A forum for the nation's physicians

■ The AMA House of Delegates is convening June 15 through June 19 in Chicago to discuss such issues as health system reform, delivery of care, practice sustainability and public health. Return to this page for top news from the meeting.

Medical Service (Committee A) Call for tougher rules to stop misleading medical device ads Updated June 17 Advertisers who promote durable medical equipment should follow tougher regulations to ensure that suppliers stop confusing patients about how to obtain their products, according to a Board of Trustees report approved by the AMA House of Delegates. The report calls on the AMA to pursue legislation or regulations that require direct-to-consumer advertising for DME to include a disclaimer saying that eligibility for and coverage of DME is subject to specific criteria and that only a physician can determine if a patient meets the standards. Such ads also should list the actual criteria from an appropriate source. Federal rules mandate that to be covered by Medicare, DME must be medically necessary and prescribed by a physician, among other criteria. Covered products include oxygen, wheelchairs, hospital beds, walkers and prosthetics. During reference committee testimony, delegates said advertisers frequently promote their products without explaining the qualification process. This leads to some patients believing they can obtain DME when they do not qualify for the supplies. Mobile, Ala., urologist Jeff Terry, MD, said not enough is being done by legislators and the Centers for Medicare & Medicaid Services to stop the inaccurate ads. “Some of the advertisements on TV are just plain wrong as far as medical facts,” Dr. Terry, a delegate for the Medical Assn. of the State of Alabama, said during reference committee testimony. “Do you call this misleading, ignorance, lying or fraud? My efforts [to discuss the problem] with CMS and my congressman just meet dead ends.” Macon, Ga., family physician Michael Greene, MD, said he refuses to work with two DME companies because of their misleading treatment of his patients regarding equipment. “I've reported them to CMS,” said Dr. Greene, an alternate delegate for the Medical Assn. of Georgia. “We've got to really focus on the fraud aspect of this.” The board report said advertisers should refrain from statements that only a physician order or signature is required to obtain the desired items. The equipment first must meet federal standards before a doctor can approve use of the device. DME companies also should stop coercive acts that inappropriately influence physicians to sign such prescriptions for their patients. In other action Delegates approved a Council on Medical Service report aimed at making sure that insurers charge appropriate co-payment rates for outpatient treatments depending on where a service is performed. Although many surgical procedures can be performed safely in physician offices, ambulatory surgical centers and hospital outpatient departments, third-party payers and Medicare often impose substantially different co-pays for the same service, depending on where it is performed, the report said. The council report says the AMA will work with states to advocate that such payers be required to assess equal or lower facility co-pays for lower-cost sites of service. The plan's participating physicians also should be allowed to perform outpatient procedures at an appropriate site as chosen by the physician and the patient.

