Attending the House of Delegates meeting of the American Medical Association

BY ANNE TRIMMER AMA SECRETARY GENERAL

The annual meeting of the House of Delegates (HOD) of the American Medical Association (AmMA) is the only event in which all of “organised medicine” in the United States physically comes together at the same time and place.

The program for the annual HOD meeting is immense. There is a mix of open sessions and committee sessions in the lead in the HOD meeting itself. Eight committees meet over the course of two days to work their way through a comprehensive agenda of reports and resolutions that amend existing policy or introduce new policy. The result of the committees’ work is then caucused by the participating representative societies and associations in preparation for debate on the floor of the HOD.

The HOD opens with a formal speech by the President (who completes a one-year term at the close of the HOD meeting) and another by the CEO. The meeting then opens to debate on the reports and resolutions that have come forward from the committees. This takes two days and can continue into a third day of the business isn’t completed.

As an international guest at this year’s meeting in June, I was invited to observe all proceedings and I made the most of the invitation by attending an open forum of the Council on Ethics and Judicial Affairs, two committee meetings, and the HOD meeting.

The conduct of the debate is democracy in action. The Speaker and Deputy Speaker control the debate with great deftness and humour. Speakers line up, as they do at the AMA National Conference, waiting to be recognised to speak.

There were several recurring issues that resonated. The first, and most pressing, was that of access to health care, even more so with legislation introduced by the Trump administration to wind back the Affordable Care Act (ObamaCare) which would have the result that 23 million Americans would lose cover. The legislation (the American Health Care Act or AHCA) is causing deep concern within the AmMA about the likely outcome.

Delegates debated the acceptability of per capita caps under federal Medicaid funding, which are a key element of the AHCA and are being considered for incorporation into the Senate version of the legislation that is still being drafted. The delegates rejected any proposal for caps on the basis that they would weaken States’ ability to respond to enrolment changes, greater care needs or breakthrough treatments.

The tactics of health insurers to deny cover for patients, or to create delays for physicians in trying to secure approval, were raised on many occasions. One of the more interesting debates focused on a resolution for AmMA to advocate for a public option to provide health cover where no insurance cover exists. This aspect of the original ObamaCare legislation was removed as a compromise to get the majority of the legislation through the Congress. AmMA voted to support the inclusion of a public option. The Australian health system was cited in debate as an exemplar of a system where there is public cover but also a right to choose private cover.

The networks established by the insurers are shrinking, often with the result that patients lose the physician they have had all of their lives. The provision of out of network care carries significant cost for patients who are not covered if they need care at a hospital that is not within their insurer’s network. This has an impact on emergency doctors who won’t turn patients away if they present at an out of network emergency department. At times the patient may not even be aware that they are out of network.

The resulting “surprise bills” come about either because the patient has presented out of network or because the cover they have is inadequate for the procedure that is undertaken. Delegates were critical of “outlier” medical colleagues who levied significant bills in these circumstances, attracting the ire of patients and media.

This has led to consideration in several States of a “fair minimum benefit”. However as States have been ratcheting down the benefits paid under Medicare, doctors are concerned that any benefit that is tied to Medicare will be inadequate for the service that is provided. Delegates discussed the potential for an independent database to be used as a reference point for charging (which sounds not dissimilar to the AMA Fees List).

Another example of egregious insurer behavior occurs in emergency departments where the insurer withdraws cover on the basis that the reason for presentation is not an emergency. To overcome this the patient is forced to seek pre-approval.

The issue of physician health was raised on several occasions. The concern is with burnout, exacerbated by the frustrations of dealing with the health insurers in seeking pre-approval for patients, and the electronic health record. Speakers referred to the extensive delays created by the system. Reference was also made to depression and suicide among doctors.

The open session of the Council on Ethics and Judicial Affairs provided a forum for the AmMA to obtain member feedback in the development of a new policy on euthanasia and physician assisted suicide. Among the speakers from the floor were physicians from the five States where it is already legal for doctors to prescribe end of life pharmaceuticals. In California, for example, physicians can choose to opt into the process with 18 per cent currently doing so. The legislation provides multiple safeguards.

Colorado is the most recent State to introduce euthanasia. The State medical society undertook a two year consultation before changing its policy to accommodate the change. In that State a patient must be able to self-administer the medication. However the cost of effective medication can be a barrier to a patient carrying out the euthanasia.

In the State of Oregon where euthanasia has been legal for 20 years, the State medical society has maintained a neutral position.

Notwithstanding that euthanasia is legal in some States, the debate emphasised the need for a better understanding of the role of palliative care and the place of hospice care. Patients at the end of life were often ignorant of the benefits of palliative care.

The address by the outgoing President of the AmMA, Dr Andrew Gurman, highlighted the big issues faced by the AmMA over the previous 12 months. These included the requirements of the health insurers for pre-authorisation of drugs and medical devices before they could be prescribed or utilised in surgery; gun control as a public health issue; the defeat of proposed health fund mergers which would have further reduced access to health care; and physician burnout.

Dr Gurman highlighted what he described as “advocacy at its most basic, human level” when he met with medical trainees who had grown up in the US but now feared deportation under proposed changes announced by the Trump administration.

The Executive Vice President and CEO, Dr James Madara, highlighted that the AmMA recently celebrated its 170^th birthday, having been established in 1847. He identified three strategic areas for current focus in the work of the AmMA:

Practice satisfaction and professional practice;
Medical education; and
Patients with pre-diabetes.

This last point relates to the fact that a staggering 83 per cent of health services in the US are for chronic conditions.

