AMA House of Delegates Meetings in 2005

Texans in Leadership Positions
Texans made more progress in obtaining national leadership positions during this meeting. Just completing a year as chair of the AMA Board of Trustees, cardiologist J. James Rohack, MD, of Temple, easily won reelection to another four-year term on the board. Joseph P Annis, MD, an Austin anesthesiologist, became chair of the Council on Medical Service, and Houston psychiatrist Priscilla Ray, MD, was the latest in the long line of Texans to assume the chair of the prestigious Council on Ethical and Judicial Affairs. Carolyn Evans, MD, a pediatrician from Plano, is the chair-elect of the Council on Long Range Planning and Development.

William G. Gamel, MD, of Austin, chair of the Texas delegation, stepped down after eight years of service on the Council on Legislation, including this past year as chair.

Despite running hard races in crowded fields, two Texas physicians lost close votes for AMA leadership spots. Larry Reeves, MD, a Fort Worth plastic surgeon, missed his bid for a seat on the Council on Constitution and Bylaws. Dale Moquist, MD, of Houston, backed by the American Academy of Family Physicians, came up short in his race for the Council on Medical Education.

Needville family practitioner Art Klawitter, MD, chaired the Reference Committee on Amendments to Constitution and Bylaws during the Chicago meeting. Baylor College of Medicine was named the AMA Medical Student Section Chapter of the Year. And Christopher Colenda, MD, dean of the Texas A&M System Health Science Center College of Medicine, was elected to the AMA Section on Medical Schools Governing Council.

Pay for Performance
While a small but vocal minority of delegates demanded that AMA oppose pay-for-performance programs as assaults on physicians' professionalism, the House of Delegates voted to adopt a strict set of principles and guidelines on which any pay-for-performance program should be based. Congress, the Centers for Medicare and Medicaid Services (CMS), and many managed care plans are devising and implementing programs that would link physicians' reimbursement to whether they meet certain quality performance measures. Delegates and AMA leaders warned that, without strict safeguards, pay-for-performance programs could become yet another cost-cutting mechanism that hurts physicians and patients and rewards only payers.

Much debate centered on the expectation that Congress will make significant progress toward fixing Medicare's flawed sustainable growth rate formula only if it also enacts pay-for-performance standards in the program. The house directed AMA to oppose pay-for-performance initiatives if they are not in alignment with the newly adopted standards and guidelines. Fair and ethical, patient-centered, pay-for-performance programs, AMA says, would:

• Ensure quality of care;
• Foster the patient-physician relationship;
• Offer voluntary physician participation;
• Use accurate and fair reporting; and
• Provide fair and equitable incentives.

The Tools to do the Job
Physicians who can't monitor their own patients' outcomes easily will be at the mercy of payers that implement pay-for-performance standards, delegates acknowledged. Affordable, interoperable health information technology (HIT), as proposed by the Texas delegation, is one key tool for the physicians' armamentarium. 

Physicians frequently shoulder most of the cost yet receive little of the financial benefits of HIT, the Texans told their colleagues.

The house-adopted Texas resolution would have AMA lobby for "positive incentives" for physicians to acquire HIT and for any legal changes needed to permit hospitals and other organizations to help finance HIT for physicians. Delegates accepted two no-strings-attached amendments that would ensure that facilities providing financial incentives cannot force specific systems on physicians and cannot override patients' privacy wishes.

Balance Billing
AMA delegates also took a strong stance on a dominant issue from the recently completed 2005 regular session of the Texas Legislature. The house directed AMA to "prepare legislation to allow physicians to balance bill regardless of the payer" and to make the issue a high congressional priority. Texas physicians, led by TMA Immediate Past President Bohn Allen, MD, noted that Medicare's 1988 prohibition on balance billing patients is one of the many factors threatening the viability of physicians' practices.

Texans Make Policy
In addition to the HIT resolution, the delegates adopted a Texas resolution stating that physicians who seek treatment for major depression shouldn't automatically place their medical licenses and credentials at risk. "The most important issue is that physicians or any other persons with depression get treatment," Austin psychiatrist Clifford Moy, MD, told the house. "The most impaired person is the untreated person."

Texas also asked AMA to support allowing pathologists to satisfy the cytology proficiency testing requirements of the Clinical Laboratory Improvement Amendments Act of 1988 through testing developed by the College of American Pathology or the American Society of Clinical Pathology. The house chose to back an alternative resolution that calls on government regulators to step carefully before instituting the proficiency tests. Delegates did not adopt a fourth Texas resolution that would make the AMA Council on Legislation operate more like its TMA counterpart, including election of council members by the AMA house rather than appointment by the AMA Board of Trustees.

