In this episode of Medscape One-on-One, Dr. John Reed sits down with Dr. James Madara, Executive Vice President and CEO of the American Medical Association (AMA), to talk about the future of the nation's largest physician organization, its role in shaping the practice of medicine, and whether the organization stands by its support of the Affordable Care Act.
Dr. Reed: Hello, and welcome to Medscape One-on-One. I'm Dr. John Reed, Professor and CEO of the Sanford-Burnham Medical Research Institute. I'm joined today by Dr. James Madara, Executive Vice President and CEO of the AMA. Welcome, Dr. Madara.
Dr. Madara: Thanks, John. It's greatly appreciated.
Dr. Reed: It's been about 9 months since you assumed the helm at the AMA. Tell us how it's going.
Dr. Madara: Well, it's going wonderfully. It's a dynamic place, with a lot of opportunity. I had yet to know the 1100 people that are in the organization; in the House of Delegates; and in Washington, DC, so I've had a wonderful and very good time meeting them all.
AMA vs Other Jobs
Dr. Reed: You've done a lot of things in your career. You've been a scientist, you're a physician, and you've been the dean of a medical school. How are you leveraging those experiences and bringing them into your new role?
Dr. Madara: It's interesting; the AMA has components of all of those experiences. The corporate center in downtown Chicago has the feel of running a hospital. It's very businesslike, with business principles. The House of Delegates is much like a facility senate, with a democratic policy setting. My time at Leavitt Partners, as the former Secretary of Health and Human Services, was policy oriented, and that really relates to our DC efforts in advocacy.
Promoting the Mission of the AMA
Dr. Reed: Dr. Madara, for our viewers today, can you remind us what the mission of the AMA is, and how do you intend to promote that mission?
Dr. Madara: Our mission statement is one of the most attractive things about the organization: to promote the art and science of medicine, and the betterment of public health. That's been our mission statement for 165 years.
I think what we need to do to promote that more strongly is to focus on areas that are strongly related to the mission. We have developed a lot of different interests over the past 165 years, and I think it's time to converge some our interests that are really mission-centric.
Weathering Tough Times at the AMA
Dr. Reed: You joined the AMA at a challenging time. Perhaps the biggest challenge is growing membership, which has been declining for several years. What are your plans for recruiting new members and enticing former members back to the AMA?
Dr. Madara: One of the things that has been great in the past year is that our membership has actually increased modestly for the first time in many years. At the end of the first quarter this year, we're certainly ahead of the increase from the first quarter of last year. Membership looks good, based on what we're doing now.
I do think that a focus on membership will help us be more impactful. But I do need to stress that the AMA is more than just membership, as important as membership is. We think of it as the "AMA equation," which consists of the sum of 5 parts.
The first part is the direct members, which includes about 20% of US physicians. The second is our House of Delegates, which includes the 175 medical societies that make up our policy, and they represent more than 95% of US physicians.
Third, we also have practice support, and business products to support physicians in practice. We recently developed a portal for information technology for modest-sized physician practices, and we're fortunate enough to partner with AT&T in the past month to scale this product. We also have the Current Procedural Terminology (CPT) coding products, and other products to help physicians in practice.
Research and education is the fourth component. It starts with our journal, Journal of the American Medical Association, or JAMA, which now has a circulation of 310,000 copies each week. It highlights important research and disparities, ethics, and public health.
Finally, we have our advocacy -- both in DC, where we sculpt and improve impending legislation, and also our advocacy in the courts. For example, in February, a federal judge upheld a $200 million settlement that we won challenging the out-of-network billing practices of UnitedHealthcare, and we're returning that money to US physicians.
How Does the AMA Decide Which Policies to Support?
Dr. Reed: That's quite a diversity of services that you offer to America's physicians. You mentioned a minute ago "policy." I'm curious: How does it work behind the scenes when the AMA develops an official policy stance on a particular issue? What actually goes on in the organization?
Dr. Madara: We have an advocacy office in DC that helps translate the policy of the AMA into our advocacy position on Capitol Hill. We also have a voice in state fora and many specialty society fora.
