Featured topic and speakers
Leading up to the AMA National Advocacy Conference in Washington, D.C., Feb. 13-15, this webinar hosted by Sandra Adamson Fryhofer, MD, chair, AMA Board of Trustees, provides information about the AMA’s advocacy on Capitol Hill and how you can get involved.
You’ll also get a sneak peek of some of the issues that will be covered at the AMA National Advocacy Conference.
Moderator
- Sandra Adamson Fryhofer, MD, chair, AMA Board of Trustees
Speakers
Hear from:
- Jack Resneck Jr., MD, AMA President, about his experience being a physician leader pushing for change
- Rob Jordan, director, political and legislative grassroots, AMA, about joining the AMA Physicians Grassroots Network and grassroots best practices
- Jason Marino, director, Congressional Affairs, AMA, about the power of physician voices at the AMA National Advocacy Conference
Transcript
Dr. Fryhofer: Hello everyone and welcome to our second AMA Advocacy Insights webinar for 2023. I'm Dr. Sandra Fryhofer—AMA Board chair—and I'll be your host for today's session.
In case you missed it, our last webinar, in January, looked at AMA's key advocacy priorities for 2023. And if you weren't able to join us live, no worries. There's a recording of it, along with all of our other advocacy webinars. Just search AMA Advocacy Insights on AMA's website or you can search it in Google.
In today's webinar, we're going to take a closer look at important advocacy issues AMA and others in organized medicine are working on at the federal level and solutions that may be on the horizon. As a reminder, next week, AMA's hosting NAC, our National Advocacy Conference, in Washington, D.C., featuring physician, leaders and policy makers from around the country, and it's not too late to join us. You can still visit AMA's website to register.
At this conference, we'll hear directly from lawmakers and from the Biden administration about issues important to all of us—issues, like, Medicare payment reform, fixing prior authorization and getting rid of step therapy, and expanding telehealth coverage, just to name a few. These issues, as well as reducing physician burnout and stopping inappropriate and unsafe scope of practice expansion by non-physicians, make up AMA's Recovery Plan for America's Physicians. A plan we've been championing in Congress and at the state level since last summer. We've made progress on these efforts, but much more work is ahead of us this year.
As we discussed in January, the 2022 Omnibus bill included some positive developments for physicians, one of which is on telehealth. The bill extends telehealth payment and regulatory flexibilities for two years. It extends the bonus for APMs—Alternative Payment Models—at 3.5%. It also delays the scheduled increase in the revenue threshold, and as a reminder, for the first few years, in order to receive an APM bonus, physicians had to get at least 50% of their revenue from patients enrolled in APMs in order to qualify. That revenue threshold was supposed to go up to 75% this year, but since no current APMs would qualify, Congress kept the threshold at 50%.
For physician mental health, there also is some progress. This new law adds an exception to Stark. Hospitals and other entities are now allowed to provide evidence-based programs to boost physician resiliency in mental health and to help prevent suicide among physicians. The bill also has an additional and welcome benefit for pregnant people covered by Medicaid. The new law provides a permanent option for states to extend Medicaid coverage for 12 months postpartum. But for many and probably, for most physicians, Medicare payment reform is top of the mind as we welcome your new Congress in 2023.
AMA was instrumental in spurring Congress to act at the end of 2022. We were able to alleviate more drastic pay cuts scheduled to kick in, but physicians now still face a 2% cut for 2023, delivering yet another financial blow for physicians, especially for independent practices already stretched thin by staffing shortages and high inflation. Physicians continue to bear the brunt of our nation's flawed and unsustainable Medicare payment model. Adjusted for inflation, Medicare physician pay dropped 22% between 2001 and 2021. This downward trajectory has already forced some practices to reduce their hours and lay off support staff, while pushing others to the brink of closure.
The fact that losses could have been worse this year misses the point. Physicians shouldn't have to face these annual financial cliffhangers year after year. We shouldn't have to worry if our practices will survive another year because of payment cuts that are beyond our control. As with all other issues in health care, it's our patients who suffer the most. Patients lose access to vital care when a physician practice closes or has to reduce its hours.
Today's webinar will discuss these and other issues in greater depth and will also highlight next steps in our advocacy work for this year. Joining our panel today are three AMA experts as we talk about advocacy and the macro and micro, from what it's like to be a physician leader at this difficult time for medicine to what our on the ground activities look like as we seek to inform and educate lawmakers on issues, and ultimately, influence their policy positions.
Our first panelist is our AMA President Dr. Jack Resneck—the public face and the voice of our AMA on these issues and so many more. Dr. Resneck has been an AMA trustee since 2014. He's a nationally recognized leader in health policy and also in dermatology. Dr. Resneck, if it's OK with you, we're going to go by first names today. So welcome, Jack.
Dr. Resneck: Thanks, Sandy. And you can definitely call me Jack.
Dr. Fryhofer: Our second guest is Rob Jordan—AMA's director of political and legislative grassroots. Rob oversees AMA's Physicians Grassroots Network and will share some of his insights into that work, and how these efforts are activating physicians to engage on these issues. So welcome, Rob.
Jordan: Thank you. It's great to be here.
Dr. Fryhofer: And back with us, again, is Jason Marino—AMA's director of Congressional affairs. In this role, Jason's responsible for lobbying Congress on AMA's federal advocacy priorities. Jason's a strong and passionate advocate of AMA policy, and I'd love to hear his story. So welcome back, Jason.
Marino: Thank you. I'm happy to be here.
