Advancing the surgical agenda: AMA House of Delegates

Advocacy can take many different forms. Most familiar is standard grassroots lobbying, where surgeons meet with their congressional or state elected officials, or send them e-mails and letters on a particular issue. Another excellent means of influencing public policy involves serving on state medical boards, public health committees, or other health care-related entities. A less recognized but equally important way to drive health policy is through medical professional organizations, such as the American College of Surgeons (ACS), the American Medical Association (AMA) and other specialty societies.

The ACS representatives to the AMA House of Delegates (HOD) advocate for surgical issues, serving as an example of driving health care policy through participation in a medical professional society. In preparation for the Annual Meeting of the AMA HOD June 11–15, in Chicago, IL, the College’s delegation (see sidebar) considered an agenda that included 64 reports from the AMA board and councils, and 182 resolutions from state medical associations, specialty societies, and AMA Sections.

Several of these reports and resolutions were of interest to surgery.

Ethics

• Council on Ethical and Judicial Affairs (CEJA) Report 2, Modernized Code of Medical Ethics, was adopted. After more than two years of discussion and comments from specialty societies, the HOD agreed that the most recent draft of the code was where it should be. Written concerns from the College’s Committee on Ethics were addressed in the revised code.
• Resolution 004, Targeted Education to Increase Organ Donation, was adopted. The AMA will study potential educational efforts on organ donations tailored to demographic groups with low organ donation rates.
• Resolution 602, Protection of Physicians’ Personal Information, was adopted. The AMA will work with the Federation of State Medical Boards to promote standardization and protection of physician personal data that are available to the public. Although this resolution addresses one avenue of potential identity theft, a more prominent source remains payor database breaches. This area will form the basis of a resolution at the November interim meeting of the HOD.

Health care reforms

• Council on Medical Service Report 9, Physician-Focused Alternative Payment Models (APMs), was adopted with an amendment proffered by the College’s delegation. The report promotes patient-centered, physician-led, team-based care coordination in APMs. The report defines principles to guide the development and implementation of APMs. APMs should achieve the following:
  • Be designed by physicians or with significant physician input and involvement
  • Provide flexibility to physicians to deliver the care their patients need
  • Promote physician-led, team-based care coordination that is collaborative and patient-centered
  • Reduce financial and administrative burdens of using health information technology
  • Provide adequate and predictable resources to support the services physician practices need to offer to patients, including mechanisms for regularly updating the amounts of payment to ensure they continue to be adequate to support the costs of high-quality care for patients
  • Limit physician accountability to aspects of spending and quality that they can reasonably influence
  • Avoid placing physician practices at substantial financial risk
  • Minimize administrative burdens on physician practices
  • Be feasible for the participation of physicians in every specialty and for practices of every size
• Resolution 104, Provider Experience as a Metric for Determining Overall Performance by ACOs (Accountable Care Organizations) and Other Payment Models, was adopted after lengthy discussion. The resolution sought AMA advocacy to expand the “Triple Aim” by adding health professional work-life balance to the mix of a “Quadruple Aim,” and to urge the Centers for Medicare & Medicaid Services (CMS) to include physician satisfaction as a clinical practice improvement activity in the Merit-based Incentive Payment System (MIPS). The Triple Aim is a concept endorsed by Donald M. Berwick, MD, MPP, president emeritus and senior fellow, Institute for Healthcare Improvement, which promotes better patient experience, better population health, and lower per capita health care costs.
• Late Resolution 1010, Fixing the VA (Veterans Affairs) Physician Shortage with Physicians, was adopted. As a result, the AMA will work with the VA to enhance its loan forgiveness programs as a way to improve physician recruitment and retention.

Legislation

• Board of Trustees Report 19, Pain as the Fifth Vital Sign, was adopted with amendments. The AMA will advocate for the elimination of pain as the fifth vital sign from professional standards and usage, and for removal of the pain management component of patient satisfaction surveys as it pertains to payment and quality metrics. Widespread concern was expressed that pain as the fifth vital sign is driving over-prescription of narcotic pain medications, particularly when complete pain relief is measured through patient satisfaction surveys. The AMA also will work with The Joint Commission to promote evidence-based, functional, and effective pain assessment and treatment measures for accreditation standards, and will strongly support timely and appropriate access to non-opioid and non-pharmacologic treatments for pain.
• Resolution 242, Preserving a Period of Stability in Implementation of MACRA (Medicare Access and CHIP [Children’s Health Insurance Plan] Reauthorization Act), passed as a late resolution. The original resolution sought legislative relief, so it was referred to the Reference Committee on Legislation. It was subsequently changed, yet remained in this reference committee report.A result of adoption of this resolution is that the AMA will advocate for CMS implementation of MIPS and APMs in a manner consistent with congressional intent, and for a stable transition period that includes appropriate testing of physicians’ ability to participate; validation of the accuracy of scores, ratings, and necessary resources; and a suitable reporting period.
• Late Resolution 1011, Gun Violence as a Public Health Crisis, sponsored by the ACS and 20 other specialty societies, and 38 state medical associations, was adopted in response to the tragic nightclub shooting in Orlando, FL, that took place at the start of the HOD. The AMA continues to regard gun violence as a public health crisis and seeks to remove prohibitions to federal funding for gun violence research.

