AMA Dermatology Section Council Update

July 2018

The AMA House of Delegates convened in Chicago in June 2018 for its Annual Meeting to formulate policies and address issues facing physicians and patients today.

The ACMS was represented well by Michel McDonald, MD (Delegate), Divya Srivastava, MD (Alternate Delegate), Nita Kohli, MD (Young Physician Delegate) and Syril Keena Que, MD (Resident/Fellow Delegate).

Other ACMS members on the Dermatology Section Council in attendance included Brett Coldiron, MD, Hillary Johnson, MD, PhD, Marta VanBeek, MD, Jessica Krant, MD, Chad Prather, MD, Anthony Rossi, MD, Eric Millican, MD, and Vineet Mishra, MD.

Dermatologists Recognized in the House of Medicine
Jack Resneck Jr., MD was re-elected to the American Medical Association’s Board of Trustees at the AMA’s 2018 annual meeting in June. Dr. Resneck also assumed the role of Chair of the AMA Board.

Additionally, several other dermatologists obtained positions within the AMA House of Delegates:

• Dr. Marta Van Beek was appointed to the Council on Legislation
• Dr. Hillary Johnson-Jahangir, MD, PhD was selected by the AMA and ACGME to serve on the Dermatology Residency Review Committee (RRC) from 2019-2025
• Dr. Josephine Nguyen was re-elected to serve as the national Delegate for the AMA Women Physicians Section

Dermatology Section Council

The Dermatology Section Council (DSC) sponsored several resolutions at the 2018 AMA Meeting including the following two:

1. Private Equity Firms: The DSC advocated for the AMA to study the positive and negative effects of private equity firms acquiring physician practices. The House of Medicine voted to expand the resolution to include corporate ownership of physician practices beyond venture capital/private equity firms.
2. Handling of Hazardous Drugs: This resolutions calls on the AMA to work with United States Pharmacopeia to revisit the requirements in General Chapter <800> of the USP Compounding Compendium and review Chapters <795> and <797> to ensure that the requirements included in those chapters are not onerous to physicians and prohibitive to their current ability to provide medications to their patients.

There were several other policies on which the DSC provided testimony:

Reducing MIPS Reporting Burden
That our American Medical Association work with the Centers for Medicare and Medicaid Services (CMS) to advocate for improvements to Merit-Based Incentive Payment System (MIPS) that have significant input from practicing physicians and reduce regulatory and paperwork burdens on physicians. Additionally, it stated that, in the interim, our AMA work with CMS to shorten the yearly data reporting period from one-year to a minimum of 90-days (of the physician’s choosing) interval within the calendar year.

Drug Shortages

1. AMA urges the FDA to require manufacturers to provide greater transparency regarding production locations of drugs and provide more detailed information regarding the causes and anticipated duration of drug shortages, and
2. AMA considers drug shortages to be an urgent public health crisis and recent shortages have had a dramatic and negative impact on the delivery and safety of appropriate health care to patients. Drug Shortages are increasingly becoming a major issue for dermatologists and many other specialties

Drug Pricing/Transparency
The final resolution, after being amended by the reference committee, stated that our AMA:

1. gather more data on the erosion of physician-led medication therapy management in order to assess the impact pharmacy benefit manager (PBM) tactics may have on patient’s timely access to medications, patient outcomes, and the physician-patient relationship, and
2. examine issues with PBM-related clawbacks and direct and indirect remuneration (DIR) fees to better inform existing advocacy efforts.

Young Physician Leaders

By Nita Kohli, MD, MPH (with excerpts from YPS MSMA report to Missouri Medicine, by Nita Kohli, MD, MPH and Albert Hsu, MD)

The Young Physician Section (YPS) of the AMA includes all physicians who are < 40 years of age *or* within their first 8 years after their terminal residency or fellowship training.  The YPS reviews all resolutions and reports that are being addressed by the full House of Delegates.