Dr. Fryhofer: So many thanks to all of you for being here. Let's get started and here's the plan. I'll begin with some questions for each of you to set the stage, then we'll move to questions from our audience. Now, many of you in our audience already submitted your questions when you registered, but if you didn't submit a question early, no worries. You can still post your questions online in the Q&A section and we'll try to get to as many of those as we can. But before we take a deeper dive into some of these issues, let's begin with some words of wisdom from our AMA president. So Jack, we'll start with you. Please explain, why our physician voices are so critical in advocacy. We'd also love to hear about some of your experiences as AMA's top position leader.
Dr. Resneck: Well, Sandy, thanks for the question, and I'm looking forward to some audience questions, as well, as we move forward in the webinar. And thank you for your leadership as board chair. I also really appreciate your mentioning, in your opening remarks, critical issues like Medicare payment reform, which are under the umbrella of our Recovery Plan for America's Physicians. These are issues which are such enormous threats to physicians and our patients and issues on which AMA is really so focused and partnership, of course, with state medical societies across the country and national specialty societies, as well.
You asked about individual voices, and they really are critical to humanize our priorities and to add stories that can be more than just statistics as we talk with lawmakers. I know, on today's webinar, we probably have a variety of experience levels in terms of people coming to Capitol Hill and talking to their lawmakers and also doing the same in their districts. I just think that's even more true right now, in terms of the importance of our own voices. This year, one of the things that has me deeply worried and that I've really used as an organizing principle for a lot of my thinking around what needs to happen, is this issue of physician burnout. And we know the stats about the soaring numbers. You've probably all heard that burnout symptoms among physicians jumped from about 38% to 63% in the last couple of years, that one in five physicians are seriously considering retirement in the next two years and that does leave me worried.
We know what drives these statistics. We know that there's fallout from the pandemic. We know that there are growing administrative burdens, like prior auth. We know that there are states trying to interfere in the doctor-patient relationship. We know that there are threats to practices, like falling Medicare payment, at this time of major inflation. And the answer really, doesn't lie in just telling physicians to buck up and be more resilient or do more yoga. Wellness is important, but the real answers lie in getting those systemic burdens out of the way so we can get back to what drew us all to medicine in the first place.
So as I said in the interim, we need to fix what's broken in health care and it's not the doctor. So when I'm talking with a policymaker, whether it's about Medicare payment or growth or scope creep or anything else, I keep coming back to that framing, and largely, they get it. They know physicians have put their lives on the line these last three years, they understand inflation, and frankly, most of them have been the victims themselves of some out-of-control prior off thing from a health plan. So I think it is really helpful to bring our stories.
Dr. Fryhofer: I think all that is so true, Jack. And as a follow-up, I want to ask you this. With the political divides across our country, what are some unifying themes that you've had success with on your various visits on the Hill?
Dr. Resneck: That's a good question. The last several years have, no doubt, been a somewhat politically fractured time in our nation. And as I think about our work, as the American Medical Association, it used to be such a small percentage of what we worked on, got politicized or viewed through partisan lenses and as we saw with COVID prevention or vaccines now, such a big percentage what we do ends up seen through those lenses and no doubt, that does present a challenge as we try to message our policies and our priorities, but we're not a partisan organization. And I work hard to hammer that point home whenever I'm with policymakers. We're here to advance the health of the nation and I'm going to work with anybody any time of any party, if there's an opportunity to align with our AMA policy and help physicians and help patients.
So sure, any individual policy maker, you're going to run into, just as you would with any physician, some individual policy of AMA that maybe they don't agree with, but I really try to focus on our policy-making process and make sure they understand that and why we speak for the profession. And that our policy is not just made up by me or you or our board or our management team. I talk about that House of Delegates, where we really gather physicians representing every state medical association, every national specialty society, from urban areas and rural areas, and docs in tiny independent practices and employed in huge settings, and across the political spectrum, and then we have open, science-based debate. And that really clears the air and I think allows me, in a meeting with a member of Congress or anybody else, to focus on our policy priorities and the shared goals that we might have with that lawmaker.
Dr. Fryhofer: Jack, thank you so much for sharing those experiences and your insight. And you've worked so hard for us this year and are continuing to work hard, as well. There's many more months to go before we're going to let you off the hook as being our AMA president. Jason, this next question's for you. We talked about this briefly in our January Advocacy Insights webinar. Can you give us a sense of the Congressional landscape, where it stands now and what we can expect in the year to come?
Marino: Sure. Well, at the beginning of every new Congress, C-SPAN staff get to control where the cameras go, not the Speaker. Until you get a speaker, C-SPAN staff gets control it because usually, when there's a speaker, they make it focus on whoever's speaking at the time and they want to keep it boring. But when this Congress started, we had an historic 15 votes to get a new speaker, and you could see all the side conversations and whoever thought that a C-SPAN 2 viewing would have higher ratings in a Georgia football game, but that's kind of what the country saw and that's how we've begun the 118th Congress. It's taken about a month to get the Senate organized just with committees, et cetera, so it's a slow start.
And I'll say big picture, the zeitgeist of the moment has changed. The 117th Congress was COVID, was trillion bipartisan bills on infrastructure, on COVID-related and then a series of partisan bills, $1,000,000,000,000 a piece, on some of the ruling party's priorities. And now, here we are, 118th Congress with now divided government and the conversation has changed to we're in a time of historic inflation, and we have a debt limit that we're now under extraordinary measures—we're under extraordinary measures because of the debt limit, which is $31.4 trillion, and it's got to get increased. And the extraordinary measures may last until June and then it's the moment of truth where, what happens?
