麻豆传媒

Fixing the healthcare system's problems will be a top priority of American Medical Association (AMA) President Bruce Scott, MD, an otolaryngologist from Louisville, Kentucky, who was sworn into his new position on June 8 at the AMA's annual House of Delegates (HOD) meeting in Chicago.

Scott, who previously served as HOD vice speaker and as a member of the AMA Board of Trustees before becoming president-elect last year, spoke online with 麻豆传媒 Washington Editor Joyce Frieden about what he hopes to accomplish as AMA president. The interview, which was conducted with a public relations person present, has been edited for length and clarity.

MPT: Tell us what you learned from your year as president-elect. Was there anything that will help you succeed in this year's role?

Scott: I learned just how big of a demand that this was going to be on my continuing active practice. It's really a 3-year gig, if you will, where we're president-elect, and then president, and immediate past president, and the three of us share the spokesperson role, with the president as the lead spokesperson. I guess I'm moving into the lead position.

MPT: What are your top priorities for the coming year?

Scott: My general priorities are getting us back to fixing what I believe is a broken healthcare system. You know, I became a physician to take care of patients, and that's getting tougher every day. The healthcare system should help doctors provide good care, not get in the way. Anything that places a burden or an obstacle between a physician and their patient and providing that good care is something that I'm going to attack, and that begins with the administrative burdens, and that's followed rapidly by the reimbursement issues.

For years, [physician reimbursement] has kind of been the topic that's the elephant in the middle of the room that no one wants to talk about, but it's time for us to begin talking about it, and I'm going to push it. By the same token, I'm in a rural area, so I think that things like telehealth and the continuation of telehealth are very important. And then finally, as we move into the digital medicine age and augmented intelligence -- as we call it -- we need to make sure that it's implemented in such a way that helps physicians provide better care for their patients, and does not become just another barrier and a burden on physicians. So those are really the big issues.

MPT: You mentioned physician payment. Obviously, Medicare is a big player here and the AMA has been trying to improve doctors' Medicare reimbursement for years. Where do things stand today?

Scott: We're thankful for the fact that MedPAC [the Medicare Payment Assessment Commission] to the fact that there needs to be some link to the inflation rate that physicians face. Adjusted for inflation, physicians have faced a 29% reduction in reimbursement since 2001, and it's simply not sustainable.

Recently, the Change Healthcare cyberattack pushed a lot of practices over the brink. My practice had to dip into a line of credit. That's just how on the edge we are with all of the financial challenges of the last number of years. So AMA's response is, we think that at a minimum -- not as a maximum, but as a minimum -- Medicare reimbursement [increases] need to be at the level of the increased cost of doing business, the increased cost of holding open a practice. And if it's not, what we're going to see is continued closure of physician practices, physicians selling out to venture capital groups, physicians selling out to hospital systems, all of which limit the choices that patients have, and increase the overall expense for Medicare and the healthcare system.

MPT: And what's happening on the prior authorization front?

Scott: There's definitely more positive momentum on the issue of prior authorization in general. We were able, earlier in the year, to convince CMS to institute a variety of changes in improvement in prior authorization in the federally funded programs -- Medicare, Medicaid, and CHIP [the Children's Health Insurance Program] -- [although] some of those, we were a little bit disappointed that they weren't as aggressive as we would like them to be. For example, CMS instituted a 72-hour [maximum time] for responding to urgent requests, rather than the 24 hours we were pushing for ... and the implementation is not going to be until 2026, or 2025 in some cases.

So now we have movement from Congress to put back in legislation that frankly had pretty broad bipartisan support last time around, until the Congressional Budget Office slapped a huge price tag on it. The current legislation that has been reintroduced [the ] has tweaked some of that to hopefully lower that scoring of the price tag, and we think there's going to again be broad bipartisan support.

The other thing that's happened over the last year or so is that there seems to be a broader understanding of the fact that prior authorization delays and denies necessary care and harms patients, and we have been able to collect stories through one of our websites called .

Here's an example from my own practice. A patient I recently saw who had a tumor growing in her maxillary sinus, next to her eye. She wasn't the highest-functioning patient, but after some time with her, I was able to explain that she needed a relatively complex surgery with reconstruction, and she agreed to it. She understood the urgency of getting this done.

We scheduled the surgery, and the next week, both she and I got a letter from the insurance company that said that the surgery was unnecessary because she had not been on an antibiotic and a steroid nasal spray. Now, that was not going to fix the tumor, but probably an algorithm and a nonphysician looked at this and said, "Oh, maxillary sinus surgery. Has the patient been on an antibiotic?" and denied the procedure. So I jumped on the phone, and I wasted my time getting in touch, finally, with a physician, and the physician immediately approved the procedure. Then I had to call the patient, and she was in tears and said, "Dr. Scott, I don't understand. You told me I needed this big surgery, and my insurance company says all I need is an antibiotic and a nasal spray."

So we talked about it, and she understood, and eventually we did the surgery and she's doing fine. But think about the anxiety for this woman, told by her trusted physician that she needs this big operation, and then told by someone else, "You don't really need that. You just need an antibiotic." There are stories after stories like that that we can tell.