Campaign Promotes "Everyday Heroes"
AMA unveiled a modern new logo and a new advertising campaign designed to increase membership and promote physicians' public image. "We are telling the world the AMA is dynamic, inclusive, and on the move," said AMA Chief Marketing Officer Gary Epstein.

In what he called an expansion of AMA's role "as the unassailable champion for the profession," Mr. Epstein previewed a series of radio, television, print, direct mail, and Internet ads that show physicians as "everyday heroes," routinely saving patients' lives. The meeting halls and hotel lobby were filled with posters espousing two new slogans: "Together we are stronger" and "Welcome to the future of medicine."

The new logo is a highly stylized, purple Staff of Asclepius, which has been the AMA symbol since 1910.

The ads "speak to the patient and physician interaction, the human side of medicine, which is why we all became doctors in the first place," said Brad Butler, MD, the resident physician on the Texas delegation.

Other Issues Merit Action
Delegates addressed various other economic, legislative, public health, and organizational topics. The house:

• Declared that a shortage of physicians exists in the United States, at least in some regions and specialties, and that the problem will get worse before it gets better. Delegates rejected a Council on Medical Education proposal that AMA support a 15 percent increase in the number of medical school seats.
• Called on AMA to oppose any attempts to restrict reimbursement for imaging procedures based on physician specialty. Beaumont neurosurgeon Mark Kubala, MD, a former TMA president, says he collaborates with local radiologists in interpreting his patients' images. "We read our MRIs and CTs days, nights, and weekends," said Dr. Kubala, who has no financial interest in an imaging center and is not reimbursed for reading his patients' scans at the hospital . "Because we know our patients, we feel very confident we can find what we're looking for."
• Determined that patients should be able to get legally valid prescriptions filled, or be referred to an alternative source, without interference from pharmacists' objections to certain medications.
• Rejected a call to ban all direct-to-consumer pharmaceutical advertising but asked for further study of how those ads affect the patient-physician relationship and health care costs.
• Directed AMA to develop a school health advocacy agenda that includes funding for school-based health programs, physical education and exercise, alternative polices for vending machines to promote healthy diets, and standards for healthier school lunches. To further combat obesity, delegates suggested that physicians should incorporate body mass index and waist circumference measurement into routine adult examinations.
• Said physicians should encourage and support pilot studies that investigate the effectiveness of presumed consent and mandated choice for organ donation.
• Voted to research and publicize studies that identify how much of the health care dollar is spent on insurance administration.
• Voted to urge the Food and Drug Administration to evaluate how recent changes to antidepressant warning labels might affect how physicians and patients, including children and adolescents, use these drugs.
• Made no change to the AMA dues levels for 2006.

J. Edward Hill, MD, a family physician from Mississippi, was installed as AMA president and encouraged physicians to use their internal professional compass to guide their activism. "If we don't transform medicine from within the profession, it will be transformed by forces from without," he said. "And it won't be pretty." Dr. Hill was a featured speaker at TMA Summit 2005 in Austin on Sept. 17. William Plested, MD, a California thoracic and cardiovascular surgeon, was chosen president-elect without opposition.

2005 Interim Meeting
The American Medical Association House of Delegates couldn't have chosen a better time for its advocacy and legislation meeting in Dallas. The physicians' November votes and discussions on Medicare, Medicaid, and pay-for-performance (PFP) programs echoed simultaneous debates on the same topics in the halls of the U.S. Congress. More than 100 Texas physicians and medical students representing the Texas Medical Association and various sections and national specialty societies participated in the Nov. 5-8 meeting at the Wyndham Anatole Hotel. The house last met in Dallas in 1997.

Fight over Medicare Fix
The delegates gathered in Dallas just days after the U.S. Senate approved what physicians consider a decidedly mixed bag of Medicare changes. The Senate voted to increase physicians' Medicare reimbursements by 1 percent for 2006, a move that would reverse the 4.4 percent rate cut required by existing law. But the Senate plan what the AMA calls a flawed PFP proposal, known as the "value-based purchasing." It also included a permanent ban on physician self-referral to new limited-service hospitals. The U.S. House of Representatives, meanwhile, was debating a budget bill that included no Medicare provisions but that would slice Medicaid spending by nearly $9 billion over five years. TMA leaders were concerned that the Medicaid cuts would undermine patients' access to services and the health care safety net.

