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AMA House of Delegates debates health reform, hears from President Obama

THE FULL PRESENCE OF THE dermatologic community at this year’s annual meeting of the American Medical Association (AMA) House of Delegates (HOD), held June 13-17 in Chicago, was critically important as the physician community de-bated its role and position in an emerging reformed health care system.

A timely and deliberate visit by U.S. President Barack Obama to the AMA HOD high-lighted his administration’s emphasis on inclusiveness. While some critics of former health system reform efforts felt the process was virtually closed to the broader health care community, and physicians in particular, Obama’s remarks, met largely with resounding applause, assured physicians that they would continue to be a critically important voice in shaping any new health care delivery system.

Health System Reform

Perhaps the most lively debate of this year’s AMA HOD meeting centered on whether or not the physician community should support any kind of government-funded, “public option” for health care insurance. The Dermatology Section Council followed the Academy position of supporting greater access for patients while cautioning against any public option that would be built upon the current Medicare system and its law approach to both health care delivery and reimbursement for services. While the issue appeared to be polarizing, with rivaling partisan opinions expressed, the AMA HOD was able to reach agreement after hours of debate, recognizing that 1) the details of any new system have yet to be developed, and 2) to remain a credible participant in the debate, the physician community should take a position that essentially supports any system that is founded upon the AMA’s current principles of pluralism, freedom of choice, freedom of practice, and universal access for patients.

Medicare Physician Payment Reform

In the spirit of moving away from the annual fight to prevent across-the-board cuts to Medicare physician fees, the AMA HOD adopted a set of principles as the basis for developing and/or assessing any proposed Medicare physician payment reform efforts. Those principles, which the Academy has been involved with developing over the past years, include “Ensuring that reform efforts: promote improved patient access to care; are designed with input by the physician community; ensure payment rates that cover the full cost of sustainable medical practice; include participation options for all physicians; and ensure an appropriate level of physician decision-making authority over any shared-savings distributions.”

Physician Workforce

The Dermatology Section Council joined with the majority of the AMA HOD in supporting several resolutions that, together, support the position that efforts to bolster the physician workforce must be part of any comprehensive health system reform. Such steps should include advocating for expanded funding for entry and continued training positions in specialties and geographic regions with documented medical workforce short-ages. The AMA HOD also moved to reaffirm its position that the cap on GME-funded residency slots should be lifted.

Vitamin D Recommendations

The AMA HOD approved a report of the Council on Science and Public Health setting forth recommendations for the AMA’s support of “continued research on vitamin D and its metabolites, particularly long term studies that address adverse outcomes and potential confounders across all life-stage groups.” The report further recommends that the AMA 1) take steps to educate physicians about the evolving science of vitamin D and its impact on health, and to develop resources for patients; 2) encourage physicians to consider measuring the serum concentration of 25-hydroxyvitamin D in patients at risk of vitamin D deficiency and counsel those with insufficient levels on ways to improve their vitamin D status; and 3) monitor the development of new dietary reference intakes for vitamin D in 2010 and respond as appropriate. The Academy had the opportunity to review an earlier draft of the report, and urged that the recommendations be strengthened to emphasize the use of vitamin supplementation vs. UVA radiation. While that specific recommendation was rejected on the basis of not wanting to micromanage how physicians counsel their patients, the report essentially makes this point by only mentioning oral supplementation and not making any recommendation for use of UV exposure. Given that the recommendations were positive, do not specify supplementation by UV exposure, and cite the Academy’s Position Statement on vitamin D, the Dermatology Section Council agreed to support the report’s recommendations.

Relationships with Industry

The AMA’s Council on Ethical and Judicial Affairs (CEJA) presented a report to the AMA HOD setting forth guidelines for assessing ethical vs. Unethical behavior in relationships with industry, specifically in the context of continuing medical education (CME). The report was a revision of a harshly debated report from last year. While this revised report was perceived by many as considerably less restrictive than last year’s, its recommendations were still considered unreasonable by organizations, including the Academy, that put on large annual scientific meetings. The recommendations essentially laid out an ethical frame-work, defining what is “ethically preferable,” for example, CME providers accept funding only from sources that have no direct financial interest in a physician’s clinical recommendations, and what is “ethically permissible,” for example, CME providers permit individuals who have modest financial interests in the educational subject matter to program, develop content for, or teach in CME activities if there is full disclosure and steps are taken to minimize any potential influence. In addition, CME providers permit an individual who currently has a direct, substantial, and unavoidable financial interest in the educational subject matter to program, develop content for, or teach in a CME activity only if the individual is demonstrated to be uniquely qualified as an expert in the relevant body of knowledge or skills. The Academy joined a significant number of specialty societies in urging that the report be rejected and sent back to the CEJA for further consideration. There was substantial opposition to the notion of tiring what is ethically preferable vs. Permissible, the argument being that policymaker would only focus on what is preferable, and disallow all else. In addition, there was significant testimony that argued about the vagueness of certain terms such as “modest financial interest” and “substantial,” and the possibility of the policy being interpreted in such a way as to essentially restrict any industry support to the exhibit hall alone. The CEJA recommendations would have been virtually impossible to accomplish in large scientific meetings with presentations by hundreds of faculty invited to participate in the activity. As Congress continues to scrutinize physician relationships with industry, CEJA will deliver yet another report on the issue at the HOD’s interim meeting in November.

Incentives for HIT Adoption

Impending requirements for the adoption of health information technology and e-prescribing were also heavily discussed. Ultimately, the Dermatology Section Council voted with the majority of the AMA HOD in supporting policy that cautions lawmakers about the impact and potential unintended consequences of en-forcing financial penalties on physicians who do not adopt within established timeframes. In particular, dermatology argued that the high costs of adopting health information technology (HIT) and implementing and maintaining electronic medical records (EMR) are substantial for private practice physicians and that there should be reasonable and positive incentives to support HIT adoption.

Follow-on biologics

The subject of follow-on biologics has heated up over the past two years as the industry has sought to ensure a reasonable pathway for the introduction of biosimilars to the market, while preserving an appropriate length of time for exclusivity for brand-name biologics. The Academy’s Environment and Drugs Committee is considering a position for the Academy; however, in the meantime, the Dermatology Section Council supported the general principles of the adopted AMA policy to “make follow-on biologics more available to patients and physicians (as a lower-cost alter-native), while protecting patient safety and allowing a reasonable timeframe for FDA exclusivity and patent expiration.”The next meeting of the AMA HOD will take place Nov. 7-11 in Houston, where one of the Academy’s delegates, Cyndi Yag-Howard, M.D., will begin her campaign for election to the AMA’s Council on Constitution and Bylaws. Dr. Yag-Howard, an active member of the AMA HOD, and faithful contributor on behalf of dermatologists and patients, started her service as a resident physician. She currently serves as the chair of the AMA’s Specialty and Service Society Section the largest caucus for specialty society and service society representatives within the AMA HOD.

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