At this meeting, I represented ACMS in the AMA Young Physicians Section, Women’s Physician Section, as well as in the House of Delegate’s Reference Committees on Science and Public Health and Medical Service. This involved giving testimony on the various resolutions pertinent to Mohs and dermatology surgery. The following resolutions are important to the Young Physician Section, Women Physicians, and Mohs surgery.

The role of private equity in medicine
At A-18, one of the most interesting issues that has direct impact on our field and others, is that of private equity in medicine. Many investors are turning to healthcare. Approximately 14% of private equity acquisitions are now in healthcare, and these private equity groups often bundle multiple medical practices, then rapidly “flip” them. The largest dermatology group in the USA is now owned by a Canadian retirement fund, and while such practices may be great for revenue generation, there is a potential loss of healthcare dollars to non-healthcare entities that have little incentive to reinvest in their healthcare practices. Some of these private equity groups have threatened to open offices in catchment areas to compete against existing private dermatology practices, if they don’t sell to them. The profit-models of private equity firms may result in high-pressure RVU production guidelines, in which physician groups lose all autonomy and essentially become indentured servants. Others raised concerns of “profit over patients” in highly-leveraged private equity environments, as well as fears about when those firms go bankrupt (where doors are locked, records aren’t retrieved, and patients are abandoned with no continuity of care).

While some decried the general increase in corporate ownership of physician practices today (with predatory practices, under-bids and subsidies, and playing fields skewed against risk-averse physicians), others pointed out the unique features of private equity, in which ownership “flips” frequently (one dermatology group was owned by 4 different groups within an 18-month period). Still others brought up the fact that some money behind these private equity groups may come from hospitals and Pharma and Insurance companies – where inherent conflicts of interest may be masked by the use of such private equity groups. Multiple physician specialties including dermatology, orthopedics, ob/gyn, and radiation oncology indicated the urgent need for the AMA to draft model contract language for when private equity groups take over medical practices. A resolution on this issue was passed by the AMA, and we look forward to a report back next June.

Young physicians in the AMA
We heard from the U.S. Surgeon General, Jerome Adams MD, MPH, who urged us all to lead the nation in civil discussions on health equity, gun violence, and the stigma surrounding substance use disorders (read more here). Dr. Adams first joined the AMA 20 years ago as a medical student in Indiana, stating that “if it weren’t for the AMA, I wouldn’t be standing before you now as the 20^th U.S. surgeon general.”

Outgoing AMA president Dr. David Barbe (from Mountain Grove, MO) also spoke about the impact that the AMA is having on the public health crises of today, especially opioid addiction and gun violence (read more here).

Other advocacy and public policy issues
Other issues that were addressed by the AMA-YPS include:

• Prohibit retrospective ER coverage denial and return to prudent layperson standard for emergency services
• Insulin affordability
• Young physician involvement in maintenance of certification
• Taking steps to advance gender equity in medicine and Advancing the goal of equal pay for women in medicine
• Handling of hazardous drugs
• Survivorship care plans
• Integration of drug price information into EMRs
• Augmented intelligence in healthcare
• Utilization review
• Legalization of interpharmacy transfer of electronic controlled substance prescriptions
• Recording law reform
• Update on maintenance of certification and osteopathic continuous certification
• Policy and economic support for early child care
• Vector borne diseases
• Alcohol use and cancer
• Biosimilar interchangeability pathway
• Physician burnout and wellness challenges
• Economic credentialing
• Modify the clinical laboratory improvement amendment of 1988

