations regarding the following types of activities that utilize AMA name and logo: • Industry-supported web, print, or conference projects directed to physicians or patients that do
not adhere to Accreditation Council for Continuing Medical Education (ACCME) Standards and Essentials.
• AMA sponsorship of external events. • Independent and company-sponsored foundation supported projects. • AMA licensing and publishing programs. (These corporate arrangements involve licensing
AMA products or information to corporate or non-profit entities in exchange for a royalty and involve the use of AMA’s name, logo, and trademarks. This does not include database or CPT licensing.)
• Member service provider programs such as new affinity or insurance programs and member
benefits. • Third-party relationships such as joint ventures, business partnerships, or co-branding
programs directed to members. • Non-profit association collaborations outside the Federation. The CRT reviews all non-profit
association projects (Federation or non-Federation) that involve corporate sponsorship. • Collaboration with academic institutions only if there is corporate sponsorship. For the above specified activities, if the CRT recommends approval, the project proceeds.
B of T Rep. 5-A-18 -- page 3 of 15
In addition to CRT review, the Executive Committee of the Board must review and approve CRT recommendations for the following AMA activities: • Any activity directed to the public with external funding. • Single-sponsor activities that do not meet ACCME Standards and Essentials. • Activities involving risk of substantial financial penalties for cancellation. • Upon request of a dissenting member of the CRT. • Any other activity upon request of the CRT. All Corporate Review recommendations are summarized annually for information to the Board of Trustees. The BOT informs the HOD of all corporate arrangements at the Annual Meeting.
B of T Rep. 5-A-18 -- page 4 of 15
Appendix B
SUMMARY OF CORPORATE REVIEW RECOMMENDATIONS FOR 2017
Project No. Project Description
Corporations Approval Date
CONFERENCES/EVENTS
27797
Sandy Hook Promise Gala – Continue AMA sponsorship, name and logo use for the June 2017 event.
Sandy Hook Promise The Sorenson Family Standard and Poor (S&P) Global, Inc. Verizon Wireless Mehlman Castagnetti Rosen & Thomas Akin Gump Straus Hauer & Feld, LLP American Health Care Association (AHCA) Discovery Communications, Inc. Bank of America Lockheed Martin Corporation Anthem, Inc. Association for Accessible Medicines (AAM) American Telephone & Telegraph, Inc. (AT&T) General Dynamics Corporation CVS Health PepsiCo, Inc. Lumina Foundation Genentech, Inc. (A Member of the Roche Group) Comcast Corporation Blue Cross / Blue Shield Association Pharmaceutical Research and Manufacturers of America (PhRMA) Amalgamated Band Pacific Gas & Electric Company (PG&E) National Association of Broadcasters (NAB) Aetna Inc. Liberty Partners Group, LLC Managed Funds Association (MFA)
5/10/2017
B of T Rep. 5-A-18 -- page 5 of 15
27981
28216
28451
Alliance for Health Policy Dinner – Repeating AMA sponsorship for 2017 event to support advocacy. Bellin Health Training Days – AMA sponsorship, name and logo use for Bellin Health conference for their nine step practice transformation framework. National Quality Forum (NQF) Annual Conference Sponsorship – Continue AMA sponsorship, name and logo use for NQF Annual Conference “Fulfilling The Quality Mandate.”
Alliance for Health Policy (formerly Alliance for Health Reform) Bellin Health Systems Institute for Healthcare Improvement (IHI) National Quality Forum (NQF) Merck & Co., Inc. Janssen Global Services, LLC Kaiser Permanente Novartis, AG Deloitte Compassus America’s Essential Hospitals Utilization Review Accreditation Commission (URAC) Henry Ford Health System Battelle Memorial Institute Heron Therapeutics, Inc. American Health Care Association (AHCA) / National Center for Assisted Living (NCAL) Federation of American Hospitals American Hospital Association (AHA) Health Care Service Corporation (HCSC) UnitedHealth Group Encompass Health Corporation Relias WellDoc, Inc. Zero Suicide Institute National Committee for Quality Assurance (NCQA) Unite Us Fair Health, Inc.
8/4/2017
6/22/2017
11/21/2017
B of T Rep. 5-A-18 -- page 6 of 15
29117 American Conference on Physician Health (ACPH) – AMA name and logo association with Stanford University and the Mayo Clinic for conference on physician well-being.
Stanford University Mayo Clinic The Physician Foundation Coalition for Physician Well-Being
1/20/2017
29213
2017 ChangeMed National Conference – External sponsorship for AMA ChangeMed conference on innovation and medical education.
ChangeMed Healthcare Eli Lilly Elsevier Pfizer Genentech, Inc. (A Member of the Roche Group)
2/15/2017
29472
2017 Sling Health Demo Day – AMA sponsoring national Sling Health Demo Day.
Sling Health Bank of America St. Louis Bioscience (BioSTL) St. Louis Cardinals Community Development Ventures, Inc. Entrepreneur’s Organization iSelect Pharmaceutical Research and Manufacturers of America (PhRMA) St. Louis Local Businesses (Randall’s, Sameem’s, Schlafly, Urban Chestnut) St. Louis Metropolitan Medical Society
4/27/2017
29797
29835
Reach Media Collaboration – AMA Improving Health Outcomes (IHO) sponsorship of the Tom Joyner Family Reunion and Take a Loved One to the Doctor Day events. 2017 Health 2.0 Annual Fall Conference – AMA name, logo and sponsorship for physician burnout workshop.
Read Media Limited Community Health of South Florida, Inc. Health 2.0 TracendInsights Cigna Health Insurance United Healthcare Services, Inc. Allscripts Developer Program Datica Health, Inc. Nordic Innovation House California Health Care Foundation Zynx Health Incorporated dotHealth, LLC
6/22/2017
8/4/2017
B of T Rep. 5-A-18 -- page 7 of 15
Privis Health Utila, LLC Berg Analytics, LLC Distil Networks, Inc. Healow, Health and Online Wellness Outcomes Rocket Humetrix Nason Group Adaptive Sound Technologies, Inc. Proper Pillow M. Ventures B.V. Thinair Veta Health Consonance Companies, Inc. Venebio Group, LLC Stitch, Inc.
29938
AMA Sponsorship of 2017 Connected Health Conference – AMA sponsoring the 2017 Connected Health Conference.
Healthcare Information and Management Systems Society (HIMSS) American Association of Retired Persons, Inc. (ARRP) Intel Phillips Verizon
8/1/2017
30050 AMA / AHIMA Clinical
Documentation Improvement (CDI) Outpatient Workshop – AMA and AHIMA co-sponsoring a one day workshop on CDI.
American Health Information Management Association
8/10/2017
30210 2017 Forbes Healthcare Summit – AMA name, logo and sponsorship to highlight opioid epidemic and showcase new AMA initiatives.
Forbes America’s Biopharmaceutical Companies Bayer CVS Health Northwell Health City of Hope Comprehensive Cancer Center
9/7/2017
30362 2018 National Rx Drug Abuse & Heroine Summit – AMA name and logo use as event supporter.
The National Rx Drug Abuse & Heroine Summit
10/11/2017
B of T Rep. 5-A-18 -- page 8 of 15
EDUCATION, CONTENT OR GRANTS
29414 Teaching EMR – AMA name and logo use on Regenstrief Teaching EMR website and materials as acknowledgement of AMA’s Accelerating Change in Medical Education grant support.
The Regenstrief Institute 4/6/2017
29570
29647
Evaluation of Interactive Virtual Technology in Teaching (i-Human Platform) – A controlled AMA research study to evaluate the effectiveness of interactive technology, assess diagnostic reason and improve accuracy utilizing the i-Human platform and funding from the Marcus Foundation. AMA and The Wall Street Journal Custom Content Digital Platform – AMA developed content for use in an AMA / WSJ co-branded platform.
The Marcus Foundation i-Human Patients, Inc. The Wall Street Journal
5/4/2017 5/24/2017
29749
29866
30190
Sling Health – Chapter Expansion Grants – An AMA grant, name and logo association with Sling Health for student chapter expansion and community on AMA Physician Network. Support for Human Diagnosis Project’s Uninsured Digital Physician Consult Program – The AMA support for MacArthur grant process. Content Collaboration with Ingenious Med – AMA name and logo association with AMA content on Ingenious Med website.
Sling Health Human Diagnosis Project MacArthur Foundation American College of Physicians Ingenious Med
6/6/2017
7/7/2017
9/12/2017
B of T Rep. 5-A-18 -- page 9 of 15
30492
AMA and The Atlantic: Custom Content Digital Platform – AMA developed content for use in an AMA / The Atlantic co-branded platform.
The Atlantic
10/16/2017
30540
30804
25556 27962
Collaboration with Gaples Institute – Integrative Cardiology nutrition curriculum for AMA Education Center. AMA-AAPL Physician Leadership Education Curriculum – Physician Satisfaction and Practice Sustainability (PS2) and the AMA Education Center in partnership with the American Academy of Physician Leadership (AAPL) to develop co-branded physician leadership curriculum. Addition of American Stroke Association to the Target: BP Initiative – Addition of American Stroke Association to previously approved AMA Improving Health Outcomes (IHO), and American Heart Association, Target: BP program. Collaborative Study on Opioid Prescribing Activity with Premier Inc. – Premier / AMA collaboration, name and logo association on research designed to reduce opioid-related harms.
Gaples Institute for Integrative Cardiology American Academy of Physician Leadership (AAPL) American Stroke Association American Heart Association Premier Inc.
10/24/2017
11/21/2017
7/21/2017
10/12/2017
COLLABORATIONS/AFFILIATIONS
B of T Rep. 5-A-18 -- page 10 of 15
28930 28964 29341
AMA Collaboration with Samsung SHealth – AMA to grant Samsung a non-exclusive, royalty free license to display AMA IHO diabetes resources in the Samsung SHealth phone application for U.S. users. AMA Physician Opportunities Portal (POP) – Organization name and logo association with AMA POP interactive tool to identify extra clinical opportunities. AMA / KPMG Co-branded MACRA Survey – A survey to gather physician feedback on the start of the MACRA Quality Payment Program.
Samsung National Court Appointed Special Advocates (CASA) Association Klynveld Peat Marwick Goerdeler (KPMG)
9/15/2017
4/17/2017
3/7/2017
29414
AMA / Accenture Co-branded Cybersecurity Research – A physician survey on cybersecurity and HIPAA compliance.
Accenture
3/23/2017
29520
Health Affairs Precision Health Sponsorship – Co-sponsorship of a “precision medicine” theme issue of the Health Affairs journal.
The Robert Wood Johnson Foundation Precision Health Economics Illumina Pharmaceutical Research and Manufacturers of America (PhRMA) Genentech, Inc. (A Member of the Roche Group) Patients Center Outcomes Research Institute (PCORI)
4/19/2017
29723
AMA Collaboration with Pew and Medstar on EHR Best Practices – Conduct research and publish report to improve usability and safety of EHRs.
PEW Charitable Trusts MedStar Health Research Institute
6/27/2017
B of T Rep. 5-A-18 -- page 11 of 15
29760 Center for Healthcare Innovation Sponsorship –The AMA name and logo to be used on the website and program collateral for The 7th annual Diversity, Inclusion, & Life Sciences Symposium.
Center for Healthcare Innovation National Biotechnology and Pharmaceutical Association National Hispanic Life Sciences Society Women in Healthcare and Life Sciences Gilead Sciences, Inc. Drinker, Biddle & Reath, LLP. Merrill Lynch Northwestern Medicine Robert H. Lurie Comprehensive Cancer Center Aurora Health Care Bridge Clinical Research and Chiltern
6/9/2017
29929
29985
Partners HealthCare Digital Health Provider Adoption Study – AMA collaboration and logo use for Partners HealthCare research study to improve clinical adoption of digital health solutions. Human Diagnosis Project Alliance – AMA name and logo association with Alliance to address gaps in specialty care for the underserved.
Partners HealthCare System, Inc. (PHS) Human Diagnosis Project The American Board of Internal Medicine (ABIM) The American Board of Specialties (ABMS) The Association of American Medical Colleges (AAMC) The Association of Clinicians for the Underserved (ACU) National Association of Community Health Centers (NACHC) The Dartmouth Institute for Health Policy and Clinical Practice MIT Computer Science & Artificial Intelligence Lab (CSAIL)
7/21/2017
8/1/2017
30105 2017 TEDMED Collaboration –Recognition as TEDMED global partner for the AMA.
TEDMED 8/23/2017
B of T Rep. 5-A-18 -- page 12 of 15
30208
Lucro Collaboration –To improve digital health solutions through integration of AMA guidelines and solutions into Lucro’s healthcare marketplace platform.
Lucro Global, LLC 9/15/2017
30260 Physician Innovation Network (PIN) Supporters – Recognizing organizations that contribute resources or cross promote the AMA Physician Innovation Network.
Physician Innovation Network (PIN) MATTER Sling Health Lucro Global, LLC Healthbox, LLC AngelMD, Inc. Texas Medical Center Accelerator (TMCx) Plug and Play Tech Center Techstars Corporation Society of Physicians Entrepreneurs (SOPE) Red Crow Crowd, Inc. Health 2047 SMART 1776 Node Health Healthcare Innovation and Technology Lab, Inc. (HITLAb) Cambia Health Solutions, Inc. BluePrint Health StartUP Health Catalyst HTI Health 2.0 Insight Product Development, LLC Health: Further American Association of Retired Persons (AARP) MedStar Health
9/15/2017
30233
AMA / HITRUST Collaboration – Workshop on cybersecurity frameworks for small physician practices.
Health Information Trust Alliance (HITRUST) Binder Dijker Otte (BDO) Global
9/22/2017
B of T Rep. 5-A-18 -- page 13 of 15
30327 Integrated Health Model Initiative (IHMI) Collaborators – AMA name and logo association with external companies as supporters of the IHMI digital platform.
International Business Machines (IBM) Prometheus Research Apervita Cerner CareCloud American Heart Association (AHA) Patient-Centered Outcomes Research Institute (PCORI) Private Company Price Index (PCPI) NEST Coordinating Center (NESTcc) American Diabetes Association (ADA) Patients Like Me American Medical Informatics Association (AMIA) Snomed CareMore The Geisinger Health System (GHS) Bioreference Laboratories Clinical Architecture M*Modal Optum360 Intermountain Healthcare Partners Healthcare University of California San Francisco (UCSF) American Society of Anesthesiology (ASA) American College of Cardiology (ACC) American Academy of Family Physicians (AAFP) American Academy of Pediatrics (AAP) American Academy of Allergy, Asthma, & Immunology (AAAAI) American College of Physicians (ACP) American College of Surgeons (ACS) Epic Qualcomm Life Medstro Omada Healthcare Trust of America (HTA) Minnesota Mining and Manufacturing (3M) Partners Healthcare Kaiser Permanente
9/22/2017
B of T Rep. 5-A-18 -- page 14 of 15
HumanDx Apple Samsung Google Logical Observation Identifiers Names and Codes (LOINC) United Healthcare UC Health
30451 Rand Payment Model Study –
AMA name and logo on co-branded study book. Study entitled, “Effects of health care payment models on physician practice in the United States.”
RAND
10/12/2017
30493
HIMSS Annual Conference Collaboration – Continuing AMA participation and logo use for HIMSS annual conference.
Healthcare Information and Management Systems Society (HIMSS)
10/16/2017
30576 28966
Collaborative Study on Antibiotic Stewardship with The Pew Charitable Trusts – Pew / AMA name and logo use on research to assess prescribing practices and the need for antibiotic stewardship in outpatient healthcare settings. MEMBER SERVICE PROVIDER PROGRAMS AMA Insurance Agency (AMAI) Ultimate Health Digital Health Benefits – AMA’s partnership with Armadacare and Kelsey National for digital, medical and dental benefits.
The Pew Charitable Trusts Armadacare / ArmadaGlobal Kelsey National Corporation
10/20/2017
1/6/2017
B of T Rep. 5-A-18 -- page 15 of 15
29057
AMA Insurance Agency (AMAI) Digital Platform – AMA Insurance relationship with NextGen Insurance Group for digital insurance customer acquisition platform. AMA Insurance Agency Carrier Change – Carrier change to New York Life Insurance Company to replace AIG for AMA – sponsored Life Insurance, AMA-sponsored Disability Insurance, AMA-sponsored Office Overhead Expense Insurance, and AMA-sponsored Accidental Death Insurance plans.
Next Generation Insurance Group LLC New York Life Insurance Company
1/12/2017
9/28/2017
© 2018 American Medical Association. All rights reserved.
REPORT OF THE BOARD OF TRUSTEES
B of T Report 6-A-18
Subject: Redefining AMA’s Position on ACA and Healthcare Reform Presented by:
Gerald E. Harmon, MD, Chair
At the 2013 Annual Meeting of the House of Delegates (HOD), the HOD adopted Policy 1 D-165.938, “Redefining AMA’s Position on ACA and Healthcare Reform,” which called on our 2 American Medical Association (AMA) to “develop a policy statement clearly outlining this 3 organization’s policies” on a number of specific issues related to the Affordable Care Act (ACA) 4 and health care reform. The adopted policy went on to call for our AMA to report back at each 5 meeting of the HOD. BOT Report 6-I-13, “Redefining AMA’s Position on ACA and Healthcare 6 Reform,” accomplished the original intent of the policy. This report serves as an update on the 7 issues and related developments occurring since the most recent meeting of the HOD. 8 9 EFFORTS TO REPEAL THE ACA 10 11 Beginning prior to the introduction on March 7, 2017 of the component parts of what would 12 become the American Health Care Act through the Senate’s failure to adopt the so-called “skinny 13 bill” in the early morning hours of July 28, 2017, the AMA consistently engaged with policy 14 makers in support of AMA policies related to the Affordable Care Act. While acknowledging that 15 improvements were needed in the ACA, the AMA opposed repeal on the basis of several policy 16 points adopted by the House of Delegates. Specifically: 17 18 • Ensure that individuals currently covered do not become uninsured and take steps toward 19
coverage and access for all Americans; 20 • Maintain key insurance market reforms, such as pre-existing conditions, guaranteed issue and 21
parental coverage for young adults; 22 • Stabilize and strengthen the individual insurance market; 23 • Ensure that low/moderate income patients are able to secure affordable and meaningful 24
coverage; 25 • Ensure that Medicaid, The Children’s Health Insurance Program (CHIP) and other safety net 26
programs are adequately funded; 27 • Reduce regulatory burdens that detract from patient care and increase costs; 28 • Provide greater cost transparency throughout the health care system; 29 • Incorporate common sense medical liability reforms; and 30 • Continue the advancement of delivery reforms and new physician-led payment models to 31
achieve better outcomes, higher quality and lower spending trends. 32 33 A number of factors played into the inability of Congress to advance repeal of the ACA, including 34 the decision to act under the limitations imposed by the budget reconciliation process and efforts to 35 go beyond ACA reform to include significantly restructuring the financing of the Medicaid 36 program without hearings or stakeholder input. Ideological differences among Republican 37 members of Congress and discomfort with projections of significant increases in the number of 38 Americans without health insurance as a result of Congressional action further compromised the 39 pathway to repeal. 40
B of T Rep. 6-A-18 -- page 2 of 4
Following the failure to repeal ACA as a whole or in part, Congress was expected to turn to efforts 1 to stabilize the current system in the short term through continuing Cost-Sharing Reduction (CSR) 2 payments to health plans and reinsurance. However, despite bipartisan efforts to reach agreement, 3 no plan to strengthen the ACA marketplaces had been brought to the floor for a vote. On October 4 12, 2017, President Trump announced that we would end CSR payments, which had continued to 5 be made during pending litigation on their legality. On the same day, the President signed an 6 Executive Order directing relevant agencies to explore options for more people to buy health 7 insurance that is exempt from many of the ACA’s requirements. 8 9 As a result of the Executive Order, the Administration has released two proposed rules. The first, 10 released January 4, 2018, would allow more flexibility to groups and small businesses to join 11 together in an association health plan (AHP). While the AMA supports efforts to maximize health 12 plan choices for individuals and small businesses, the policy of the House of Delegates also calls 13 on the AMA to work with federal legislators to ensure that AHP programs safeguard state and 14 federal patient protection laws. In comments to the Department of Labor (DOL) on the proposal, 15 the AMA urged DOL to withdraw the proposed rule and work with state insurance commissioners 16 and health care stakeholders to seek a solution that would expand affordable insurance coverage 17 options through AHPs without undermining state authority to regulate AHPs to protect patients and 18 physicians against such things as fraud and insurer solvency. AMA expressed concern that “DOL’s 19 proposal does not maintain key consumer protections and does not meet the AMA’s key principles 20 on health system reform ... and would result in substandard health insurance coverage.” 21 22 The AMA also warned that without proper oversight to account for insolvency and fraud, AHPs 23 have the potential to increase already high insurance premiums and overall health care costs, while 24 threatening patients’ health and financial security and the financial stability of physician practices 25 and made recommendations to address those concerns. 26 27 On February 20, 2018, the Administration released a second proposed rule in keeping with the 28 Executive Order, this time to make it easier for individuals to buy health plans that do not comply 29 with ACA coverage requirements. The proposal would extend the time that consumers may be 30 covered by short-term, limited duration health plans that are not required to comply with coverage 31 requirements from three months to 364 days. These plans may not provide coverage for pre-32 existing conditions and benefits such as maternity care and mental health care are often excluded. 33 Critics have charged that the proposal would fracture the individual market, though administration 34 officials have disagreed with that assessment. At this writing, the AMA is reviewing the proposal. 35 36 Throughout the autumn of 2017, Congress also turned its attention to tax reform. While many in 37 Congress had considered the possibility of using tax reform to repeal portions of the ACA, such as 38 the requirement to obtain coverage, to take advantage of the protections from filibuster afforded it 39 by the Reconciliation process, others expressed serious reservations. Many thought that including 40 efforts to undermine ACA would erode support for the tax legislation. On November 8, 2017, the 41 Congressional Budget Office (CBO) released an estimate that repeal of the individual mandate 42 would result in 13 million fewer individuals having health coverage and premiums increasing an 43 average of 10 percent. However, CBO also predicted that repeal would produce $338 billion in 44 budgetary savings over 10 years, savings which could be used to offset some of the deficits 45 produced by the growing tax cut proposal. On November 16, 2017, the Tax Cuts and Jobs Act bill 46 passed the House by a vote of 227-205. The Senate followed on December 2, 2017 on a vote of 51-47 49. On December 19, the reconciled version of the Tax Cuts and Jobs Act passed both chambers 48 and was signed into law by President Trump December 22, 2017. The new law eliminates the 49 penalty for failure to obtain coverage repealing the individual mandate beginning in 2019. 50
B of T Rep. 6-A-18 -- page 3 of 4
REPEAL AND APPROPRIATE REPLACEMENT OF THE SGR AND PAY-FOR-1 PERFORMANCE 2 3 Our AMA continues to work with Congress and the Administration on the implementation of and 4 improvements to the Quality Payment Program (QPP) established by the Medicare Access and 5 CHIP Reauthorization Act (MACRA). Considerable progress was made in this regard through 6 multiple provisions of the Bipartisan Budget Act of 2018. 7 8 On February 9, 2018, the President signed the Bipartisan Budget Act of 2018. The budget bill 9 accomplished a number of critical Congressional priorities, including enacting continuing 10 appropriations through March 22 and setting spending caps for fiscal years 2018 and 2019, 11 suspending the debt ceiling for approximately one year, providing badly needed disaster relief 12 (including increased Medicaid spending for Puerto Rico and the U.S. Virgin Islands as called for 13 by the AMA House of Delegates), extending CHIP reauthorization for an additional four years 14 (through 2027) and addressing the so-called Medicare extenders, including repealing Medicare 15 outpatient therapy caps. 16 17 As a result of the work of our AMA and numerous state and national specialty medical 18 associations, a number of improvements to the QPP program were included in the final bill. These 19 included additional flexibility on the establishment of performance thresholds and the application 20 of cost measures, both of which will allow the Centers for Medicare & Medicaid Services to 21 continue to work with the physician community on implementation issues rather than having to 22 proceed immediately to more stringent requirements. Provisions of MACRA that applied the Merit-23 based Incentive Payment System (MIPS) payment adjustments to Part B drugs were also repealed 24 and the authority of the Physician-focused Payment Model Technical Advisory Committee (PTAC) 25 to provide technical assistance to physicians developing alternative payment models was clarified 26 and broadened. Additionally, the requirement that the Advancing Care Information requirements 27 for physicians under MIPS become more stringent each year was repealed. 28 29 REPEAL AND REPLACE THE INDEPENDENT PAYMENT ADVISORY BOARD (IPAB) 30 31 The Bipartisan Budget Act of 2018 also repealed the IPAB which had been put into place by the 32 ACA. Prior to its repeal, no appointments had ever been made to IPAB and the requirement for 33 recommendations for Medicare cuts by the board was never triggered. 34 35 SUPPORT FOR MEDICAL SAVINGS ACCOUNTS, FLEXIBLE SPENDING ACCOUNTS, 36 AND THE MEDICARE PATIENT EMPOWERMENT ACT 37 38 While the AMA continues to support efforts to expand access to health savings accounts and 39 expand the use of flexible spending accounts, including support of the “Restoring Access to 40 Medication Act,” no new developments have occurred since the last meeting of the HOD. 41 42 The Medicare Patient Empowerment Act has not been reintroduced in the 115th Congress. The 43 AMA will continue to seek opportunities, however, to increase private contacting opportunities 44 under the Medicare program without penalty to the patient or physician. 45 46 STEPS TO LOWER HEALTH CARE COSTS 47 48 Policymakers continue to explore legislative and regulatory options to reduce the cost of care, 49 particularly as it relates to the costs of pharmaceuticals. While dozens of bills have been introduced 50 and multiple Congressional hearings have been held, no action on these proposals has been 51
B of T Rep. 6-A-18 -- page 4 of 4
scheduled to date. Our AMA continues to engage physicians and the public 1 through www.TruthinRX.org, including collecting patient stories. 2 3 On February 28, 2018, a bipartisan group of U.S. Senators, including Sen. Bill Cassidy, MD, (R-4 LA) wrote to the AMA and other health care stakeholders regarding their efforts “to increase health 5 care price and information transparency to empower patients, improve the quality of health care, 6 and lower health care costs.” The letter requests stakeholder views on currently available 7 information, what is not available, different methods to achieve price transparency, and other 8 “common-sense” policies to empower patients and lower health care costs. Our AMA will respond 9 to the inquiry and looks forward to engaging with these Senators and others on ways to lower 10 health care costs. 11 12 One way to lower costs that is not in dispute is to lower the tremendous amount of time, effort, and 13 resources that go into complying with overly burdensome, duplicative, and unnecessary 14 administrative and regulatory requirements that do not benefit patient care. Physicians and other 15 providers are spending more and more time on paperwork and less time directly on patient care, 16 driving up costs for everyone. Since last summer, the House Committee on Ways and Means has 17 been collecting information from health care providers as part of its Medicare Red Tape Relief 18 Project. In announcing the efforts, Ways and Means Chairman Kevin Brady (R-TX) stated “we will 19 be doing outreach to health care providers, doctors, nurses, hospitals, clinicians on what red tape 20 and regulation out of Washington is interfering with the doctor-patient relationship, driving up the 21 cost of health care, or simply getting in the way of the highest quality health care possible. And so 22 Chairman Tiberi is going to be the one leading that effort. It will include soliciting ideas on what 23 the Administration and executive branch can do, as well, and ultimately leading – we hope – to 24 some action legislatively, as well.” While Subcommittee Chairman Tiberi has left Congress, we are 25 pleased that the new Subcommittee Chairman, Peter Roskam (R-IL), has taken up this mantle, and 26 we will continue to work with him and the committee to identify regulatory changes that can 27 reduce the burden of providing care to Medicare beneficiaries as well as lower health care costs for 28 all. 29 30 REPEAL NON-PHYSICIAN PROVIDER NON-DISCRIMINATION PROVISIONS OF THE 31 ACA 32 33 Guidance released by the Department of Health and Human Services in 2014 included a positive 34 interpretation of health plan requirements under section 2706(a) of the ACA, specifically clarifying 35 that the section does not require “that a group health plan or health insurance issuer contract with 36 any provider willing to abide by the terms and conditions for participation.” Nevertheless, the 37 AMA will continue to seek legislative opportunities to repeal this provision. 38 39 CONCLUSION 40 41 While much of the federal activity since the 2017 Interim Meeting of the House of Delegates has 42 centered on tax cuts and budgetary issues, health care is never far from the center of the debate. As 43 we have over the last several months, our AMA will continue to seek opportunities to advance the 44 policies that are the subject of this report as well as others adopted by the HOD. 45
© 2018 American Medical Association. All rights reserved.