And the divide is, on the Republican majority side, we've got to do something about this debt. We've got to try and balance the government in 10 years, the budget in 10 years. We have to stop the $2.4 trillion deficits. On the Democratic side, it's, well, we already spent this money and we just got to pay our obligations, and we shouldn't be cutting Social Security and Medicare to do any of this stuff. And then, you have the counter, but we're not going to touch Medicare and Social Security.
And it's high stakes and it reflects the divide in this country. We're a very divided country and the constituents are telling their members—and you've got to hold the line here on both sides. And so the members are in this dance where they're trying to negotiate or not on the debt limit and the deficit. And so, in this environment, a divided government and people have staked some lines out here now, things that need to get done are appropriation bills, usually towards the end of the year.
And there's been shutdowns in the past when divided government and you had these big debt limit debates. Sometimes, the funding bills for the federal government don't work out by the October 1 deadline each year and there's sometimes a temporary delay or not. We don't know if we're headed to that. There's always the defense bill that has to get done. It's always gotten done for 50 plus years. There's a farm bill that's usually bipartisan that needs to get done, and now with the China balloon, there's probably something on China. So that's out there. And then, where does everyone else fit in, other priorities, especially priorities that spend money? And so, you always hear about, it's the worst climate ever in Congress. Well, this really is one of the worst climates ever, and it's not an exaggeration.
Dr. Fryhofer: Wow. Thanks for setting the stage, as to what you're dealing with on the Hill right now, but I've got one more question for you, Jason, before I let you go. NAC—our National Advocacy Conference—is next week and I'm so excited, we'll be able to meet in person, but as we're gearing up for physicians to come to Washington, D.C. next week, can you talk about some of the issues that will be addressed and why they're so important?
Marino: Absolutely, And I hope everyone's coming next week. We're all looking forward to it. So next week, the three big issues we're going to talk about are Medicare physician payment reform, we're going to talk about the scope of practices and scope creep—as Dr. Resneck mentioned, scope creep—and then, we're going to talk about physician workforce issues, but I want to spend most of my time right now on the real big one—the real big issue—and it's the Medicare physician payment reform and where we go in this new 118th Congress.
I just painted a picture of how difficult it is, and we do have—I'm going to lay out a four-point plan—four-point plan—to reform the Medicare physician payment system and it starts with diagnosing the problem of what is wrong with Medicare payment system, with MACRA—that's the bill that governs the program for Medicare payment system. And you don't need ChatGPT or A.I. to tell you what's wrong with the problem, it's there's no inflationary update at all.
The last 20 years, because of that, it's been a 22% real dollar decline when you adjust for inflation. We're in a time of historic inflation and going forward, it's going to be 0.25, not 2.5%, 0.25%. That's laughable. That's not—how do you pay your staff? How do you innovate? How do you go forward with that? So that's a big issue right there. That's kind of right—and other providers all have it in statute, they have an update. So we've got to get that fixed.
The second part is alternative payment models. They have a lot of promise. New innovative models for care, there was incentive payments to help these come online. Unfortunately, in 2015, when MACRA passed, the promise of all these APMs would come online for all different specialties, all different types, and they were going to be promising and save money and that would be a win-win, it didn't really happen. It happened somewhat in the ACO—Accountable Care Organizations—that came online that have had some success. It just hasn't been as broad as we'd like. And all of those bonuses are all going away—these incentive payments—and we've got to get those incentive payments continued and find a way to keep the pipeline going so there's new APMs for every physician of all types. That's important.
Then, the third is the MIPS program. Right now, because of COVID, it's kind of been on pause, but it's like a Hunger Games, in that you get a MIPS score and then if you don't—if you get a good score, you might get a little bit of bump up. If you get a bad score, you get cut and it's a zero sum game. And there's winners and losers, and it's not always the fairest system. It's been on pause so physicians haven't felt it fully, yet.
And then, there's quality metrics that, are they really, the right metrics? Are you checking boxes or are you really innovating? And the CMS, do they have a right? There's a lot of questions there and a lot of room to reform that and make it work better.
And then, finally, why do we have these cliffhangers every year? What's going on? You probably wonder. And it's every year the physician payment rule that comes out and they can modify payment. They increased payments for E&M services, but every time you increase it somewhere, you do an across the board cut to every service to pay for it because it has to be done in, what's called, a budget neutral way. And this has been happening and it's been triggering significant cuts for non-E&M services.
And we've been trying—we've gotten some success the last few years to get some amelioration to get those cuts addressed, but we're hearing from Congress, no, that's it. We're not in the business of dealing with this every year. And we're saying, well, let's fix it, then. Let's fix the budget neutrality problem.
Let's go from $20 million that was written in 1989, probably at some late night deal for the OBRA bill—some big bill they put together in the '80s—and this $20 million never got updated to inflation. It should be $100 million. Let's make it $100 million.
Things like dental—new codes maybe that deal with dental or things that are non-vision related, why is that triggering budget neutrality for physician services? That doesn't make any sense. Let's stop that.
And then, let's find a way—historically, CMS, when they estimate a new service, they tend to overestimate and then it triggers bigger cuts than are necessary, and they never look back. It's just, the cut is built in and, oh, well, everyone moves on, except those who got cut, they have to live with that cut. We can fix that in a way that doesn't cost a lot of money.