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Legislation (Committee B) Pharmacists cautioned not to intrude on medical practice Updated June 19 Delegates voted to adopt policy that says pharmacists who make inappropriate queries to verify a physician's rationale behind a prescription, diagnosis or treatment plan are interfering with the practice of medicine. If the problem isn't resolved, the AMA will advocate for regulatory and legislative solutions to prohibit pharmacies from denying therapeutic treatments to patients that are legitimate or medically necessary, the policy states. Physicians need to send a clear message to pharmacists “that they can't intrude on our practice of medicine,” said Robert Wailes, MD, an alternate delegate for the American Academy of Pain Medicine and pain medicine specialist from Carlsbad, Calif. As a collaborative step, the policy directs the AMA to work with the National Assn. of Chain Drug Stores, the Drug Enforcement Administration and other federal regulators and stakeholders to develop policies on reducing inappropriate dispensing and drug diversion incidents. In other action Delegates approved a Board of Trustees report that provides guidelines on invasive pain management procedures for treating chronic pain, including procedures that use fluoroscopy. One issue that commanded delegates' attention during committee testimony was the degree of supervision required for nonphysicians. Such procedures require physician-level training, the report stated, but there are instances where appropriately trained and credentialed nonphysicians could perform certain technical aspects under the direct and/or personal supervision of an experienced physician. Nonphysicians such as physician assistants “are extremely valuable, and we believe strongly that we want to work in cooperation and partnership with them,” said AMA Trustee Joseph P. Annis, MD, who chaired the task force that wrote the board report. In cases where radiologic imaging is involved, the report specified that invasive pain management procedures should be performed only by doctors with appropriate credentials and training. Policies to support a proactive role for doctors in gun control issues were adopted, including a provision that encourages doctors to educate and have open discussions with patients about firearm safety and the use of gun locks in homes. To promote public health and injury prevention, the language urged physicians to take part in local firearm safety classes. Other measures support research on firearm-related deaths and injuries and increased funding for firearms injury databases such as the National Violent Death Reporting System. The policy calls on the AMA to work with specialty and state medical societies and other stakeholders “to identify and develop standardized approaches to mental health assessment for potential violent behavior.” The House addressed several payment issues, fine-tuning policy to phase out Medicare's sustainable growth rate formula and adopt newer payment models. Such an approach would reflect diversity in physician-led practice models such as patient-centered medical homes and regional health collaboratives, while continuing to support fee-for-service and private practice medicine as options for providing high-quality, patient-centered care. Doctors should have the flexibility to determine the basic payment method for their services, as well as the right “to establish their compensation arrangements, including private contracting, at a level which they believe fairly reflects the value of their professional judgment and services,” the policy states. Delegates voted to support federal legislation that would require all payers to implement ICD-10 or ICD-11 over two years. The move gives “our members time to get used to the sticker shock” of ICD-10, said Reid B. Blackwelder, MD, president-elect of the American Academy of Family Physicians. Payers during that period “will not be allowed to deny payment based on specificity of ICD-10-11 diagnosis,” but would be required to give doctors feedback for incorrect diagnoses, the policy says. “We should not allow payers to find loopholes to not pay us for services we provide under contract,” said M. Eugene Sherman, MD, an alternate delegate for the American College of Cardiology and a cardiovascular disease specialist from Englewood, Colo.

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Medical Education (Committee C) Impact of board certification process on doctors to be examined Updated June 18 The house directed the AMA to take several steps to look at the maintenance of certification process and ensure it is not burdensome to physicians. The AMA will commission an independent study to evaluate the impact that MOC and maintenance of licensure requirements have on physicians' practices, the doctor work force and patients. A progress report on the study will be presented at the Annual Meeting in 2014. The Association will work with the American Board of Medical Specialties and its specialty boards to determine if the mandatory exams are still needed and to explore alternatives to the exams. The house directed the AMA to encourage the ABMS to ensure that its member boards are transparent on the costs of preparing and administering certification exams. During reference committee testimony, some delegates said that MOC is expensive and time-consuming. They said doctors need to fulfill continuing medical education requirements, and being board-certified doesn't necessarily mean you're a better physician. “If I see 15 patients every day, I'm taking 15 tests and I need to get an 'A' on every one of them,” said Leah McCormack, MD, a dermatologist and past president of the Medical Society of the State of New York. Dr. McCormack called the requirements onerous and an insult to physicians. Brigitta Robinson, MD, general surgeon, speaking on behalf of the Colorado Medical Society, expressed concern about the cost and travel time involved in taking the exams, which often are administered in another state. In other action The house directed the AMA to work with other health profession organizations to advocate for a reduction of the fixed interest rate of the Stafford student loan program. Delegates also adopted policy calling on the AMA to collaborate with other organizations to explore evidence-based approaches to quality and accountability in residency programs and support of enhanced funding for graduate medical education. Delegates said it is crucial to expand the number of GME positions to allow the growing number of medical school graduates to obtain a residency program slot.