REPORT OF THE BOARD OF TRUSTEES
B of T Report 7-A-18
Subject: AMA Performance, Activities and Status in 2017 Presented by:
Gerald E. Harmon, MD, Chair
Policy G-605.050, “Annual Reporting Responsibilities of the AMA Board of Trustees,” calls for 1 the Board of Trustees to submit a report at the American Medical Association (AMA) Annual 2 Meeting each year summarizing AMA performance, activities, and status for the prior year. 3 4 INTRODUCTION 5 6 The AMA’s mission is to promote the art and science of medicine and the betterment of public 7 health. As the physician organization whose reach and depth extends across all physicians, as well 8 as policymakers, thought leaders and medical schools, the AMA is uniquely positioned to deliver 9 results-focused initiatives that enable physicians to answer a national imperative to measurably 10 improve the health of the nation. 11 12 Creating Thriving Physician Practices: Tools For The Field 13 14 PS2 Research: The AMA and KPMG surveyed 1,000 practicing physicians in the U.S. who had 15 some awareness of the Medicare and Chip Reauthorization Act of 2015 (MACRA) and are 16 involved in practice decisions related to the Quality Payment Program (QPP). This research aimed 17 to better understand physician preparation and positioning for the QPP in 2017, which was the first 18 reporting year under the program. Key findings of this research have helped the AMA develop 19 educational and training resources for physicians, and have helped carve a path forward for 20 practices participating or planning to participate in alternative payment models and the Merit-based 21 Incentive Payment System (MIPS) through the QPP. The findings of this research were published 22 in June 2017. 23 24 In a special report co-authored by senior AMA staff and published in The New England Journal of 25 Medicine, relevant policy trends were identified and key recommendations made to grow the body 26 of evidence on telehealth care delivery. This will have the potential to accelerate telehealth 27 adoption, allowing physicians to enhance their delivery of clinical care. 28 29 Digital Health: The AMA formally launched the AMA Physician Innovation Network. Since 30 launch in October, more than 2,070 users (companies and physicians) have joined the site. More 31 than 1,100 of the users are physicians. There have been 1,000+ connection requests sent through 32 the site, approximately 100 opportunities created thus far and numerous collaborators that have 33 signed on to cross promote our efforts (e.g., MATTER, TMCx, Healthbox, and the Society of 34 Physician Entrepreneurs). 35 36 More than 1.7 million clinical documents were shared in October 2017 among health care 37 organizations through the Carequality Interoperability Framework. The rate of exchange has been 38 rapidly accelerating each month as 2 million documents were exchanged in total for the first 12 39
B of T Rep. 7-A-18 -- page 2 of 6
months. With existing users continuing to onboard clients, and more than a half dozen users 1 expected to go live in the first quarter of 2018, there will be continued growth. 2 3 Xcertia, an mHealth app collaborative effort pioneered by the AMA, the American Heart 4 Association (AHA), the DHX Group, and the Healthcare Information and Management Systems 5 Society (HIMSS), builds on each organization’s ongoing efforts to foster safe, effective, and 6 reputable health technologies. Initial content for Xcertia has been completed covering four areas: 7 operability, security, privacy, and clinical evidence, and was released for public comment. The 8 feedback will inform where to focus 2018 work group efforts. 9 10 Physician Payment and Quality: The AMA is working diligently so that practicing physicians are 11 integral partners in the movement toward a thriving value-based health care system. AMA has 12 created resources and tools for physicians and practice leaders that provide strategic guidance and 13 education, implementation and decision support, and practice financial forecasting, among others. 14 15 By providing doctors with tools such as the AMA MIPS Action Plan (https://apps.ama-16 assn.org/pme/#/actionplan), we assisted physician decision-making and participation in Medicare’s 17 QPP, and in their making the larger move to value-based reimbursement. 18 19 Practice Transformation: The Professional Satisfaction and Sustainability unit’s (PS2) efforts in 20 measuring physician burnout expanded with the addition of residency programs. We have worked 21 closely with our partners in adapting the Mini-Z to measure burnout amongst residents and fellows. 22 PS2 partnered with AMA Membership in designing and piloting this tool. We confirmed burnout 23 assessments with 11 residency programs across the country. This is an excellent opportunity to 24 further understand the resident and fellow experience, as well as opportunities to identify solutions 25 to enhance the practice of medicine for the next generation of clinicians. 26 27 The AMA developed seven new modules in 2017 for STEPS Forward™: 28
o Creating the organizational foundation for Joy in Medicine 29 o Adopting OpenNotes: Partnering with patients 30 o Adult vaccinations: Team-based immunization 31 o Building a patient experience program 32 o EHR in-basket restructuring for improved efficiency 33 o Embedding pharmacists into the practice 34 o Managing type 2 diabetes: A team-based approach 35
36 Guiding Professional Development: A Commitment To Physician Growth 37 38 In collaboration with IHO, the ACE consortium created and piloted educational programing within 39 the chronic disease prevention and management curriculum at four medical schools. The 40 consortium, also in conjunction with IHO, developed a unique history and physical tool 41 emphasizing biopsychosocial factors. This tool is being piloted at two medical schools. 42 43 Osteopathic residencies are now being accredited by ACGME, and staffers have been rapidly 44 adding these newly accredited residencies to FREIDA Online, the AMA Residency & Fellowship 45 Database. Searches for osteopathic residencies increased 95 percent in 2017 compared to 2016. 46 There are now 455 programs on FREIDA that have osteopathic recognition or are formerly 47 American Osteopathic Association accredited programs. 48
B of T Rep. 7-A-18 -- page 3 of 6
The Regenstrief EHR Clinical Learning Platform, an EHR specifically created for educational 1 settings by Indiana University School of Medicine and the Regenstrief Institute with financial 2 support from the ACE consortium, launched and is now used by five schools. 3 4 Innovations emerging from the ACE consortium continued to spread. Health systems science is 5 increasingly recognized as the third pillar of medical education and taught alongside the other two 6 pillars, basic and clinical science. The Health Systems Science textbook, published by Elsevier in 7 December 2016, sold thousands of copies around the world and was adopted by 12 schools across 8 the United States. 9 10 Chronic Care: Improving Health Outcomes 11 12 The AMA and American Heart Association launched a national “Health Care Provider High Blood 13 Pressure Education” campaign that has garnered more than 500K acts of engagement via our 14 various platforms. These platforms include Target: BP, a web platform that offers physician 15 practices and health systems access to the new Target: BP Improvement Program (based on the 16 2017 Hypertension Guideline), which includes self-measured blood pressure as a key component to 17 drive improved health outcomes. 18 19 In the fourth quarter of 2017 IHO co-led the successful launch of a new “National High Blood 20 Pressure Awareness Consumer” campaign in collaboration with the AHA and the Ad Council that 21 has already yielded more than 400K visitors to the campaign website (loweryourhbp.org) and 22 garnered $747M in donated media placements across the country. 23 24 To date IHO is actively engaged with 11 state medical societies that will serve as models to help 25 scale type 2 diabetes efforts nationwide. The list of states includes: 26 27
o Maryland State Medical Society 28 o Pennsylvania Medical Society 29 o Mississippi State Medical Association 30 o Nebraska Medical Association 31 o Ohio State Medical Association 32 o Oregon Medical Association 33 o Massachusetts Medical Society 34 o Minnesota Medical Association 35 o Michigan State Medical Society 36 o South Carolina State Medical Association 37 o Medical Society of the State of New York 38
39 The AMA and American Diabetes Association (ADA) collaborated with Samsung, one of the 40 world’s leading electronics companies, to create a first-of-its-kind “mobile public awareness 41 experience” during National Diabetes Awareness month in November 2017. Aimed at type 2 42 diabetes prevention, the goal of the collaboration was to help increase awareness among U.S. adults 43 ages 18 to 60 about prediabetes as a condition, and to drive more individuals within this target 44 population to assess their prediabetes risk via Samsung’s “S-Health App” for monitoring physical 45 and other health activities. During the month more than 340K adults completed the prediabetes risk 46 assessment. Our public awareness campaign with the Ad Council, CDC and ADA through 47 television, radio, and print has to date yielded another 560,000 risk test completions. 48
B of T Rep. 7-A-18 -- page 4 of 6
Advocacy 1 2 The AMA took a leading role in the successful fight to preserve access to affordable health care 3 coverage for millions of Americans. Through our site patientsbeforepolitics.org, the AMA 4 generated more than 7 million actions, including calls, emails, and social interactions that helped 5 shape the debate on Capitol Hill. 6 7 The AMA blocked two insurance mega-mergers that effectively protected over $500 million in 8 annual physicians’ payments. The U.S. Court of Appeals in Washington, D.C., upheld the lower 9 court’s decision to block the Anthem-Cigna merger. The AMA filed an amicus brief in that case, in 10 which the AMA argued (among many other key points) that the trial court properly found that 11 Anthem's reimbursement cuts, rather than enhancing consumer welfare, could cause quality to 12 degrade and consumers to be deprived of choice. Also, at the AMA’s suggestion, the nation’s 13 experts on antitrust and competition submitted their own amicus brief that supported AMA’s 14 contention. On May 12, 2017, Anthem abandoned the Cigna merger. 15 16 The AMA secured retroactive changes to the Medicare legacy reporting requirements that will help 17 physicians avoid $22 million in penalties in 2018, and addressed the biggest regulatory and 18 administrative hurdles for physicians, including prior authorization, electronic health records, and 19 insurer payment practices, such as new federal guidance that stops hidden transaction fees that 20 could cost physician practices thousands of dollars per year. 21 22 The AMA secured more than 130 state legislative and regulatory victories on issues related to 23 halting unfair health insurer practices, reversing the opioid epidemic, promoting medical liability 24 reform, protecting Medicaid, and promoting team-based care/opposing inappropriate scope of 25 practice expansions by non-physicians, as well as secured coverage for the Medicare Diabetes 26 Prevention Program and for remote patient monitoring. 27 28 Health and Science 29 30 The AMA made progress on reversing the opioid epidemic. In 2017 the AMA was able to report 31 fewer opioids being prescribed and an increase in prescription drug monitoring program use. The 32 AMA continues its efforts to address the opioid epidemic by developing resources and advocating 33 for policies intended to reduce opioid-related harm, increase access to effective treatment for pain, 34 and broaden the base for accessing medication-assisted treatment for those suffering from opioid 35 use disorder. A new opioid microsite was developed that contains a multitude of AMA and 36 Federation-based resources addressing the intersection of pain, opioids, and addiction. Physicians 37 are learning/following best practices for opioid prescribing. They continue, in increasing numbers, 38 to access educational resources, register with and check patient information in prescription drug 39 monitoring programs, obtain waivers for offering office-based treatment with buprenorphine, and 40 co-prescribe naloxone for patients at risk of opioid overdose. Naloxone is now widely available for 41 overdose interventions. Additionally, new partnerships were formed with hospitals, payers, 42 government, and others in the public and private sector to work collaboratively to advance a public 43 health solution to this enduring problem. 44 45 Health Solutions Group 46 47 In 2017 the AMA launched the Integrated Health Model Initiative (IHMI), a collaborative effort 48 across health care and technology stakeholders that will unleash a new era of better, more effective 49 patient care. IHMI supports a continuous learning environment to enable interoperable technology 50 solutions and care models that will evolve with real-world use and feedback. IHMI uses the best 51
B of T Rep. 7-A-18 -- page 5 of 6
available science to incorporate essential data elements around function, state, and patient goals. 1 Key components of IHMI are: digital communities around costly and burdensome clinical areas, a 2 physician-led validation process to review clinical applicability, and a data model for organizing 3 and exchanging information. Since the public release in mid-October 2017, 1,000 individuals from 4 47 states and 33 countries have joined the IHMI platform, in addition to 17 collaborating 5 organizations resulting in wide representation across external stakeholders. 6 7 In 2017 AMA Business Solutions, a subsidiary of the American Medical Association, collaborated 8 with LexisNexis® Risk Solutions to create VerifyHCP™, a pre-populated physician data solution 9 that aims to address the issue of inaccurate provider directories by streamlining verification and 10 updates across participating health plans. VerifyHCP allows physicians to focus their resources on 11 patient care and gives patients access to the credible information they need to make important 12 health care decisions. A single interface with highly accurate pre-populated physician profile data 13 allows for updates to all participating payer directories at one time. The solution reduces the 14 administrative burden on physicians and helps patients access more accurate directories when 15 selecting physicians. 16 17 The AMA in 2017 also established the Digital Medicine Payment Advisory Group, a collective of 18 clinical and technical subject matter experts with years of hands-on experience integrating digital 19 medicine services and tools into clinical practice to provide leadership in digital medicine adoption. 20 This initiative will help open access to high-quality and safe clinical care for patients and their 21 physicians that promote improved health outcomes. The group has identified payment and 22 coverage strategies—with an initial emphasis on coding, coverage, and payment for remote patient 23 monitoring services—to help overcome existing barriers to adoption. This group of 14 experts has 24 been working as a cohesive group for more than a year with clear goals and objectives set for 2018 25 and beyond. 26 27 JAMA/JAMA Network 28 29 JAMA and the JAMA Network continue to expand the amount of content produced, the formats for 30 distribution, the audiences they engage, and the impact their content has on research and practice. 31 In 2017, JAMA users viewed full-text content over 31 million times and downloaded and listened 32 to over 2 million podcasts. Downloads across the JAMA Network are up significantly as well, with 33 over 70 million full-text views in 2017. JAMA’s impact factor rose to 44.4, and JAMA Oncology 34 debuted with an impact factor of 16.6. Finally, in October, the JAMA Network announced the 35 launch of JAMA Network Open, an open access journal that launched in 2018. 36 37 Communications 38 39 The AMA played a central role in health system reform by clearly and firmly articulating a positive 40 vision for bipartisan reform, and by calling attention to the deficiencies in the various proposals 41 that came through Congress. The AMA commanded attention as demonstrated by a nearly 50 42 percent share of voice of media coverage among its advocacy peers. The AMA was referenced 43 more often—and by more media publications, broadcasts, and blogs—than any other health care 44 organization in 2017, earning nearly 33 billion media impressions, which is more than on any other 45 single issue in AMA history. 46 47 The AMA unveiled a bold brand campaign, the first in more than a decade, that in a brief 48 timeframe helped change perceptions of the AMA among students, residents, and physicians and 49 paved the way for the introduction of an ambitious membership campaign. 50
B of T Rep. 7-A-18 -- page 6 of 6
Physician Engagement 1 2 Physician Engagement: AMA launched the new “Membership Moves Medicine™” campaign, a 3 multi-channel effort to educate prospective and existing members about AMA’s activities and 4 accomplishments on behalf of patients and physicians—and provide tangible and compelling 5 reasons to join the AMA. It also launched a digital communities pilot program (with nearly 4,000 6 initial participants across three main communities: IMGs, Medical Students, Physician— 7 Reinventing Medical Practice) and the initial version of the Ambassador Program that leverages 8 nearly 1,000 AMA council and section leaders to represent the AMA online, in social forums, and 9 at live events. 10 11 Digital Transformation: The AMA launched more than 15 new areas on the AMA website, 12 including a new House of Delegates/Annual Meeting site. The AMA revised the digital marketing 13 platform with new landing pages, sign-up process, and account management center, greatly 14 improving membership conversion rates. The website updates include five new thematically driven 15 destinations that combine news storytelling and aggregated high-value content on subjects that 16 connect with audiences for impact and engagement (i.e., compelling stories, research, tools, and 17 resources to show the AMA’s impact and how members move medicine). 18 19 Membership: In 2017 the AMA saw its seventh consecutive year of membership growth, a 1.8 20 percent increase in dues paying members over 2016, and maintained a strong retention rate of 21 nearly 82 percent. 22 23 Resident Program: The AMA launched the new GCEP Resident Education Platform (formerly 24 known as the “Introduction to the Practice of Medicine”). By converging the strategic goals of 25 Physician Engagement, the Education Center (EC), and ACE, the AMA was able to improve 26 significantly on the former program’s appeal and performance. The new platform advances AMA 27 content offerings and encourages frequent engagement; it provides opportunity to extend and 28 expand programming at the UME, GME, and CME levels; and it drives lifelong affiliation and 29 membership with the AMA. 30 31 EVP Compensation 32 33 During 2017, pursuant to his employment agreement, total cash compensation paid to James L. 34 Madara, MD, as AMA Executive Vice President was $1,053,515 in salary and $987,735 in 35 incentive compensation, reduced by $5,114 in pre-tax deductions. Other taxable amounts per the 36 contract are as follows: $14,478 imputed costs for life insurance, $7,620 imputed costs for 37 executive life insurance, $2,500 paid for health club fees, $2,880 paid for parking and $3,500 paid 38 for a physical. An $81,000 contribution to a deferred compensation account was also made by the 39 AMA. This will not be taxable until vested and paid pursuant to provisions in the deferred 40 compensation agreement. 41 42 For additional information about AMA activities and accomplishments, please see the “AMA 2017 43 Annual Report.” 44
© 2018 American Medical Association. All rights reserved.
REPORT OF THE BOARD OF TRUSTEES
B of T Report 8-A-18
Subject: Annual Update on Activities and Progress in Tobacco Control: March 2017
through February 2018 Presented by:
Gerald E. Harmon, MD, Chair
This report summarizes American Medical Association (AMA) activities and progress in tobacco 1 control from March 2017 through February 2018 and is written pursuant to AMA Policy D-2 490.983, “Annual Tobacco Report.” 3 4 TOBACCO USE IN THE UNITED STATES: CDC MORBIDITY AND MORTALITY WEEKLY 5 REPORTS (MMWR) 6 7 According to the Centers for Disease Control and Prevention (CDC) tobacco use remains the 8 leading preventable cause of disease and death in the United States with an estimated 480,000 9 premature deaths annually, including more than 41,000 deaths resulting from secondhand smoke 10 exposure. These data translate to about one in five deaths related to tobacco use annually, or 1,300 11 deaths every day. From March 2017 through February 2018, the CDC released 13 MMWRs related 12 to tobacco use. These reports provide useful data that researchers, health departments, community 13 organizations and others use to assess and develop ongoing evidence-based programs, policies and 14 interventions to eliminate and/or prevent the economic and social costs of tobacco use. 15 16 2017: 17 https://www.cdc.gov/tobacco/data_statistics/mmwrs/byyear/2017/index.htm 18 19 2018 20 https://www.cdc.gov/tobacco/data_statistics/mmwrs/byyear/2018/index.htm 21 22 Youth Smoking Rates and Trends 23 24 According to the June 16, 2017 MMWR, which was an analysis of data from the 2011-2016 25 National Youth Tobacco Surveys (NYTS), there were substantial increases in electronic cigarette 26 (e-cigarette) and hookah use among high school and middle school students, whereas significant 27 decreases were observed in the use of cigarettes, cigars, smokeless tobacco, pipe tobacco, and 28 bidis. The NYTS is a cross-sectional, voluntary, school-based, pencil-and-paper questionnaire self-29 administered to U.S. middle and high school students. A three-stage cluster sampling procedure 30 was used to generate a nationally representative sample of U.S. students attending public and 31 private schools in grades 6–12. 32 33 Specifically among all high school students, current use of any tobacco product did not change 34 significantly from 2011 (24.2%) to 2016 (20.2%); however, there was a significant decrease in 35 current use of any combustible tobacco product (21.8% to 13.8%). The use of e-cigarettes 36 increased from 1.5% to 11.3% during this same period. 37
B of T Rep. 8-A-18 -- page 2 of 5
In 2016, among youth tobacco products users, 47.2% of high school students and 42.4% of middle 1 school students used 2 or more tobacco products. E-cigarettes were the most commonly used 2 tobacco product among high school (11.3%) and middle school (4.3%) students. 3 4 The authors highlight the need for sustained efforts to implement proven tobacco control policies 5 and strategies that are critical to preventing youth use of all tobacco products. There is concern 6 about the rising popularity of e-cigarettes. The FDA deeming rule that went into effect in August 7 2016, gives FDA jurisdiction over products made or derived from tobacco, including e-cigarettes, 8 cigars, pipe tobacco and hookah tobacco. This oversight could reduce youth tobacco product 9 initiation and use if combined with other environmental strategies such as taxes and raising the 10 purchase age to 21. 11 12 Adult Smoking Rates 13 14 To assess progress toward the Healthy People 2020 target of reducing the proportion of U.S. adults 15 aged 18 years and older who smoke cigarettes to12.0% or lower, the January 19, 2018 MMWR 16 analyzed data from the 2016 National Health Interview Survey (NHIS). The NHIS is an annual, 17 nationally representative in-person survey of the noninstitutionalized U.S. civilian population. The 18 NHIS core questionnaire is administered to a randomly selected adult in the household (the sample 19 adult). 20 21 In 2016, the prevalence of current cigarette smoking among adults was 15.5%, which was a 22 significant decline from 2005 (20.9%); however, no significant change has occurred since 2015 23 (15.1%). Current cigarette smoking prevalence was higher among males (17.5%) than among 24 females (13.5%). By age group, prevalence was higher among adults aged 25–44 years (17.6%) 25 and lower in adults 65 and older (8.8%). 26 27 Veterans Smoke at Higher Rates 28 29 The January 12, 2018 MMWR looked at tobacco use among military veterans in the U.S. from 30 2010-2015. An estimated 30% of veterans reported tobacco use and among those, 7% reported use 31 of two or more tobacco products. Cigarettes were the most commonly used tobacco product 32 (21.6%), followed by cigars (6.2%), smokeless tobacco (5.2%), roll-your-own tobacco (3.0%), and 33 pipes (1.5%). Within subgroups of veterans, current use of any of the assessed tobacco products 34 was higher among persons aged 18–25 years (56.8%), Hispanics (34.0%), or persons with less than 35 a high school diploma (37.9%). 36 37 The authors highlighted the significant impact of tobacco use among veterans on healthcare costs. 38 During 2010, the Veterans Health Administration (VHA) spent an estimated $2.7 billion on 39 smoking-related ambulatory care, prescription drugs, hospitalization, and home health care for the 40 segment of the veteran population receiving VHA services. Tobacco use among active military 41 personnel can eventually contribute to VHA expenditures. Reducing tobacco use among both 42 active duty military and veterans can therefore result in a substantial reduction in tobacco-related 43 morbidity and mortality and billions of dollars in savings from averted medical costs. 44 45 Recommendations to address the high rates of tobacco use in veterans include promoting cessation 46 to current military personnel and veterans, implementing tobacco-free policies at military 47 installations and Veterans Affairs medical centers and clinics, increasing the age requirement to 48 buy tobacco on military bases to 21 years, and eliminating tobacco product discounts through 49 military retailers. 50
B of T Rep. 8-A-18 -- page 3 of 5
AMA TOBACCO CONTROL ACTIVITIES 1 2 AMA Calls on Walgreens to Stop Selling Cigarettes 3 4 According to an online survey, 82% of Walgreens’ shoppers surveyed agreed that “the primary 5 focus of stores with pharmacies should be to sell products that help people get and stay healthy” 6 and 73% reported that they favor a ban on tobacco sales at Walgreens. The survey was conducted 7 by the Truth Initiative, a national nonprofit focused on eliminating tobacco use through youth 8 engagement research and education. 9 10 The survey results were highlighted in a joint letter (January 2018) signed by the AMA and other 11 medical and health groups calling on Walgreens to discontinue sales of tobacco products. The letter 12 to the Walgreens Chief Medical Officer cited research that confirms that retail marketing, in-store 13 advertising, and displays are associated with compromising quit attempts and cause the initiation 14 and progression of tobacco use among young people. The letter also called on Walgreens to: 15 16
• refrain from opposing policies that reduce tobacco use including those that require tobacco-17 free retailers and regulate retail licensing and density; 18
• eliminate sales of tobacco products while continuing to sell FDA approved nicotine 19 therapies; and 20
• employ pharmacy-based plans to assist smokers with quit attempts including cessation 21 counseling. 22
23 The AMA opposed sales of tobacco products in pharmacies as early as 2003. As stated in the 24 Board of Trustees Report 02-I-03, “Opposition to Sales of Tobacco in Pharmacies”, the sale of 25 tobacco products in pharmacies presents an ethical conflict for pharmacists; sends unhealthy, 26 mixed messages to consumers about the role of pharmacies in the community; is not a clear 27 economic necessity; and negatively affects the health of our patients. By selling and promoting 28 tobacco, pharmacies undermine the tobacco control efforts of the rest of the health community. 29 30 AMA first adopted its policy calling for a ban on sales of tobacco products in pharmacies in 2009 31 and reaffirmed Policy D-495.994, in 2013. 32 33 Declines in Smoking in Movies Stalled since 2010 34 35 In response to the July 7, 2017, MMWR, Tobacco Use in Top-Grossing Movies - United States, 36 2010–2016, the AMA signed on to a letter to film industry leaders demanding that movie 37 producers, distributors and exhibitors apply an R-rating to all films that include depictions of 38 smoking or tobacco. According to the MMWR, the average number of tobacco incidents increased 39 55% in youth-rated movies with any tobacco depiction from 22 incidents in 2010 to 34 incidents in 40 2016. Previous studies had shown a steady decline, and if that trend had continued, all youth-rated 41 films would have been smoke-free by 2015. 42 43 The AMA was one of several organizations, including the American Academy of Pediatrics, 44 American College of Physicians, American Heart Association, American Lung Association, 45 American Public Health Association and others, who signed the letter citing the report. The 46 medical and public health groups set a deadline of June 1, 2018 for the industry to end its practice 47 of using tobacco depictions in youth-rated movies because research has shown these images have a 48 direct impact on children. 49
B of T Rep. 8-A-18 -- page 4 of 5
In a press statement, AMA President Dr. David O. Barbe said “We urge the motion picture industry 1 to listen to the collective plea of the nation's physicians and once and for all apply an 'R' rating to 2 films depicting cigarette smoking to help keep lethal, addictive tobacco products out of the hands 3 of young people. We will continue to advocate for more stringent policies and support efforts to 4 protect our nation's youth from the dangers caused by tobacco use.” 5 6 AMA House of Delegates Continues to Support Strong Tobacco Control Policies 7 8 The AMA House of Delegates adopted new or modified existing tobacco control policies at its 9 2017 Annual Meeting and 2017 Interim Meeting. Among the policies adopted was H-490.905, 10 “Use of Tobacco Industry-Sponsored Cessation and Prevention Materials,” which called on 11 physicians to use smoking cessation materials from credible sources when talking with their 12 patients. Physicians and health organizations are urged to avoid providing to patients and 13 consumers information or materials on tobacco cessation that come from tobacco companies or 14 other groups aligned with the tobacco industry. 15 16 The AMA also adopted D-490.974, “Corrective Statements Ordered to be Published by Tobacco 17 Companies for the Violation of the Racketeer Influenced and Corrupt Organizations Act,” that calls 18 for educating the public and policymakers about the organized conspiracy of several tobacco 19 companies to commit fraud and mislead consumers about the negative health effects of tobacco 20 use. In 2006, several tobacco companies were found in violation of the U.S. Racketeer Influenced 21 and Corrupt Organizations (RICO) Act. Ten years after that decision, the U.S. Court of Appeals 22 finalized the content of the corrective statements the companies are required to make public. 23 24 Under this policy, the AMA will work with state and medical specialty societies as well as public 25 health organizations to increase public awareness of the tobacco companies that were found in 26 violation of the RICO Act and the corrective statements that they are being required to publish. The 27 policy also encourages state and medical specialty societies to work with appropriate public health 28 organizations in their states to help identify public policies that may have been directly or indirectly 29 influenced by tobacco companies, and encourage lawmakers to reject any potential tobacco 30 industry influences on future policy. 31 32 AMA Fights for Tobacco Provisions in Appropriations Bill 33 34 The AMA joined with medical groups and health organizations to oppose the House Agriculture, 35 Rural Development, Food and Drug Administration (FDA), and Related Agencies appropriations 36 bill. The bill called for weakening the FDA’s authority over certain tobacco products and would 37 exempt the Agency’s oversight over large and premium cigars entirely. This bill was of particular 38 concern because it would have created a loophole that would enable manufacturers of some cheap, 39 fruit- and candy-flavored cigars to escape from FDA oversight and prevent FDA from 40 implementing common sense rules for all cigars. 41 42 A 2009 law requires FDA review of new or changed tobacco products and applies to new products 43 introduced after February 15, 2007. This review is critical to stop tobacco companies from 44 introducing products that are more appealing to children, more addictive and even more harmful. 45 46 The House appropriations language would completely exempt from this requirement any e-47 cigarettes or cigars that are already on the market. Exempted products would include cigars and e-48 cigarettes in an array of candy and fruit flavors that clearly appeal to children. The proposed 49 language would allow these products to stay on the market without any FDA review to determine 50 whether they attract children or otherwise harm public health. 51
B of T Rep. 8-A-18 -- page 5 of 5
The advocacy efforts by the medical and health groups were successful. In March 2018, the House 1 policy riders to exempt “large and premium cigars” from FDA oversight and to change the 2 “grandfather date” in order to exempt e-cigarettes, cigars, and other tobacco products from an FDA 3 product review requirement were not included in the final bill. 4
© 2018 American Medical Association. All rights reserved.