So those four things that could be done to fix it, and we have the template. We've written—in the last Congress, we respond to RFIs and a lot of—we work all the specialty groups and all the states to develop feedback. We have the template for everything I just said to fix MACRA. So that's the first point, is just diagnosing the problem and getting people to realize, this is a problem.
The second is, how do you get 60 senators and these 218 members of the House to pass a bill to fix it? How do you make that happen? It's not so simple. And it starts with, as you talked earlier, about educating members of Congress.
And one big mistake I think a lot of people make when they first come to the Hill that don't do this every day because you're too busy saving lives and you focus on the Hill, and you come to the Hill and you think that everyone knows more than they really do.
I mean, my own personal history, I'm 25 years old and I'm studying romantic love at Yale with a professor who's a famous love theorist. And then, I fell in love with someone and I didn't want to research anymore. And a year later—a year later—I'm working as top health advisor for the chairman of the Senate Appropriations Committee and I'm dealing with NIH budget. I'm dealing with AMA meetings. My boss says, I don't like health care, it's complicated, I trust you, and I think I know it all. And I got some real power and I don't know anything about what I don't know.
And that's how a lot of the Hill is. It's people that are from all walks, a lot are in their 20s. They think they know it all. They're smart folks, but they have a lot of power that you wouldn't realize, and they don't understand things, like, what's the budget neutrality? What's MACRA from 2015? I was still in elementary school. I mean—and they turn over a lot, they switch offices. And so, they don't know a lot and that's why you have to keep coming. That's why we have the NAC, so you come and we talk about it and you go to the Hill and you educate members and the staff over and over and over, again, and don't assume their knowledge.
And then, the third part of the plan is we've got to have some committee hearings. We asked the last Congress for hearings that never happened. This Congress, we need hearings where you have the key committees and they focus and you do a deep dive and you have people, like us, that testify and say, "Hey, this is where it's broken." You have real world examples, this is how it hurts patient care and you get the messaging out. And you get the committee staff, who write some of the bills, to really focus on it.
And another thing is no one's just going to drop a bill to fix the whole thing. It's too big and complicated, but you can take pieces, like I mentioned, on ... update. Someone could drop a bill to give an MEI inflationary update. Someone could drop a bill on the APM side to fix that. Someone can fix budget neutrality. You get different bills, then you do a co-sponsorship campaign around those bills. And you drive support throughout the whole Congress, and use that kind of as a proxy for where people are. Why aren't you sponsoring the bill? Jump on in. So that those are things that we hope.
And then, the fourth point, final point, is the tortoise and the hare play, in that, it goes back got to keep educating. You've got to play the long game. You've got to stay focused on the issue and try not to divert too much. And you've got to wear them down. This is one of the issues where it might take it the whole Congress, but you've got to wear members down over and over. They keep thinking, oh, God, I got to meet with Dr. Resneck, Dr. Fryhofer again, what am I going to say? They met with me six months ago. We haven't done anything. You've got to hold them accountable—members of Congress. And that race ended well. I mean, the tortoise won because he played the long game. So that's kind of the four points on that.
And then, briefly, I'll just mention, the other issues on scope. And scope of practice is one of those where it's the tortoise in the hare in reverse, where we could be the hare and our allied friends and the professionals are the tortoise, and they're trying to expand scope in any way they can. And they've dropped several bills. There's a big one they've dropped called the ICAN, and it brings in a lot of different professionals in one bill—one big, mega scope bill—it's called the ICAN—and we're saying, we can't.
There's a reason that you went to medical school and the training. There's a difference, and the physician-led teams are what the patients want so it's for the best for the patients and the outcomes and we'll talk about some of the research that shows that some of our allied professional friends can be more costly and not as effective in delivery of care. So that's something we're going to bring up.
And we're vulnerable on that because now, I mention this environment where they're not going to spend much money. The way it's framed is, look, there's a shortage of access to health care issues, a shortage of physicians, and we need more people and these professionals want to come and serve these patients. And it's just removing red tape. It doesn't cost anything. CBO—Congressional Budget Office—won't score. It made me be a saver. And so, this makes sense and you can get a bipartisan support for that.
And so, we have to counter that. And they only have to get one of the bills passed and they can kind of build from that. That's the game. And a lot of the groups are focused on just scope issues, not our breadth of issues.
And then finally, we do have an answer on scope. It's workforce. It's a bill called the Residency Physician Reduction Act. We need more medical residency slots. This bill would have 14,000. It used to be 15,000 because two years ago, we got 1,000 slots—the most in 25 years, 1,000 new slots. And then the last December, we got a bill that 200 slots for psychiatry and psychiatric subspecialties. So we're making progress and we want to build on that. We want more slots. We're not going to get all 14,000 at one time, but we'll take them as they come and it's important. And there's a bill out there that would create 1,000 new slots to deal with the opioid and substance abuse disorder training. So that's out there.
And then, finally, Conrad 30 is a program that physicians who come—IMG physicians—who do their medical training in the U.S., there's a rule that if they're on a J-1 visa, they have to go back to their home country for two years or if they serve in a rural area for three years, they can be exempt from that requirement, to return to their home country for three years. And it's a win-win. 30 slots for each state. There's the ability to increase those slots since it's so popular.
And there's also a provision in that bill that says if you're a physician who serves five years—IMG physician—in an uninsured community, then you can be eligible to be exempt from the green card cap because we all know, the current per country green card cap—many physicians, including some from India, a 40-year plus wait list, and this would make you exempt. So win-win. It doesn't cost the government anything. It's a win for the IMG physician, it's a win for their patients, a win for their community.