Does the AMA Still Support the Affordable Care Act?
Dr. Reed: Let's talk about one of the policies that's foremost in everyone's mind, and that is the policy of healthcare reform. I use that term "reform" in quotations, because I fully recognize that one man's idea of reform is another's form of repulsion. But the AMA took a bold stance in support of affordable healthcare and the Affordable Care Act. That was controversial; it rattled some members. Now, with the Supreme Court set to weigh in on the constitutionality of the individual mandate, where does the AMA stand now? Do you still stand behind the Affordable Care Act?
Dr. Madara: We supported the Affordable Care Act at its inception, and in 2010 and in 2011 we revisited the Act in-house, and the AMA House of Delegates supported and reaffirmed its support each of those times.
The reason it was supported is that there are many important elements of the Affordable Care Act that align with long-standing AMA policy. For example, we support individual responsibility to secure health insurance. We support coverage for the uninsured; health insurance reforms, which include allowing children to remain their parents' plans until age 26; and eliminating the lifetime cap on insurance policies.
But, like any complex law, the Affordable Care Act is not perfect. For example, the Independent Payment Advisory Board, a nonelected board that could set Medicare pricing independently without accountability, is something we would not encourage, particularly at a time when we're looking at the sustainable growth rate effects on pending Medicare cuts that in January could be as high as 30%. The cuts have not occurred yet, but we have come to that cliff multiple times over the last 10 years.
In essence, there are many good things about this bill for US medicine, but like anything, it's not perfect.
Healthcare Cost Containment
Dr. Reed: Dr. Madara, healthcare cost containment is a hot political topic, and voices have arisen calling for more standardization in medical practice of treatment protocols using evidence-based outcomes research. What are you hearing from the AMA's membership about this trend, and does the AMA have a formal policy about government driven efforts to standardize medical practice toward what may be more of a European-like healthcare system?
Dr. Madara: The AMA policy supports comparative effectiveness research to identify best practices. We do that to protect the individual patient, to protect the sanctity of the doctor/patient relationship. Part of that protection is also to recognize that there are times when a best practices strategy needs to be recognized. But individual specification also needs to be taken into account so that a physician can, in particular circumstances, recognize that the best practice for most is not necessarily the best practice for this particular patient. And this will be a very important view of the world as we move into this area of personalized medicine.
Tort Reform and the Medicare Sustainable Growth Rate
Dr. Reed: Let's change subjects a little bit. Perhaps 2 of the biggest issues that I suspect physicians would like to see resolved, and would like the AMA's help in resolving, are tort reform and a permanent fix to the Medicare sustainable growth rate (SGR) formula. How is the AMA helping to resolve those issues for physicians?
Dr. Madara: We're in strong support of HR5, which has passed the House of Representatives and would have a tort reform-like positioning, as we've seen in Texas and California. We are strongly supportive of that bill and helped with the crafting of that bill.
The SGR is something that is a trick of budgetary or an off-the-books kind of budget. The $300 billion that we faced peering off the cliff and that would have cut physician Medicare reimbursement 30% last January has already been spent. It's already on the national credit card. Congress recognizes that if this were to be enacted, it would really decrease access for Medicare patients. Therefore, they seem to give short-term patches to fix this formula, and have done so for a decade. But why have this budgetary maneuver that makes physicians feel threatened continually each year?
How Do the AMA and FDA Work Together?
Dr. Reed: I couldn't agree more. I want to change subjects again a little bit and talk about the US Food and Drug Administration (FDA). You know the FDA has a tough job: They have to balance risks against benefits of new medications and medical devices, and the agency often gets criticized for not quite getting that delicate balance right. What is the relationship of the AMA currently with the FDA?
Dr. Madara: We have a great relationship with the FDA, and our role in that relationship is to bring to the floor the view of the practicing physician when the FDA is making its decisions and make sure that those views are embedded in their mind and in the deliberations that they have. There are really important issues where we align with the FDA.