REPORT OF THE BOARD OF TRUSTEES
B of T Report 21-A-18
Subject: Ownership of Patient Data
Presented by: Gerald E. Harmon, MD, Chair At the 2017 Annual Meeting the House of Delegates adopted Policy D-315.976, “Ownership of 1 Patient Data,” which asks that our American Medical Association undertake a study on the misuse 2 of patient information by hospitals, corporations, insurance companies, and big pharma, including 3 the impact on patient safety, quality of care, and access to care when a patient’s data is withheld 4 from his or her physician. 5 6 The testimony on this resolution was unanimously in favor of adoption. Those who spoke 7 discussed the many challenges related to accessing patient data and medical records by physicians, 8 and agreed that a study is needed to better identify these obstacles and begin exploring solutions to 9 the use and misuse of patient information. 10 11 This informational report provides an overview of the current laws and regulations at the state and 12 federal levels that address ownership, access and use of patient data including under the Health 13 Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations. It 14 also looks at controls and processes in place to address physician and healthcare industry access 15 and use of patient information. 16 17 LEGAL AND REGULATORY OVERVIEW 18 19 Ownership of, and access to, patient data contained in a medical record are distinct concepts under 20 the law. State laws vary on the topic of who owns a patient’s medical record. As depicted in the 21 following graphic from Health Information & the Law1 the majority of state legislatures either 22 grant ownership of the medical record to the clinician or institution, or remain silent on medical 23
B of T Rep. 21-A-18 -- page 2 of 13
record ownership. New Hampshire uniquely provides that the patient owns the information 1 contained in the medical record. 2 3 Ownership of patient data is not specified under HIPAA. Patients, however, have broad access 4 rights to their protected health information (PHI). Patients can also exercise control over whether 5 and how their health information is used and disclosed for certain purposes, including marketing. 6 The following points are highlighted for patients by the U.S. Department of Health & Human 7 Services Office of Civil Rights document titled “Your Health Information Privacy Rights”2: (1) 8 Generally, patient health information cannot be used for purposes not directly related to care 9 without permission. For example, a doctor cannot give it to a patient’s employer, or share it for 10 things like marketing and advertising, without written patient authorization and (2) patients can ask 11 that their health information not be shared with certain people, groups, or companies. 12 13 The Office for Civil Rights (OCR) has an online complaint portal in which anyone can file a 14 complaint against covered entities and their business associates if there is a potential violation of an 15 individual’s health information privacy rights or other violation of the Privacy, Security, or Breach 16 Notification Rules. A “Covered Entity” is defined as either a health plan, health care clearinghouse, 17 or health care provider who transmits PHI in electronic form. “Business Associate” is defined in 18 part as a person that provides data transmission services with respect to PHI to a covered entity and 19 that requires access on a routine basis to such PHI. Additionally, a Business Associate may also be 20 a subcontractor that creates, receives, maintains, or transmits PHI on behalf of the business 21 associate. If OCR determines that a covered entity or business associate may have violated the 22 HIPAA Rules, that entity or business associate must either voluntarily comply with the HIPAA 23 Rules, take corrective action, or agree to a settlement with the injured party. Additionally, a civil 24 monetary penalty (CMP) may be imposed on the covered entity if the corrective action is not 25 viewed as satisfactory. 26 27 PHYSICIAN ACCESS TO PATIENT RECORDS 28 29 Much of the discussion on this resolution centered on the obstacles in accessing patient and 30 medical record data by physicians. This can be a symptom of the physician’s contract with the 31 hospital or healthcare entity they are employed by or contracted for services with, or the electronic 32 healthcare record vendor that they or their employer has contracted with. 33 34 Contractual Considerations – Employment Agreements 35 36 In cases where a physician is an employee of a hospital or other healthcare entity, access to patient 37 and medical record data both during and following employment is often addressed by the 38 employment agreement. The AMA, as well as many state medical societies, provides physicians 39 resources to assist in navigating various issues and ensuring a fair and comprehensive employment 40 agreement. This is especially important during separation. 41 42 Depending on its terms, an employment or independent contractor (IC) arrangement between a 43 physician and a hospital or health system should specify who owns the patient records and patient 44 data, and which parties have access rights to the data, including after termination. The parties will 45 negotiate their rights with respect to ownership of and access to the records for specified purposes, 46 including upon patient request. 47 48 The “AMA Annotated Model Physician-Hospital Employment Agreement”3 addresses access to 49 patient records and confidentiality in Section 8.7. While continuity of care is a high priority upon 50 the termination of the contractual employment relationship between a hospital and a physician, 51
B of T Rep. 21-A-18 -- page 3 of 13
equally important is contractual language that acknowledges the physician’s entitlement to copies 1 of patient charts and records. “The employer may wish to specify that, upon termination, the 2 physician will not be entitled to keep or copy charts, files, or patient lists;” however, it is common 3 practice to negotiate a provision that allows the physician to obtain the patient records after 4 termination for situations such as a malpractice action, administrative investigation or proceeding 5 against the physician, as they would be necessary to the physician’s defense. 6 7 AMA Advocacy Efforts and Resources 8 9 The AMA model state bill titled “Physician Employment Patient Notification and Records Act” 10 states that, in order to ensure that the termination of their physicians’ employment does not disrupt 11 their care; patients must be timely provided with information enabling them to obtain care from 12 alternative physicians or continue to receive care from their physicians post-termination. The 13 model bill also states that access to medical records should be addressed in the employment 14 agreement and should state that the physician is entitled to copies of patient charts and records 15 relating to the physician’s provision of physician services: (1) upon written request from the 16 patient, or (2) when records are necessary to address any current or future legal, professional, 17 administrative, regulatory, or other issues, claims, allegations, proceedings, or investigations 18 against, involving or in connection with those services. 19 20 The AMA Advocacy Resource Center (ARC) has developed a legislative campaign with the goal 21 of assisting physicians with issues throughout the employment spectrum including negotiating 22 employment contracts, maintaining autonomy during employment, and terminating the 23 relationship. 24 25 Federal Regulation and Guidance 26 27 The U.S. Department of Health and Human Services (HHS) has also weighed in on the related 28 matter of charging for access to patient or medical records. In March of 2016, OCR issued new 29 guidance4 including the stipulation that in the case of a request for an electronic copy of PHI 30 maintained electronically, covered entities may charge a flat fee not to exceed $6.50 (inclusive of 31 all labor, supplies, and postage). 32 33 Accessing Data through an Electronic Health Record (EHR) Vendor 34 35 The second party with which a physician can encounter issues regarding access to patient and 36 medical record data is with their electronic health records vendor. Concerns over ensuring data are 37 readily available to physicians and patients, prompted HHS and the Office of the National 38 Coordinator (ONC) to release a Health IT Playbook5 to help clinicians navigate the EHR market. 39 HHS and ONC also have developed an EHR contracting guide6, “EHR Contracts Untangled: 40 Selecting Wisely, Negotiating Terms, and Understanding the Fine Print.” The Health IT Playbook 41 and contracting guide are meant to assist clinicians and healthcare institutions in negotiating 42 contract terms with EHR vendors. The publication includes guidance and sample contract terms 43 addressing compliance with HIPAA and the control and access to EHR data - including the 44 avoidance of data blocking. 45 46 Contractual Considerations – EHR Vendor Agreement 47 48 The use of an EHR contract, including a Business Associate Agreement (BAA), can provide a 49 covered entity, such as a physician, the legal protection necessary to use and disclose patient PHI 50 with a health information exchange (HIE) or third party subcontractor for various purposes. These 51
B of T Rep. 21-A-18 -- page 4 of 13
activities may include health care activities, including but not limited to, claims processing, data 1 analysis, or quality assurance. 2 3 Physicians are encouraged to ensure the contract with the EHR vendor clearly defines data rights. 4 Failing to clearly address data access rights in the BAA and any other vendor contract can severely 5 impact the physician’s ability to share data with patient registries and HIEs as well as easily 6 transition to a new EHR vendor in the future. 7 8 The EHR vendor contract and BAA should also clearly identify what the EHR can and cannot do 9 with the data that is created and used by the physician. The vendor agreement or BAA should 10 address whether or not the vendor is permitted to aggregate de-identified data across different 11 covered entities for medical research, population health management, or other purposes. 12 13 AMA Tools and Resources 14 15 The AMA’s Steps ForwardTM module titled “Electronic Records Software Selection and Purchase”7 16 provides guidance on negotiating favorable contract terms. The AMA also has model legislation 17 created in response to Policy D-478.972 that required the AMA to develop model state legislation 18 to eliminate pricing barriers to EHR interfaces and connections to HIEs. The bill, titled “An Act to 19 Improve the Transparency of Electronic Health Record Systems Costs and Promote Data Sharing,” 20 identifies appropriate disclosures including data sharing capabilities and detailed fees. 21 22 Federal Regulations and Guidance 23 24 There are cases where it may be challenging to implement this guidance in today’s environment. 25 Because of unequal bargaining power and the fact that a hospital or health system, and not an 26 individual physician, often contracts with an EHR vendor, it can be difficult for a physician, 27 practice, or institution to obtain favorable contract provisions. The 21st Century Cures Act (the 28 Act) directs the Secretary of HHS to develop a strategy to reduce EHR regulatory and 29 administrative burdens while placing new requirements upon developers as a condition of 30 certification and maintenance of certification. These requirements address many of the AMA’s 31 long-standing concerns with EHRs, including prohibiting vendor data blocking; improving the 32 usability, interoperability, and security of EHRs; and testing certified EHR technology in real-33 world settings. 34 35 The Act provides for penalties of up to $1.0 million per instance for any developers, networks, or 36 exchanges that the Office of Inspector General (OIG) of HHS finds to have committed information 37 blocking. 38 The AMA has actively provided feedback to ONC, OIG, and HHS on what should and should not 39 be considered blocking and publically, through numerous comment letters, supports the 40 operationalization of the Act’s information blocking requirements for health IT vendors. The AMA 41 is expecting the release of the proposed rule around the implementation of the Act’s requirements 42 in April of 2018. 43 44 USE OF PATIENT RECORDS BY THE HEALTHCARE INDUSTRY 45 46 A search on use of EHR records reveals instances where health systems and EHR vendors are 47 entering data agreements to provide de-identified, anonymized data to organizations including 48 medical device manufacturers, technology providers, health information aggregators and clinical 49 researchers. Two recent examples include a partnership between Mercy Health System and 50 Medtronic8 to share de-identified data from approximately 80,000 patients with heart failure to 51
B of T Rep. 21-A-18 -- page 5 of 13
focus on how patients respond to Cardiac Resynchronization Therapy (CRT). In another recent 1 example Google9 partnered with academic medical centers to explore how machine learning can be 2 used to mine EHR data for improved outcomes. 3 4 EHR vendors also use de-identified patient data gathered through use of their products in 5 population health tools. In a less common scenario, some EHR vendors are providing de-identified, 6 anonymized patient data to health information organizations (HIO) who in turn merge the data with 7 other available datasets and license the combination to government agencies, academia, and 8 businesses for a range of medical research and commercial purposes. This includes pharmaceutical 9 manufacturers who use this information in various aspects of clinical development and 10 commercialization. HIOs also use anonymized patient data to deliver evidenced-based insights 11 about drug safety issues as well as the quality and cost of care. 12 13 The search on use of anonymized EHR records also revealed a number of white papers and 14 opinions on the promise of using EHR data for clinical research and improving outcomes stating, 15 however, that there are a number of challenges yet to be overcome to make this effective. 16 17 A LOOK FORWARD 18 19 A scan of the health technology market shows that data continues to grow in importance. Several 20 companies have announced initiatives and platforms that provide patients access and control of 21 their information. These organizations include a Virginia-based Health IT company, Health Wizz10, 22 who has created a patient-data platform that allows patients pull their data into the Health Wizz app 23 via EHR patient portals and then use the DirectTrust framework to send their data to providers and 24 other organizations. Apple11 is giving iPhone users a means to download their health records from a 25 patient portal, store them safely, and share them with others. The Apple feature, Health Records, is 26 currently in a beta release which includes integration with twelve participating hospital systems. 27 Most recently, CMS Administrator Seema Verma announced the launch of the MyHealthEData 28 Initiative. “MyHealthEData is a government-wide initiative that will break down the barriers that 29 contribute to preventing patients from being able to access and control their medical records. 30 MyHealthEData makes it clear that patients should have access and control to share their data with 31 whomever they want, making the patient the center of our health care system. Patients need to be 32 able to control their information and know that it’s secure and private. Having access to their 33 medical information will help them make decisions about their care, and have a better 34 understanding of their health.”12 35 36 AMA POLICY 37 38 The AMA has several policies related to this topic (see Appendix). Policy H-315.973, “Guiding 39 Principles for the Collection, Use and Warehousing of Electronic Medical Records and Claims 40 Data,” which was last updated and reaffirmed in 2013, establishes principles around the use of 41 these data that include compliance with HIPAA, requires physician consent for analysis of the data, 42 and requires data to remain accessible to authorized users for purposes of treatment, public health, 43 patient safety, quality improvement, medical liability defense, and research. 44 45 In addition, Policy H-315.975, “Police, Payer, and Government Access to Patient Health 46 Information,” and Policy H-315.987, “Limiting Access to Medical Records,” look to further define 47 who should and should not have access to this information. 48 Finally, Ethical Opinions E-3.2.4, “Access to Medical Records by Data Collection Companies,” E-49 3.2.1 “Confidentiality”, and E-3.3.2, “Confidentiality and Electronic Medical Records,” are also 50 relevant to this discussion. 51
B of T Rep. 21-A-18 -- page 6 of 13
CONCLUSION 1 2 This is an issue that will become more complicated as the healthcare industry looks to further 3 connect disparate patient information in an effort to map the patient journey and improve health 4 outcomes. Throughout the progression it is important that patients have appropriate access to their 5 data and physicians have the tools and controls they need to be good stewards of their patients’ 6 information while at the same time have the ability to share information to seamlessly coordinate 7 the best care. In support of these initiatives, the AMA has actively engaged with HHS, OIG, and 8 ONC and has broad policy in place covering all aspects of patient record maintenance, access and 9 control. 10 11 Physicians and healthcare institutions have the ability to control use and access to the patient data 12 they create within an EHR through agreements with the EHR vendor and business associate 13 agreements. Additionally all PHI contained in the EHR is protected under HIPAA. 14 15 Our AMA has taken a leadership role in ensuring appropriate use and access of these data by (1) 16 working with ONC and HHS to encourage operational implementation of provisions in the 21st 17 Century Cures Act to prohibit EHR vendors from blocking access to data and limiting a physician’s 18 ability to effectively utilize their EHR system; (2) providing physicians and practices with 19 resources on negotiating employment and independent contractor agreements to assist in clarifying 20 ownership of and access to patient information upon termination of employment or contracting; (3) 21 supplying physicians and practices with educational tools about favorable EHR vendor contract 22 terms covering ownership of, access to, and use of patient information; (4) educating physicians 23 and practices on how to file a HIPAA complaint with the OCR; and (5) providing the Federation of 24 Medicine with model legislation that ensures appropriate handling and access to patient data. 25 26 Lastly, technologies are emerging every day that are focused on putting patient data in the patient’s 27 hands with the capability of providing access and control to the patient with a mechanism of doing 28 so in a systematic way. 29
B of T Rep. 21-A-18 -- page 7 of 13
REFERENCES 1. “Who Owns Medical Records: 50 State Comparison” http://www.healthinfolaw.org/comparative-analysis/who-owns-medical-records-50-state-comparison. Retrieved on March 6, 2018 2. “Your Health Information Privacy Rights” https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/consumers/consumer_rights.pdf 3. “Understanding Employment Contracts” https://www.ama-assn.org/life-career/understanding-employment-contracts 4. “Individuals’ Right under HIPAA to Access their Health Information 45 CFR § 164.524” https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/#newlyreleasedfaqs 5. “The Office of National Coordinator for Information Technology Patient Engagement Playbook” https://www.healthit.gov/playbook/ 6. “EHR Contracts Untangled” https://www.healthit.gov/sites/default/files/EHR_Contracts_Untangled.pdf 7. “Electronic Health Record (EHR) Software Selection and Purchase” https://www.stepsforward.org/modules/ehr-software-vendor-selection 8. “Medtronic and Mercy: Sharing Data to Improve Health Care” https://www.mercy.net/newsroom/2017-11-20/medtronic-and-mercy--sharing-data-to-improve-health-care/ 9. “Google strikes several hospital partnerships for machine learning research” http://www.healthcareitnews.com/news/google-strikes-several-hospital-partnerships-machine-learning-research 10. “New platform lets patients sell their health data” http://www.modernhealthcare.com/article/20171130/NEWS/171139996 11. “Apple announces effortless solution bringing health records to iPhone” https://www.apple.com/newsroom/2018/01/apple-announces-effortless-solution-bringing-health-records-to-iPhone/ 12. Speech: Remarks by CMS Administrator Seema Verma at the HIMSS18 Conference, accessed at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-03-06-2.html APPENDIX – AMA POLICIES RELATED TO THIS REPORT AMA Code of Medical Ethics Code of Medical Ethics Opinion E-3.2.4, “Access to Medical Records by Data Collection Companies” Disclosing information to third parties for commercial purposes without consent undermines trust, violates principles of informed consent and confidentiality. Information contained in patients’ medical records about physicians’ prescribing practices or other treatment decisions can serve many valuable purposes, such as improving quality of care. However, ethical concerns arise when access to such information is sought for marketing purposes on behalf of commercial entities that have financial interests in physicians’ treatment recommendations, such as pharmaceutical or medical device companies. Information gathered and recorded in association with the care of a patient is confidential. Patients are entitled to expect that the sensitive personal information they divulge will be used solely to
B of T Rep. 21-A-18 -- page 8 of 13
enable their physician to most effectively provide needed services. Disclosing information to third parties for commercial purposes without consent undermines trust, violates principles of informed consent and confidentiality, and may harm the integrity of the patient-physician relationship. Physicians who propose to permit third-party access to specific patient information for commercial purposes should: (a) Only provide data that has been de-identified. (b) Fully inform each patient whose record would be involved (or the patient’s authorized surrogate when the individual lacks decision-making capacity) about the purpose(s) for which access would be granted. Physicians who propose to permit third parties to access the patient’s full medical record should: (a) Obtain the consent of the patient (or authorized surrogate) to permit access to the patient’s medical record. (b) Prohibit access to or decline to provide information from individual medical records for which consent has not been given. (c) Decline incentives that constitute ethically inappropriate gifts, in keeping with ethics guidance. Code of Medical Ethics Opinion E-3.3.1, “Management of Medical Records” Physicians have an ethical obligation to manage medical records appropriately. Medical records serve important patient interests for present health care and future needs, as well as insurance, employment, and other purposes. In keeping with the professional responsibility to safeguard the confidentiality of patients’ personal information, physicians have an ethical obligation to manage medical records appropriately. This obligation encompasses not only managing the records of current patients, but also retaining old records against possible future need, and providing copies or transferring records to a third party as requested by the patient or the patient’s authorized representative when the physician leaves a practice, sells his or her practice, retires, or dies. To manage medical records responsibly, physicians (or the individual responsible for the practice’s medical records) should: (a) Ensure that the practice or institution has and enforces clear policy prohibiting access to patients’ medical records by unauthorized staff. (b) Use medical considerations to determine how long to keep records, retaining information that another physician seeing the patient for the first time could reasonably be expected to need or want to know unless otherwise required by law, including: 1. Immunization records, which should be kept indefinitely 2. Records of significant health events or conditions and interventions that could be expected to have a bearing on the patient’s future health care needs, such as records of chemotherapy (c) Make the medical record available: 1. As requested or authorized by the patient (or the patient’s authorized representative) 2. To the succeeding physician or other authorized person when the physician discontinues his or her practice (whether through departure, sale of the practice, retirement, or death) 3. As otherwise required by law
B of T Rep. 21-A-18 -- page 9 of 13
(d) Never refuse to transfer the record on request by the patient or the patient’s authorized representative, for any reason. (e) Charge a reasonable fee (if any) for the cost of transferring the record. (f) Appropriately store records not transferred to the patient’s current physician. (g) Notify the patient about how to access the stored record and for how long the record will be available. (h) Ensure that records that are to be discarded are destroyed to protect confidentiality. Code of Medical Ethics Opinion 3.3.2, “Confidentiality and Electronic Medical Records” Information gathered and recorded in association with the care of a patient is confidential, regardless of the form in which it is collected or stored. Physicians who collect or store patient information electronically, whether on stand-alone systems in their own practice or through contracts with service providers, must: (a) Choose a system that conforms to acceptable industry practices and standards with respect to: 1. Restriction of data entry and access to authorized personnel 2. Capacity to routinely monitor/audit access to records 3. Measures to ensure data security and integrity 4. Policies and practices to address record retrieval, data sharing, third-party access and release of information, and disposition of records (when outdated or on termination of the service relationship) in keeping with ethics guidance (b) Describe how the confidentiality and integrity of information is protected if the patient requests. (c) Release patient information only in keeping with ethics guidance for confidentiality. Code of Medical Ethics Opinion 3.2.1, “Confidentiality” Medical records serve important patient interests for present health care and future needs, as well as insurance, employment, and other purposes. In keeping with the professional responsibility to safeguard the confidentiality of patients’ personal information, physicians have an ethical obligation to manage medical records appropriately. This obligation encompasses not only managing the records of current patients, but also retaining old records against possible future need, and providing copies or transferring records to a third party as requested by the patient or the patient’s authorized representative when the physician leaves a practice, sells his or her practice, retires, or dies. To manage medical records responsibly, physicians (or the individual responsible for the practice’s medical records) should: (a) Ensure that the practice or institution has and enforces clear policy prohibiting access to patients’ medical records by unauthorized staff.
