AMA Offers Guidance on Physician Employment

In a sweeping series of recommendations, the American Medical Association's governing body this week issued "guiding principles" for physician employment, reaffirmed its opposition to ICD-10, sought improved government payments, and acknowledged the need for improved clinical care on issues ranging from genetic testing to whooping cough.

In meetings over the last two days, the AMA's House of Delegates voted on economic, clinical, scientific and public health issues that the nation's largest physician organization wants to advance in order to "shape the healthcare agenda" of the nation.

The organization's sessions began Monday and ended Tuesday in Honolulu, Hawaii, but even the AMA's top leaders acknowledge that the association is not in a position to shape the entire healthcare agenda.

Indeed, the AMA continues to be frustrated and confronts nagging issues such as pending implementation of the ICD-10 coding. Those frustrations were reflected in what was described as "vigorous debate."

For many physicians, some of the biggest concerns revolved around the workplace. As more doctors are becoming employed by hospitals, the AMA adopted new guiding principles that govern physician relationships with the institutions, AMA President Jeremy A. Lazarus, MD, told HealthLeaders Media in a phone interview.

The guiding principles are intended to help physicians address potential conflicts in hospital relationships, Lazarus said during a break in the AMA's semi-annual policy-making meeting.

The principles address six potentially problematic areas of employer-employee relationships, including:

1. Conflicts of interest
2. Advocacy
3. Contracting
4. Hospital-medical staff relations
5. Peer review and performance evaluations
6. Payment agreements

"It's important that the patient-physician relationship is protected and the patient comes first in terms of what we are doing for them," Lazarus said. "We want to make sure in the employment relationship that there is unfettered communication and that we make sure we do what is best for patients."

Essentially, the AMA Principles for Physician Employment provide a framework to help "guide physicians and their employers as they collaborate to provide safe, high-quality and cost-effective patient care," AMA board member Joseph P. Annis, MD said in a statement.

Physician employment trends are expected to continue, with more doctors entering into employment and other contractual relationships with hospitals, group practices, and other health systems. Nearly one-third of final year residents list hospital employment as their first choice of practice setting, according to physician recruiting firm Merritt Hawkins.

"We are moving into an area where more physicians are employed and we are guiding physicians for that employment," Lazarus added. "And that fits very well with our strategic plan. We spent a lot of time educating our members about the plan."

Earlier this year, the AMA adopted a five-year strategic plan to ensure that enhancements to healthcare are physician-led, advance the physician-patient relationship and ensure that healthcare costs are prudently managed.

While the AMA again flatly sought to rid the government of the sustainable growth rate  formula, (SGR) its officials were enmeshed in a "lot of vigorous debate" about the ICD-10, Lazarus said. The AMA has opposed implementation of ICD-10, the disease coding set with an October 2013 launch deadline.

"It's our policy [that] we want to get the ICD-10 stopped, but there was a lot of vigorous testimony on different sides of that. There was recognition by some people that we need to move on to something different." Still, Lazarus said, "the House of Delegates made it very clear we want (ICD-10) stopped."

In other actions, the AMA board:

Outlined a set of principles to guide physician leaders of healthcare teams.  "The future of health care delivery is patient-centered and will require a team approach, and physicians and health care professionals need to be prepared to efficiently work together to provide quality patient care," said AMA Board Member Carl A. Sirio, M.D, in a statement.

Presented a report on "workplace violence" in non-hospital work environments. An AMA survey found that 12% of physicians who responded said they were a victim of "at least one incidence of workplace violence in the past 18 months." The most commonly reported form was characterized as verbal complaints.

"In order to provide the best possible care to patients, and maintain a rewarding work environment for physicians and other health professionals, all forms of workplace violence must be addressed," AMA Board Member Patrice A. Harris, M.D., noted in a statement. "This report is an important step towards enhancing the health care workplace setting for both physicians and patients."

Urged the removal of barriers to generic medications. The AMA board adopted a policy to end the practice of "pay for delay" in prescription medicine. That refers to the practice of brand prescription drug manufacturers paying generic drug manufacturers for not creating generic versions of their medications.

Sought federal legislation or regulatory changes to stop Medicare and Medicaid from decertifying physicians due to unpaid student loan debt. The current practice of decertifying physicians with outstanding loan debt stops them from accepting Medicare and Medicaid patients and undermines their ability to repay the student loans, AMA officials say.

Recognized "next-generation" genomic sequencing in clinical applications "for dramatically reduced costs, but said that "implementation challenges must be addressed" to realize the potential of the technologies for improved outcomes.

Advocated for encouraging birth-year based screening practices for Hepatitis C in line with recent Centers for Disease Control and Prevention recommendations. About 3.2 million Americans are infected with Hepatitis C virus, according to the AMA, but more than half are unaware they have the virus, the CDC estimates.

Urged Medicare to improve vaccination coverage for whooping cough by covering Tdap (Tetanus, Diptheria, Acellular Pertussis) vaccines under Medicare Part B. Tdap vaccinations are currently not reimbursed under Medicare Part B, but the rates of whooping cough, formally known of Pertussis, are increasing.

Supported Medicaid expansion in the wake of the Supreme Court decision that upheld the Affordable Care Act. Under the law, it is optional for states to expand Medicaid eligibility to 133% of the federal poverty level.  The AMA board advocates for an increase in Medicaid payments to physicians and improvements in Medicaid that will "reduce administrative burdens and deliver healthcare services more efficiently.

Despite the Medicaid expansion vote, sure enough, there wasn't much debate on the Affordable Care Act, a subject of much contention among physicians over the last few years.

"We're moving ahead to implement the Affordable Care Act," the AMA's president says. "There wasn't a lot in the House action related to that."

There was another issue, a longstanding and frustrating one, for the AMA, that made its presence felt at the board meeting. And that's the Sustainable Growth Rate (SGR) formula, which is slated to cut Medicare rates by 30% in 2013.  

AMA's "position is very clear" on the SGR: It wants to get rid of it. This week, although there was some discussion about it, the board didn't take a vote on it, Lazarus says. "The Medicare cuts may come in January, and we are looking at the lame duck Congress. The SGR is the looming issue for the next couple of months."