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Public Health (Committee D) Delegates classify obesity as a disease state Updated June 18 Designating obesity as a disease could lead to greater investments by government and the private sector to develop treatments and ensure that doctors are paid for those services. The house approved a Council on Science and Public Health report that assessed the arguments for and against creating the classification on obesity. The report said better clinical and public health strategies are needed to help obese patients improve their lifestyle behaviors and reduce adverse outcomes associated with unhealthy weight. The report also recommended that a better measure of obesity than body mass index is needed. But the report stopped short of calling for the AMA to consider obesity a disease. However, delegates adopted new policy that recognized obesity as a disease state, requiring “a range of interventions” to advance treatment and prevention of the disease. Obesity “affects patients psychologically, functionally, physically and medically,” said Ethan Lazarus, MD, speaking for the American Society of Bariatric Physicians. For those reasons, obesity should be classified as a disease, said Dr. Lazarus, a delegate for the society from Denver. The council had opposed the designation because of the difficulty of screening for obesity, the lack of a clear definition of what constitutes a disease and potential problems associated with medicalizing obesity, said Robert A. Gilchick, MD, MPH, a member of the council. “It's a very serious condition … a pandemic, a significant risk factor for many other diseases,” said Dr. Gilchick, a public health and preventive medicine physician from Los Angeles. “But that does not alone mean it is a distinct medical disease state.” He is among the physicians concerned about the implication of labeling the estimated one in three U.S. adults who is obese as having a disease, even if an individual isn't sick. Other concerns with medicalizing obesity that were discussed at the meeting include an increased emphasis on treating the condition with medication and surgery rather than improving diet and boosting physical activity. Laguna Beach, Calif., ob-gyn Diana Ramos, MD, MPH, supported classifying obesity as a disease. Her position is based, in part, on the fact that obesity has a significant impact on minority populations. For instance, black women are 40% more likely to be obese than similarly aged white women, said Dr. Ramos, a delegate for the Minority Affairs Section, speaking for the section in reference committee testimony. “We should not be afraid to call [obesity] what it is,” Dr. Ramos said. The new policy comes as the nation's obesity epidemic has skyrocketed to epic proportions, according to the Centers for Disease Control and Prevention. Researchers project a dramatic increase in adult obesity and related health care costs by 2030 if the trend continues. Obesity increases the risk of a variety of potentially fatal health conditions, including breast cancer, coronary heart disease, type 2 diabetes and stroke. It also leads to rising health care costs. About $147 billion was spent on medical costs related to obesity for U.S. adults in 2008, according to the latest available CDC data. In other action Delegates directed the AMA to encourage screening for social and economic risk factors to improve patient care. Such screens “will make the physician aware of what's happening with [the patient] socially,” said Dr. Ramos, speaking for the Minority Affairs Section during reference committee testimony. “Maybe you will understand why they can't afford fruits and vegetables and then you will” suggest other ways to improve their diet.

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Science and Technology (Committee E) FDA, birth control pill makers asked to examine OTC option Updated June 18 The AMA House of Delegates is calling for the U.S. Food and Drug Administration to encourage manufacturers of oral contraceptives to submit applications and supporting evidence to the agency to consider approving a switch of birth control pills from prescription to over-the-counter status. The policy also calls on the AMA to encourage the continued study of issues relevant to OTC access for oral contraceptives. The vote came after delegates debated an earlier resolution that called on the AMA to adopt a philosophical statement of support for OTC status for birth control pills. Some argued in reference committee testimony that allowing contraceptive drugs to be sold over the counter could result in patients not receiving crucial drug education and possibly skipping important preventive procedures such as Pap smears and pelvic exams. Kenneth Crabb, MD, a delegate for the Minnesota Medical Assn. and an ob-gyn in St. Paul, testified on his own behalf against the resolution in virtual reference committee testimony. But during live testimony, he said he had since changed his mind after learning that the benefits outweigh the risks. He said the potential health risks of pregnancy were higher than possible side effects from birth control pills. Kira Geraci-Ciardullo, MD, a delegate for the Medical Society of the State of New York, spoke on her own behalf against the original resolution during reference committee testimony. She questioned the possible precedent that might be set by allowing the resolution to move forward. “I am shocked, frankly, at the abrogation of the physician in this discussion,” said Dr. Geraci-Ciardullo, an allergist and immunologist in Mamaroneck. “How many medications are we going to allow over the counter so that the pharmacist and the nurses are the ones doing the education and advice for medication use? If we send these prescriptions over the counter to patients, who is going to advise them? Where is the value of the relationship between the physician, particularly on ob-gyn, and her patient?” In other action The House approved a report that called for an amendment to AMA policy supporting tighter restrictions on compounding pharmacies. Compounding refers to the act of combining, mixing or altering pharmaceutical ingredients to prepare a customized medication for a patient. According to the Food and Drug Administration, compounding, “if done properly, can serve an important public health need if a patient cannot be treated with an FDA-approved medication.” The report calls on the Association to support efforts to subject compounding facilities to state board of pharmacy oversight and comply with current United States Pharmacopeia and National Formulary compounding regulations regarding uniformity, quality and safety of compounding medications. Several ophthalmologists testified in opposition to the policy during reference committee testimony, saying tighter restrictions could prevent them from keeping compounded medications in their offices, which they frequently use on patients with glaucoma and macular degeneration. Tighter restrictions could delay treatment, which could lead to sight loss, some delegates said. The report supports the view that allowances should be made to manage urgent and emergency case scenarios. The House also approved a report that calls for the AMA to oppose discrimination based on a patient's genetic information. It calls on the AMA to support legislation intended to strengthen protections against such discrimination, and endorse education for physicians and patients about federal and state laws protecting a person's genetic information. In virtual reference committee testimony, forensic pathologist J. Scott Denton, MD, a delegate for the National Assn. of Medical Examiners from Bloomington, Ill., speaking on behalf of the Pathology Section Council, supported the report's recommendations. “The medical community must take a leadership role in alleviating patient fears and concerns about how results from genetic testing might be used by third parties,” Dr. Denton said. “Physician involvement in legislation to provide comprehensive protections will ensure that those protections will be drafted to protect against discrimination but not interfere with providing appropriate medical care to patients.” Dr. Denton said the council believes patients would forgo molecular testing that could aid diagnosis and appropriate medical management for fear of being discriminated against.