Medical education

• Resolution 309, Continuing Medical Education Pathway for Recertification, dominated the last day of the meeting and passed with amendments. The AMA now calls for an immediate end to any mandatory, secured recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process for all specialties that still require a secure, high-stakes recertification examination. The AMA will continue to work with ABMS to encourage the development of alternative assessments of medical knowledge beyond a secure exam.
• Resolution 310, Standardizing the Allopathic Residency Match System and Timeline, was referred to the AMA Board of Trustees for report back. The resolution asked that the AMA support the movement toward a single U.S. residency match system and notification timeline for all non-military allopathic specialties and work with the Association of University Professors in Ophthalmology, the American Academy of Ophthalmology, the Society of University Urologists, the American Urological Association, and any other appropriate stakeholders to switch ophthalmology and urology to the National Resident Matching Program. Ophthalmologists and urologists disagreed.
• Resolution 315, MOC (Maintenance of Certification) and MOL (Maintenance of Licensure) vs. Board Certification, CME (continuing medical education), and Life-long Commitment to Learning, was referred to the AMA Board of Trustees for a subsequent report. The resolution asked the AMA to oppose discrimination by any hospital or employer, state board of medical licensure, insurers, Medicare, Medicaid, and other entities that results in the restriction of a physician’s right to practice medicine without interference (including discrimination by varying fee schedules) due to lack of recertification or participation in MOC or MOL programs, as well as a lapse of a time-limited board certification.

Science and technology

• The ACS achieved an important health and public policy victory with the passage of Resolution 519, Support for Hemorrhage Control Training. This resolution was sponsored by the College delegation with six specialty society cosponsors. As adopted, the AMA will encourage state medical and specialty societies to promote the training of both lay public and professional responders in essential techniques of bleeding control, as well as the inclusion of hemorrhage control kits for all first responders. (See “AMA HOD approves ACS-sponsored resolution on mass casualty bleeding control” in the August Bulletin for details.)

Medical practice

• Resolution 703, Voluntary Reporting of Complications from Medical Tourism, was adopted. The resolution instructs the AMA to support efforts that allow for the reporting and tracking of quality and safety issues associated with medical procedures performed abroad, rather than asking organizations to maintain a voluntary database for collection of this information.
• Resolution 710, Eliminate the Requirement of “H&P [Comprehensive Medical History and Physical Assessment] Update,” was referred for study. This resolution sought to have the AMA work to remove the H&P update from CMS regulations. ACS delegation testimony regarding the importance of confirming satisfactory patient condition on the day of surgery was a leading factor in the resolution being referred for study.

AMA elections

A number of ACS Fellows were successful in their election bids at the June meeting of the HOD. Andrew W. Gurman, MD, FACS, a hand surgeon from Pennsylvania, was inaugurated as the 171st AMA President. ACS-endorsed candidates Lynn Jeffers, MD, FACS, and David Welsh, MD, FACS, an ACS Governor from Indiana, were elected in tough campaigns to the Council on Medical Service and the Council on Science and Public Health, respectively.

Surgical Caucus of the AMA

The Caucus CME program, Navigating Health Care Policy in a Presidential Election Year, featured Sara Morse, Manager of Legislative and Political Affairs, ACS Division of Advocacy and Health Policy, and Manuel Bonilla, MS, Chief Advocacy Officer for the American Society of Anesthesiologists. Panelists provided an overview of the health policy positions of the two presidential campaigns, followed by a discussion of the dynamics of the November 2016 election season, grassroots advocacy programs of organized medicine, and the critical role of surgeons and other specialists in effective advocacy.

Upcoming HOD meeting

The next meeting of the AMA House of Delegates is the interim meeting, November 11–14 in Orlando. The College’s delegation welcomes comments and suggestions for potential resolutions and will continue to advance surgery’s agenda within the policymaking process of the HOD. For more information or to submit comments or suggestions, contact Jon Sutton, State Affairs, ACS Division of Advocacy and Health Policy Manager, at jsutton@facs.org.