In November 2008 the American Medical Association (AMA) held its semiannual meeting of the House of Delegates in Orlando, Florida. Whether you like it or not, the AMA is by far the largest of the medical associations and continues to play a dominant role in shaping national health policy. Which is why this year’s meeting, following on the heels of such a healthcare-focused election, demands the attention of emergency physicians everywhere.
Representing emergency medicine at this meeting was the official Section on Emergency Medicine, comprised of five delegates and four alternate delegates from ACEP and several other voting and non-voting members, including AAEM. There is one specialty society delegate allotted for every 1000 AMA members who designate that specialty society as their society. In the case of emergency medicine, there are currently some 3100 AMA members who have designated ACEP as their specialty society. Emergency medicine also demonstrated its collective strength by showcasing no fewer than seven emergency physicians who are current or past presidents or chairs of their respective state societies. There are also a host of delegates and alternates, 14 and 11 this year respectively, from the various state medical societies who are emergency physicians. And lastly, there are many emergency physicians who occupy other positions of importance and influence within the AMA, including three members of the board of trustees.
To be fair, these numbers, while strong, can be misleading when considering emergency medicine’s influence at the table. It’s important to put in perspective just how many interests are represented at an AMA meeting. There are more than 600 state delegates and alternates, over 400 specialty society delegates and alternates, and a myriad of society executives and physicians representing groups that have no official voting representation in the House of Delegates. There are councils and committees and multiple sections spanning from medical schools to residencies to specialty societies. And that doesn’t begin to scratch the surface of the newly sprouting “Member Groups” that represent various special interests, from “Minority Affairs” to “Women” to “LGBT.” There were several resolutions of interest to emergency physicians presented at the meeting. Foremost among all of these was the rather hotly debated concept of the “medical home,” which requires that patients be assigned to primary care providers as their “medical home,” from which all their care and referrals for care would come. Of course there is a price (fee) to be paid for this service, which means that it is likely that the reimbursement rates for all other non-primary care providers would drop a corresponding amount. The emergency medicine section testified that there is no real provision for compensation of emergency services in this model. The vote was to support the concept but also to urge CMS (and other payors) to pay for the service from new monies, not the current pool.
On the topic of reimbursement there was unanimous endorsement of resolutions calling for reform of the physician payment system, currently based on the flawed SGR formula as well as the entire Medicare payment system. The SGR, or “sustainable growth rate,” is a target that is used by CMS in computing the Medicare Conversion Factor, which determines the dollar value of an RVU. Changing this formula has long been a goal for the AMA, but the reluctance of congress and the administration to do so has been overwhelming.
Also of interest was a resolution that would have made on-call panels for emergency departments voluntary and not mandatory. This resolution was defeated following considerable testimony from emergency physicians as well as several other specialty societies. Also defeated was the recommendation that “secret shoppers” be used as quality improvement tools in hospitals and emergency departments. For those of you who have not been “secret shopped,” this involves an anonymous patient who could present to an emergency department (or other medical facility) and “grade” the ED on various consumer aspects, such as waiting times, courtesy, comfort, etc…
Other resolutions adopted relevant to emergency medicine included ones dealing with disruptive physicians (a simple statement that disruptive behavior should not be tolerated), advocating for model state laws to prohibit the use of hand held communication devices while operating motor vehicles, reaffirming current AMA policy advocating for appropriate compensation for emergency physicians and on-call physicians for EMTALA-mandated services. It is important to remember that the adoption of AMA resolutions is only one step in a process of trying to change a law or behavior; it is not a guarantee that a definitive action will follow.
All in all, it was a most productive and interesting House of Delegates Meeting. Although frequently viewed by emergency physicians as irrelevant to the practice of emergency medicine, the AMA remains a dynamic force politically and professionally in this country. Historically, it is also important to remember that it was the AMA which first recognized emergency medicine as an emerging specialty by granting it Section status in 1973. It is in the best interests of all emergency physicians to work for change from within rather than to stand outside of organized medicine and simply hope for the best.