Resolution details

1. Young Physician Involvement in Maintenance of Certification: this resolution calls for inclusion of younger physicians on the ABMS boards
2. Taking Steps to Advance Gender Equity in Medicine: This resolution calls on the AMA to work with relevant stakeholders to conduct initiatives to support the advancement of gender equity in medicine. Despite the increasing number of women in medicine, gender discrepancies in professional advancement still occur.  Women physicians continue to be underrepresented among leadership roles in main practice settings, professional organizations, or academic departments.
3. Advancing the Goal of Equal Pay for Women in Medicine: This resolution calls for the AMA to conduct various initiatives to support equal pay for women in medicine. Gender disparities in income persist even when controlling for age, specialty, and practice characteristics. This resolution calls for AMA to draft and disseminate a report clarifying principles of equal pay that can form the basis for policy making as well as for academic centers and entities that employ physicians.  
4. Corporate Investors:  This resolution calls for the AMA to study the effects on the healthcare marketplace of  corporate investors (e.g. public companies, venture capital/private equity firms, insurance companies, and health systems) acquiring a majority and/or controlling interest in entities that manage physician practices, such as:
   • the degree of corporate investor penetration and investment in the healthcare marketplace;
   • the impact on physician practice and independence;
   • patient access;
   • resultant trends in the use of non-physician extenders;
   • long term financial viability of practices;
   • effects of ownership turnovers and bankruptcies on patients and practice patterns;
   • effectiveness of methodologies employed by unpurchased private independent, small group and large group practices to compete for insurance contracts in consolidated marketplaces;
   • and the relative impact corporate investor  transactions have on the paths and durations of junior, mid-career and senior physicians.
   • The resolution also calls for the AMA to amend the AMA Annotated Model Physician-Group Practice Employment Agreement (H-215.981) to read: "(2) At the request of state medical associations, our AMA will provide guidance, consultation, and model legislation regarding the corporate practice of medicine, to ensure the autonomy of hospital medical staffs, employed physicians in non-hospital settings, and physicians contracting with corporately-owned management service organizations."
5. Handling of Hazardous Drugs: This resolution calls for our AMA to work with United States Pharmacopeia to revisit the requirements in General Chapter <800> of the USP Compounding Compendium and review Chapters <795> and <797> to ensure that the requirements included in those chapters are not onerous to physicians and prohibitive to their current ability to provide medications to their patients.
6. Insulin Affordability: This report calls for policies on drug pricing to be reaffirmed and establish new policies including:  encouraging the FTC to monitor drug prices/competition and take appropriate enforcement actions; disseminate model state legislation to promote increased drug price and cost transparency and to prohibit gag clauses in contracts between pharmacies and pharmacy benefit managers; provide assistance to state medical societies in support of state legislative and regulatory efforts addressing drug price and cost transparency. 
7. Prohibit Retrospective ER Coverage Denial and Return to Prudent Layperson Standard for Emergency Services: This resolution calls for actively working toward ensuring strong enforcement of federal and state laws which require health insurance companies to cover emergency room care when a patient reasonably believes they are in need of immediate medical attention, including the imposition of meaningful financial penalties on insurers who do not comply with the law. Missouri authored the second resolution which opposes the arbitrary denial of payment for emergency services based on diagnostic coding alone and support the use of the prudent layperson standard which would conclude there was an emergency condition. 
8. Survivorship Care Plans: This calls on the AMA to look into coding and billing challenges related to cancer survivorship care as well as development of new ICD-10 codes to track such encounters. It also calls for collaboration with CMMS implementation to provide standards of care and reimbursement for survivorship care plans. 
9. Integration of Drug Price Information into Electronic Medical Records: Physicians and patients should have access to real time cost information at the point of prescribing to ensure cost considerations are part of the decision-making process.  This report asks the AMA to collaborate with stakeholders to explore a) current availability of EHR, pharmacy, and payer functionalities that enable price integration, insurance coverage, formulary tier, cost information at point of care, b) barriers, c) what is currently being done to address barriers. 