AMA leaders and the House of Delegates made a public show of their outrage over the looming cut in Medicare reimbursements. From the meeting in Dallas, doctors made 1,726 phone calls in one day to their members of Congress to demand an immediate stop to the reductions. The calls went out on the same day AMA, TMA, and the Dallas County Medical Society (DCMS) held a news conference to draw more public attention to the cuts and their disastrous effect on patient access to care. TMA President Robert T. Gunby Jr., MD, detailed how Medicare's flawed sustainable growth rate formula will generate $4.32 billion in cuts by 2011 in Texas alone.

"Dallas' seniors should be particularly concerned," said DCMS President Leslie Secrest, MD. "We asked local physicians what they would do if the cuts occurred, and 36 percent said they will no longer accept new Medicare patients. This is a difficult decision for physicians, but steep cuts make it impossible for Dallas' physicians to continue with business-as-usual."

Delegates were adamant, however, that AMA not accept the Senate's value-based purchasing plan or any other PFP plans that violate the guidelines the house adopted at its June 2005 meeting. Those guidelines state that AMA would support PFP proposals only if they are fair, ethical, and patient-centered. Critics insisted that programs like value-based purchasing would allow the government to deny patients care simply to contain costs. Delegates adopted a resolution calling on AMA to oppose any PFP program that does not meet the June guidelines.

The Limits of Limited-License Practitioners
The Texas delegation brought just one resolution to the meeting. The house approved without dissent TMA's request that AMA develop a comprehensive report of "the qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes, and peer review" of limited-license health care providers and limited independent practitioners.

Beaumont orthopedic surgeon David Teuscher, MD, says the report will help physicians work with legislators who are asked to adjust or expand limited license practitioners' scope of practice.

Learning from Disaster
Following an educational program on medicine's lessons from Hurricanes Katrina and Rita -- which included presentations from Houston surgeon Kenneth Mattox, MD, and TMA Executive Vice President Lou Goodman, PhD -- the house adopted broad new policy on disaster preparedness.

AMA will work with state and territorial governments and licensing boards to create a clearinghouse to speed up licensure review for physician volunteers working in disaster areas. AMA also will support national legislation giving physicians automatic medical liability immunity when volunteering in declared federal emergency areas. The delegates urged all state and local public health jurisdictions to create comprehensive public health disaster plans.

Following TMA's more comprehensive study of the medical response to the twin hurricanes, TMA Trustee Josie Williams, MD, said, Texas physicians will ask the house in June to "be sure that AMA understands and specifically requests that physicians be at the table for local and state disaster planning."

Other Issues Merit Action
Delegates addressed various other economic, legislative, and organizational topics. The house:

• Voted to actively support laws and regulations banning smoking in all workplaces;
• Called for the development of uniform guidelines to govern the collection, use, and ownership of electronic medical record information;
• Adopted new ethical guidelines on quarantine and isolation measures that will help physicians balance public health goals with individual patients' interests during epidemics;
• Requested a study on the concept of requiring all Americans to have at least catastrophic and preventive health care coverage;
• Asked AMA experts to work up the pros and cons of using Health Savings Accounts for Medicaid patients;
• Asked AMA to investigate a plan that would address what some delegates called "indentured servitude" for international medical graduates holding J-1 Visa Waivers; and
• Heard a report stating that the number of full-dues-paying AMA members has increased for the first time since 1994.

Texans in Action
The Dallas gathering was the last AMA house meeting for Texas Delegation Chair William G. Gamel, MD. For nearly two decades, Dr. Gamel has represented Texas physicians at the national level. A past president of both TMA and the Travis County Medical Society, Dr. Gamel has chaired the Texas Delegation for nine years.

Jon Hornaday, the 47-year TMA employee who recently retired as director of special services, received an AMA 2005 Medical Executive Achievement Award for his dedication to organized medicine. He has worked at TMA since 1958. AMA also honored two Dallas pediatric orthopedic surgeons for their work at Texas Scottish Rite Hospital for Children. J. A. "Tony" Herring, MD, received the Benjamin Rush Award for Citizenship and Community Service, and Daniel J. Sucato, MD, received the Doctor William Beaumont Award in Medicine.

At the meeting, Dr. Teuscher sat on the reference committee that heard issues related to AMA advocacy in government health programs, and Austin psychiatrist Clifford Moy, MD, was a member of the convention's Committee on Rules and Credentials. Also, Austin anesthesiologist Joseph P. Annis, MD, currently chair of the AMA Council on Medical Service, announced he will seek a spot on the AMA Board of Trustees at the June elections.

TMA House of Delegates: TexMed 2006