‘Advocacy Is Hard, and Washington Is a Difficult Place’

Last week, the American Medical Association (AMA) held its annual advocacy meeting in Washington, where AMA members heard from Biden administration officials as well as senators and members of Congress. During the meeting, MedPage Today Washington Editor Joyce Frieden sat down with AMA President Jack Resneck Jr., MD, to find out how things are going during his term in office. The interview was conducted with a press person present, and has been edited for length and clarity.

Hi — thanks for sitting down with us! How is your year going so far?

Resneck: It’s great; it’s amazing how fast a year can go. What an exciting opportunity to be able to represent this profession that I’m so proud to be a part of, and to be doing it at a time that feels really important, where there are serious threats to the profession and to our ability to take care of patients, and where the profession is facing a lot of burnout after these last 3 years. But it feels like we’re so aligned on some things that we need to do to make healthcare delivery better for doctors and patients.

So I feel really good on the policy and about what the organization is doing, and it’s an exciting time to be leading it.

What are the challenges of the job, or things you didn’t expect?

Resneck: Well, the challenges are — advocacy is hard, and Washington is a difficult place. State legislatures are difficult places, and you can’t get everything done overnight. And when you really know that, and see things that you’re alarmed by, that keep you up at night, like soaring burnout rates in the profession and you know that what we need to do to fix it — we know that we can’t have across-the-board Medicare payment cuts that cause small practices to close.

We know that this spiraling-out-of-control prior auth[orization] mess that the healthcare system put us in are demoralizing to physicians … We know the things we need to do, so the frustrating part of the job is not being able — in a day — to deliver on all those things that I know that we need.

The other thing is, this is a time when the country’s really politically fractured. And so talking about things that are really common sense at a time where science is being questioned, there’s misinformation out there, and social media is such a divisive place — it makes talking about these things sometimes more difficult.

But then the reality is, we bring our House of Delegates together at the AMA and we end up with enormous consensus on a lot of these controversial issues, because we have science-based debate and evidence-based debate, and minds get changed, and so it’s pretty cool to be a part of that. And that’s actually sustaining.

How are things going with the Recovery Plan and the goals the AMA has set out?

Resneck: So these are big, ambitious goals, and we can’t get everything done overnight. But these are the most important things to sustain physician practices. The Recovery Plan for America’s Physicians is where a lot of our work is focused on legislative activity around reviving and supporting physician practices as we come out of this first 3 years of the pandemic.

For instance, Medicare payment — things have gotten worse. We have a 2% cut across the board on January 1, which is just incredibly demoralizing for the physician community who is dealing with rampant inflation, trying to keep their practices open, dealing with misinformation, and held their practices together through this difficult pandemic.

We need inflation-based, automatic, yearly, positive updates — just like hospitals get, just like nursing facilities get, just like hospices get. Why physicians are different is a weird accident of history that has got to be fixed. So that is the focus.

What’s different, though, and what’s progress is that when I talk to members of Congress about this — in the House and the Senate and on both sides of the aisle — there’s pretty universal understanding that this is broken, it’s not okay, and it has to be fixed.

Now, the will to get it across the finish line — the question that from a budget standpoint, that this gets scored as new spending even though this is really fulfilling promises long made to Medicare beneficiaries — that’s where the hurdles are going to be, and so that’s where the work now lies.

But I feel like patients and the physician community, across geographic areas and specialties, and across the political spectrum, have been pretty clear. And yes, while you can identify some issues that may be highly partisan and where we bump into people going back to that lens, I think this is not one of those areas.

I will put prior authorization in that same category, and it is one where we’re actually beginning to see real momentum and progress. We had the House, in overwhelming bipartisan fashion — shocking! — pass a bill to address prior auth overreaches by health plans and Medicare Advantage plans. We couldn’t quite get it across the finish line in the Senate because of a CBO [Congressional Budget Office] score issue, and we’re going back to work on that.

The CMS [Centers for Medicare & Medicaid Services] administrator was here [at the conference] today, and she and her team put out two proposed rules in the last several weeks to really address the same thing: prior auth in Medicare Advantage plans and some other plans that they have under their jurisdiction. And the physician community is feeling so heard on this issue and feeling like our patients are heard, and part of it is, when I go meet with a team at CMS or I go meet with legislators on either side of the aisle or in statehouses, I don’t run into anybody who hasn’t personally had, for themselves or a family member, the same infuriating experience of sitting down with a doctor, figuring out a diagnosis, talking about treatment options and side effects, settling on what they think is best in a collaborative way, going to the pharmacy and getting the disappointing reply, “Your insurance doesn’t cover this” and it’s going to require weeks of fighting and fax machines and peer-to-peer phone calls with people who aren’t really peers, all that stuff.

So we’re seeing all these proposals in Medicare make progress, and we’re seeing action in individual states; for instance, Texas passed a “gold card” bill [allowing doctors who have good track records for getting treatments approved to skip some prior authorization]. So it’s an area where I think we’re seeing more progress.

How does the AMA feel about the specifics in those proposed rules? For instance, I think one rule gives plans specific deadlines for making prior authorization decisions and makes them include a reason for any denials.

Resneck: We actually think those [decision] timelines should be shorter. There’s a time for urgent and a time for regular. We’re going to continue to work with the team at CMS on making sure those are short enough to be appropriate.

But there are things in there like continuity of care, like when insurance companies say, “We authorize this surgery,” but there’s a little disclaimer at the bottom that says, “This is not a guarantee of payment” and then after the surgery, they say, “We retract the authorization,” or they only authorize it for a certain number of days, and the surgery gets delayed 5 days and now it’s not authorized.

It also has in those proposed regulations that the person you are talking to [at the insurance company about the prior authorization] should have expertise in the disease you’re talking about. So we really do feel heard.

Now, there’s a lot in those proposed regulations about tests and procedures, and less about medications, so we’re definitely asking CMS to see if they can expand it to say more about medications, because that is such a pain point for our patients.

And what about the burnout issue?

Resneck: On the physician wellness and burnout, and even the physician suicide issue — all under that one Recovery Plan pillar around burnout — we helped get the Lorna Breen Act across the finish line, to help get resources for physicians. We are beginning to see slow but sure de-stigmatization of mental health concerns among the physician population, and people are increasingly seeking the help they need.

We’re beginning to see, whether it’s state medical boards or hospitals, or others, take off of their credentialing forms questions like “Have you ever had a mental health issue?” While it is appropriate to ask people if they have current impairment, if people know that they’re going to be asked forever if they have ever had impairment or a mental health issue, that makes them not seek help.

So I think on a number of these things, we actually are seeing some good progress.

What about telehealth?

Resneck: Congress actually extended telehealth coverage to the end of 2024. [A] permanent [extension] would be better, but cheers — this gives us some breathing room. And it was a recognition [of the importance of] this benefit where Medicare patients — rather than going off and only being able to get telehealth on the web through some corporate provider not coordinated with their existing healthcare — can actually get coordinated, seamless telehealth integrated with their existing healthcare team who also can see them in person when they need it.

I think this was great recognition that we should not strip away this benefit from Medicare beneficiaries.