If there's a larger immigration bill, which we can't control the politics of that, this is ready to go, just a matter of keeping people on the Hill educated. This is a solution. This is one solution to the workforce. So we have a great story to tell and I'm excited about the NAC to kind of tell that story. And we always love it when the doctors and the physicians come to town to go to the Hill and help us out.
Dr. Fryhofer: Well, Jason, you've had a lot on your plate and it sounds like you're just going at this at so many different angles. Thank you—thank you so much for all of your hard work. And I keep thinking about that graph of physician payment, when physician payment goes down and everybody else's payment over the last few years goes up because they do have those inflationary updates, but thanks for that great description of all those different steps that we're taking—the AMA's leading to help physicians and our patients.
Rob, I want to turn now, to you for this next question. Please, tell us about AMA and Physician Grassroots, and we'll talk more about NAC in just a minute, but what's the best way to get involved year round?
Jordan: Sure. Thank you, Dr. Fryhofer. I think, as most on the call probably know already, when advocating on health care issues with your elected officials, whether it's here in DC or back at home, you all have such a built in advantage, being physicians. You're really looked to as the experts because lawmakers know that you're the ones that are implementing the policy on the front lines.
What you can impart from your own experiences and that of your colleagues and providing patient care, it's much more powerful than any one chart or graph or simple statistic. So being involved and you guys staying involved at the grassroots level, I think, is absolutely critical for us to be successful. The best way to do that really, throughout the year, from the AMA's perspective, is to ensure that you're signed up as a member of the Physicians Grassroots Network. This includes physicians, the residents, the students all across the country, all committed to strengthening medicine's voice in Washington, D.C.
Our online platforms—the website is physiciansgrassrootsnetwork.org, as well as Twitter, Facebook and Instagram channels that we have through the Physicians Grassroots Network. We'll keep you updated on the key issues. We'll give you the access to the online tools that puts you in touch with your elected officials and ensure that your message is being seen and being felt by these Capitol Hill offices.
We talked about a few issues and Jason went through, but Medicare, first and foremost, it's going to be soon that we're talking about that with the Grassroots, with specific to-do items. So I really encourage, if you're not already a member, sign up there so that you're staying up-to-date on what you can do, the latest on the issues and activities that we're going to have to really start to raise the volume on this, as well as other issues, but Medicare, first and foremost.
The other thing I would say, in addition to just again, ensuring that you're a member with our PGN, is take part in AMA events. Now that we're back to doing more in-person, thankfully, the AMA's Annual/Interim meetings, as well as advocacy events, like the NAC next week, the State Advocacy Summit that's held in January, and others, where possible, we incorporate grassroots training programming in these events. We have grassroots resources, like our advocacy handbook, congressional calendars, directories, things like that on hand. But moreover, members of my team and I attend these meetings, typically, and it's a great opportunity to ask us questions, get to know us a little better. We get to know you better and we find out what else we can be providing, and how we can better help you with your individual legislator on a particular issue and help you craft messaging or do whatever we can.
Dr. Fryhofer: So PGN—Physicians Grassroots Network—it sounds like a great way to get involved and it sounds like you're doing some very effective work through this. Rob, I have one more question for you. For those in-person Hill visits, like the ones that physicians will have next week during NAC, what are some of the best tips you'd offer up?
Jordan: The first thing I'd say is don't be disheartened if you're not meeting with the member. The nature of the Congressional calendar just, it is what it is. With Congress not in session, I imagine, a lot of you will be meeting with staff, but that's not necessarily a bad thing. A congressional office is not what you would think of as a large operation. I mean, even Senate offices, the staff that you're going to be talking to, chief of staff often, legislative director, but even a health LA—health Legislative Assistant—they have the ear of the member on the issues that you're there to discuss and they're going to help shape his or her opinion. Jason talked a little bit about the demographic of congressional staff and you can have a huge impact on how they view the issue, and that, in turn, will affect their boss's view on the issue.
For the meeting itself, I would say a few things. Be aware of how much time you have. Stay on task, in terms of the issues that you're there to talk about. Don't get caught up talking about the Super Bowl for too long. Make sure you're able to communicate all your points in the time that you have.
Just, a simple little agenda or an outline you can sketch for yourself to talk through with your fellow attendees. Many of you are going as groups, which is great. You can just tick things off right in the meeting as you're going through.
With policy materials and we have a lot of intellectual ammo on this stuff and we're going to have great information there, talking points on the issue and other resources, you may have some things that you put together from other organizations or other sources, but for materials that you want to leave behind with the staff that you meet with or with the office—and that's a good idea to do that—but keep it simple. Keep it concise. Dense policy studies and 50-page weight papers, those are just going to get tossed. So I would just, try to keep it as concise as you can and to the point.
Ask what you can do to help them is another thing. Is there more information in a particular area that they need? Do they have specific questions? You can bring that back to us and we can help there.
Are they in need of specific examples, real-life stories that demonstrate the problem? I think, you guys, you have those in droves. But whatever it may be, I think, just being willing to help and expressing that. I don't think many people do that, but it is appreciated, particularly from the perspective of a staffer. And it also reinforces your level of commitment.
And then, the last thing I would say is provide us with feedback. I mean, that's an easy thing to forget. And especially, ironically, when the meeting went well, a lot of times, we don't hear that, but we'll have feedback forms for you, and you can follow back up with the office as well, just a short note to thank them, recap the discussion, and just, periodically stay in touch with them throughout the year because this will be, as Jason said, a tortoise and hare thing. It's going to be throughout the year for us. So make sure to keep in touch, but those are just a few things as it relates to meetings.