B of T Rep. 21-A-18 -- page 10 of 13
(b) Use medical considerations to determine how long to keep records, retaining information that another physician seeing the patient for the first time could reasonably be expected to need or want to know unless otherwise required by law, including: 1. Immunization records, which should be kept indefinitely 2. Records of significant health events or conditions and interventions that could be expected to have a bearing on the patient’s future health care needs, such as records of chemotherapy (c) Make the medical record available: 1. As requested or authorized by the patient (or the patient’s authorized representative) 2. To the succeeding physician or other authorized person when the physician discontinues his or her practice (whether through departure, sale of the practice, retirement, or death) 3. As otherwise required by law (d) Never refuse to transfer the record on request by the patient or the patient’s authorized representative, for any reason. (e) Charge a reasonable fee (if any) for the cost of transferring the record. (f) Appropriately store records not transferred to the patient’s current physician. (g) Notify the patient about how to access the stored record and for how long the record will be available. (h) Ensure that records that are to be discarded are destroyed to protect confidentiality. AMA Policy H-315.973, “Guiding Principles for the Collection, Use and Warehousing of Electronic Medical Records and Claims Data” 1. It is AMA policy that any payer, clearinghouse, vendor, or other entity that collects and uses electronic medical records and claims data adhere to the following principles: a. Electronic medical records and claims data transmitted for any given purpose to a third party must be the minimum necessary needed to accomplish the intended purpose. b. All covered entities involved in the collection and use of electronic medical records and claims data must comply with the HIPAA Privacy and Security Rules. c. The physician must be informed and provide permission for any analysis undertaken with his/her electronic medical records and claims data, including the data being studied and how the results will be used. d. Any additional work required by the physician practice to collect data beyond the average data collection for the submission of transactions (e.g., claims, eligibility) must be compensated by the entity requesting the data. e. Criteria developed for the analysis of physician claims or medical record data must be open for review and input by relevant outside entities. f. Methods and criteria for analyzing the electronic medical records and claims data must be provided to the physician or an independent third party so re-analysis of the data can be performed. g. An appeals process must be in place for a physician to appeal, prior to public release, any adverse decision derived from an analysis of his/her electronic medical records and claims data. h. Clinical data collected by a data exchange network and searchable by a record locator service must be accessible only for payment and health care operations.
B of T Rep. 21-A-18 -- page 11 of 13
2. It is AMA policy that any physician, payer, clearinghouse, vendor, or other entity that warehouses electronic medical records and claims data adhere to the following principles: a. The warehouse vendor must take the necessary steps to ensure the confidentiality, integrity, and availability of electronic medical records and claims data while protecting against threats to the security or integrity and unauthorized uses or disclosure of the information. b. Electronic medical records data must remain accessible to authorized users for purposes of treatment, public health, patient safety, quality improvement, medical liability defense, and research. c. Physician and patient permission must be obtained for any person or entity other than the physician or patient to access and use individually identifiable clinical data, when the physician is specifically identified. d. Following the request from a physician to transfer his/her data to another data warehouse, the current vendor must transfer the electronic medical records and claims data and must delete/destroy the data from its data warehouse once the transfer has been completed and confirmed. H-315.987, “Limiting Access to Medical Records” Our AMA: (1) will pursue the adoption of federal legislation and regulations that will: limit third party payers' random access to patient records unrelated to required quality assurance activities; limit third party payers' access to medical records to only that portion of the record (or only an abstract of the patient's records) necessary to evaluate for reimbursement purposes; require that requests for information and completion of forms be delineated and case specific; allow a summary of pertinent information relative to any inquiry into a patient's medical record be provided in lieu of a full copy of the records (except in instances of litigation where the records would be discoverable); and provide proper compensation for the time and skill spent by physicians and others in preparing and completing forms or summaries pertaining to patient records; and (2) supports the policy that copies of medical records of service no longer be required to be sent to insurance companies, Medicaid or Medicare with medical bills. H-315.975, “Police, Payer, and Government Access to Patient Health Information” (1) Our AMA advocates vigorously, with respect to the final privacy rule or other privacy legislation, to define "health care operations" narrowly to include only those activities and functions that are routine and critical for general business operations and that cannot reasonably be undertaken with de-identified information. (2) Our AMA advocates vigorously, with respect to the final privacy rule or other privacy legislation, that the Centers for Medicare & Medicaid Services (CMMS) and other payers shall have access to medical records and individually identifiable health information solely for billing and payment purposes, and routine and critical health care operations that cannot reasonably be undertaken with de-identified health information. (3) Our AMA advocates vigorously, with respect to the final privacy rule or other privacy legislation, that CMMS and other payers may access and use medical records and individually identifiable health information for non-billing, non-payment purposes and non-routine, non-critical health care operations that cannot reasonably be undertaken with de-identified health information, only with the express written consent of the patient or the patient's authorized representative, each and every time, separate and apart from blanket consent at time of enrollment. (4) Our AMA advocates vigorously, with respect to the final privacy rule or other privacy legislation that no government agency, including law enforcement agencies, be permitted access to medical records or individually identifiable health information (except for any discretionary or
B of T Rep. 21-A-18 -- page 12 of 13
mandatory disclosures made by physicians and other health care providers pursuant to ethical guidelines or to comply with applicable state or federal reporting laws) without the express written consent of the patient, or a court order or warrant permitting such access. (5) Our AMA continues to strongly support and advocate a minimum necessary standard of disclosure of individually identifiable health information requested by payers, so that the information necessary to accomplish the intended purpose of the request be determined by physicians and other health care providers, as permitted under the final privacy rule. H-315.979, “Electronic Data Interchange Status Report” Our AMA will: (1) work to establish consensus on industry security guidelines for electronic storage and transmission of medical records as an important means of protecting patient privacy in a manner that avoids undue and non-productive burdens on physician practices; and (2) develop relevant educational tools or models in accordance with industry electronic security guidelines to assist physicians in compliance with state and federal regulations. H-155.994, “Sharing of Diagnostic Findings” The AMA (1) urges all physicians, when admitting patients to hospitals, to send pertinent abstracts of the patients' medical records, including histories and diagnostic procedures, so that the hospital physicians sharing in the care of those patients can practice more cost-effective and better medical care; (2) urges the hospital to return all information on in-hospital care to the attending physician upon patient discharge; and (3) encourages providers, working at the local level, to develop mechanisms for the sharing of diagnostic findings for a given patient in order to avoid duplication of expensive diagnostic tests and procedures. H-315.977, “Abuse of the Medical Record for Regulation or Financing the Practice of Medicine” 1) Our AMA continues to oppose the use of the physician office medical record as a tool of CMS, as well as any other agency or third party, to regulate the financing and practice of medicine. (2) The medical record shall be the property of the physician and the information contained therein, the property of the patient. (3) The physician's office medical record should be used solely to document the delivery of health care. H-315.971, “Patient Information in the Electronic Medical Record” AMA Guidelines for Patient Access to Physicians' Electronic Medical Record Systems: (1) Online interactions are best conducted over a secure network, with provisions for privacy and security, including encryption. (2) Physicians should take reasonable steps to authenticate the identity of correspondent(s) in electronic communication and to ensure that recipients of information are authorized to receive it. Physicians are encouraged to follow the following guidelines for patient authentication: (a) Have a written patient authentication protocol for all practice personnel and require all members of the physician's staff to understand and adhere to the protocol. (b) Establish minimum standards for patient authentication when a patient is new to a practice or not well known. (c) Keep a written record, electronic or paper, of each patient authenticated. (3) Prior to granting a patient access to his or her EMR, informed consent should be obtained regarding the appropriate use of and limitations to access of personal health information contained in the EMR. Physicians should develop and adhere to specific guidelines and protocols for online communications and/or patient access to the EMR for all patients, and make these guidelines known to the patient as part of the informed consent process. Such guidelines should specify
B of T Rep. 21-A-18 -- page 13 of 13
mechanisms for emergency access to the EMR and protection for and limitation of access to, highly sensitive medical information. (4) If the patient is allowed to make annotations to his or her EMR (i.e., over-the-counter drug treatments, family medical history, other health information), the annotation should be indicated as authored by the patient with sourcing information (i.e., date and time stamp, login and IP address if applicable). A permanent record of all allowed annotations and communications relevant to the ongoing medical care of the patient should be maintained as part of the patient's medical record. (5) Physicians retain the right to determine which information they do and/or do not import from a PHR into their EHR/EMR and to set parameters based on the clinical relevance of data contained within personal health records. (6) Any data imported into a physician's EMR/EHR from a patient's personal health record (PHR) must preserve the source information of the original data and be further identified as to the PHR from which it was imported as additional source information to preserve an accurate audit trail. (7) In order to maintain the legitimate recording of clinical events, patients should not be able to delete any health information in the record. Rather, in order to maintain the forensic nature of the record, patients should only be able to add notations when appropriate. (8) Disclosures of Personal Health Information should comply with all applicable federal and state laws, privileges recognized in federal or state law, including common law, and the ethical requirements of physicians. D-478.972, “EHR Interoperability” Our AMA: (1) will enhance efforts to accelerate development and adoption of universal, enforceable electronic health record (EHR) interoperability standards for all vendors before the implementation of penalties associated with the Medicare Incentive Based Payment System; (2) supports and encourages Congress to introduce legislation to eliminate unjustified information blocking and excessive costs which prevent data exchange; (3) will develop model state legislation to eliminate pricing barriers to EHR interfaces and connections to Health Information Exchanges; (4) will continue efforts to promote interoperability of EHRs and clinical registries; (5) will seek ways to facilitate physician choice in selecting or migrating between EHR systems that are independent from hospital or health system mandates; and (6) will seek exemptions from Meaningful Use penalties due to the lack of interoperability or decertified EHRs and seek suspension of all Meaningful Use penalties by insurers, both public and private.
© 2018 American Medical Association. All rights reserved.
REPORT OF THE BOARD OF TRUSTEES
B of T Report 32-A-18
Subject: Studying Healthcare Institutions that Provide Child Care Services Presented by:
Gerald E. Harmon, MD, Chair
INTRODUCTION 1 2 At the 2017 Annual Meeting, Policy D-215.987, “Studying Healthcare Institutions that Provide 3 Child Care Services,” was adopted by the House of Delegates. This policy directs the American 4 Medical Association (AMA) to work with relevant entities to study healthcare institutions to 5 determine whether they provide childcare services and report on those findings at the 2018 Annual 6 Meeting. This report, which is presented for the information of the House, provides background on 7 child care services in health care and the implications of access to child care for physicians, as well 8 as results of a study conducted by the AMA and other relevant research. 9 10 BACKGROUND 11 12 Physicians and residents often work irregular, long and overnight hours. Those with young 13 children, specifically pre-school age and younger, face significant challenges in ensuring their 14 children are cared for during work hours. This is especially true for dual-physician couples, 15 physicians with spouses or partners that work full time, and single parent physicians. According to 16 a 2017 AMA study of women physicians, 56 percent of respondents indicated onsite child care is 17 either somewhat or strongly important in helping them balance work and family responsibilities.1 18 Some challenges physicians encounter in trying to secure care for their children include 19 accessibility, affordability, and flexibility in hours. Many child care centers are full to capacity and 20 have wait lists that keep parents waiting for months or even years before their child can be 21 accepted. 22 23 Parents often experience stress and anxiety in dealing with family responsibilities that may affect 24 their work.2 Contending with the task of obtaining care for young children can increase stress, 25 which contributes to higher rates of burnout.3-5 Burnout can lead to diminished concentration, 26 medical errors or misdiagnoses, lack of empathy, and lower professional satisfaction.6 27 Implementing tactics to reduce personal and professional stress is associated with decreased rates 28 of burnout7 and having access to child care services, either onsite or near their workplace, can help 29 alleviate stress and anxiety for parents. Research also demonstrates that employees report improved 30 productivity while using quality child care.8 Despite the correlations between parental stress and 31 burnout and between access to child care and improved productivity,9 access to onsite child care is 32 limited for most employees. 33 34 AMA POLICY 35 36 AMA Policy H-215.985, “Child Care in Hospitals,” states that the AMA: (1) strongly encourages 37 hospitals to establish and support child care facilities; (2) encourages that priority be given to 38 children of those in training and that services be structured to take their needs into consideration; 39 (3) supports informing the AHA, hospital medical staffs, and residency program directors of these 40
B of T Rep. 32-A-18 -- page 2 of 4
policies; and (4) supports studying the elements of quality child care and availability of child care 1 on a 24-hour basis. 2 3 AMA Policy H-525.998, “Women in Organized Medicine,” states that the “AMA (3) (a) supports 4 the concept of proper child care for families of working parents; (b) reaffirms its position on child 5 care facilities in or near medical centers and hospitals; (c) encourages business and industry to 6 establish employee child care centers on or near their premises when possible; and (d) encourages 7 local medical societies to survey physicians to determine the interest in clearinghouse activities and 8 in child care services during medical society meetings.” 9 10 DISCUSSION 11 12 Although there is evidence to show that reducing burnout and stress can lead to higher rates of job 13 satisfaction and productivity, there is limited research showing a direct relationship between access 14 to employer-sponsored child care services and employee productivity or job satisfaction, and what 15 research is available is not consistent. An evaluation of existing research, published in Personnel 16 Psychology, concluded there is not a credible evidence base to support the claims that employer-17 sponsored child care increases productivity and job satisfaction, or that it reduces absenteeism.10 18 However, another more recent review demonstrates that offering onsite child care improves 19 employee recruitment and productivity, and reduces turnover and absenteeism.9 Notwithstanding 20 evidence for or against its perceived or actual benefits, access to employer-sponsored child care is 21 an important consideration for physicians when making major decisions about their practices and 22 their families. 23 24 Only seven percent of employers in the U.S. report offering onsite child care as a benefit to their 25 employees.11 Employers are most likely to provide Dependent Care Assistance Plans (56 percent) 26 which help employees pay for child care with pre-tax dollars, or Child Care Resource and Referral 27 (41 percent), which is simply access to information about child care in the area. These options are 28 easier to implement and less costly than offering child care at or near the worksite.12 Employers 29 that provide onsite child care are eligible for a federal tax credit and a state tax credit in many 30 states. The tax credit is not applicable for funds provided to employees to assist with the cost of 31 outside child care. 32 33 In the health care industry, access to employer-provided child care assistance is more prevalent 34 than in other industries.13 According to the Bureau of Labor Statistics, 17 percent of civilian 35 workers in the health care/social assistance sector have access to an employer-sponsored child care 36 benefit.13 Thirty-seven percent of civilian workers in hospitals have access to a workplace program 37 that provides for either the full or partial cost of child care in a nursery, day care center, or a baby 38 sitter in facilities either on or off the employer's premises.13 According to the AMA women 39 physician study, one in ten physicians indicated their employer offers onsite child care services, 40 and of those, 19 percent have access to a subsidy, allowance, or discount to help cover the cost of 41 the onsite care.1 The majority of respondents (57 percent) who report that their employer offers 42 onsite care work in large practices with 26 or more physicians.1 43 44 Residency and fellowship programs may also provide access to onsite or subsidized child care 45 services. According to the AMA Residency & Fellowship Database® (FREIDA), which comprises 46 information about more than 10,000 ACGME-accredited programs, 35 percent of the programs 47 provide access to some type of child care service assistance, 3,344 offer onsite child care, 771 offer 48 subsidies to assist with cost, and 528 offer both onsite care and subsidies.14 Users of the FREIDA 49 database can find details about residency programs nationwide, including whether or not they offer 50
B of T Rep. 32-A-18 -- page 3 of 4
onsite child care or subsidies to assist with the cost of offsite child care. FREIDA is free for anyone 1 to access and has enhanced features for AMA members. 2 3 The AMA sought collaboration from relevant stakeholders to conduct a census and capture specific 4 data on employer-provided child care resources and assistance in the health care industry. 5 However, since none of the organizations contacted expressed interest in pursuing the research 6 topic, the AMA Professional Satisfaction and Practice Sustainability and Market Research groups 7 developed and deployed the survey in-house. 8 9 The brief two-minute survey was distributed in an email invitation to 264 chief operating officers 10 and human resource decision-makers in health care organizations. Only seven of the individuals 11 invited to participate in the survey responded. The very small response rate could be due to a few 12 factors: (1) the AMA does not have an established relationship with the professionals that make 13 employee benefit decisions, so these individuals may not feel compelled to respond to an inquiry 14 from the AMA, implying that the AMA may not be the most appropriate organization to effectively 15 acquire this information; (2) employee benefit information may be confidential or leadership may 16 be otherwise hesitant to share the information even on an anonymous basis; and (3) the initial 17 target population was small due to the AMA’s lack of email contact information for the designated 18 audience, resulting in a relatively low response rate. Given the extremely small response rate it is 19 difficult and not advisable to draw any significant conclusions from this research. Additional 20 research is needed to understand the prevalence of employer-provided or -assisted child care; 21 however, it is not clear that the AMA is the appropriate organization to pursue such research, given 22 our limited access to the relevant health care human resource decision-makers and leaders who are 23 knowledgeable about the subject. 24 25 CONCLUSION 26 27 Access to child care can help physicians and physicians in training alleviate stress and focus on 28 their patients while at work. Reducing stress can help physicians’ combat burnout and increase 29 satisfaction in practice. Given the information available, it is apparent only a small portion of 30 employers, including health care organizations, offers onsite child care services.1, 12, 13 However, 31 determining how many health care organizations offer these benefits is difficult. Some employers 32 provide subsidies to help employees pay for child care, and others provide access to resources to 33 help employees locate and arrange child care. 34 35 Physicians seeking employment or medical students applying for residency or fellowship may be 36 interested in obtaining information about child care options provided by potential employers or 37 programs. Physicians seeking employment should always ask prospective employers about child 38 care during exploration of compensation and benefits packages. Additionally, the AMA’s FREIDA 39 database provides this information for many of the residency and fellowship programs listed. A 40 comprehensive list of health care organizations and employers that provides employment benefit 41 information such as availability of employer-sponsored child care could not be identified. Creating 42 and maintaining such a list would be challenging due to limited availability of the information, 43 limited access to the individuals that could disclose the information, the scale of the effort that 44 would be required to collect and maintain it, and the frequency at which the information could 45 change over time. 46
B of T Rep. 32-A-18 -- page 4 of 4
REFERENCES 1. American Medical Association, Women Physicians Study. 2017: Chicago, IL. 2. Bright Horizons, Bright Horizons Modern Family Index. 2016: Watertown, MA. 3. Brown, S.D., M.J. Goske, and C.M. Johnson, Beyond substance abuse: stress, burnout, and
depression as causes of physician impairment and disruptive behavior. J Am Coll Radiol, 2009. 6(7): p. 479-85.
4. Keller, K.L. and W.J. Koenig, Management of stress and prevention of burnout in emergency physicians. Ann Emerg Med, 1989. 18(1): p. 42-7.
5. Balch, C.M., J.A. Freischlag, and T.D. Shanafelt, Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences. Arch Surg, 2009. 144(4): p. 371-6.
6. Chopra, S.S., W.M. Sotile, and M.O. Sotile, Physician burnout. JAMA, 2004. 291(5): p. 633-633.
7. Lee, F.J., M. Stewart, and J.B. Brown, Stress, burnout, and strategies for reducing them: What’s the situation among Canadian family physicians? Can Fam Physician, 2008. 54(2): p. 234-5.
8. Shellenbeck, K., Child Care & Parent Productivity: Making the Business Case 2004, Cornell University: Ithaca, NY.
9. Early Care & Learning Council, Why Should Employers Care? Relationship Between Productivity and Working Parents. 2014: Albany, NY.
10. Miller, T.I., The effects of employer-sponsored child care on employee absenteeism, turnover, productivity, recruitment or job satisfaction: What is claimed and what is known. Vol. 37. 1984. 277-289.
11. Matos, K., E. Galinsky, and J.T. Bond, National Study of Employers. 2016, Society of Human Resource Management.
12. Society for Human Resource Management. Work/Life Balance: What are the pros and cons of a corporate onsite or near-site child care center? 2015 [cited 2017 November 1]; Available from: https://www.shrm.org/resourcesandtools/tools-and-samples/hr-qa/pages/onsitechildcare.aspx.
13. United States Department of Labor Bureau of Labor Statistics, Table 40. Quality of life benefits: Access, civilian workers, March 2017. 2017: Washington, D.C.
14. American Medical Association, AMA Residency & Fellowship Database. 2017.
© 2018 American Medical Association. All rights reserved.