10. Augmented Intelligence in HealthCare: The AMA has an opportunity to ensure that the evolution of augmented intelligence in medicine benefits patients, physicians, and the health care community. This resolution asks the AMA to help set priorities for healthcare AI; integrate practicing physicians’ perspectives into healthcare AI; promote development of thoughtful high quality validated healthcare AI; encourage education for healthcare professionals and administrators; and explore the legal implications of healthcare AI. 
11. Utilization Review: This resolution was actively supported, and asks the AMA to seek legislation that would require insurance companies, peer review organizations, and CMMS to use review criteria that existed at the time that services were provided when making their determinations. 
12. Legalization of Interpharmacy Transfer of Electronic Controlled Substance Prescriptions: This advocates for the federal legalization of interpharmacy transfers of valid e-prescriptions for Schedule II-IV medications. This is relevant to Mohs surgeons who prescribe pain medications post surgery.
13. Recording Law Reform: The YPS actively supported this resolution asking our AMA to draft model state legislation requiring consent of all parties to the recording of a physician-patient conversation.  
14. Update on Maintenance of Certification and Osteopathic Continuous Certification: This report recommends the AMA continue working with medical societies and ABMS member boards to improve the Part III secure, high stakes examination. It also asks the AMA to continue to be actively engaged in following the work of the ABMS Continuing Board Certification: Vision for the Future Commission.
15. Policy and Economic Support for Early Child Care: The AMA board of trustees recommends the AMA reaffirm its policy on Paid Sick Leave, which recognizes the public health benefits of paid sick leave and other discretionary paid time off, and supports employer policies that allow employees to accrue paid time off and to use such time to care for themselves or a family member. This report encourages employers to offer and/or expand paid parental leave policies. It also asks the AMA to encourage state medical associations to work with their state legislatures to establish and promote paid parental leave policies.
16.  Vector Borne Disease:  The ACMS cosponsored this resolution along with the other dermatologic societies.  This resolution asks the AMA to study the emerging epidemic of vector borne diseases including an analysis of currently available testing and treatment standards and their effectiveness. It also asks the AMA to issue a white paper on vector borne diseases for increasing awareness, and to advocate for local, state, national research, education, reporting, and tracking on these diseases. There is a growing incidence of these diseases with cross border travel. Bites and stings are observed during dermatology visits and may be the first indication of a serious underlying illness. 
17. Alcohol Use and Cancer: This resolution, introduced by the American Society of Clinical Oncology, asks the AMA to recognize alcohol use as a modifiable risk factor for cancer; to support research and education about the connection between alcohol use and several types of cancer. Links between alcohol intake and the development of basal cell and squamous cell carcinoma and melanoma have been established.
18. Biosimilar Interchangeability Pathway: A primary driver of pharmaceutical costs is the reduced level of competition for drugs and biologics. Biosimilars could be cost saving alternatives to biologics. This resolution asks the AMA to support the pathway for demonstrating biosimilar interchangeability, including supporting legislative efforts to provide the FDA with added authority and resources needed to expedite the review process and get additional drugs and biologics to market.
19. Physician Burnout and Wellness Challenges: The AMA board of trustees recommended the AMA include the following in existing policy:
    • recognize burnout
    • work with interested groups to inform appropriate institutional officials about the issue
    • encourage ACGME and AAMC to address the issue among trainees
    • encourage further studies and disseminate results
    • encourage mindfulness education as an effective intervention
    • develop guidance to help hospitals and medical staffs implement organizational strategies that will help reduce burnout and promote wellbeing
    • address institutional causes, such as burden of documentation, inefficient work flows, regulatory oversight
20. Economic Credentialing: The YPS actively supported this resolution, which calls on the AMA to vigorously oppose clinical credentialing based solely on case volume when no other basis for evaluating ability to function with skill and safety exists.
21. Modify the Clinical Laboratory Improvement Amendment of 1988: This resolution was actively supported by ACMS. It calls on the AMA to advocate for regulatory relief from two of three CLIA certificate complexity levels: waived and moderate complexity test requirements. This resolution is timely in that the current Congress and Administration are open to pursuing greater deregulation that can create further opportunities for health care reform. This resolution asks the AMA to adopt the position that it is proper to remove the CLIA certification mandate requirement for physicians who only use CLIA-waived tests and physician performed microscopy.