The other thing that's happened is, believe it or not, we've even gotten some of the big insurance carriers to lessen their prior authorization. Now, one of the other components of the federal legislation is including what we call "gold carding," where physicians who have a certain threshold -- maybe 90% -- of approval of their prior authorization would be exempted from future prior authorization.

I can't remember the last time that one of my denials did not get overturned. Now you might guess that I'm pretty aggressive with insurance companies, and so I appeal every single denial. So invariably, when I get on the phone, I'm able to convince the person on the phone.

Now, what are the challenges I face? A lot of times, the person on the other end of the phone is not a doctor. Most times they're not an otolaryngologist. And I jokingly say sometimes they can't even pronounce otolaryngology. And yet, they're the people who are trying to tell me what was right for my patient without doing an examination, without talking to the patient, without reviewing any of the information. It's just a bad system and it needs to be changed.

MPT: Are there other components of Medicare physician pay that you're working on -- ones that don't get as much limelight?

Scott: One of the things is the [federal] budget, which is one of the reasons why we get this cut. And we believe the budget neutrality formula is flawed; it is based upon financial numbers that are many years old.

In my area, every private insurance company and Medicaid is tied to the Medicare rate. So this year, we had a major carrier -- a private insurance company that controls 60% of our practices -- offer us surgical payment rates that were less than they paid us in 2017, and visit rates that were less than Medicare. We were stunned, and we told them that we wanted to negotiate. After months, we were able to get them to the table to negotiate, and they gave us about 2% over what they had originally offered us.

And the truth of the matter is, we were in a jam. We couldn't say no, because then a large percentage of our patients would suffer. They would lose access to care. And on the other hand, if we said yes, we're trying to figure out how to work. When reimbursement goes down, physicians have to make difficult choices. In some cases, they don't invest in the newest, latest technology. Maybe they don't fill all the needed staff positions that they used to employ.

In other cases, they're simply dropping out of the system altogether. And perhaps most tragically, some of the physicians are throwing their hands up and retiring and saying, "I've had it," and just quitting. I talked to a doctor today in the doctors' lounge who told me that he's had it and that he's closing his practice at the end of the year. We can't afford to lose even one more doctor.

MPT: One other question related to reimbursement: How do you feel about physician practices being bought up by private equity?

Scott: Well, I think that a plurality of modes of practice is important. I think that a lot of physicians have moved to private equity because they didn't feel like they had a lot of choice. There's an advantage of private equity in the age of shrinking reimbursement for physicians -- they have deep pockets, and so they can invest in digital medicine and new technology ... So there's an advantage of the deeper pocket, but at the same time, I am concerned about the profit motivation. Physicians have always had to balance the ethics of our professional oath with a need to obviously bring in enough reimbursement to keep our practices afloat and make a feasible living. My concern is, does that get tilted too much when private equity gets involved? And I think we just have to be careful. We need to watch carefully and shepherd it in the right direction.

MPT: Another front-burner issue has been physician burnout. What is the AMA doing on this front, and have their efforts borne any fruit?

Scott: Yes, we've seen results, but we need to do more. Physician burnout was at a record level during the pandemic, and it really hasn't come down the way that we wished it would. The first thing we did was try to find out the root cause of this burnout, and what we found out is that physicians are just as resilient as they've always been, and it is all of these system problems that are pushing doctors to be burned out, or to retire, or to lessen their practice numbers.

The data are not good. One in five doctors say they hope to be able to retire or significantly change their practice in the next 2 years, 60% are showing signs of burnout, and unfortunately, the rate of physician suicide is high.

So the first thing we're doing is attacking the root cause of the systemic problems that exist. The second thing that we've been doing is trying to reduce the stigma of physicians seeking mental healthcare. One of the challenges has been that for years, every time you fill out a licensure application or a credentialing for a hospital, there's a question that says, "Have you ever had a mental health issue?"

You may have had a mental health issue 20 years ago when you were a medical student, or when your spouse left you, or when a parent or a loved one died, and you appropriately went in for counseling. Those questions need to be changed to say, "...a current mental health issue or impairment." We've actually been able to get over 25 states to agree with that, and gotten a large number of hospital systems to change their questionnaires in the credentialing farms as well. So we continue to work on that.

MPT: How do you plan to handle controversial issues? For example, at this year's House of Delegates meeting there was a that caused some heated debate.

Scott: My approach is that we need to unify over the things that unite us. I mean, all of us became physicians to take care of patients, and we need to address the things that get in the way of us taking care of our patients. There's so much more that binds us together, our professional oath, our commitment to our patients, our desire to provide good medical care. These are the things that we need to be focusing on, because there's general agreement on all of these issues, and we need to stop concentrating on the things that potentially tear us apart.

Now, I will be clear that the resolution you speak of that ultimately came out of the reference committee with a recognition that we believe and want to push for peace and protection of healthcare workers and humanitarian aid, that was passed by an 84% majority of the House of Delegates. An 84% support of a policy position is pretty darn strong.

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