Dr. Fryhofer: Well, those are some great tips. And I love that term "intellectual ammo," and as Jason outlines so many specific things that we know really need to get done, and you mentioned the role of the LAs—the Legislative Assistants—these younger people that might have a little more time to dive into some of these important issues and dot the I's and cross the T's. And there's so much to be done this year so thank you so much for those tips.
So we now have some time for questions from you, our audience, and many of you submitted questions when you registered. So we'll start with those, but you can still submit your questions online in the Q&A section and we'll try to get to those, as well. And, of course, if we can't get to them today, we'll try our best to address them during a future webinar. OK. Jason, this first question is for you. How do you decide which issues to focus advocacy on at the National Advocacy Conference?
Marino: Sure. Well, this year was really, pretty easy in that we all know Medicare has got to get fixed and we've been at this battle for a while so we've got to keep at it. So that was an easy one. And also, following the physician recovery plan, which we mentioned earlier. On scope, historically, it's been a more state issue, but we were surprised by the last Congress. We had some close calls in the 117th Congress on some scope battles and didn't realize the level of how organized and tenacious the allied professionals are. They really want to get a win.
And so we have to—it's important to get everyone aware that it's not just a state issue anymore. We have to pay attention to it on the federal level.
And it goes hand in hand. You can't just always be saying no, we have a solution. We do want to address workforce issues And so, it pairs nicely with our advocacy on workforce, and we have solutions to deal with shortage areas and getting more physicians out there, and we have data that shows you, and mapping that some places, no one's going to. NPs and others are also not going there. And we have a good story to tell on those two fronts so this year was kind of recovery plan and the issues that we see that we're going to be a little defensive on and where we go on offense this next year.
Dr. Fryhofer: OK. Rob, I want you to help with this next question. How different are in-person Hill visits than ones that are done virtually and which one is more effective?
Jordan: Well, in-person are more effective, I think that's the short answer, but you're always going to have greater focus and just an all around better exchange, I think, in person. There's no technical filter that's going to get in the way. I think, just about all of us probably, can attest to at least some amount of Zoom virtual fatigue—not today, of course—but I would say, also, at the same time, though, not to discount virtual meetings altogether, especially when an in-person meeting isn't feasible.
Offices have really gotten much, much better about doing them. There was a survey done recently where I think it was, like, 77% of offices plan on doing these going forward, regardless of pandemic. They're working for them and providing constituent service so they've invested in video conferencing capabilities. They're learning how to conduct these virtual meetings better. They take them seriously. Sometimes, when a member would not be able to do an in-person meeting, they can do a Zoom or a Teams call and the member has greater comfort level now that they've been doing them for a while, as well. So again, I'd say, in-person are preferable, but if a virtual option is there, I wouldn't discount it entirely. I would definitely take advantage of that.
Dr. Fryhofer: So next week at NAC, we'll have the opportunity, hopefully, to do those in-person visits. And so, it sounds, like, you're kind of evolving into some sort of a hybrid model, so you do the in-person, get that connection going and maybe use that virtual interaction to keep that relationship going so we can continue to make our points.
Jordan: That's a great point, yeah.
Dr. Fryhofer: Yeah. So Jack, this one's for you. As our AMA president and the public face of our AMA, we'd love to hear your take, as well, about this and perhaps, you can share your experiences doing Hill visits last year virtually as compared to previous years and recently, when you were able to meet in person in DC.
Dr. Resneck: Well, I think Rob captured this really well. What I would add is that every opportunity to interact with either a member or their staff is an important opportunity. And sometimes, that gets to be in their fancier office in a building on the Hill, sometimes it's in a hallway outside their office, sometimes it's in a basement cafeteria, sometimes it's back in the district when they're back home when Congress isn't in session, and sometimes, yeah, it is on Zoom or on the phone. And we are moving into this hybrid world where we can use all those. It's all about relationship building. And so, I think really, it's like, as we talked about, seamlessly integrating in-person health care and telemedicine, it's the same thing, really taking advantage of all those opportunities.
I agree with Rob. I'd be lying, if I said I preferred virtual. I like in-person meetings. I like that connection, being able to read body language and read the room. I still get chills walking the halls of those office buildings on the Hill and feeling, like, hey, I'm actually petitioning my government and speaking up for the profession, but there are some occasional advantages to building in virtual, as well. And if you have members, if you come to NAC next week and some of your members might be out of town, still accepting those virtual meetings, you can actually cover a lot more meetings in the same period of time because you're not going through security and walking through tunnels and doing all that.
And then, I think, we heard about this earlier from both Jason and Rob, but the last thing I would say is do not be dismissive of staff. And if you end up at the last minute getting a meeting with a member of the staff, they have such influence over the members. And really, recognizing that and treating them as such is important because you can have just as much influence building those relationships, as well.
Dr. Fryhofer: And I think, a lot of times, they will have a particular staff focusing on an issue and they'll be reporting back to the senator or the representative so those relationships, as you say, are so, so important, and giving them the information that they need and connecting with them. So Jason, back to you. How do you tailor your lobbying to lawmakers on opposite sides of the aisle? Are there some issues supported more by one party than the other?