If you or someone you know if a young physician who may be interested in getting involved in the AMA-YPS, please visit the AMA-YPS web page at https://www.ama-assn.org/yps-annual-overview

Respectfully submitted by Nita Kohli, MD, MPH, American College of Mohs Surgery young physician representative to AMA-YPS and Dermatology Section Council; Mohs and Dermatologic Surgery at Washington University, St. Louis MO

Next meetings

• 2018 American Medical Association (AMA) House of Delegates: November 10-13 at the Gaylord National Harbor Hotel in National Harbor, Maryland
  • AMA Sections and Special Group meetings will be held November 8-11

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July 2017

The Value of Organized Medicine and What It Can Do For You

By Syril Keena Que, MD and Divya Srivastava, MD

What comes to mind when you think of the American Medical Association (AMA)? Many physicians might associate it with the JAMA journals, the CPT coding system, and maybe even the AMA Physician Profile for medical licensure. But on a larger scale, what does this organization do and why should it matter to ACMS members specifically?

The AMA is the largest representative body of physicians and continues to advocate for our interests so that we can continue our job of providing exemplary care for our patients. The AMA has certainly made some great strides in the past year.

Take, for example, the AMA’s movement to combat physician burnout and decrease burdensome regulatory measures. As a result of the AMA’s advocacy efforts, the Centers for Medicare & Medicaid Services (CMS) removed computerized physician order entry and clinical decisions support measures from the Advancing Care Information component of the Merit-based Incentive Payment System (MIPS), which would have effectively doubled the administrative burden from coding. This relieves us from the burden of reporting such data to CMS, outside of the standard clinical workflow.

The AMA also helped to ease transitions to the Medicare Access and CHIP Reauthorization Act’s (MACRA) Quality Payment Program. Thanks in part to recommendations from the AMA, CMS adopted a revised low-volume threshold—clinicians who bill less than or equal to $30,000 in Medicare Part B allowed charges or provide care for 100 or fewer Medicare beneficiaries are now exempt from MIPS reporting. This helps protect physicians in smaller practices, who would otherwise have been subject to a 4% penalty.

More recently, the AMA worked with several state societies to defeat the mega-merger between the insurance companies Anthem-Cigna and Aetna-Humana. These two mergers would have consolidated competition in the health insurance marketplace. This would have threatened patient access, affordability of care, and reimbursement of physicians. According to the AMA, “the Anthem-Cigna merger alone would have reduced provider payments by $2.4 billion, including physician payment cuts of at least $500 million per year.” Fortunately, the AMA helped to block this merger, ensuring market competition and maintaining the status quo.

For any ACMS member who is not already a dues paying member of the AMA, please consider joining to further strengthen our specialty’s voice within the House of Medicine. Why now? The health care environment is rapidly changing, with policies continuing to evolve. Value-based care and quality reporting (eg. MACRA, MIPS etc.) impose increased regulatory burdens that potentially impact our job satisfaction and interaction with patients. We as physicians cannot sit idly by while politicians and policymakers dictate how we practice. It is imperative that we participate in the discourse, that we actively help shape and set the tone for future health care reform. While our dermatology societies are effective conduits for advocacy, the AMA offers us a complementary channel within the broader House of Medicine, where we can collaborate with other specialties to achieve shared goals and an amplified voice. Considering the ongoing vital changes to the practice of medicine, membership within the AMA is both essential and valuable.

Additionally, tangible AMA member benefits include:

• Complementary AMA Physician Profile, required by many states as part of the medical licensure application (value of $40)
• Online access to all JAMA journals and the print version of JAMA (value of $180 for JAMA Dermatology online alone)
• Discounts on insurance, travel, and practice support services
• Resources to help with the transition to MACRA (eg. AMA Payment Model Evaluator - https://apps.ama-assn.org/pme/#/)

For trainees, membership is only $45 annually. Residents and fellows in their final year have an effective $5 cost for that year of membership, factoring in the Physician Profile. Membership is on a calendar year, so trainees may want to join in the same year they plan to purchase their Profile for state credentialing, if that is a deciding factor.

For physicians, regular membership is $420 annually (other categories are $84-315). For physicians in private practice, membership has an effective cost of $240, factoring in online access to JAMA Dermatology (and additionally access to JAMA Otolaryngology, Facial Plastic Surgery, Ophthalmology, Oncology, Surgery etc.). For solo and smaller group private practitioners, the various insurance discounts offered by the AMA may be competitive offerings with added value.