REPORT OF THE BOARD OF TRUSTEES
B of T Report 36-A-18
Subject: Management of Physician and Medical Student Stress Presented by:
Gerald E. Harmon, MD, Chair
INTRODUCTION 1 2 At the 2017 Annual Meeting, Policy D-405.982, “Management of Physician and Medical Student 3 Stress,” was adopted by the House of Delegates. This policy directs the American Medical 4 Association (AMA) to produce a report on administrative and regulatory burdens placed on 5 physicians, residents and fellows, and medical students, and pursue strategies to reduce these 6 burdens. This report, which is presented for the information of the House, outlines various 7 administrative and regulatory processes that adversely affect medical students, residents, and 8 physicians. It also discusses AMA’s efforts, including existing policies, to reduce administrative 9 burdens and address physician stress and burnout, one of the major effects of overwhelming and 10 burdensome mandates, tasks and processes. 11 12 BACKGROUND 13 14 Physicians, residents and medical students face work-related stresses at high rates.1-3 Rates of stress 15 and resulting burnout have increased in recent years, with more than 54 percent of physicians 16 reporting at least one symptom of burnout in 2015 compared to 45 percent in 2011.4 Forty nine 17 percent of physicians often or always experience symptoms of burnout.5 There are many 18 influences, both internal and external, that contribute to stress and burnout among health 19 professionals. Many of the external factors are imposed by administrative and regulatory factors 20 outside of the physicians’ control. 21 22 AMA POLICY 23 24 The AMA maintains numerous policies supporting physician wellness and the importance of 25 reducing and preventing physician stress and burnout, as well as the reduction in 26 administrative/regulatory burdens associated with medical practice that can cause stress and lead to 27 burnout. 28 29 The AMA recognizes burnout and stress, and their effects, as serious issues that affect physicians 30 and medical students (Policy D-310.968, “Physician and Medical Student Burnout”). AMA places 31 great importance on physician health and wellness and the need for continued education on its 32 importance (Policy H-405.961, “Physician Health Programs”). AMA policy and the Code of Ethics 33 recognize that when physician health and wellness is compromised the safety and care of the 34 patient can be as well (Code of Ethics 9.3.1). The AMA supports programs to assist physicians in 35 early identification and management of stress, and is committed to helping physicians, practices, 36 and health systems identify and manage stress-related burnout (Policy H-405.957, “Programs on 37 Managing Physician Stress and Burnout”). The AMA developed principles to guide residency 38 programs in the supervision of residents and the avoidance of the harmful effects of excessive 39 fatigue and stress (Policy H-310.979, “Resident Physician Working Hours and Supervision”). The 40
B of T Rep. 36-A-18 -- page 2 of 8
AMA encourages research on the type and impact of external factors adversely affecting 1 physicians, including workplace stress, litigation issues, and restructuring of the health care 2 delivery systems (Policy H-95.955, “Physician Impairment”). 3 4 Reducing administrative burdens has been a top priority of the AMA for many years, and the 5 policies on record demonstrate the AMA’s continued commitment to addressing the issue at all 6 levels. The AMA continues working to simplify administrative processes such as claims processes, 7 prior authorizations, quality reporting, and other payer interactions (Policy D-190.974, 8 “Administrative Simplification in the Physician Practice”; H-320.939, “Prior Authorization and 9 Utilization Management Reform”; and D-125.992, “Opposition to Prescription Prior Approval”). 10 The AMA advocates for the Centers for Medicare & Medicaid Services (CMS) to simplify existing 11 requirements of federal regulations such as the Medicare and CHIP Reauthorization Act of 2015 12 (MACRA) and Quality Payment Program (QPP), and supports legislation that introduces 13 improved, more streamlined solutions (Policy H-390.837, “MACRA and the Independent Practice 14 of Medicine”; H-335.984, “Medicare Regulatory Relief Legislation”; H-180.973, “The ‘Hassle 15 Factor’”; D-320.991, “Creating a Fair and Balanced Medicare and Medicaid RAC Program”; 16 H-385.908, “Physician-Focused Alternative Payment Models: Reducing Barriers”; H-165.838, 17 “Health System Reform Legislation”; H-385.913, “Physician-Focused Alternative Payment 18 Models”; H-450.946, “Ensuring Quality in Health System Reform”; and H-320.958, “Emerging 19 Trends in Utilization Management”). The AMA supports and encourages the development of 20 health care technology, but actively works to ensure physicians are not burdened with additional 21 administrative tasks or processes it may create (Policy H-315.979, “Electronic Data Interchange 22 Status Report”; D-120.984, “Streamlining the Process for Prescription Refills”; D-478.996, 23 “Information Technology Standards and Costs”; and D-460.968, “The Precision Medicine 24 Initiative”). Licensing, continuing medical education and maintenance of certification (MOC) have 25 historically been cumbersome and time-consuming processes for physicians. The AMA supports 26 efforts to increase efficiencies in some of these processes and reduce the number of cumbersome or 27 unnecessary steps in an effort to lessen the burden on physicians (Policy D-275.954, “Maintenance 28 of Certification and Osteopathic Continuous Certification”; D-300.995, “Reducing Burdens of 29 CME Accreditation and Documentation”; D-275.994, “Facilitating Credentialing for State 30 Licensure”; H-275.917, “An Update on Maintenance of Licensure”; and H-275.924, “Maintenance 31 of Certification”). 32 33 In addition, the AMA recognizes the unique stress medical students face with student debt and 34 career choices, and has prioritized reducing medical student debt for legislative and other action 35 (Policy H 305.928, “Proposed Revisions to AMA Policy on Medical Student Debt”). The prospect 36 of finishing medical school without matching to a residency program is an added stress for medical 37 students. Due to an increase in medical students and funding caps for graduate medical education 38 (GME) programs, this has become increasingly burdensome. The AMA has also worked with CMS 39 and other key organizations to increase the number of GME positions in order to accommodate the 40 increase in medical students and accommodate the projected need for more physicians (Policy D-41 305.958, “Increasing Graduate Medical Education Positions as a Component to any Federal Health 42 Care Reform Policy”). 43 44 DISCUSSION 45 46 Physicians report better professional satisfaction when they perceive that they are providing 47 high-quality care, and obstacles to providing such care are major sources of professional 48 dissatisfaction.6 Potential effects of physician stress and burnout include reduced empathy toward 49 patients, poorer interactions during a visit, and medical errors, all which have the potential to 50 decrease the quality of care.7-11 Burnout can lead to lower professional satisfaction and a desire to 51
B of T Rep. 36-A-18 -- page 3 of 8
reduce clinical hours or leave the practice of medicine.5, 6 There is evidence that stress and burnout 1 affect medical students, residents and physicians at higher rates than the general U.S. population12, 2 13 and burnout has been connected to higher rates of suicidal ideation among physicians.14-17 3 4 In accord with the amplified attention on the effects of burnout, identifying the causes of stress and 5 burnout has increasingly become the focus of research. Sources of stress and burnout among 6 medical students and residents often include personal stressors, adjustment to a new work 7 environment, ethical conflicts, financial issues, long hours, and exposure to human suffering.12, 18 8 While the practicing physician can be adversely impacted with the same stressors as medical 9 students and residents, there are additional factors that are often tied to administrative and 10 regulatory burdens experienced in practice. These factors affect physicians in multiple aspects of 11 their work, including those related to the business of medicine, such as dealing with insurance 12 companies and complying with regulatory requirements, as well as those related to the practice of 13 medicine, such as licensing, credentialing, privileging, and maintenance of certification. 14 15 For physicians in practice, increased clerical burdens, including bureaucratic tasks and productivity 16 requirements, are often cited as the top reasons physicians experience burnout.5, 19-21 The amount of 17 time physicians spend doing administrative work includes more than half their day spent 18 completing tasks in the electronic health record (EHR) system and almost 90 minutes of EHR work 19 at home after hours.22 External factors detract from the quality of care physicians feel they can 20 provide: nearly 40 percent of physicians report patient care is adversely impacted to a great degree 21 by external factors such as third party authorizations, treatment protocols, and EHR design.5 22 Physicians also report that their EHRs have reduced or detracted from the quality of care, 23 efficiency of practice, and interaction with patients.5 24 25 Prior authorizations required by payers are another source of dissatisfaction and burden for 26 physicians.23 In a 2016 AMA study, 75 percent of physicians reported that burdens associated with 27 prior authorization are high or extremely high in their practice, and 90 percent indicated that prior 28 authorizations can delay patients’ access to necessary care. On average, physicians or their staff 29 complete 37 prior authorizations per week, with almost a quarter of physicians completing more 30 than 40 per week.24 Obtaining prior authorizations involves inefficient and sometimes difficult 31 processes that cost practices time and money, and often create stress and add pressure on 32 physicians. 33 34 Increasing documentation requirements from Medicare and commercial payers have also added to 35 physicians’ administrative workload. Dated documentation requirements for Evaluation and 36 Management (E/M) services are considered to be over burdensome and no longer aligned with the 37 modern practice of medicine.25 A 2013 survey indicated 92 percent of medical residents and 38 fellows reported that documentation requirements were excessive.26 Clinical documentation 39 requirements have increased over time with the mandated use of EHRs, increased quality reporting 40 and other factors,27 contributing significantly to the administrative overload. 41 42 Regulatory requirements can be an additional source of time-consuming tasks that lead to stress 43 and burnout for physicians. The QPP, a new Medicare physician payment system created by 44 MACRA, comprises two tracks through which physicians and practices can participate: the 45 Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). 46 Participation in either track of the QPP requires specific uses of EHRs as well as recording, 47 tracking and submitting quality and clinical practice improvement data to CMS in order to receive 48 payment incentives and/or avoid payment penalties. While the changes implemented through the 49 QPP represent an improvement over legacy Medicare pay-for-reporting programs, time and 50 education are needed for physicians to feel prepared and comfortable conforming to new 51
B of T Rep. 36-A-18 -- page 4 of 8
requirements. A recent KPMG-AMA survey demonstrated that more than half of physicians are 1 just somewhat knowledgeable about MACRA or QPP, and 41 percent have heard of MACRA or 2 QPP but do not consider themselves knowledgeable.28 Additionally, 90 percent of the physicians 3 participating in MIPS felt that the requirements are slightly or very burdensome, and the time 4 required to report the required metrics is the most significant challenge.28 5 6 In addition to the strains created by tasks involved in day to day business of medicine, there are 7 other processes that require time away from patient care and/or add stressful tasks to the physician 8 workload. MOC, which is in some states a prerequisite for credentialing or insurance network 9 participation, involves costly fees and lengthy tests which more than 80 percent of physicians feel 10 are over burdensome.29 After years of advocating for change, physician groups, including the 11 AMA, have prompted the American Board of Internal Medicine to relax its MOC requirements 12 with the introduction of simplified open-book exams starting in 2018.30 There is also evidence that 13 requests for information about mental illness and medical conditions on state medical license 14 applications may deter physicians from seeking needed health care, for fear of the impact on 15 licensure or employment.31 Leaving mental health issues or conditions untreated can result in 16 further exacerbation of stress or depression that can lead to burnout, and can even lead to other 17 illnesses and effects on job stability.32 18 19 The AMA has dedicated numerous resources to reduce administrative burdens that cause stress and 20 excessive workloads, assist physicians in navigating complex processes that come with new 21 regulations, and combat the burnout epidemic. 22 23 Through ongoing advocacy, the AMA works to address administrative burdens such as utilization 24 management programs, prior authorization requirements, complex claim processes and other 25 nonclinical activities that contribute to increased complexity and expense for physicians in practice. 26 In addition, the AMA provides practical interpretation of legislation and regulations to help the 27 practicing physician understand changes that may impact their practice. These are done via the 28 AMA website, webinars, podcasts, STEPS Forward™ modules and live presentations to organized 29 medicine. The AMA sections’ governing councils also continue their respective efforts to provide 30 strategies and recommendations to address payment reform, prior authorization, and other issues 31 that affect the practice of medicine. 32 33 In addition to advocacy, the AMA is working to provide useful tools for physicians to learn about 34 and navigate new payment models, including MIPS and APMs. The “Navigating the Payment 35 Process” topic page within the AMA website is a continuously growing wealth of information, 36 resources and actionable tools to assist physicians in these complex administrative functions. 37 38 For physicians, residents, medical students and practices, AMA offers free access to its STEPS 39 Forward online educational platform. The modules in the STEPS Forward platform provide simple, 40 meaningful step-based strategies for addressing stress and burnout. Relevant modules include 41 “Preventing Physician Distress and Suicide,” “Physician Wellness: Preventing Resident and Fellow 42 Burnout,” “Improving Physician Resiliency,” “Preventing Physician Burnout,” and “Creating the 43 Organizational Foundation for Joy in Medicine™.” Through the STEPS Forward site the AMA 44 also provides access to the Mini-Z Burnout Survey, which enables organizational leaders, including 45 residency program administrators, to periodically measure burnout levels among their staff and 46 residents. The Mini-Z survey also affords the AMA an opportunity to create a robust data set to aid 47 in the understanding of unique drivers of burnout and inform the AMA’s continued work in this 48 area. 49
B of T Rep. 36-A-18 -- page 5 of 8
The Professional Satisfaction and Practice Sustainability strategy group, one of the AMA’s three 1 strategic focus areas, continues to study and publish findings on burnout, its causes and effects, and 2 strategies for addressing it.22, 23, 33-39 Currently in progress is a collaboration with Stanford Medicine 3 WellMD Center and the Mayo Clinic to produce a follow-up study to the 2011 and 2014 burnout 4 and satisfaction research. The AMA has collaborated with the Canadian and British Medical 5 Associations for decades to co-host the International Conference on Physician Health, and will 6 continue this long-standing partnership in 2018. The AMA will also co-host with Stanford 7 University School of Medicine and the Mayo Clinic the second American Conference on Physician 8 Health in 2019. Both of these highly attended conferences offer programming to educate and 9 engage physicians, residents and medical students in organizational and individual level solutions 10 to promote and improve physician and trainee health and wellness. 11 12 The AMA’s Accelerating Change in Medical Education strategy group is dedicated to fostering 13 innovations in medical education that will create a learning environment and culture that ensures 14 the psychological, emotional and physical wellbeing of medical students and residents. One 15 example of the programming being put forth by this initiative is an online webinar that discusses 16 national and local efforts to prevent burnout and promote wellness throughout the physician 17 education continuum. The AMA also hosts a “Succeeding in Medical School” topic hub in which a 18 variety of relevant resources cover issues such as easing stressors, managing medical school stress, 19 and alleviating anxiety over exams. 20 21 CONCLUSION 22 23 The AMA recognizes the significant stressors and burdens that face medical students, residents and 24 physicians throughout their careers, and the effects those tolls have on physician well-being and 25 patient care. It is part of AMA’s strategic focus to help physicians create thriving, sustainable 26 practices and improve professional satisfaction with the practice of medicine. The AMA is 27 demonstrably committed to this work and continues to study the prevalence and severity of burnout 28 among physicians and trainees, identify factors that contribute to burnout, and develop solutions to 29 address the issue. The AMA will also persist in its efforts to advocate for better legislation and 30 regulations that do not overburden physicians with excessive administrative tasks and 31 requirements. 32
B of T Rep. 36-A-18 -- page 6 of 8
REFERENCES 1. Firth-Cozens, J. and R.L. Payne, Stress in Health Professionals: Psychological and
Organisational Causes and Interventions. 1999: Wiley; Available from: https://www.wiley.com/en-us/Stress+in+Health+Professionals%3A+Psychological+and+Organisational+Causes+and+Interventions-p-9780471998761
2. Balch, C.M., J.A. Freischlag, and T.D. Shanafelt, Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences. Arch Surg, 2009. 144(4): p. 371-6; Available from: https://jamanetwork.com/journals/jamasurgery/fullarticle/404847
3. Lee, F.J., M. Stewart, and J.B. Brown, Stress, burnout, and strategies for reducing them What’s the situation among Canadian family physicians? Canadian Family Physician, 2008. 54(2): p. 234-235; Available from: http://www.cfp.ca/content/54/2/234.long
4. Shanafelt, T.D., et al., Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings, 2015. 90(12): p. 1600-1613; Available from: http://www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/abstract
5. The Physicians’ Foundation, M.H.A., 2016 Survey of America's Physicians: Practical Patterns and Perspectives. 2016, The Physician's Foundation; Available from: https://physiciansfoundation.org/press-releases/the-physicians-foundation-2016-physician-survey/
6. Friedberg, M.W., et al., Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. RAND Corporation, 2013; Available from: https://www.rand.org/pubs/research_reports/RR439.html
7. West, C.P., et al., Association of resident fatigue and distress with perceived medical errors. JAMA, 2009. 302(12): p. 1294-300; Available from: https://jamanetwork.com/journals/jama/fullarticle/184625
8. Shanafelt, T.D., et al., Burnout and medical errors among American surgeons. Ann Surg, 2010. 251(6): p. 995-1000; Available from: https://journals.lww.com/annalsofsurgery/Abstract/2010/06000/Burnout_and_Medical_Errors_Among_American_Surgeons.1.aspx
9. Williams, E.S., et al., The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev, 2007. 32(3): p. 203-12; Available from: https://www.ncbi.nlm.nih.gov/pubmed/17666991
10. Shanafelt, T.D., et al., Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med, 2002. 136(5): p. 358-67; Available from: http://annals.org/aim/fullarticle/715151/burnout-self-reported-patient-care-internal-medicine-residency-program
11. Lyndon, A. Burnout Among Health Professionals and Its Effect on Patient Safety. 2016; Available from: https://psnet.ahrq.gov/perspectives/perspective/190/burnout-among-health-professionals-and-its-effect-on-patient-safety
12. Dyrbye, L.N., et al., Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med, 2014. 89(3): p. 443-51; Available from: https://journals.lww.com/academicmedicine/fulltext/2014/03000/Burnout_Among_U_S__Medical_Students,_Residents,.25.aspx
13. Shanafelt, T.D., et al., Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med, 2012. 172(18): p. 1377-85; Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1351351
B of T Rep. 36-A-18 -- page 7 of 8
14. Dyrbye, L.N., et al., Burnout and suicidal ideation among u.s. medical students. Annals of Internal Medicine, 2008. 149(5): p. 334-341; Available from: http://annals.org/aim/fullarticle/742530/burnout-suicidal-ideation-among-u-s-medical-students
15. Center, C., et al., Confronting depression and suicide in physicians: a consensus statement. Jama, 2003. 289(23): p. 3161-6; Available from: https://jamanetwork.com/journals/jama/fullarticle/196774
16. Hampton, T., Experts address risk of physician suicide. Jama, 2005. 294(10): p. 1189-91; Available from: https://jamanetwork.com/journals/jama/fullarticle/201513
17. Andrew, L. and B. Brenner, Physician Suicide. Medscape, 2016; Available from: https://emedicine.medscape.com/article/806779-overview
18. Dyrbye, L.N., M.R. Thomas, and T.D. Shanafelt, Medical Student Distress: Causes, Consequences, and Proposed Solutions. Mayo Clinic Proceedings. 80(12): p. 1613-1622; Available from: https://mayoclinic.pure.elsevier.com/en/publications/medical-student-distress-causes-consequences-and-proposed-solutio
19. Swensen, S., T. Shanafelt, and N. Mohta, Leadership Survey: Why Physician Burnout Is Endemic, and How Health Care Must Respond, in N Engl J Med Catalyst. 2016; Available from: https://catalyst.nejm.org/physician-burnout-endemic-healthcare-respond/
20. Williams, E.S., et al., Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study. Health Serv Res, 2002. 37(1): p. 121-43; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1430344/
21. Peckham, C. Physician Burnout: It Just Keeps Getting Worse. Medscape, 2015; Available from: https://www.medscape.com/viewarticle/838437
22. Arndt, B.G., et al., Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med, 2017. 15(5): p. 419-426; Available from: http://www.annfammed.org/content/15/5/419.full
23. Colligan, L., et al., Sources of physician satisfaction and dissatisfaction and review of administrative tasks in ambulatory practice: A qualitative analysis of physician and staff interviews. 2016, American Medical Association, Dartmouth-Hitchcock, Sharp End Advisory; Available from: https://www.ama-assn.org/sites/default/files/media-browser/public/ps2/ps2-dartmouth-study-111016.pdf
24. American Medical Association, 2016 AMA Prior Authorization Physician Survey. 2016, American Medical Association: Chicago; Available from: https://www.ama-assn.org/sites/default/files/media-browser/public/government/advocacy/2016-pa-survey-results.pdf
25. Centers for Medicare & Medicaid Services, 2018 Physician Fee Schedule Proposed Rule, CMMS, Editor. 2017. p. 373-8; Available from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/
26. Christino, M.A., et al., Paperwork Versus Patient Care: A Nationwide Survey of Residents' Perceptions of Clinical Documentation Requirements and Patient Care. J Grad Med Educ, 2013. 5(4): p. 600-4; Available from: http://www.jgme.org/doi/abs/10.4300/JGME-D-12-00377.1?code=gmed-site
27. Kuhn, T., et al., Clinical documentation in the 21st century: Executive summary of a policy position paper from the american college of physicians. Annals of Internal Medicine, 2015. 162(4): p. 301-303; Available from: http://annals.org/aim/fullarticle/2089368/clinical-documentation-21st-century-executive-summary-policy-position-paper-from
28. Kocot SL, et al., Are physicians ready for MACRA/QPP? Results from a KPMG-AMA Survey. 2017; Available from: http://www.kpmg-institutes.com/institutes/healthcare-life-sciences-institute/articles/2017/07/are-physicians-ready-for-macra-qpp.html
https://www.ama-assn.org/sites/default/files/media-browser/public/ps2/ps2-dartmouth-study-111016.pdf
B of T Rep. 36-A-18 -- page 8 of 8
29. Cook, D.A., et al., Physician Attitudes About Maintenance of Certification. Mayo Clinic Proceedings. 91(10): p. 1336-1345; Available from: http://www.mayoclinicproceedings.org/article/S0025-6196(16)30371-8/fulltext
30. American Board of Internal Medicine. MOC Assessments in 2018. Maintenance of Certification 2017 [cited 2017 November 30]; Available from: http://www.abim.org/maintenance-of-certification/new-in-2018/moc-assessments.aspx.
31. Dyrbye, L.N., et al., Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions. Mayo Clinic Proceedings. 92(10): p. 1486-1493; Available from: http://www.mayoclinicproceedings.org/article/S0025-6196(17)30522-0/fulltext
32. Clinic, M. Mental Illness Complications. Diseases and Conditions 2015 [cited 2017 November 30]; Available from: https://www.mayoclinic.org/diseases-conditions/mental-illness/basics/complications/con-20033813.
33. Sinsky, C., et al., Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Annals of Internal Medicine, 2016. 165(11): p. 753-760; Available from: http://annals.org/aim/fullarticle/2546704/allocation-physician-time-ambulatory-practice-time-motion-study-4-specialties
34. Sinsky, C.A., Beware the burden of measurement. Arch Intern Med, 2007. 167(9): p. 971-2; Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/412358
35. Shanafelt, T.D., et al., Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc, 2015. 90(12): p. 1600-13; Available from: http://www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/abstract
36. Bodenheimer, T. and C. Sinsky, From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med, 2014. 12(6): p. 573-6; Available from: http://www.annfammed.org/content/12/6/573.full
37. Shanafelt, T.D., et al., Potential Impact of Burnout on the US Physician Workforce. Mayo Clin Proc, 2016. 91(11): p. 1667-1668; Available from: http://www.mayoclinicproceedings.org/article/S0025-6196(16)30508-0/abstract
38. Shanafelt, T.D., et al., Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clinic Proceedings, 2016. 91(7): p. 836-848; Available from: http://www.mayoclinicproceedings.org/article/S0025-6196(16)30215-4/abstract
39. Shanafelt, T., J. Goh, and C. Sinsky, The business case for investing in physician well-being. JAMA Internal Medicine, 2017; Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2653912
© 2018 American Medical Association. All rights reserved.
REPORT OF THE BOARD OF TRUSTEES
B of T Report 42-A-18
Subject: Demographic Report of the House of Delegates and AMA Membership Presented by:
Gerald E. Harmon, MD, Chair
INTRODUCTION 1 2 This informational report, “Demographic Report of the House of Delegates and AMA 3 Membership,” is prepared pursuant to Policy G-600.035, “House of Delegates Demographic 4 Report,” which states: 5 6
A report on the demographics of our AMA House of Delegates will be issued annually and 7 include information regarding age, gender, race/ethnicity, education, life stage, present 8 employment, and self-designated specialty. 9
10 In addition, this report includes information pursuant to Policy G-635.125, “AMA Membership 11 Demographics,” which states: 12 13
Stratified demographics of our AMA membership will be reported annually and include 14 information regarding age, gender, race/ethnicity, education, life stage, present employment, 15 and self-designated specialty. 16
17 This document compares the House of Delegates (HOD) with the entire American Medical 18 Association (AMA) membership and with the overall United States physician and medical student 19 population. Medical students are included in all references to the total physician population 20 throughout this report to remain consistent with the bi-annual Council on Long Range Planning and 21 Development report. In addition, residents and fellows endorsed by their states to serve as sectional 22 delegates and alternate delegates are included in the appropriate comparisons for the state and 23 specialty societies. For the purposes of this report, AMA-HOD includes both delegates and 24 alternate delegates. 25 26 DATA SOURCES 27 28 Lists of delegates and alternate delegates are maintained in the Office of House of Delegates 29 Affairs and are based on official rosters provided by the relevant society. The lists used in this 30 report reflect 2017 year-end delegation rosters. 31 32 Data on individual demographic characteristics are taken from the AMA Physician Masterfile, 33 which provides comprehensive demographic, medical education, and other information on all 34 United States and international medical graduates (IMGs) who have undertaken residency training 35 in the United States. Data on AMA membership and the total physician and medical student 36 population are taken from the Masterfile and are based on 2017 year-end information. 37 38 Some key considerations must be kept in mind regarding the information captured in this report. 39 Vacancies in delegation rosters mean that the total number of delegates is less than the 556 allotted 40
B of T Rep. 42-A-18 -- page 2 of 4
at the 2017 Interim Meeting, and the number of alternate delegates is nearly always less than the 1 full allotment. As such, the total number of delegates and alternate delegates is 985 rather than the 2 1,112 allotted. Race and ethnicity information, which is provided directly by physicians, is missing 3 for approximately 18% of AMA members and approximately 20.6% of the total United States 4 physician and medical student population, limiting the ability to draw firm conclusions. Efforts to 5 improve AMA data on race and ethnicity are part of Policy D-630.972. Improvements have been 6 made in collecting data on race and ethnicity, resulting in a decline in reporting race/ethnicity as 7 unknown in the HOD and the overall AMA membership. 8 9 CHARACTERISTICS OF AMA MEMBERSHIP AND DELEGATES 10 11 Table 1 presents basic demographic characteristics of AMA membership and delegates along with 12 corresponding figures for the entire physician and medical student population. 13 14 Data on physicians’ and students’ current activities appear in Table 2. This includes life stage as 15 well as present employment and self-designated specialty. 16
Table 1. Basic Demographic Characteristics of AMA Members & Delegates, December 2017
2017 AMA Members
All Physicians and Medical Students
AMA Delegates & Alternate Delegates 1,2
Total 243,449 1,306,770 985 Mean age (years)3 46.9 51.9 55.2 Age distribution (percent) Under age 40 51.00% 29.37% 18.07% 40-49 years 9.93% 18.88% 12.59% 50-59 years 10.47% 17.80% 22.03% 60-69 years 10.88% 16.98% 31.78% 70 or more 17.72% 16.98% 15.53% Gender (percent) Male 64.94% 65.55% 71.57% Female 35.03% 34.36% 28.43% Unknown 0.03% 0.09% 0.00% Race/ethnicity (percent) White non-Hispanic 54.26% 51.74% 69.24% Black non-Hispanic 4.61% 4.20% 3.96% Hispanic 5.41% 5.44% 3.35% Asian/Asian American 14.74% 15.24% 10.66% Native American 0.35% 0.26% 0.10% Other4 2.64% 2.52% 1.42% Unknown 17.99% 20.62% 11.27% Education (percent) US or Canada 83.06% 76.98% 91.88% IMG 16.94% 23.02% 8.12%
1 There were 127 vacancies as of year’s end, most of which are unfilled alternate delegate slots. 2 Numbers include medical students and residents endorsed by their states for delegate and alternate delegate positions. 3 Age as of December 31. Mean age is the arithmetic average. 4 Includes other self-reported racial and ethnic groups.
B of T Rep. 42-A-18 -- page 3 of 4
Table 2. Life Stage, Present Employment and Self-Designated Specialty5, December 2017
2017 AMA Members
All Physicians and Medical Students
AMA Delegates & Alternate Delegates 1,2
Life Stage (percent) Student6 23.46% 7.68% 7.21% Resident6 23.61% 10.31% 5.38% Young (under 40 or first 8 years
in practice) 7.44% 15.86% 7.51%
Established (40-64) 22.90% 41.45% 50.36% Senior (65+) 22.59% 24.71% 29.54% Present Employment (percent) Self-employed solo practice 8.22% 8.96% 13.60% Two physician practice 1.57% 1.72% 1.93% Group practice 22.53% 41.14% 39.49% HMO 0.09% 0.17% 0.71% Medical school 1.22% 1.68% 4.47% Non-government hospital 2.33% 2.84% 5.79% State or local government hospital 4.59% 6.96% 10.46% US government 1.09% 2.03% 4.06% Locum Tenens 0.19% 0.21% 0.10% Retired/Inactive 10.21% 11.44% 5.79% Resident/Intern/Fellow 23.61% 10.31% 5.38% Student 23.46% 7.68% 7.21% Other/Unknown 0.89% 4.87% 1.02% Specialty (percent) Family Medicine 8.61% 11.74% 10.76% Internal Medicine 19.17% 23.08% 20.20% Surgery 13.93% 13.49% 21.52% Pediatrics 4.93% 8.77% 3.65% OB/GYN 5.22% 4.73% 5.48% Radiology 3.57% 4.53% 5.08% Psychiatry 3.92% 5.28% 5.18% Anesthesiology 3.69% 4.66% 3.86% Pathology 1.77% 2.24% 2.13% Other specialty 11.75% 13.82% 14.92% Students 23.46% 7.68% 7.21%
5 See Appendix for a listing of specialty classifications. 6 Students and residents are categorized without regard to age.
B of T Rep. 42-A-18 -- page 4 of 4
Appendix
Specialty classification using physician’s self-designated specialties.
Major Specialty Classification
AMA Physician Masterfile Classification
Family Practice General Practice, Family Practice
Internal Medicine Internal Medicine, Allergy, Allergy and Immunology, Cardiovascular Diseases, Diabetes, Diagnostic Laboratory Immunology, Endocrinology, Gastroenterology, Geriatrics, Hematology, Immunology, Infectious Diseases, Nephrology, Nutrition, Medical Oncology, Pulmonary Disease, Rheumatology
Surgery General Surgery, Otolaryngology, Ophthalmology, Neurological Surgery, Orthopedic Surgery, Plastic Surgery, Colon and Rectal Surgery, Thoracic Surgery, Urological Surgery
Pediatrics Pediatrics, Pediatric Allergy, Pediatric Cardiology
Obstetrics/Gynecology Obstetrics and Gynecology
Radiology Diagnostic Radiology, Radiology, Radiation Oncology
Psychiatry Psychiatry, Child Psychiatry
Anesthesiology Anesthesiology
Pathology Forensic Pathology, Pathology
Other Specialty Aerospace Medicine, Dermatology, Emergency Medicine, General Preventive Medicine, Neurology, Nuclear Medicine, Occupational Medicine, Physical Medicine and Rehabilitation, Public Health, Other Specialty, Unspecified
© 2018 American Medical Association. All rights reserved.