Marino: There are. I think, big picture, if you look at our advocacy agenda, it's very bipartisan. In the Medicare, there's no—fixing Medicare, it's not a Democratic or Republican issue. It's an issue that just needs to get fixed and work better for everyone. And telehealth and prior authorization issues, our issues that we deal with are mostly, all bipartisan.
So the messaging, in general, I'm not giving a whole different talk to different staff based on what party. I'm trying to be consistent because you don't want to be too all over the place. You were just meeting with so and so, because people are friends, too, on both sides, and they go out. The Jason Marino guy was in there and he was saying this. You want to keep your credibility in are issues and we're very focused on having a non-partisan message.
And, of course, there are times when you do your homework and certain members have things that can trigger them in a negative way or positive way, and you always be mindful of those and some of those are along ideological fault lines. And you don't go out of your way to rub something in someone's eye. If you know they're somewhere else and you're not going to move them, you play it smart.
And so, you don't walk into some offices that you know what you're saying is not going to—you respect that people have different opinions in Congress, and you focus on the champions and those on the issue that you can lie with or you can get or gettable. And most people are gettable, but some are not and you've got to be smart about that.
So it's more selective in what you say and don't trigger people, but on the whole, our message is consistent to everyone. And it's kind of boring, but that's how it is. It's Medicare payment and there's a lot of complexity to it and we're not trying to chase the latest, hot, controversial topic. That happens time to time, but I think a consistent message is important.
Dr. Fryhofer: Right and our messages are not partisan. Our message is focus on physicians and helping patients and helping the physicians who care for these patients. So I think that's an important message, too. Rob, I'd like you to help with this next one. For those of us who may not already have relationships with our lawmakers, what can we do to establish ongoing relationships with them, particularly when we don't have a specific ask?
Jordan: That's a great question. It's a good opportunity for me to promote the AMA's Very Influential Physicians—VIP—program. This helps physicians who already have relationships, but also those who, as you say, want to establish relationships with members of Congress and their staff to do so over the course of time, but also, to maintain them, to make them stronger and ultimately leverage them at key times, as well. We have a host of content available through the program and things like exclusive newsletters, updates, advocacy webinars, like this one, that are more specific to training tactics that you can use and effective ways to communicate with your legislators. Things that are tailored for this type of grasstops, as opposed to grassroots, activity.
And when there's not a specific ask, a specific bill, or a piece of legislation, we can help you tailor messages that will continue to give you touch points with the legislators, with the office to keep that relationship going so that you're building that all the time. So anyone who's interested in that and I think we can put this up in the chat, but it's physiciansgrassr ootsnetwork.org—just like the PGN website—and then it's /vip. You can learn more about the program and also sign up for it there.
Dr. Fryhofer: Oh, great to know. So thank you for putting that up in the chat, and we'll all take a look at that. Jack, you're our AMA House of Medicine expert on this one and we'd love to hear your insight. How have you established relationships with your lawmakers and how have you kept those relationships going?
Dr. Resneck: I'm not sure that I"m the expert, but I've certainly learned a lot from our advocacy team and from fellow physicians who've been at this a long time, but I think, at the end of the day, it's about being a trusted voice to the lawmaker and to their staff. And right now, we have some pretty big important asks and it's important if we show up at a week like next week to actually focus on those assets and not get derailed.
But I think, in order to build those relationships, it's also important to show up sometimes when you don't have an ask. And sometimes, it's easier when the member is back in the district and just scheduling a meeting and saying, actually, I'm not asking for anything from you today. I just want to know, what's on your mind, what can we help you with, are there issues that you want to talk about with me? And that just, gives you more credibility when you come back the next time and you really need to talk to them about why the Medicare physician payment system is broken, for example.
It means really being available to them when they happen to have questions and more urgent questions or something they want to talk about. And it means being consistently credible. As physicians, we always want to come in and be the experts and have the data, but it means never exaggerating or if they ask us something that we don't know, I've learned to say, I need to get back to you about that, I'll go research that for you, when we don't know something. But that relationship building and making it durable over time, I think, is the most important way to get there.
Dr. Fryhofer: And Dr. Jack Resneck, our AMA president, you have credibility with a capital C, but hold on. I want to turn to a question on the chat and I'm going to have you answer this one. How do we coordinate efforts at the federal and state levels for prior authorization or insurance problems?
Dr. Resneck: This is a great question. And anybody who's heard me speak, pretty much, anywhere knows that in my list of top issues, the annoyance of the prior auth burden and how it's gotten completely out of control is very high on my list. It's an enormous burden for our physician offices and practices, where the average doctor is doing 41 of these a week. It's no longer focused on brand new expensive things. And patients are showing up at the pharmacy and getting frustrated and not able to get their medications, and a bunch of them never even come back after we fight those battles to get their medications approved. So it's a huge problem.
As the person who asked this question, I think, gets it, that unfortunately, this is a patchwork of regulation. So Medicare Advantage Plans, for example, are regulated by Congress and HHS, whereas some commercial insurance plans are regulated at the state. So we have to be in all those places in partnership with state medical associations and a number of states have passed some really cool laws to try to rein this in.
And in Congress, for example, we got a bill across the finish line in the House in shockingly, bipartisan fashion to try to rein in prior auth and Medicare Advantage Plans. We still need to do some work to get that across the finish line in the Senate in the year ahead. We've seen some—actually, the CMS—the Center for Medicare and Medicaid Services—just released a few weeks ago, a couple of proposed rules where it's the most heard I have felt as a profession on this prior auth issue in a long time. I don't have time to get into the details today, but some really great stuff in there to fix some problems in prior auth.