We strongly support the Prescription Medication User Fee Act. We support an act that would promote ways in which we would prevent what we now have, which is a serious threat of drug shortages, particularly generic injectables. We work with the FDA as a companion organization toward these ends because, after all, we have the exact same goals, which are the health and welfare of the US citizens and the sanctity of the relationship between physicians and patients.
Dr. Reed: Do you have any specific initiatives planned with the FDA that you can share with us at this time?
Dr. Madara: Certainly, the support of the Prescription Medication User Fee Act is a really important one that has multiple subcomponents to it, including touching on orphan drug utilization and the like. We've spent a fair amount of time in that area.
The Future of Medical Education in America
Dr. Reed: You were the dean of a prestigious medical school. What's the role of AMA in shaping the future of medical education in America? I'm particularly curious about what changes in medical education you would personally advocate, given the transformative developments in genomic medicine, for example, that promise a future era of molecularly based personalized medicine.
Dr. Madara: The board has just approved a multiyear strategic plan. That plan is focused on outcomes -- outcomes for patients, outcomes for medical students, and outcomes for physicians, and physician satisfaction. In thinking about outcomes for medical students, we have to recognize that although the curriculum has been continually updated, the structure of medical school essentially is the same as it was a half a century ago.
We will work toward improving medical education and think of medical education changes, such as a shift from time in chair to actual demonstrated competencies. We'd like to see a shift that helps blend the clinical training with the basic science training so that they aren't 2 separate pieces. A shift that allows enriched simulation training so that students aren't limited to the type of patients that happen to be in the institution during their particular rotations. And finally, we'd like to see an emphasis on things that relate the social aspects of practicing medicine -- an important one being the group practice, which is a team-based, patient-centered view of the world, with the physician as the leader of that team.
Another aspect is the inclusion of genetics in the training of emerging doctors. This is going to be such an important piece of the future of medicine. Our graduates not only have to be adept at understanding genetics, genomics, and the implications, but they have to be prepared to do reading in these areas of summaries of updates, as would occur in our journal JAMA, so that they can interpret what this field means to their patients as the field progresses along.
Changes Coming to the Practice of Medicine
Dr. Reed: As we look at these coming changes to medicine in this country, where have you seen the future of US medicine? Can you give some examples of organizations or initiatives that really help point the way for what the future may look like for us?
Dr. Madara: Two general points I would make are that first, we have to be less fragmented. We are 900,000 physicians, more than one half of whom are in isolated or small practices. We are 5500 separate hospitals, with multiple payers, and yet no other industry in the United States of our scale is this fragmented. We have to have less fragmentation, fewer silos, and that's important for things like continuity of care as well.
Second, we have to stop incentivizing what we don't want: volume over utilization. We want to start incentivizing what we do want: value and quality, and better outcomes for our patients.
Current and Future Endeavors of the AMA
Dr. Reed: You've spent about 9 months in this new role as the chief executive of the AMA. What are you most excited about, or most proud of, in these first few months of your stewardship of this very prestigious organization?
Dr. Madara: Every day when I go to work, I feel like the mission statement of the AMA is hanging over my head: to promote the art and science of medicine, and the betterment of public health. That's really worth going to work for.
I get to work on that mission at a national level in a complicated healthcare system where there are going to be multitudes of changes that happen, and thinking through these changes from the perspective of allowing physicians' practices to thrive and physicians to be satisfied. That's important, because physician satisfaction relates to patient satisfaction, but if we don't have thriving practices in this new healthcare environment, how are we going to encourage and entice the next generation of the brightest young people in this country to go into this field?
Dr. Reed: In that regard, what are some of the ways our physicians can look forward to the AMA helping to move America's medical system forward?
Dr. Madara: One of our strategic goals is to develop, with our partners, a set of outcome measures that would capture a substantial swath of disease burden in the United States, and then bring to that set our research on disparities in public health and ethics -- to take a deep, rich step into this area of outcomes, rather than process, when it comes to treating our patients in this country.