REPORT OF THE COUNCIL ON ETHICAL AND JUDICIAL AFFAIRS∗
CEJA Opinion 1-A-18
Subject: Ethical Physician Conduct in the Media Presented by:
Dennis S. Agliano, MD, Chair
INTRODUCTION 1 2 At the 2017 Interim Meeting, the American Medical Association House of Delegates adopted the 3 recommendations of Council on Ethical and Judicial Affairs Report 2-I-17, “Ethical Physician 4 Conduct in the Media.” The Council issues this Opinion, which will appear in the next version of 5 AMA PolicyFinder and the next print edition of the Code of Medical Ethics. 6 7 E-8.12 – Ethical Physician Conduct in the Media 8
9 Physicians who participate in the media can offer effective and accessible medical perspectives 10 leading to a healthier and better informed society. However, ethical challenges present themselves 11 when the worlds of medicine, journalism, and entertainment intersect. In the context of the media 12 marketplace, understanding the role as a physician being distinct from a journalist, commentator, 13 or media personality is imperative. 14
15 Physicians involved in the media environment should be aware of their ethical obligations to 16 patients, the public, and the medical profession; and that their conduct can affect their medical 17 colleagues, other health care professionals, as well as institutions with which they are affiliated. 18 They should also recognize that members of the audience might not understand the unidirectional 19 nature of the relationship and might think of themselves as patients. Physicians should: 20
21 (a) Always remember that they are physicians first and foremost, and must uphold the values, 22
norms, and integrity of the medical profession. 23 24
(b) Encourage audience members to seek out qualified physicians to address the unique questions 25 and concerns they have about their respective care when providing general medical advice. 26
27 (c) Be aware of how their medical training, qualifications, experience, and advice are being used 28
by media forums and how this information is being communicated to the viewing public. 29
∗ Opinions of the Council on Ethical and Judicial Affairs will be placed on the Consent Calendar for informational reports, but may be withdrawn from the Consent Calendar on motion of any member of the House of Delegates and referred to a Reference Committee. The members of the House may discuss an Opinion fully in Reference Committee and on the floor of the House. After concluding its discussion, the House shall file the Opinion. The House may adopt a resolution requesting the Council on Ethical and Judicial Affairs to reconsider or withdraw the Opinion.
CEJA Op. 1-A-18 -- page 2 of 2
(d) Understand that as physicians, they will be taken as authorities when they engage with the 1 media and therefore should ensure that the medical information they provide is: 2 3 (i) accurate; 4 5 (ii) inclusive of known risks and benefits; 6
7 (iii) commensurate with their medical expertise; 8 9 (iv) based on valid scientific evidence and insight gained from professional experience. 10
11 (e) Confine their medical advice to their area(s) of expertise, and should clearly distinguish the 12
limits of their medical knowledge where appropriate. 13 14
(f) Refrain from making clinical diagnoses about individuals (e.g., public officials, celebrities, 15 persons in the news) they have not had the opportunity to personally examine. 16 17
(g) Protect patient privacy and confidentiality by refraining from the discussion of identifiable 18 information, unless given specific permission by the patient to do so. 19 20
(h) Fully disclose any conflicts of interest and avoid situations that may lead to potential conflicts. 21 (II, V, VII) 22
©2018 American Medical Association. All rights reserved.
REPORT OF THE COUNCIL ON ETHICAL AND JUDICIAL AFFAIRS
CEJA Report 7-A-18
Subject: Judicial Function of the Council on Ethical and Judicial Affairs – Annual
Report Presented by:
Dennis S. Agliano, MD, Chair
At the 2003 Annual Meeting, the Council on Ethical and Judicial Affairs (CEJA) presented a detailed 1 explanation of its judicial function. This undertaking was motivated in part by the considerable attention 2 professionalism has received in many areas of medicine, including the concept of professional self-3 regulation. 4 5 CEJA has authority under the Bylaws of the American Medical Association (AMA) to disapprove a 6 membership application or to take action against a member. The disciplinary process begins when a 7 possible violation of the Principles of Medical Ethics or illegal or other unethical conduct by an applicant 8 or member is reported to the AMA. This information most often comes from statements made in the 9 membership application form, a report of disciplinary action taken by state licensing authorities or other 10 membership organizations, or a report of action taken by a government tribunal. 11 12 The Council rarely re-examines determinations of liability or sanctions imposed by other entities. 13 However, it also does not impose its own sanctions without first offering a hearing to the physician. CEJA 14 can impose the following sanctions: applicants can be accepted into membership without any condition, 15 placed under monitoring, or placed on probation. They also may be accepted, but be the object of an 16 admonishment, a reprimand, or censure. In some cases, their application can be rejected. Existing 17 members similarly may be placed under monitoring or on probation, and can be admonished, reprimanded 18 or censured. Additionally, their membership may be suspended or they may be expelled. Updated rules 19 for review of membership can be found at https://www.ama-assn.org/governing-rules. 20 21 Beginning with the 2003 report, the Council has provided an annual tabulation of its judicial activities to 22 the House of Delegates. In the appendix to this report, a tabulation of CEJA’s activities during the most 23 recent reporting period is presented. 24
CEJA Rep. 7-A-18 -- page 2 of 2
APPENDIX
CEJA Judicial Function
Statistics
APRIL 1, 2017 – MARCH 31, 2018
Physicians Reviewed
SUMMARY OF CEJA ACTIVITIES
3 Determinations of no probable cause
37 Determinations following a plenary hearing
11
Determinations after a finding of probable cause, based only on the written record, after the physician waived their plenary hearing right
Physicians Reviewed
FINAL DETERMINATIONS FOLLOWING INITIAL REVIEWS
11 No sanction or other type of action 8 Monitoring
12 Probation 6 Revocation
12 Suspension 2 Application denied
11 Censure 1 Reprimand
Physicians Reviewed
PROBATION/MONITORING STATUS
12 Members placed on Probation/Monitoring during reporting interval 8 Members placed on Probation without reporting to Data Bank 4 Probation/Monitoring concluded satisfactorily during reporting interval 1 Memberships revoked due to non-compliance with the terms of probation
46 Physicians on Probation/Monitoring at any time during reporting interval who paid their AMA membership dues
26 Physicians on Probation/Monitoring at any time during reporting interval who did not pay their AMA membership dues
© 2018 American Medical Association. All rights reserved.
REPORT OF THE COUNCIL ON LONG RANGE PLANNING AND DEVELOPMENT
CLRPD Report 1-A-18
Subject: A Primer on Artificial and Augmented Intelligence Presented by:
Glenn Loomis, MD, Chair
Last year, the Council on Long Range Planning and Development (CLRPD) created the 1 educational module, Health Care Trends: Scientific Innovation,1 which accelerated its interest in 2 artificial and augmented intelligence (AI), and prompted a series of discussions on these topics and 3 their influences on the practice of medicine. Due to the complexity of the field, the Council 4 developed this primer, which provides a history, definitions and components, and the status of AI 5 in health care. Additionally, CLRPD postulated ways the field may progress, including the 6 identification of opportunities and challenges for physicians. The Council feels it essential to 7 provide a high-level look at this emerging issue that could dramatically affect medicine. 8 9 HISTORY OF AI 10 11 The most influential ideas underpinning computer science came from Alan Turing in 1950, who 12 proposed a formal model of computing. Turing’s classic essay, Computing Machinery and 13 Intelligence,2 imagines the possibility of computers created for simulating intelligence and explores 14 many of the components now associated with artificial intelligence, including how intelligence 15 might be tested, and how machines might automatically learn. Though these ideas inspired AI, 16 Turing did not have access to the computing resources needed to translate his ideas into action. 17 18 In 1956, the field of AI came to the forefront with the Dartmouth Summer Research Project on 19 Artificial Intelligence. The goal was to investigate ways in which machines could be made to 20 simulate aspects of intelligence—the essential idea that has continued to drive the field forward. 21 Subsequently, experts in the field of computer science research pioneered the foray into heuristic 22 search—a method that produces a solution in a reasonable timeframe that is sufficient for solving a 23 given problem. In the area of computer vision, early work in character recognition laid the basis for 24 more complex applications such as face recognition. By the late sixties, work had also begun on 25 natural language processing (NLP). 26 27 In the nineties, technological progress made the task of building systems driven by real-world 28 data more feasible. Cheaper and more reliable hardware for sensing and actuation made 29 robots easier to build. Further, the Internet’s capacity for gathering large amounts of data, 30 and the availability of computing power and storage to process those data enabled statistical 31 techniques that, by design, derive solutions from data. These developments have allowed AI 32 to emerge in the past two decades as a profound influence on our daily lives.3 33 34 DEFINITIONS AND COMPONENTS OF AI 35 36 The concepts of AI and machine learning have quickly become attractive to health care 37 organizations; however, the related terminologies are not well understood. While many in the 38 health care industry foresee their technological goals hovering just over the horizon, plotting a 39 course to get there can be a difficult proposition, especially when the landscape is clouded by 40
CLRPD Rep. 1-A-18 -- page 2 of 5
marketing hyperbole, confusing vocabulary, technical terminology, and as-yet-undeliverable 1 promises of truly automated insights. 2 3 Algorithms are a sequence of instructions used to solve a problem. Developed by programmers to 4 instruct computers in new tasks, algorithms are the building blocks of the advanced digital world. 5 Computer algorithms organize enormous amounts of data into information and services, based on 6 certain instructions and rules. 7 8 Artificial Intelligence is the ability of a computer to complete tasks in a manner typically associated 9 with a rational human being—a quality that enables an entity to function appropriately and with 10 foresight in its environment. True AI is widely regarded as a program or algorithm that can beat the 11 Turing Test, which states that an artificial intelligence must be able to exhibit intelligent behavior 12 that is indistinguishable from that of a human. 13 14 Augmented Intelligence is an alternative conceptualization that focuses on AI's assistive role, 15 emphasizing the fact that its design enhances human intelligence rather than replaces it. 16 17 Machine Learning is a part of the discipline of artificial intelligence and refers to constructing 18 algorithms that can make accurate predictions about future outcomes. Machine learning can be 19 supervised or unsupervised. In supervised learning, algorithms are presented with “training data” 20 that contain examples with their desired conclusions, such as pathology slides that contain 21 cancerous cells as well as slides that do not. Unsupervised learning does not typically leverage 22 labeled training data. Instead, algorithms are tasked with identifying patterns in data sets on their 23 own by defining signals and potential abnormalities based on the frequency or clustering of certain 24 data. 25 26 Deep Learning is a subset of machine learning that employs artificial neural networks (ANNs) and 27 algorithms structured to mimic biological brains with neurons and synapses. ANNs are often 28 constructed in layers, each of which performs a slightly different function that contributes to the 29 result. Deep learning is the study of how these layers interact and the practice of applying these 30 principles to data. 31 32 Cognitive Computing, a term coined by IBM, is often used interchangeably with machine learning 33 and artificial intelligence. However, cognitive computing systems do not necessarily aspire to 34 imitate intelligent human behavior, but instead to supplement human decision-making power by 35 identifying potentially useful insights with a high degree of certainty. Clinical decision support and 36 augmented intelligence come to mind when considering this definition. 37 38 Natural Language Processing (NLP) forms the foundation for many cognitive computing exercises. 39 The ingestion of source materials, such as medical literature, clinical notes, or audio dictation 40 records requires a computer to understand what is written, spoken or otherwise being 41 communicated. One commonly used application of NLP is optical character recognition (OCR) 42 technology that can turn static text, such as a PDF of a lab report or a scan of a handwritten clinical 43 note, into machine readable data. Once the data are in a workable format, the algorithm parses the 44 meaning of each element to complete a task such as translating into a different language, querying 45 a database, summarizing information or supplying a response to a conversation partner. In the 46 health care field, where acronyms and abbreviations are common, accurately parsing through this 47 “incomplete” data can be challenging. 48 49 On a basic level, classical computer programming takes rules and data as inputs, and generates an 50 output or answer. Conversely, machine learning algorithms take data and answers as inputs, and 51
CLRPD Rep. 1-A-18 -- page 3 of 5
generate rules or insights as an output. For example, a computer may be given two sets of MRI 1 images: one set that clearly shows a variety of brain tumors, and one that does not. By breaking 2 down these images into machine-readable patterns, the computer can understand which patterns are 3 likely to indicate a brain tumor and which represent healthy patients. When fed a new batch of 4 images that may or may not contain tumors, the computer should be able to use that initial 5 reference data to identify patterns that are similar to known positive diagnoses. Every time it makes 6 an incorrect diagnosis, validated by a human clinician, it “learns” to adjust its criteria a little bit 7 more by using the previous experience to inform its future decision-making. With enough training, 8 it can become accurate enough to present reliable results to the user. 9 10 Humans complete these types of tasks almost without thought every moment of every day, but few 11 algorithms are sophisticated enough to effectively mimic our natural capacity to process external 12 input, extrapolate unspoken information from a query, consider complex ethical issues, use logic 13 and reason to make a decision, and predict the likely outcomes of each action before they occur. 14 When comparing the common definition of AI as the capability of a machine to imitate intelligent 15 human behavior with the Turing Test challenge of creating an algorithm that performs a task 16 indistinguishably from a human counterpart, it becomes clear that machines are still in the process 17 of evolving. However, there are a few examples of use cases in health care that are coming closer 18 to realizing the Turing Test. 19 20 STATUS OF HEALTH CARE AI 21 22 Some of the most promising use cases for health care AI tools include predictive analytics, 23 precision medicine, and clinical decision support. Development in all of these areas is already well 24 underway. The private sector has acknowledged these opportunities, and investments in AI have 25 grown over the past several years. 4 A recent report from Markets and Markets pins the health care 26 AI sector at nearly $8 billion in 2022, accelerating at a compound annual growth rate of 52.68 27 percent over the forecast period.5 28 29 In 2011, IBM got an early start in the health care AI space by using Watson’s NLP and cognitive 30 computing abilities to train in clinical decision support at some of the top medical institutions in the 31 country. IBM has also committed extensive resources, such as its $2.6 billion acquisition of 32 Truven, to imaging analytics, genomics, pharmaceuticals, and population health management. 6 33 Their efforts are not without roadblocks—a multiyear project to apply IBM Watson to cancer 34 diagnostics with MD Anderson ended in failure.7 Other industry leaders, Google and Microsoft, are 35 ramping up their efforts to apply advanced machine learning algorithms to the mysteries of human 36 biology. Microsoft is tackling genomics, cancer, myopia and blindness, transplants, and imaging 37 analytics,8 while Google recently published research on the role of machine learning in pathology 38 and breast cancer, 9 and diabetic retinopathy.10 Additionally, Google is the first of the titans to 39 establish a formal program, Launchpad Studio, for working with startups specific to the industry, 40 such as Augmedix, BrainQ, Byteflies, and Cytovale.11 41 42 Currently, machine learning has started to prove its value in the realm of pattern recognition, NLP, 43 and deep learning. At the Stanford University School of Medicine, a machine-learning algorithm 44 out-performed pathologists at predicting patient survival times for two types of lung cancer.12 In 45 the United Kingdom, a NLP tool applied to free-text peer assessments of physician performance, 46 derived by human raters, agreed with the content of the documents 98 percent of the time.13 At 47 Indiana University-Purdue University Indianapolis, machine learning correctly predicted relapse 48 rates for a type of leukemia 90 percent of the time. It identified patients who would experience 49 remission with 100 percent accuracy.14 Engineers at Boston University are working with Brigham 50 and Women’s Hospital, and Boston Medical center to manage heart diseases and diabetes using 51
CLRPD Rep. 1-A-18 -- page 4 of 5
algorithms that have the ability to predict hospitalizations up to a year in advance with 82 percent 1 accuracy.15 However, current algorithms do not result in autonomous decisions. Instead, they play 2 an assistive role to augment human intelligence rather than replace it. 3 4 FUTURE OF AI IN MEDICINE 5 6 What does the future of AI hold in medicine? AI technology could change the world for the better 7 by making care delivery safer, improving diagnostic accuracy, increasing physician productivity 8 and scale, or contributing to applications that improve quality of life. As the technology of AI 9 continues to develop, physicians and medical associations must ensure that AI-enabled systems are 10 governable; are open, transparent, and understandable; can work effectively with people; are 11 included in medical education for students and practicing physicians; and remain consistent with 12 human and medical ethics. Physician involvement with the evolution of this active field may help 13 them to chart a better and wiser path forward for themselves, their patients, and the health care 14 system. 15 16 Opportunities and challenges of AI in health care are equally profound for physicians: 17 18 Opportunities 19 20 • Office and hospital automation – patient scheduling, order entry, chat bots, voice recognition, 21
etc. 22 • Data mining to surface the right data at the right time, and improve EHRs 23 • Diagnosis – analyze all the known data about the patient and produce insights 24 • Treatment – analyze the diagnosis and all other known data and produce best practice 25
treatments, perhaps even comparing to “patients like me” data 26 • Additional time for physicians to spend with patients to focus on their health 27 • Improve patient experience, and aid behavioral change and treatment compliance 28 • Medical education – personal assistant for students and residents to surface information (less 29
memorization), automated continuous assessment of competencies, and coaching 30 31 Challenges 32 33 • Data structure, integrity and security 34 • Technological mistrust – transparency is key 35 • Demonstrate that AI can reduce costs, deliver the quadruple aim, support the patient-physician 36
relationship, and/or alleviate administrative burden 37 • Implement and integrate AI into clinical practices and patient care 38 • Uncertain long term employment outlook for health care professionals 39 • Susceptibility to training bias, malfeasance, and other possible technical problems 40 • Questions as to who will benefit and who may lose—what is best for an individual is not 41
always best for public health, especially when limited resources are available 42 43 Additionally, AI opportunities and challenges lead to questions physicians will need to confront: 44 45 • What evidence is needed to demonstrate value, utility, and trust? 46 • How does AI intersect with other emerging health care capabilities, such as genomic medicine? 47 • How will regulatory bodies and professional organizations provide proper oversight for AI 48
benefits and risks, and communicate these to the public? 49 • How can public and systemic expectations be managed, and concerns allayed? 50
CLRPD Rep. 1-A-18 -- page 5 of 5
• What education and training will health care professionals need to acquire in order to 1 understand how AI solutions might help them, and their patients in clinical settings? 2
• What can health systems considering AI opportunities do now to maximize their chances of 3 success for gaining efficiencies, improving care, and integrating into clinical workflows? 4
• How will risk be allocated, given the “black box” nature of AI systems? 5 • How will legal, policy, and regulatory implications, including standards for professional 6
services, intellectual property rights, and FDA oversight be monitored and addressed? 7 8 Beyond the potential to dramatically affect the economy and society in the near future, AI has 9 moved to the forefront of many policy debates around the world. These debates range from the 10 governance of AI, such as ensuring accountability of algorithmic decisions, to mitigating the 11 impact of AI on employment. Clear challenges must be addressed to support AI’s future in 12 medicine. Therefore, it is up to all stakeholders, be they health care professionals, medical 13 associations, policymakers, businesses, the technology industry, or civil society to ensure that AI’s 14 impact is a positive one by proactively tackling the challenges, while ensuring the opportunities 15 remain available. 16 REFERENCES 1 AMA-CLRPD. Health Care Trends: Scientific Innovation. https://cme.ama-assn.org/Activity/5617091/Detail.aspx. 2 Turing, AM. Computing Machinery and Intelligence. http://phil415.pbworks.com/f/TuringComputing.pdf. 3 Stanford. One Hundred Year Study on Artificial Intelligence, 2016 Report. https://ai100.stanford.edu/2016-report. 4 CB Insights. The Race for AI: Google, Baidu, Intel, Apple in a Rush to Grab Artificial Intelligence Startups. https://www.cbinsights.com/research/top-acquirers-ai-startups-ma-timeline/. 5 MarketsandMarkets. Artificial Intelligence in Healthcare Market by Offering (Hardware, Software and Services), Technology (Deep Learning, Querying Method, NLP, and Context Aware Processing), Application, End-User Industry, and Geography – Global Forecast to 2022. https://www.marketsandmarkets.com/Market-Reports/artificial-intelligence-healthcare-market-54679303.html?gclid=CjwKCAiAr_TQBRB5EiwAC_QCq3mVjD0-a0Lo3XVAu-TwQC4n8H5xUriz6q9BSmKYT2J_WfPwNLA0VBoC6vQQAvD_BwE. 6 IBM. IBM Watson Health Closes Acquisition of Truven Health Analytics. https://truvenhealth.com/media-room/press-releases/detail/prid/185/ibm-watson-health-announces-plans-to-acquire-truven-health-analytics. 7 ARS Technica. IBM’s Watson Proves Useful at Fighting Cancer-Except in Texas. https://arstechnica.com/science/2017/02/ibms-watson-proves-useful-at-fighting-cancer-except-in-texas/. 8 Xconomy. Microsoft’s Strategy for Finding What’s Next in Healthcare AI. https://www.xconomy.com/seattle/2017/11/08/microsofts-strategy-for-finding-whats-next-in-healthcare-a-i/. 9 Google Inc. Detecting Cancer Metastases on Gigapixel Pathology Images. https://arxiv.org/abs/1703.02442. 10 GulshanV, et al. Development and Validation of a Deep Learning Algorithm for Detection of Diabetic Retinopathy in Retinal Fundus Photographs. https://jamanetwork.com/journals/jama/fullarticle/2588763. 11 HealthIT News. Google powers up AI, machine learning accelerator for healthcare. http://www.healthcareitnews.com/news/google-powers-ai-machine-learning-accelerator-healthcare. 12 Yu KH, et al. Predicting non-small cell lung cancer prognosis by fully automated microscopic pathology image features. https://www.nature.com/articles/ncomms12474. 13Gibbons C, et al. Supervised Machine Learning Algorithms Can Classify Open-Text Feedback of Doctor Performance With Human-Level Accuracy. http://www.jmir.org/2017/3/e65/. 14 Rajwa B, et al. Automated Assessment of Disease Progression in Acute Myeloid Leukemia by Probabilistic Analysis of Flow Cytometry Data. https://www.ncbi.nlm.nih.gov/pubmed/27416585. 15 Dai W, et al. Prediction of hospitalizations due to heart diseases by supervised learning methods. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314395/pdf/nihms643126.pdf.
© 2018 American Medical Association. All rights reserved.