And we've seen states do similar things. Texas, for example, passed a Gold Card Bill, which is sort, like, TSA pre-check for prior auth that says, hey, if you're a physician practicing evidence-based medicine, as the vast majority of us are, and you ultimately get your prior auths approved, you shouldn't even have to do these anymore. And the way that we're coordinating that all around is having very consistent asks. We have on our website, at fixedpriorauth.org, I think, we have a list of what our asks are. And so, there are five very clear asks on prior auth and they're the same in all those places in Congress, at HHS and in the States.
Dr. Fryhofer: Well, I know, you have been working so hard on this issue for many years and so has our AMA advocacy staff. So let's hope that we'll have some real progress this year with this new Congress. All right. I've got another question and I think this one, we'll turn to Jason. A recent article noted more physicians in AMA are supporting reproductive choices, much to the consternation of one side of the aisle. Will this continue?
Marino: Well, first, I want to jump to the last question first because I want to tell more to the story on the prior auth because—
Dr. Fryhofer: Go for it.
Marino: If I had to give this talk two years ago and I had a four-point plan to get prior authorization addressed in Congress, it largely happened, in that we got a bill dropped, bipartisan in the House and Senate. We had 300 plus co-sponsors on a prior authorization bill. We had almost 60 in the Senate and we got it through the committees in the House. You got to passed by voice vote in the House and then we got this horrible $16 billion score from the Congressional Budget Office they based on. We questioned their assumptions and you can't—$16 billion was too much and it was the fatal blow. And it killed it, the bill, but it didn't kill the issue and it didn't kill momentum.
This is a tortoise and hare play, in that, here we are in 2023 and we have two rules that came out that largely, mirror the bill—the legislation that we were pushing—and it does it through regulation. And it does even more so because it applies not just to Medicare Advantage, but some other plans.
So it's a great win. We're on the cusp of a great win that no one's seen because it's kind of complicated because of the rule-making. And it may help—it may help—because now you have the key staff, members of Congress on both sides following this rule because it may change the scoring for CBO because CMS use different assumptions. And if you get it finalized as a rule, then it also becomes the new law, so to speak, and it changes CBO scoring. So we may be on the cusp of a follow on bill that this rule is making possible. But even if the bill doesn't happen right away, the rule is still promising and it will be really, real world into largely, what the bill was doing and it was all because of this foundation Rob's grassroots team, all the physicians calling in, Dr. Resneck telling all the stories about how this is real world. And so have a lot of momentum on that issue.
And the second question—some of those issues have been around for a long time, some of these social issues and it's hard. As a DC lobbyist, we're not going to move certain numbers on some issues that people have had strong opinions on their entire lives. You try and do the best you can to make your points and your cases.
And I'll just say that, for the NAC, we're just very focused on the Medicare issue because it's such a big issue, that it can consume—most groups don't have the issues that the physicians have, where we have to get things passed. Usually, you're on the defensive and trying to block bad bills and so it can take a lot of your oxygen and need to focus to get—because our bill could be $100 billion plus. That's where most of my energy and what keeps me up at night is, how do we get $100 billion bill passed through Congress at a time when they're trying to cut the budget deficit?
Dr. Resneck: Sandy, can I jump in and just say one additional thing on that? And Jason is right, about where a lot of our congressional energy is right now on Medicare, but, as I mentioned earlier, our policy is set by our House of Delegates, and it's spoken loudly and clearly about government interference and health care in our exam rooms. So as the spokesperson in my role, I'm going to speak up about that and give voice to that because that's what the profession really feels and believes.
But also, I'm an optimist that lawmakers that may happen to disagree with us on an issue like that are ultimately, going to do the right thing for Medicare beneficiaries and physicians and are ultimately going to do the right thing on prior auth. And we'll have areas of disagreement and we'll talk about those, but I know that all of these issues are so important, and that ultimately, we're going to work with Congress to get these things done.
Dr. Fryhofer: Thank you, Jack. And we have time for one more question, and I'm going to send this one to Rob. Does PGN have information as to the cost of medications to pharmacy benefit managers to use as arguments against prior authorization recommendations?
Jordan: Well, I'm not going to punt exactly on that. I would say, stay tuned. I know, we've been talking with policy folks and there will be more information coming. I can't speak as to the level of specificity as it goes to prices for PBMs, but more stuff directed at PBMs coming through the pipeline. We're going to be updating through TruthinRX—another campaign site for you to remember—but through the PGN, as well. So if you're signed up, you will get our updates on that issue as well, and that will be coming in the weeks and months to come certainly, new information on that front.
Dr. Fryhofer: So as a reminder, how do people sign up for PGN?
Jordan: It's physiciansgrassrootsnetwork.org.
Dr. Fryhofer: Thank you. Well, unfortunately, we are out of time for today's session. Many thanks to our wonderful panel of experts and many thanks to all of you, for your great questions. And if we didn't get to your question today, we will try our best to answer it during our next webinar. Again, as a reminder, please take a look at our previous editions of AMA Advocacy Insight webinars. They're on the AMA website. And please, join us next week at AMA's National Advocacy Conference, in person this year, in Washington, D.C., and we also hope you'll join us again for future webinars in this series.
Until then, thank you for being here and thank you for being engaged on issues that most directly impact America's physicians and our patients. And remember, AMA is your ally and your partner as we work to create a health care system that's better for patients and the physicians who care for them. Thank you and have a great rest of your day. I'm Dr. Sandra Fryhofer.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