Updates from the AMA Dermatology Section Council

The AMA House of Delegates convened in Chicago in June for its Annual Meeting to formulate policies and address issues facing physicians and patients today.

The ACMS was represented well by Michel McDonald, MD (Delegate), Divya Srivastava, MD (Alternate Delegate), Nita Kohli, MD (Young Physician Delegate) and Syril Keena Que, MD (Resident/Fellow Delegate). Other ACMS members on the Dermatology Section Council in attendance included Brett Coldiron, MD, Hillary Johnson-Jahangir, MD, PhD, Marta VanBeek, MD, Jessica Krant, MD, Chad Prather, MD, Anthony Rossi, MD, William Waller, MD, and Eric Millican, MD.

In addition to policy discussion, Divya Srivastava, MD and William Waller, MD participated in the Medical Specialty Showcase to introduce medical students to the specialty of Dermatology and Dermatologic Surgery.

The Dermatology Section Council authored/co-authored the following resolutions regarding maintaining regulation of physician assistants by the medical boards, advocating for out of network care for patients, and advocating for access to care for transgender patients. The following policies relevant to ACMS members were passed:

• Regulation of Physician Assistants
  This resolution called on the AMA to advocate in support of maintaining the authority of medical licensing and regulatory boards to regulate the practice of medicine through oversight of physicians, physician assistants and related medical personnel. It also asks the AMA to oppose legislative efforts to establish autonomous PA regulatory boards outside of the existing state medical licensing and regulatory bodies’ authority and purview.
• Out of Network Care
  The resolution requests that the AMA develop model state legislation addressing the coverage of and payment for unanticipated out-of-network care. Some specific principles include that patients must not be financially penalized for receiving unanticipated care form an OON-provider, insurers must meet appropriate network adequacy standards, insurers must be transparent in informing enrollees about anticipated costs, OON payments must not be based on a contrived percentage of Medicare or insurance payor rates, and a minimum coverage standard for unanticipated OON services should be identified.

Other relevant policies that the DSC and ACMS delegates supported were passed included the following:

• Remove Practice Expense and Malpractice Expense from Publicly Reported Payments
  The DSC supported a resolution calling on the AMA to petition the Centers for Medicare & Medicaid Services and the Office of Health & Human Services to remove practice expense and malpractice expense from reimbursements reported to the public. When reporting the data CMS removes some practice expense data such as some office-administered drugs but does not remove all practice and malpractice expense. By failing to remove these expenses it creates a misrepresentation of a physician’s income.
• Certified Interpreter and Translation Services
  The DSC supported a resolution calling on the AMA to work to relieve the burden of the costs associated with translation. It also requests for the AMA to advocate for legislative and/or regulatory changes to require that payers including Medicare programs and Medicaid managed care plans cover interpreter services and directly pay interpreters for such services.
• Risk Adjustment Provisions in MACRA
  The DSC testified in support of a resolution that called on the AMA, in the interest of patients and physicians, encourage the Centers for Medicare and Medicaid Services and Congress to revise the Merit-Based Incentive Payment System to a simplified quality and payment system with significant input from practicing physicians, that focuses on easing regulatory burden on physicians, allowing physicians to focus on quality patient care. The resolution also requested that the AMA advocate for appropriate scoring adjustments for physicians treating high-risk beneficiaries in the MACRA program and urge CMS to continue studying whether MACRA creates a disincentive for physicians to provide care to sicker Medicare patients.
• Drug Pricing/Transparency
  The DSC testified regarding its concern for the sudden dramatic price increases of older drugs which were once affordable. The AMA passed policy supporting drug price transparency legislation that requires pharmaceutical manufacturers to provide public notice before increasing the price of any drug (generic, brand, or specialty) by 10% or more each year or per course of treatment and provide justification for the price increase.
• New policy on texting
  The DSC supported that the AMA work with the Office of Civil Rights to develop guidance on text messaging to facilitate the appropriate and safe use of this technology when communicating patient information.