REPORT OF THE COUNCIL ON MEDICAL EDUCATION
CME Report 5-A-18
Subject: Study of Declining Native American Medical Student Enrollment Presented by:
Lynne Kirk, MD, Chair
American Medical Association (AMA) Policy D-200.985 (5), “Strategies for Enhancing Diversity 1 in the Physician Workforce,” reads as follows: 2 3
5. Our AMA will partner with key stakeholders (including but not limited to the Association of 4 American Medical Colleges, Association of American Indian Physicians, Association of Native 5 American Medical Students, We Are Healers, and the Indian Health Service) to study and 6 report back by July 2018 on why enrollment in medical school for Native Americans is 7 declining in spite of an overall substantial increase in medical school enrollment, and lastly to 8 propose remedies to solve the problems identified in the AMA study. 9
10 This section of the policy was appended through Resolution 313-A-17, “Study of Declining Native 11 American Medical Student Enrollment,” which was introduced by the AMA Minority Affairs 12 Section at the 2017 Annual Meeting of the AMA House of Delegates (HOD). 13 14 Testimony before Reference Committee C during the meeting reflected limited but supportive 15 testimony on this item focused on the need for increased diversity of the physician workforce to 16 support access to patient care among underserved populations. It was noted that existing AMA 17 policy on diversity dovetails with the intent of this resolution, and that the decline in the number of 18 Native Americans entering medical school is worrisome and may hold future negative 19 ramifications for access to care. Accordingly, Reference Committee C recommended adoption of 20 Resolution 313 to the HOD, and the HOD accepted this recommendation. This report is in response 21 to this policy. 22 23 BACKGROUND 24 25 The concern regarding Native American student enrollment and the Native American physician 26 workforce is supported by Native American population health outcomes data, Native American 27 health care accessibility data, student enrollment data, workforce data, and the quest for a culturally 28 diverse and culturally competent physician workforce able to meet the health care needs of people 29 from all ethnic backgrounds. The estimated 5.2 million American Indians and Alaska Natives 30 (AI/ANs) living in the U.S. have long experienced lower health status when compared with other 31 Americans. Between 1999 and 2014, premature mortality rates increased for AI/AN populations, 32 while decreasing for blacks, Hispanics, Asians, and Pacific Islanders during the same period. The 33 rates are particularly high for young adult AI/AN individuals. Lack of access to health care and 34 mental health resources is believed to be a causative factor.1 Lower life expectancy and a 35 disproportionate disease burden exist for a variety of reasons, including inadequate education, lack 36 of economic development and investment, disproportionate poverty, discrimination in the delivery 37 of health services, and cultural differences. These are broad quality of life issues rooted in 38 economic adversity and poor social conditions. Diseases of the heart, malignant neoplasm, 39 unintentional injuries, and diabetes are leading causes of AI/AN deaths (2008-2010). AI/AN 40
CME Rep. 5-A-18 -- page 2 of 11
individuals born today have a life expectancy 4.4 years shorter than the U.S. population as a whole2 1 and seven years shorter than non-Hispanic whites.3 In a 2016 U.S. Government Accountability 2 Office report to Congress, difficulties in filling health care provider vacancies and long wait times 3 for primary care appointments were noted to be contributing factors to the health care disparities 4 facing AI/ANs.4 A survey by the Harvard School of Public Health found that 23% of AI/ANs 5 surveyed experienced discrimination when seeking health care, and 15% avoided seeking 6 healthcare for themselves or their family because of concern that they would be discriminated 7 against.5 8 9 The Indian Health Service (IHS), an agency within the U.S. Department of Health and Human 10 Services, states there is “ample opportunity—and pressing need—for physicians practicing a wide 11 range of specializations.” The IHS website lists numerous job openings across multiple medical 12 specialties and geographic locations.6 Federal law requires that absolute preference be given to 13 AI/AN applicants. Out of the total active MD workforce (approximately 850,000) in the U.S., 0.4% 14 (3,400) are self-identified as AI/AN.7 15 16 In addition to the positive impact on the educational environment through, for example—(1) 17 cultural competence in care delivery; (2) intellectual benefits; and (3) interpersonal benefits for 18 patients, learners and faculty8— increasing AI/AN medical school enrollment would translate into 19 an increase in the AI/AN physician workforce. A workforce increase of this nature could positively 20 impact AI/AN population health and improve access to physician services. A report from the 21 Health Resources and Services Administration on physician workforce characteristics found that 22 minority physicians have a greater propensity to practice in physician shortage areas (although the 23 report did not specifically address AI/AN physicians or the AI/AN population).9 Another review on 24 this subject concluded that underrepresented minority health professionals have been consistently 25 more likely to deliver health care to the underserved; this study did include AI/AN providers but 26 did not specifically address AI/AN physicians in the findings or conclusions.10 There are few 27 conclusive data demonstrating that increasing the number of AI/AN medical students (and 28 ultimately AI/AN physicians) would result in increased numbers of physicians who serve AI/AN 29 communities. A literature search uncovered only one study, published in 1989, which concluded 30 that most AI/AN physicians, while residing in areas with significant AI/AN populations, were 31 primarily serving non-AI/AN patient populations.11 Collecting data on AI/AN physician practice 32 patterns has proven difficult for a number of reasons, including the organization of providers to 33 serve AI/AN needs. The Indian Self Determination and Education Assistance Act, also known as 34 Public Law 93-638, allows the IHS to provide funds directly to tribes for administration and 35 delivery of health services.12 An unintended consequence of this law has been to make collection of 36 provider data difficult. A comprehensive study is currently underway to determine the practice 37 setting and populations served by AI/AN physicians (personal communication with the study 38 author, Siobhan Wescott, February 22, 2018). 39 40 When considering the available information on this topic, it is important to note that most data on 41 AI/AN medical student enrollment and the physician workforce rely on an individual’s self-42 identification as American Indian, Native American, or Alaska Native. There is no established 43 definition of AI/AN. The U.S. government relies on each of the 567 recognized tribes to set the 44 standards for inclusion as a member of the tribe and official status of AI/AN or Native American.13 45 Inconsistency in criteria for recognition of AI/AN status may result in inaccuracies and 46 inconsistencies in data. Some data sources also allow individuals to self-identify as “multiple 47 race/ethnicity,” which may lead to underreporting of AI/AN data. 48
CME Rep. 5-A-18 -- page 3 of 11
MEDICAL SCHOOL ENROLLMENT OF AI/AN STUDENTS 1 2 Among the ethnic groups traditionally considered to be underrepresented in medicine, AI/AN 3 ethnicity is the least represented among U.S. allopathic medical students. Data from the 4 Association of American Medical Colleges (AAMC) show that in 2016 a total of 20 schools 5 reported at least one applicant who self-identified as AI/AN. The percentage of AI/AN applicants 6 to these schools ranged from 0.9% to 3.8% of the total applicant pool. AAMC enrollment data for 7 academic year 2016-17 show that 223 students, or 0.25% of the total allopathic medical school 8 enrollees, self-identified as AI/AN. The majority of these students were enrolled in medical schools 9 in Oklahoma (20), New Mexico (17), Minnesota (17), Texas (16), North Dakota (15), and Arizona 10 (10). For the allopathic medical school graduating class of 2016, 31 individuals, or 0.16%, self-11 identified as AI/AN.14 Since 2002, the number of AI/AN applicants and matriculants to allopathic 12 medical schools has been relatively consistent, despite the increase in the overall number of 13 applicants and enrollees. 14 15 Data for osteopathic medical schools show that in 2016, a total of 51 applicants, or 0.3%, self-16 identified as AI/AN. Over the last 15 years, the number of AI/AN applicants to osteopathic schools 17 has remained relatively constant (between 38 to 69 annually). Nine AI/AN students, or 0.1% of the 18 total enrollee pool, matriculated into osteopathic schools in 2016. Data were not available for 19 AI/AN enrollment in individual osteopathic medical schools in 2016, but the greatest numbers of 20 applications were to schools located in Arizona (31), Pennsylvania (32) and Oklahoma (29).15 21 These data likely include students who applied to multiple programs. 22 23 Data regarding allopathic and osteopathic AI/AN applicants and enrollment are shown in the table 24 at the end of this report. There are no data on the number of AI/AN applicants who applied to both 25 allopathic and osteopathic programs. Of note, while both the Liaison Committee on Medical 26 Education and the Commission on Osteopathic College Accreditation have standards requiring 27 medical schools to achieve diversity in enrollment, the standards do not specify what groups the 28 schools must include in their respective definitions of diversity and efforts to achieve diversity 29 outcomes.16 17 30 31 Although the absolute numbers of applicants and matriculants, albeit small, have remained 32 relatively constant over the last 15 years, the growth in total medical school applications and 33 enrollment has resulted in a declining percentage of AI/AN applicants and matriculating students. 34 This has occurred despite the emphasis on increasing diversity in matriculants to medical school 35 and the physician workforce; an acceptance rate for AI/AN (44.9%) that exceeds all other racial 36 and ethnic groups, including whites; and increases in the applicant and matriculation rates for other 37 groups traditionally identified as underrepresented in medicine.18 These data indicate that efforts to 38 recruit AI/AN students to enter health professions education are inadequate. 39 40 MEDICAL SCHOOL AND HEALTH PROFESSIONS PROGRAMS TO SUPPORT AI/AN 41 ENTRY INTO HEALTH CARE CAREERS 42 43 The relative decline in AI/AN applicants and matriculants has occurred despite focused efforts by 44 institutions in states with large AI/AN populations. Several medical schools, alone or in 45 collaboration with other schools, have implemented programs to encourage and support AI/AN 46 students into the health professions. 47 48 For example, the North Dakota School of Medicine and Health Sciences has developed the Indians 49 Into Medicine Program (INMED™), a comprehensive program designed to assist American Indian 50 students who aspire to be health professionals and to meet the needs of tribal communities. 51
CME Rep. 5-A-18 -- page 4 of 11
Established in 1973, the program aims to address three major problems: 1) too few health 1 professionals in AI communities, 2) too few AI health professionals, and 3) the substandard level 2 of health and health care in AI communities. INMED support services include academic and 3 personal counseling for students, assistance with financial aid applications, and summer enrichment 4 sessions at the junior high through professional school levels. Each year, more than 100 AI students 5 attend INMED’s annual summer enrichment sessions at the junior high, high school, and medical 6 preparatory levels. These summer programs bolster participants’ math and science backgrounds 7 and introduce them to health careers.19 8 9 The state of Oklahoma is home to two medical schools as well as a significant AI population. The 10 University of Oklahoma supports a summer enrichment program which aims to identify and 11 support minority students, including AI students, who aspire to enter medical school.20 In 2014 the 12 Oklahoma State University Center for Health Sciences, which houses the Oklahoma State 13 University College of Osteopathic Medicine (OSUCOM), launched an Office for the Advancement 14 of American Indians in Medicine and Science (OAAIMS) to recruit more American Indian high 15 school and college students into medicine and science careers. Through mentoring and targeted 16 programs, the initiative aims to increase the number of American Indians practicing medicine and 17 working in the science fields. Ultimately, efforts made by the OAAIMS are intended to provide 18 Native American students the means to be successful in these fields by offering hands-on 19 experiences that combine Native culture, medicine, and science.21 Programs include a culturally-20 based scientific expedition experience for high school students, residential camps with simulation 21 exercises, and a number of outreach programs on-site with tribal partnerships. These focused 22 efforts have been effective, as OSUCOM’s latest incoming class of 2017 included 17 students who 23 self-identified as AI/AN.22 24 25 The University of Minnesota Medical School (UMMS) founded its Duluth campus in 1972 26 specifically for the purpose of serving the needs of rural Minnesota and Native American 27 communities and to be a national leader in improving health care access and outcomes in rural 28 Minnesota and AI/AN communities. The UMMS also launched the Center for American Indian and 29 Minority Health in 1987.23 The purpose of the Center is to raise the health status of American 30 Indians and Alaska Natives by: 1) recruiting and educating Native American medical students, 2) 31 increasing awareness of American Indian health care issues, and 3) conducting research that serves 32 the health interests of Native American communities. 33 34 Five medical schools in the southwest—the Universities of Arizona (Phoenix and Tucson), 35 Colorado, New Mexico, and Utah—identified a collective need to increase student diversity, 36 particularly with regard to AI/AN students. These five schools created the “4 Corners Alliance,” 37 and, in collaboration with the Association of American Indian Physicians, invite pre-med/health 38 American Indian students to a free two-day Pre-Admissions Workshop (PAW) annually. The PAW 39 aims to provide students with the information and skills necessary to succeed in the medical and 40 health professions school admission process.24 41 42 Medical schools also have developed programs to address AI/AN health. For example, the 43 University of Washington School of Medicine offers an Indian Health Pathways Certificate 44 Program for medical students. The program’s goals are to: 1) prepare both native and non-native 45 medical students for careers in AI/AN health, 2) encourage research on AI/AN health issues, and 3) 46 enhance curriculum on AI/AN health issues at the University of Washington School of Medicine.25 47 48 On a national level, the IHS supports AI/AN entry into the health professions and opportunities to 49 explore career paths in AI/AN health care. Scholarships are available through the IHS Scholarship 50 program, which has awarded more than 7,000 health professions scholarships since 1978. The IHS 51
CME Rep. 5-A-18 -- page 5 of 11
website provides links to allow potential students to arrange IHS externships (with salary), and to 1 coordinate AI/AN clerkship opportunities for medical students. In addition, post-graduation 2 financial support is available through the IHS, with a loan repayment program of $20,000 per year 3 of commitment (maximum $40,000) for health professions education loans, as well as a 4 supplemental loan repayment program. The IHS also participates in the National Health Service 5 Corps loan repayment program, with awards up to $50,000 for a two-year commitment.26 6 7 The University of Wisconsin, in collaboration with tribal organizations in Wisconsin and the Great 8 Lakes Region, supports an outreach program, We are Healers, which aims to inspire AI youth to 9 envision themselves as health professionals through stories of Native role models.27 10 11 Two organizations specifically provide support for AI/AN students aspiring to become physicians: 12 the Association of American Indian Physicians (AAIP) and the Association of Native American 13 Medical Students (ANAMS). The AAIP, whose mission includes promoting education in the 14 medical disciplines, supports workshops, summer programs, scholarship programs, internships, and 15 fellowships aimed at increasing the number of AI/AN students entering the health professions.28 16 The ANAMS, whose mission is to assist with the recruitment, retention, and support of AI/AN 17 students into medicine and other health careers, provides information on a number of scholarship 18 opportunities available to AI/AN students.29 19 20 The causes of the declining percentages of applicants and matriculants are not clear, but in part 21 may be explained by the pre-secondary education success of and college education opportunities 22 for AI/AN students. AI/AN students have the highest high school dropout rates among all racial 23 and ethnic groups tracked by the National Center for Educational Statistics (NCES).30 Additionally, 24 the college enrollment rate (23%) for AI/AN 18- to 24-year-olds is the lowest of all ethnic and 25 racial groups tracked by the NCES.31A recent survey of AI/ANs found that for almost half of 26 respondents, college attendance was never discussed during adolescence and young adulthood.3 27 Overall, the AI/AN college graduation rate of 9.3% is well below the national average of 20.3%. 28 The relative ineffectiveness of health professions pipeline programs for AI/AN has been described 29 in the literature, possibly attributable to less rigor in primary and secondary education in science 30 and mathematics.32 31 32 RELEVANT AMA POLICY AND ACTIVITIES 33 34 A list of relevant AMA policies on this issue is shown in the appendix. These include: 35 36
• D-200.985, “Strategies for Enhancing Diversity in the Physician Workforce” 37 • H-350.970, “Diversity in Medical Education” 38 • H-350.979, “Increase the Representation of Minority and Economically Disadvantaged 39
Populations in the Medical Profession” 40 • H-350.960, “Underrepresented Student Access to US Medical Schools” 41
42 Aside from policy, since 2002 the AMA has supported the Doctors Back to School™ (DBTS), 43 designed by the AMA Minority Affairs Consortium (today the Minority Affairs Section, or MAS) 44 to highlight the need to expand the pipeline of underrepresented minorities (i.e., black, Latino, 45 Native American) in medicine and eliminate minority health disparities. Through DBTS, 46 physicians and medical students return to their communities to 1) pique young minority students’ 47 interest in medicine by introducing them to “real-life” role models and 2) raise awareness of the 48 need for more underrepresented minorities in the physician workforce. To date, DBTS has engaged 49 more than 100,000 underrepresented minority youth. To expand the reach of the program and 50
CME Rep. 5-A-18 -- page 6 of 11
number of volunteers, the MAS has developed partnerships with other AMA sections (e.g., 1 Medical Student Section); medical societies/associations (e.g., American Society of 2 Anesthesiologists; Association of American Medical Colleges); coalitions (e.g., Commission to 3 End Health Care Disparities); nonprofit organizations (e.g., National Minority Quality Forum), and 4 diversity pipeline programs in medicine (e.g., Tour for Diversity; Mentoring in Medicine). 5 6 Each year, the MAS also partners with the AMA Foundation’s Physicians of Tomorrow 7 scholarship program to offer the Minority Scholars Award to underrepresented minority medical 8 students, with $10,000 awards toward their tuition expenses. Up to two students can be nominated 9 by each medical school dean. In recent years, awards have been disbursed to 20-25 recipients 10 annually. Since the inception of the program in 2004, 11 recipients have self-identified as Native 11 Alaskans. 12 13 SUMMARY 14 15 Despite the current level of support, outreach, and pipeline programs as noted above, the number of 16 AI/AN applicants/matriculants to medical schools remains quite low and essentially unchanged 17 over the last 15 years, even as the total enrollment in U.S. medical schools has markedly increased. 18 19 Although AI/AN students who are able to succeed in pre-medical training have ample opportunity 20 and high rates of success in gaining entry into medical schools, the current primary and secondary 21 education infrastructure and socioeconomic factors for AI/AN students may be inadequate to 22 promote successful entry in larger numbers into college-level education. While health professions 23 pipeline programs to promote AI/AN entry are in place at a number of institutions, and these 24 programs are showing success at the local level to promote medicine as a career path for AI/AN 25 students, they are limited in size and scope and have not been successful to date in increasing 26 AI/AN diversity in overall medical school enrollment or the physician workforce. Future initiatives 27 might benefit from focused efforts to improve preparation of AI/AN students for entry into post-28 secondary education, particularly in the areas of science and mathematics. 29
CME Rep. 5-A-18 -- page 7 of 11
TABLE: AI/AN APPLICANTS AND ENROLLMENT AT U.S. ALLOPATHIC AND OSTEOPATHIC MEDICAL SCHOOLS Year Allopathic medical schools Osteopathic medical schools
AI/AN
applicants AI/AN
matriculants Total
matriculants AI/AN
applicants AI/AN
matriculants Total
matriculants 16-17 127 54 21,025 54 21 7,575 15-16 115 55 20,627 30 20 7,219 14-15 117 53 20,343 39 26 7,012 13-14 110 43 20,055 38 30 6,636 12-13 108 52 19,517 46 32 5,986 11-12 101 46 19,230 40 27 5,788 10-11 114 55 18,665 40 32 5,428 09-10 111 51 18,390 43 23 5,227 08-09 131 66 18,036 51 39 4,950 07-08 152 67 17,759 59 34 4,528 06-07 147 70 17,880* 63 22 4,055 05-06 95 38 17,435* 59 22 3,908 04-05 107 53 17,109* 63 28 3,646 03-04 85 38 17,118* 60 18 3,308 02-03 112 56 16,488 55 26 3,079 Allopathic data extracted from data tables found on the AAMC website, unless otherwise noted. Osteopathic data extracted from data tables found on the AACOM website. * Data from Barzansky B, Etzel S. Medical Schools in the United States, JAMA annual data publications. Data are for first year enrollment, not matriculants.
CME Rep. 5-A-18 -- page 8 of 11
APPENDIX: RELEVANT AMA POLICY D-200.985, “Strategies for Enhancing Diversity in the Physician Workforce” 1. Our AMA, independently and in collaboration with other groups such as the Association of American Medical Colleges (AAMC), will actively work and advocate for funding at the federal and state levels and in the private sector to support the following: a. Pipeline programs to prepare and motivate members of underrepresented groups to enter medical school; b. Diversity or minority affairs offices at medical schools; c. Financial aid programs for students from groups that are underrepresented in medicine; and d. Financial support programs to recruit and develop faculty members from underrepresented groups. 2. Our AMA will work to obtain full restoration and protection of federal Title VII funding, and similar state funding programs, for the Centers of Excellence Program, Health Careers Opportunity Program, Area Health Education Centers, and other programs that support physician training, recruitment, and retention in geographically-underserved areas. 3. Our AMA will take a leadership role in efforts to enhance diversity in the physician workforce, including engaging in broad-based efforts that involve partners within and beyond the medical profession and medical education community. 4. Our AMA will encourage the Liaison Committee on Medical Education to assure that medical schools demonstrate compliance with its requirements for a diverse student body and faculty. 5. Our AMA will partner with key stakeholders (including but not limited to the Association of American Medical Colleges, Association of American Indian Physicians, Association of Native American Medical Students, We Are Healers, and the Indian Health Service) to study and report back by July 2018 on why enrollment in medical school for Native Americans is declining in spite of an overall substantial increase in medical school enrollment, and lastly to propose remedies to solve the problems identified in the AMA study. 6. Our AMA will develop an internal education program for its members on the issues and possibilities involved in creating a diverse physician population. 7. Our AMA will provide on-line educational materials for its membership that address diversity issues in patient care including, but not limited to, culture, religion, race and ethnicity. 8. Our AMA will create and support programs that introduce elementary through high school students, especially those from groups that are underrepresented in medicine (URM), to healthcare careers. 9. Our AMA will create and support pipeline programs and encourage support services for URM college students that will support them as they move through college, medical school and residency programs. 10. Our AMA will recommend that medical school admissions committees use holistic assessments of admission applicants that take into account the diversity of preparation and the variety of talents that applicants bring to their education. 11. Our AMA will advocate for the tracking and reporting to interested stakeholders of demographic information pertaining to URM status collected from Electronic Residency Application Service (ERAS) applications through the National Resident Matching Program (NRMP). 12. Our AMA will continue the research, advocacy, collaborative partnerships and other work that was initiated by the Commission to End Health Care Disparities. (CME Rep. 1, I-06 Reaffirmation I-10 Reaffirmation A-13 Modified: CCB/CLRPD Rep. 2, A-14 Reaffirmation: A-16 Appended: Res. 313, A-17 Appended: Res. 314, A-17) H-350.970, “Diversity in Medical Education” Our AMA will: (1) request that the AMA Foundation seek ways of supporting innovative programs that strengthen pre-medical and pre-college preparation for minority students; (2) support and work in partnership with local state and specialty medical societies and other relevant groups to provide
CME Rep. 5-A-18 -- page 9 of 11
education on and promote programs aimed at increasing the number of minority medical school admissions; applicants who are admitted; and (3) encourage medical schools to consider the likelihood of service to underserved populations as a medical school admissions criterion. (BOT Rep. 15, A-99 Reaffirmed: CME Rep. 2, A-09 Reaffirmed in lieu of Res. 311, A-15) H-350.979, “Increase the Representation of Minority and Economically Disadvantaged Populations in the Medical Profession” Our AMA supports increasing the representation of minorities in the physician population by: (1) Supporting efforts to increase the applicant pool of qualified minority students by: (a) Encouraging state and local governments to make quality elementary and secondary education opportunities available to all; (b) Urging medical schools to strengthen or initiate programs that offer special premedical and pre-collegiate experiences to underrepresented minority students; (c) urging medical schools and other health training institutions to develop new and innovative measures to recruit underrepresented minority students, and (d) Supporting legislation that provides targeted financial aid to financially disadvantaged students at both the collegiate and medical school levels. (2) Encouraging all medical schools to reaffirm the goal of increasing representation of underrepresented minorities in their student bodies and faculties. (3) Urging medical school admission committees to consider minority representation as one factor in reaching their decisions. (4) Increasing the supply of minority health professionals. (5) Continuing its efforts to increase the proportion of minorities in medical schools and medical school faculty. (6) Facilitating communication between medical school admission committees and premedical counselors concerning the relative importance of requirements, including grade point average and Medical College Aptitude Test scores. (7) Continuing to urge for state legislation that will provide funds for medical education both directly to medical schools and indirectly through financial support to students. (8) Continuing to provide strong support for federal legislation that provides financial assistance for able students whose financial need is such that otherwise they would be unable to attend medical school. (CLRPD Rep. 3, I-98 Reaffirmed: CLRPD Rep. 1, A-08) H-350.960, “Underrepresented Student Access to US Medical Schools” Our AMA: (1) recommends that medical schools should consider in their planning: elements of diversity including but not limited to gender, racial, cultural and economic, reflective of the diversity of their patient population; and (2) supports the development of new and the enhancement of existing programs that will identify and prepare underrepresented students from the high-school level onward and to enroll, retain and graduate increased numbers of underrepresented students. (Res. 908, I-08 Reaffirmed in lieu of Res. 311, A-15)
CME Rep. 5-A-18 -- page 10 of 11
REFERENCES 1 Abbasi J. Why are America Indians dying young? JAMA. 2018;319(2):109-111. 2 U.S. Department of Health and Human Services; Indian Health Service Fact Sheet. Available at: https://www.ihs.gov/newsroom/factsheets/disparities/. Accessed December 14, 2017. 3 Sancar, F, Abbassi J, Bucher K. Mortality among American Indians and Alaska natives. JAMA. 2018;319(2):112. 4 United States Government Accountability Office. Report to the Committee on Indian Affairs, U.S. Senate. GAO-16-333. March 2016. 5 Discrimination in America: Experiences and Views of Native Americans, November 2017. Available at: https://www.npr.org/documents/2017/nov/NPR-discrimination-native-americans-final.pdf. Accessed January 2, 2018. 6 Indian Health Service: Health Professions. Available at: https://www.ihs.gov/careeropps/healthprofessions/. Accessed January 2, 2018. 7 Diversity in the Physican Workforce: Facts and Figures 2014. AAMC. Available at: http://aamcdiversityfactsandfigures.org. Accessed January 2, 2018. 8 Whitla DK et al. Educational benefits of diversity in medical school: a survey of students. Academic Medicine. 2003;78(5):460-466. 9 The Physican Workforce: Projections and Research into Current Issues Affecting Supply and Demand. U.S. Department of Health and Human Services. 2008. Available at: https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/physiciansupplyissues.pdf. Accessed January 2, 2018. 10 Saha S, Shipman SA. Race-neutral versus race-conscious workforce policy to improve access to care. Health Affairs; Jan-Feb 2008. Available at: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.27.1.234. Accessed January 2, 2018. 11 Taylor TL. A practice profile of native American physicians. Academic Medicine. 1989 Jul;64(7):393-396. 12 What is the Tribal Self-Governance Program? Indian Health Service. Available at: https://www.ihs.gov/selfgovernance/aboutus/. Accessed February 22, 2018. 13 DNAeXplained – Genetic Genealogy. Available at: https://dna-explained.com/2012/12/18/proving-native-american-ancestry-using-dna/. Accessed December 14, 2017. 14 Association of American Medical Colleges. FACTS: Applicants, Matriculants, Enrollment, Graduates, MD-PhD, and Residency Applicants Data. Available at: https://www.aamc.org/data/facts/. Accessed December 14, 2017. 15 American Association of Colleges of Osteopathic Medicine. Available at: https://www.aacom.org/. Accessed December 14, 2017. 16 Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree. March 2016. Available at: www.lcme.org. Accessed January 2, 2018. 17 Accreditation of Colleges of Osteopathic Medicine: COM Continuing Accreditation Standards. 2017. Available at: www.osteopathic.org/inside-aoa/accreditation/COM-accreditation. Accessed January 2, 2018. 18 Acosta D, Eliason J. Trends in Racial and Ethnic Minority Applicants and Matriculants to U.S. Medical Schools, 1980-2016. AAMC’s Analysis in Brief 10(3): 2017. 19 Indians into Medicine. Available at: https://med.und.edu/indians-into-medicine. Accessed December 14, 2017. 20 OU Medicine Admissions. Available at: https://www.oumedicine.com/college-of-medicine/information-about/admissions. Accessed December 14, 2017. 21 Office for the Advancement of American Indians in Medicine and Science. Available at: http://www.healthsciences.okstate.edu/oaaims. Accessed December 14, 2017. 22 Shrum K, Vuong A. Summary of American Indian Physician Pipeline Program at OSU-COM. Report distributed at Oklahoma State University Center for Health Sciences. September 18, 2017; Tulsa, OK. 23 University of Minnesota Medical School Center of American Indian and Minority Health. Available at: https://www.med.umn.edu/about/duluth-campus. Accessed December 14, 2017. 24 Association of American Indian Physicians Pre Admission Workshop. Available at: https://www.aaip.org/media/news/m.blog/76/pre-admission-workshop. Accessed December 14, 2017. 25 Indian Health Pathways (IHP). Available at: https://catalyst.uw.edu/workspace/dolson/38538/269261. Accessed December 14, 2017.
CME Rep. 5-A-18 -- page 11 of 11
26 Indian Health Service: Loan Repayment. Available at: https://www.ihs.gov/careeropps/loanrepayment/. Accessed December 14, 2017. 27 We Are Healers. Available at: https://www.wearehealers.org. Accessed January 17, 2018. 28 Association of American Indian Physicians. Available at: https://www.aaip.org. Accessed January 2, 2018. 29 Association of Native American Medical Students. Available at: http://www.anamstudents.org/premed. Accessed January 2, 2018. 30 National Center for Education Statistics. Status and Trends in the Education of Racial and Ethnic Groups. Indicator 16: High School Status Dropout rates. Available at: https://nces.ed.gov/programs/raceindicators/indicator_rdc.asp. Accessed December 14, 2017. 31 National Center for Education Statistics. Status and Trends in the Education of Racial and Ethnic Groups. Indicator 21: Post-secondary graduation rates. Available at: https://nces.ed.gov/programs/raceindicators/indicator_red.asp. Accessed December 14, 2017. 32 Smith SG, et al. Pipeline programs in the health professions, Part 1: Preserving diversity and reducing health disparities. Journal of the National Medical Association. 2009;101(9):836-851.
© 2018 American Medical Association. All rights reserved.