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AMA Finance and Governance (Committee F) House votes to keep Interim Meeting Updated June 17 After several years of debate and a report on whether to have the AMA House of Delegates continue to meet twice a year, the house voted to continue the November Interim Meeting. Fifty-seven percent of delegates voted in favor of retaining the Interim Meeting. In November 2012, delegates called for a pilot project that would combine the Interim Meeting with the National Advocacy Conference. The Board of Trustees convened a task force to review options, and delegates were surveyed. The resulting report said that 43% of the delegates believe the policymaking activity could be conducted in a single yearly meeting. Among medical society executives, 79% said one meeting would be sufficient. Although 68% of executives said the Interim Meeting created a fiscal barrier or strain on their medical society, only 35% of delegates had that opinion. The task force said there is a disconnect between what delegates and their sponsoring societies want. It recommended that the AMA's policymaking activities be done in a single meeting, and the board agreed with that recommendation. But some delegates fought to keep the meeting, saying it is valuable for policymaking and interaction among delegates. They also said it is needed to address issues in medicine that cannot wait until the Annual Meeting in June. “This is the wrong time to turn around and dissolve this,” said Theodore Kanellakes, MD, a delegate for the Illinois State Medical Society who spoke on his own behalf in reference committee testimony. He is an internist in Joliet who specializes in allergies and immunology. Others supported the board report and said the house should conduct business at one meeting. Almost everyone wanted some definite decision to be made. “It's time for choosing. We have debated this for years and years,” said David Teuscher, MD, an orthopedic surgeon in Beaumont, Texas, and an alternate delegate for the Texas Medical Assn. In other action Delegates approved a board report on the use of virtual reference committees by the house. Although many like the concept of having delegates comment online before house meetings, some said not enough people are using the process. “On most issues, there were only five to seven comments,” said Edmund Donoghue Jr., MD, a forensic pathologist in Savannah, Ga., and a delegate for the American Society of Clinical Pathology. “I really don't think we're getting enough comments to make relevant decisions.” Several delegates said they don't think reference committee leaders should write a preliminary report based on sparse online testimony. Some are concerned that report may bias the direction to be taken on issues discussed in live reference committee testimony. At future meetings, virtual testimony should be used to prepare a summary report that reflects the comments received up to that point, the house said. The house also approved the formation of a Women Physicians Section, changing the status of the Women Physicians Congress from an advisory committee to a section with representation in the house.