REPORT OF THE COUNCIL ON MEDICAL SERVICE
CMS Report 8-A-18
Subject: Addressing the Site-of-Service Differential
(Resolution 817-I-17)
Presented by: Paul A. Wertsch, MD, Chair At the 2017 Interim Meeting, the House of Delegates referred Resolution 817, “Addressing the Site 1 of Service Differential,” which was introduced by the New Mexico Delegation and assigned to the 2 Council on Medical Service for a report back to the House of Delegates at the 2018 Annual 3 Meeting. Resolution 817-I-17 asked: 4 5
That our American Medical Association (AMA) study the site-of-service differential with a 6 report back no later than the 2018 Interim Meeting, including: a) the rising gap between 7 independent practice expenses and Medicare reimbursement, taking into account the costs of 8 the regulatory requirements; b) the increased cost of medical personnel and equipment, 9 including electronic health record (EHR/EMR) purchase, software requirements, and ongoing 10 support and maintenance; c) the expense of maintaining hospital based facilities not common 11 to independent practices, such as burn units and emergency departments, and determine what 12 payment should be provided to cover those explicit costs; and d) the methodology by which 13 hospitals report their uncompensated care, and the extent to which this is based on actual costs, 14 not charges; and 15 16 That our AMA advocate for a combined Health Care Payment System for patients who receive 17 care that is paid for by the Centers for Medicare & Medicaid Services, that: a) follows the 18 recommendation of MedPAC to pay “site-neutral” reimbursement that sufficiently covers 19 practice expenses without regard to whether services are performed under the Hospital 20 Outpatient Prospective Payment System (HOPPS) or the Physician Fee Schedule (PFS); 21 b) pays appropriate facility fees for both hospital owned facilities and independently owned 22 non-hospital facilities, computed using the real costs of a facility based on its fair market value; 23 and c) provides independent practices with the same opportunity to receive reimbursement for 24 uncompensated care as is provided to hospital owned practices. 25
26 Resolution 817-I-17 raised a number of complex cost and payment issues spanning several subject 27 matter areas in need of extensive study. These issues are further complicated by the Medicare 28 program’s use of separate payment methodologies for each outpatient setting (ie, physician offices, 29 hospital outpatient facilities, and ambulatory surgical centers). A current AMA Issue Brief provides 30 an overview of these payment variations. The Council supports payment policies that are site-31 neutral to the extent possible without lowering payments overall and that fairly reflect the actual 32 costs of providing services. AMA policy supporting equitable payments across outpatient sites of 33 service, including policy established via Council reports, is appended. The Council recognizes the 34 need for further study, and its deliberations of options for achieving payment parity under the 35 Medicare program are ongoing. Accordingly, the Council intends to submit its final report with 36 recommendations addressing the site-of-service differential at the 2018 Interim Meeting. 37
CMS Rep. 8-A-18 -- page 2 of 4
Appendix H-240.979 Intrusion by Hospitals into the Private Practice of Medicine The AMA urges private third party payers to implement coverage policies that do not unfairly discriminate between hospital-owned and independently-owned outpatient facilities with respect to payment of “facility” costs. (CMS Rep. H, I-87; Modified: Sunset Report, I-97; Reaffirmed: CMS Rep. 9, A-07; Reaffirmed: Res. 116, A-14; Reaffirmation A-14; Reaffirmation A-15) H-240.993 Discontinuance of Federal Funding for Ambulatory Care Centers The AMA strongly urges more aggressive implementation by HHS of existing provisions in federal legislation calling for equity of reimbursement between services provided by hospitals on an outpatient basis and similar services in physicians’ offices. (CMS Rep. B, A-83; Reaffirmed: CLRPD Rep. 1, I-93; Reaffirmation I-98; Reaffirmation I-03; Reaffirmation I-07; Reaffirmed: CMS Rep. 3, A-13; Reaffirmation A-15) D-240.994 Payment Variations Across Outpatient Sites of Service Our AMA will work with states to advocate that third party payers be required to: a. Assess equal or lower facility coinsurance for lower-cost sites of service (hospital outpatient department, ambulatory surgical center, or office-based facility); b. Publish and routinely update pertinent information related to patient cost-sharing; and c. Allow their plan’s participating physicians to perform outpatient procedures at an appropriate site of service as chosen by the physician and the patient. (CMS Rep. 3, A-13; Reaffirmation I-17) H-330.925 Appropriate Payment Level Differences by Place and Type of Service Our AMA (1) encourages CMS to adopt policy and establish mechanisms to fairly reimburse physicians for office-based procedures; (2) encourages CMS to adopt a site neutral payment policy for hospital outpatient departments and ambulatory surgical centers; (3) advocates for the use of valid and reliable data in the development of any payment methodology for the provision of ambulatory services; (4) advocates that in place of the Consumer Price Index for all Urban Consumers (CPI-U), CMS use the hospital market basket index to annually update ambulatory surgical center payment rates; (5) encourages the use of CPT codes across all sites-of-service as the only acceptable approach to payment methodology; and (6) will join other interested organizations and lobby for any needed changes in existing and proposed regulations affecting payment for ambulatory surgical centers to assure a fair rate of reimbursement for ambulatory surgery. (Sub. Res. 104, A-98; Reaffirmation I-98; Appended: CMS Rep. 7, A-99; Reaffirmation A-00; Reaffirmation I-03; Reaffirmation A-11; Reaffirmed: CMS Rep. 3, A-13; Reaffirmed: Sub. Res. 104, A-14; Reaffirmed: Res. 116, A-14; Modified: CMS Rep. 3, A-14; Reaffirmation A-14; Reaffirmation A-15; Reaffirmation I-17) D-330.997 Appropriate Payment Level Differences by Place and Type of Service 1. Our AMA encourages CMS to: (A) define Medicare services consistently across settings and, in particular, to avoid the use of diagnosis codes in determining Medicare payments to hospital outpatient departments and other ambulatory settings; and (B) adopt payment methodology for hospital outpatient departments and ambulatory surgical centers that will assist in leveling the playing field across all sites-of-service. If necessary, the AMA should consider seeking a legislative remedy to the payment disparities between hospital outpatient departments and ambulatory surgical centers. 2. Our AMA will continue to encourage the CMS to collect data on the frequency, type and cost of services furnished in off-campus, provider-based departments. (CMS Rep. 7, A-99; Reaffirmation I-03; Reaffirmed: CMS Rep. 3, A-13; Reaffirmed: CMS Rep. 4, A-13; Appended: CMS Rep. 3, A-14; Reaffirmed: Sub. Res. 104, A-14; Reaffirmation A-14; Reaffirmation A-15; Reaffirmation I-17)
CMS Rep. 8-A-18 -- page 3 of 4
D-390.997 CMS Practice Expense Formula Our AMA will seek from Congress legislation directing CMS that it include in the RBRVS practice expense allocation all costs incurred by physicians, including those costs incurred in hospitals and ambulatory surgical centers. (Sub. Res. 819, I-99 Reaffirmed: CMS Rep. 5, A-09) H-400.957 Medicare Reimbursement of Office-Based Procedures Our AMA will: (1) encourage CMS to expand the extent and amount of reimbursement for procedures performed in the physician's office, to shift more procedures from the hospital to the office setting, which is more cost effective; (2) seek to have the RBRVS practice expense RVUs reflect the true cost of performing office procedures; and (3) work with CMS to develop consistent regulations to be followed by carriers that include reimbursement for the costs of disposable supplies and surgical tray fees incurred with office-based procedures and surgery. (Sub. Res. 103, I-93 Reaffirmed by Rules & Credentials Cmt., A-96 Reaffirmation A-04 Reaffirmation I-04 Reaffirmed: CMS Rep. 1, A-14 Reaffirmed: CMS Rep. 3, A-14) H-400.966 Medicare Payment Schedule Conversion Factor (1) The AMA will aggressively promote the compilation of accurate data on all components of physician practice costs and the changes in such costs over time, as the basis for informed and effective advocacy with Congress and the Administration concerning physician payment under Medicare. (2) The AMA will work aggressively with CMS, the Bureau of Labor Statistics, and other appropriate federal agencies to improve the accuracy of such indices of market activity as the Medicare Economic Index and the medical component of the Consumer Price Index. (CMS Rep. B, I-92 Reaffirmed: CMS Rep. 10, A-03 Reaffirmed: CMS Rep. 6, I-08 Reaffirmed: CMS Rep. 1, I11 Reaffirmation: I-12 Reaffirmed in lieu of Res. 113, A-13 Reaffirmation I-13 Reaffirmed: CMS Rep. 3, A-14) H-400.956 RBRVS Development (1) That the AMA strongly advocate CMS adoption and implementation of all the RUC's recommendations for the five-year review; (2) That the AMA closely monitor all phases in the development of resource-based practice expense relative values to ensure that studies are methodologically sound and produce valid data, that practicing physicians and organized medicine have meaningful opportunities to participate, and that any implementation plans are consistent with AMA policies; (3) That the AMA work to ensure that the integrity of the physician work relative values is not compromised by annual budget neutrality or other adjustments that are unrelated to physician work; (4) That the AMA encourage payers using the relative work values of the Medicare RBRVS to also incorporate the key assumptions underlying these values, such as the Medicare global periods; and (5) That the AMA continue to pursue a favorable advisory opinion from the Federal Trade Commission regarding AMA provision of a valid RBRVS as developed by the RUC process to private payers and physicians. (BOT Rep. 16, A-95 BOT Rep. 11, A-96 Reaffirmed: CMS Rep. 4, I-02 Reaffirmed: BOT Rep. 14, A-08 Reaffirmed: Sub. Res. 104, A-14 Reaffirmation A-15) H-400.969 RVS Updating Status Report and Future Plans: The AMA/Specialty Society RVS Update Committee (RUC) represents an important opportunity for the medical profession to maintain professional control of the clinical practice of medicine. The AMA urges each and every organization represented in its House of Delegates to become an advocate for the RUC process in its interactions with the federal government and with its physician members. The AMA (1) will continue to urge CMS to adopt the recommendations of the AMA/Specialty Society RVS Update Committee for physician work relative values for new and revised CPT codes; (2) supports strongly use of this AMA/Specialty Society process as the principal method of refining and maintaining the Medicare RVS; (3)
CMS Rep. 8-A-18 -- page 4 of 4
encourages CMS to rely upon this process as it considers new methodologies for addressing the practice expense components of the Medicare RVS and other RBRVS issues; and (4) opposes changes in Relative Value Units that are in excess of those recommended by the AMA/Specialty Society Relative Value Scale Update Committee (RUC). (BOT Rep. O, I-92 Reaffirmed by BOT Rep. 8 - I-94 Reaffirmed by BOT Rep. 7, A-98 Reaffirmed: CMS Rep.12, A-99 Reaffirmed: CMS Rep. 4, I-02 Reaffirmed: BOT Rep. 14, A-08 Reaffirmation I-10 Appended: Res. 822, I-12 Reaffirmation I-13 Reaffirmed: Sub. Res. 104, A-14 Reaffirmed in lieu of Res. 216, I-14 Reaffirmation A-15) D-478.996 Information Technology Standards and Costs 1. Our AMA will: (a) encourage the setting of standards for health care information technology whereby the different products will be interoperable and able to retrieve and share data for the identified important functions while allowing the software companies to develop competitive systems; (b) work with Congress and insurance companies to appropriately align incentives as part of the development of a National Health Information Infrastructure (NHII), so that the financial burden on physicians is not disproportionate when they implement these technologies in their offices; (c) review the following issues when participating in or commenting on initiatives to create a NHII: (i) cost to physicians at the office-based level; (ii) security of electronic records; and (iii) the standardization of electronic systems; (d) continue to advocate for and support initiatives that minimize the financial burden to physician practices of adopting and maintaining electronic medical records; and (e) continue its active involvement in efforts to define and promote standards that will facilitate the interoperability of health information technology systems. 2. Our AMA advocates that physicians: (a) are offered flexibility related to the adoption and use of new certified Electronic Health Records (EHRs) versions or editions when there is not a sufficient choice of EHR products that meet the specified certification standards; and (b) not be financially penalized for certified EHR technology not meeting current standards. (Res. 717, A-04; Reaffirmation, A-05; Appended: Sub. Res. 707, A-06; Reaffirmation A-07; Reaffirmed in lieu of Res. 818, I-07; Reaffirmed in lieu of Res. 726, A-08; Reaffirmation I-08; Reaffirmation I-09; Reaffirmation A-10; Reaffirmation I-10; Reaffirmed: Res. 205, A-11; Reaffirmed in lieu of Res. 714, A-12; Reaffirmed in lieu of Res. 715, A-12; Reaffirmed in lieu of Res. 724, A-13; Reaffirmation I-13; Reaffirmation A-14; Reaffirmed: BOT Rep. 03, I-16; Reaffirmed: BOT Rep. 05, I-16; Appended: Res. 204, I-17; Reaffirmation I-17)
© 2018 American Medical Association. All rights reserved.
REPORT OF THE SPEAKERS
Speakers’ Report 1-A-18 Subject: Recommendations for Policy Reconciliation Presented by:
Susan R. Bailey, MD, Speaker Bruce A. Scott, MD, Vice Speaker
Policy G-600.111, “Consolidation and Reconciliation of AMA Policy,” calls on your Speakers to 1 “present one or more reconciliation reports for action by the House of Delegates relating to newly 2 passed policies from recent meetings that caused one or more existing policies to be redundant 3 and/or obsolete.” 4 5 Your Speakers present this report to deal with policies, or portions of policies, that are no longer 6 relevant or that were affected by actions taken in 2017. Suggestions on other policy statements that 7 your Speakers might address should be sent to [email protected] for possible action. Where 8 changes to language will be made, additions are shown with underscore and deletions are shown 9 with red strikethrough. 10 11 RECOMMENDED RECONCILIATIONS 12 13 Policy to be modified in light of later House of Delegates action 14 15 I. G-600.027, “Designation of Specialty Societies for Representation in the House of Delegates” 16 17 This policy requires a minor change in the first paragraph given that the House amended the 18 bylaws and adopted policy to implement the new procedure for apportioning delegates to national 19 medical specialty societies. The change is a modest deletion from the policy and includes an 20 appropriate capitalization in the first sentence. No other change to the policy is necessary. 21 22
1. The current specialty society delegation allocation system (using a formula that incorporates 23 the ballot) will be discontinued; and s Specialty society delegate allocation in the House of 24 Delegates will be determined so that the total number of national specialty society delegates 25 shall be equal to the total number of delegates apportioned to constituent societies under 26 section 2.1.1 (and subsections thereof) of AMA bylaws, and will be distributed based on the 27 latest available membership data for each society, which is generally from the society's most 28 recent five year review, but may be determined annually at the society's request…. 29
30 Policy to be modified for clarification and consistency with practice 31 32 II. G-600.061, “Guidelines for Drafting a Resolution or Report” 33 34 The title of Policy G-600.061, “Guidelines for Drafting a Resolution or Report,” suggests that it 35 applies to both resolutions and reports, and in fact several parts of the policy refer specifically to 36 both resolutions and reports. However, some subparagraphs of Paragraph 1 do not reference 37 reports, despite the fact that practice has enforced the guidelines with respect to all reports 38 submitted to the House, and the House of Delegates Reference Manual plainly states (page 30) that 39
Speakers’ Report 1-A-18 -- page 2 of 6
a fiscal note “indicating the financial implications of the report’s recommendations” will be 1 included. To ensure correspondence between the policy title and actual practice, the policy should 2 explicitly address reports in Paragraphs 1, 1b, 1c and 1d. 3 4
G-600.061, Guidelines for Drafting a Resolution or Report 5 Resolutions or reports with recommendations to the AMA House of Delegates shall meet the 6 following guidelines: 7 8 1. When proposing new AMA policy or modification of existing policy, the resolution or 9
report should meet the following criteria: 10 11
a. The proposed policy should be stated as a broad guiding principle that sets forth the 12 general philosophy of the Association on specific issues of concern to the medical 13 profession; 14
15 b. The proposed policy should be clearly identified at the end of the resolution or report; 16
17 c. Recommendations for new or modified policy should include existing policy related to 18
the subject as an appendix provided by the sponsor and supplemented as necessary by 19 AMA staff. If a modification of existing policy is being proposed, the resolution or 20 report should set out the pertinent text of the existing policy, citing the policy number 21 from the AMA policy database, and clearly identify the proposed modification. 22 Modifications should be indicated by underlining proposed new text and lining through 23 any proposed text deletions. If adoption of the new or modified policy would render 24 obsolete or supersede one or more existing policies, those existing policies as set out in 25 the AMA policy database should be identified and recommended for rescission. 26 Reminders of this requirement should be sent to all organizations represented in the 27 House prior to the resolution submission deadline; 28
29 d. A fiscal note setting forth the estimated resource implications (expense increase, 30
expense reduction, or change in revenue) of the proposed policy, program, or action 31 shall be generated by AMA staff in consultation with the sponsor. Estimated changes 32 in expenses will include direct outlays by the AMA as well as the value of the time of 33 AMA’s elected leaders and staff. A succinct description of the assumptions used to 34 estimate the resource implications must be included in each fiscal note. When the 35 resolution or report is estimated to have a resource implication of $50,000 or more, the 36 AMA shall publish and distribute a document explaining the major financial 37 components or cost centers (such as travel, consulting fees, meeting costs, or mailing). 38 No resolution or report that proposes policies, programs, or actions that require 39 financial support by the AMA shall be considered without a fiscal note that meets the 40 criteria set forth in this policy. 41
42 2. When proposing to reaffirm existing policy, the resolution or report should contain a clear 43
restatement of existing policy, citing the policy number from the AMA policy database. 44 45 3. When proposing to establish a directive, the resolution or report should include all 46
elements required for establishing new policy as well as a clear statement of existing 47 policy, citing the policy number from the AMA policy database, underlying the directive. 48
49 4. Reports responding to a referred resolution should include the resolves of that resolution in 50
its original form or as last amended prior to the referral. Such reports should include a 51
Speakers’ Report 1-A-18 -- page 3 of 6
recommendation specific to the referred resolution. When a report is written in response to 1 a directive, the report should sunset the directive calling for the report. 2
3 5. The House’s action is limited to recommendations, conclusions, and policy statements at 4
the end of report. While the supporting text of reports is filed and does not become policy, 5 the House may correct factual errors in AMA reports, reword portions of a report that are 6 objectionable, and rewrite portions that could be misinterpreted or misconstrued, so that 7 the “revised” or “corrected” report can be presented for House action at the same meeting 8 whenever possible. The supporting texts of reports are filed. 9
10 6. All resolutions and reports should be written to include both “MD and DO,” unless 11
specifically applicable to one or the other. 12 13 7. Reports or resolutions should include, whenever possible or applicable, appropriate 14
reference citations to facilitate independent review by delegates prior to policy 15 development. 16
17 8. Each resolution resolve clause or report recommendation must be followed by a phrase, in 18
parentheses, that indicates the nature and purpose of the resolve. These phrases are the 19 following: 20 a. New HOD Policy; 21 b. Modify Current HOD Policy; 22 c. Consolidate Existing HOD Policy; 23 d. Modify Bylaws; 24 e. Rescind HOD Policy; 25 f. Reaffirm HOD Policy; or 26 g. Directive to Take Action. 27
28 9. Our AMA’s Board of Trustees, AMA councils, House of Delegates reference committees, 29
and sponsors of resolutions will try, whenever possible, to make adjustments, additions, or 30 elaborations of AMA policy positions by recommending modifications to existing AMA 31 policy statements rather than creating new policy. 32
33 References to completed reports to be deleted from policies 34 35 The following policies will be modified by deleting references to requested reports that have been 36 sent to and considered by the House of Delegates. Other, substantive portions of these directives 37 are unchanged. 38 39 III. H-95.990, “Drug Abuse Related to Prescribing Practices” 40 41 The policy includes a request for a study that has been completed, so that section of the policy will 42 be stricken. The remainder of the policy remains intact. 43 44
1. Our AMA recommends the following series of actions for implementation by state medical 45 societies concerning drug abuse related to prescribing practices: 46 A. institution of comprehensive statewide programs to curtail prescription drug abuse and 47
to promote appropriate prescribing practices, a program that reflects drug abuse 48 problems currently within the state, and takes into account the fact that practices, laws 49 and regulations differ from state to state. The program should incorporate these 50 elements: (1) Determination of the nature and extent of the prescription drug abuse 51
Speakers’ Report 1-A-18 -- page 4 of 6
problem; (2) Cooperative relationships with law enforcement, regulatory agencies, 1 pharmacists and other professional groups to identify "script doctors" and bring them 2 to justice, and to prevent forgeries, thefts and other unlawful activities related to 3 prescription drugs; (3) Cooperative relationships with such bodies to provide education 4 to "duped doctors" and "dated doctors" so their prescribing practices can be improved 5 in the future; (4) Educational materials on appropriate prescribing of controlled 6 substances for all physicians and for medical students. 7
B. placement of the prescription drug abuse programs within the context of other drug 8 abuse control efforts by law enforcement, regulating agencies and the health 9 professions, in recognition of the fact that even optimal prescribing practices will not 10 eliminate the availability of drugs for abuse purposes, nor appreciably affect the root 11 causes of drug abuse. State medical societies should, in this regard, emphasize in 12 particular: (1) Education of patients and the public on the appropriate medical uses of 13 controlled drugs, and the deleterious effects of the abuse of these substances; 14 (2) Instruction and consultation to practicing physicians on the treatment of drug abuse 15 and drug dependence in its various forms. 16
17 2. Our AMA: 18
A. promotes physician training and competence on the proper use of controlled 19 substances; 20
B. encourages physicians to use screening tools (such as NIDAMED) for drug use in their 21 patients; 22
C. will provide references and resources for physicians so they identify and promote 23 treatment for unhealthy behaviors before they become life-threatening; and 24
D. encourages physicians to query a state's controlled substances databases for 25 information on their patients on controlled substances. 26
27 3. The Council on Science and Public Health will report at the 2012 Annual Meeting on the 28
effectiveness of current drug policies, ways to prevent fraudulent prescriptions, and 29 additional reporting requirements for state-based prescription drug monitoring programs 30 for veterinarians, hospitals, opioid treatment programs, and Department of Veterans Affairs 31 facilities. 32
33 4. Our AMA opposes any federal legislation that would require physicians to check a 34
prescription drug monitoring program (PDMP) prior to prescribing controlled substances. 35 36 Council on Science and Public Health Report 2-I-13, “A Contemporary View of National Drug 37 Control Policy,” reviewed the material and addressed the elements of paragraph 3 within the 38 Council’s expertise. For that reason, paragraph 3 will be deleted. 39 40 IV. D-160.927, “Risk Adjustment Refinement in ACO Settings and Medicare Shared Savings 41
Programs” 42 43
Our AMA will continue seeking the even application of risk-adjustment in ACO settings to 44 allow Hierarchical Condition Category risk scores to increase year-over-year within an 45 agreement period for the continuously assigned Medicare Shared Savings Program 46 beneficiaries and report progress back to this House at the 2017 Annual Meeting. 47
48 At the 2017 Annual Meeting, the Board of Trustees offered Report 21, “Risk Adjustment 49 Refinement in Accountable Care Organization (ACO) Settings and Medicare Shared Savings 50 Programs (MSSP),” which described efforts that had been undertaken to address the CMS policies 51
Speakers’ Report 1-A-18 -- page 5 of 6
and noted that our AMA would continue to urge CMS to improve risk adjustment methodology in 1 ACOs. 2 3 V. D-165.935, “Protecting Patient Access to Health Insurance Coverage, Physicians, and Quality 4
Health Care” 5 6
1. Our AMA will: (a) actively engage the new Administration and Congress in discussions 7 about the future of health care reform, in collaboration with state and specialty medical 8 societies, emphasizing our AMA's extensive body of policy on health system reform; and (b) 9 craft a strong public statement for immediate and broad release, articulating the priorities and 10 firm commitment to our current AMA policies and our dedication in the development of 11 comprehensive health care reform that continues and improves access to care for all patients. 12 13 2. Our AMA Board of Trustees will report back to our AMA House of Delegates at the 2017 14 Annual Meeting. 15 16
BOT Report 24-A-17, “Protecting Patient Access to Health Insurance Coverage, Physicians, and 17 Quality Health Care,” characterized the efforts that had been undertaken to that point, including 18 engagement with the Federation, collaborations with various patient advocacy groups and letters to 19 congressional leadership as well as the White House. 20 21 VI. D-478.970, Physician-Patient Text Messaging and Non-HIPAA Compliant Electronic 22
Messaging 23 24
Our AMA: (1) will study the medicolegal implications of text messaging and other non-25 HIPAA-compliant electronic messaging between physicians, patients, and members of the 26 health care team, with report back at the 2017 Annual Meeting; and 2) will develop patient-27 oriented educational materials about text messaging and other non-HIPAA-compliant 28 electronic messaging communication between physicians, patients, and members of the health 29 care team. 30 31
The report requested in part 1 of the policy was fulfilled by Board of Trustees Report 11-A-17, 32 “Physician-Patient Text Messaging and Non-HIPAA Compliant Electronic Messaging,” which 33 modified Policy H-478.997, “Guidelines for Patient-Physician Electronic Mail and Text 34 Messaging,” which remains current policy. 35 36 Policy with a title change 37 38 VII. D-478.964, “High Cost to Authors for Open Source Peer Reviewed Publications” 39 40 Following usual practice, Board of Trustees Report 10-I-17 took its title from the underlying 41 referred resolution. While the body of the report correctly referred to open access journals, the title, 42 taken directly from the resolution, employed the term “open source.” As “open access” is the 43 preferred terminology, the title of Policy D-478.964 will be changed to “High Cost to Authors for 44 Open Access Source Peer Reviewed Publications.” 45 46 Directives to be rescinded in full 47 48 The following directives will be rescinded in full, as the requested studies have been completed, 49 with reports presented to the House of Delegates several years ago. 50
Speakers’ Report 1-A-18 -- page 6 of 6
VIII. D-160.930, “Studying Physician Access to ACO Participation” 1 2
Our AMA will study: (a) the criteria and processes by which various types of accountable care 3 organizations (ACOs) determine which physicians will be selected to join vs. excluded from 4 the ACO; (b) the criteria and processes by which physicians can be de-selected once they are 5 members of an ACO; (c) the implications of such criteria and processes for patient access to 6 care outside the ACO; and (d) the effect of evolving system alignments and integration on 7 physician recruitment and retention. The results of this study will be reported back to the HOD 8 and to our AMA membership at large by the 2015 Annual Meeting. 9 10
The directive was fulfilled by Council on Medical Service Report 7-A-15, “Physician Access to 11 ACO Participation,” which noted that efforts to identify and support current and emerging payment 12 and care delivery models that work best for physicians across a variety of practice settings are 13 ongoing. 14 15 IX. D-165.940, “Monitoring the Affordable Care Act” 16 17
Our AMA will assess the progress of implementation of the Patient Protection and Affordable 18 Care Act based on AMA policy, as well as the estimated budgetary, coverage and physician-19 practice impacts of the law, and report back to the House of Delegates at the 2013 Interim 20 Meeting. 21
22 Council on Medical Service Report 5-I-13, “Monitoring the Affordable Care Act,” was prepared in 23 response to this directive. 24 25 The changes outlined above do not reset the sunset clock and will be implemented when this report 26 is filed. 27 Fiscal note: $250 to edit policy database.
Related Documents