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Medical Practice (Committee G) AMA urged to pursue EHR vendor standardization Updated June 18 Delegates directed the AMA to seek legislation or regulations requiring all electronic health records vendors to standardize their software. “Our message [to EHR vendors] must come from Washington, otherwise it's never going to happen,” said Hugh Vincent, MD, a delegate for the California Medical Assn., shortly before the vote. He is an anesthesiologist in Mill Valley. Delegates also asked the AMA to partner with the Centers for Medicare & Medicaid Services to develop incentives for hospitals and health systems that would promote more efficient sharing of EHRs with independent physicians. The policy noted that some hospital EHR systems were incompatible with systems of physicians who worked outside the hospital. It also said that no state or other government entity required vendors to standardize interconnectivity among EHR systems. In other action Delegates approved a report on work site health clinics. “Review of the literature reveals that [such clinics] can provide a valuable service, but there are issues to consider,” said Paul Wertsch, MD, writing on behalf of himself in virtual testimony. He is a delegate for the Wisconsin Medical Society and a family physician from Madison. “Since most do not provide 24/7 coverage, there must be a way for the community physicians who are providing 24/7 coverage to have access to the records when the clinic is not open.” The Council on Medical Service report recommended 14 principles on the operation of work site health clinics. The principles focus on: establishing referral systems with physician practices if patient conditions are beyond a clinic's scope of care; adopting protocols to ensure continuity of care with local practicing physicians; and developing expertise in specific occupational hazards and medical conditions that are likely to be more common in particular industries.

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Constitution and Bylaws Federal payment sought for Medicaid organ transplants Updated June 17 The House of Delegates voted to support federal funding of organ transplants for patients on Medicaid. The move comes after a 2010 action in Arizona that cut funding for certain “optional services,” including some organ transplants. That state policy affected nearly 100 Arizona patients on the organ wait list and was overturned in 2011 after intense pressure from transplant surgeons and the public. Delegates wanted to take action on the issue because transplantation is not among the core medical services that must be covered by states choosing to participate in the joint state-federal Medicaid program. With the struggling economy driving many state budgets deep into the red, physicians feared that other states would move to restrict or cut coverage of transplantation for financial rather than medical reasons. Allowing that sort of coverage decision would be tantamount to “organ allocation by wallet biopsy,” said Jacksonville, Fla., transplant surgeon Thomas G. Peters, MD, an alternate delegate who spoke on behalf of the Florida Medical Assn. The house also voted to encourage states and local organ procurement organizations to provide educational materials about organ and tissue donation to driver education and safety classes. Nine out of 10 Americans say they are interested in registering as organ donors, but less than a third know the steps involved in doing so, according to Donate Life America, the nonprofit alliance of organ procurement organizations. Including education about organ and tissue donation could help narrow the gap, said Jan Kief, MD, a Highlands Ranch, Colo., internist. “I work with a lot of high school students, and many don't think they're allowed to make that decision themselves, and there's a lot of confusion about that. This will be very important for those students,” said Dr. Kief, an alternate delegate for the Colorado Medical Society who testified in favor of the action in reference committee testimony. Individuals 18 and older can register as organ donors through their state systems. Meanwhile, a proposal asking the AMA to study the feasibility of a unified registry of living kidney donors was referred to the Association's Board of Trustees for a decision. The Organ Procurement and Transplantation Network already is working with the American Society of Transplant Surgeons and other bodies to examine this issue, and delegates did not want to duplicate those efforts. More than 90,000 Americans are on the waiting list for a kidney transplant. In other action It should be up to physicians to determine when a person has successfully completed transition from one sex to the other, delegates said. Many U.S. jurisdictions require transgender patients to have undergone surgical sex changes to qualify for alteration of the sex designation listed on their birth certificates. But the standard of care for transgender patients has shifted, with many individuals choosing to complete transition to a different gender identity without surgery. The house voted to support changing jurisdictional policies so that a physician's verification “that the individual has undergone transition according to applicable medical standards of care” is sufficient for the purposes of changing the birth certificate sex designation. Delegates also approved policy barring discrimination against patients by medical students. Previous policy addressed only physicians. And, delegates directed the AMA to raise awareness about human trafficking and how doctors can recognize the signs and symptoms of those victimized by the practice. Two Council on Ethical and Judicial Affairs reports that received extensive debate in reference committee — one to revise the AMA's policy on gifts from industry and the other to outline physicians' right to refuse treatment based on conscience grounds — were referred for further study.

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