Unsurprisingly an opinion poll released while I was in the US has health as the number one issue for the electorate.

The AmMA’s work on medical education centres on online learning to provide tools and resources to physicians, including the recent release of an online education program on best use of electronic health records. This is part of a project entitled health 2047 (for the 200^th birthday of the establishment of the AmMA) which aims to return to the physician one hour per day of the working week. Many speakers identified that navigating the current EHR system currently consumes up to two days each working week.

The AmMA is also working to protect patients at risk of losing their health cover by expanding meaningful coverage and including safety nets.

Resident mental health is now mandated as part of every residency program.

The contributions from the medical students were among the most compelling. The medical student section put forward a motion calling on the AmMA to be a leader in advocacy on the social determinants of health. The National Academy of Medicine established a framework in 2016 to better understand the social determinants. As several delegates pointed out, without understanding the social context of a patient there may be impacts on the care that is given. Examples provided were a patient living in accommodation with no running water, or with no access to transport to attend a pharmacy to have a prescription filled.

Another significant public health issue that attracted debate is the opioid epidemic in the US which has arisen as a result of the over-prescribing of pain medication.

The organisation

The AmMA’s revenue in 2016 was $323.7 million with a profit of $13.6 million.

The House of Delegates is the supreme policy making body and elects the office-holders, including the President-elect who then becomes President the following year. It also elects the members of the Board of Trustees.

The Board of Trustees is the principal governing body and takes actions based on the policy and directives of the HOD. It exercises broad oversight and guidance with respect to management systems and risk through the oversight of the Executive Vice President (the CEO). It has 21 members who have fiduciary responsibility for the organization and select and evaluate the CEO. The members include a student, a resident, a young physician, and a public member.

The eight Councils are standing, domain based, expert bodies. They are:

Council on Constitution and Bylaws
Council on Ethical and Judicial Affairs
Council on Legislation
Council on Long Range Planning and Development
Council on Medical Education
Council on Medical Service
Council on Science and Public Health
American Medical Political Action Committee.

The Sections and Special Groups represent the constituent groups and provide a channel for outreach and member insights. They are as diverse as the Advisory Committee on LGBT Issues, the International Medical Graduates Section, the Medical Student Section, and the Organised Medical Staff Section.

The HOD draws representation from the State and territorial medical associations (260 delegates) and national medical specialty societies (205 delegates). It has 528 delegates and the same number of alternate delegates. With Past Presidents and observers there are approximately 1200 attendees at the HOD annual meeting.

The rules for participation of a national medical specialty society are complex and are based on the number of its members who are members of the AmMA at the rate of one delegate per 1,000 AmMA members with every eligible national medical specialty entitled to at least one delegate. Similarly every State/territory is entitled to at least one delegate.

In addition delegates represent Federal Services (Air Force, Army, Navy, Department of Veterans Affairs, and the US Public Health Service); AMA Sections; other national societies; and professional interest medical associations.

AmMA represents approximately 25 per cent of American physicians. However as the umbrella body representing the entire profession it is the voice in Washington DC that speaks for all physicians.

Each policy that is put before the HOD has a fiscal note on the likely cost of the proposal if adopted. This is a good discipline in either reducing or refining some resolutions.

Every policy is recorded in PolicyFinder which is an electronic database available online and updated after each meeting of the HOD.

As a final note, every resolution or policy that is put forward is framed as ‘our AMA’ undertaking the specified action. This engenders a sense of ownership and pride in the organisation’s advocacy.

Radiotherapy in Australia 2015–16

This report publishes data on 60,600 courses of radiotherapy that were delivered in Australia in 2015–16. For non-emergency treatment, 50% of patients started treatment within 9 days, and 90% within 27 days. For those who needed emergency treatment, 91% began treatment within the emergency timeframe. Data were submitted from 44 public-sector sites and 33 private-sector sites, covering effectively 100% of courses delivered in Australia.

Australia’s hospitals at a glance 2015–16

Australia’s hospitals 2015–16 at a glance provides summary information on Australia’s public and private hospitals. In 2015–16, there were 10.6 million hospitalisations (6.3 million in public hospitals, 4.3 million in private hospitals). The average length of stay was over 5 days (5.7 days in public hospitals; 5.2 days in private hospitals). 1 in 4 hospitalisations involved a surgical procedure. 27% were emergency admissions. 149,000 hospitalisations involved a stay in intensive care. 60% were same-day hospitalisations.

[Comment] Offline: The G20 and health—platitudes and broken promises

Imagine “Anycountry”. A low-income nation-state with a weak health system. People have begun to report a mysterious respiratory infection that is rapidly fatal. The cause is an unknown virus. A localised outbreak quickly spreads from village to village. The virus is not only extremely pathogenic but also highly transmissible. The epidemic soon crosses the country’s border to neighbouring states. A global health emergency beckons. This scenario is fictional. But earlier this year G20 health ministers were locked in a room in Berlin to test their ability to deal with such a global health crisis.

Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score-matched observational cohort study [Research]

BACKGROUND:

Delay of surgery for hip fracture is associated with increased risk of morbidity and mortality, but the effects of surgical delays on mortality and resource use in the context of other emergency surgeries is poorly described. Our objective was to measure the independent association between delay of emergency surgery and in-hospital mortality, length of stay and costs.

METHODS:

We identified all adult patients who underwent emergency noncardiac surgery between January 2012 and October 2014 at a single tertiary care centre. Delay of surgery was defined as the time from surgical booking to operating room entry exceeding institutionally defined acceptable wait times, based on a standardized 5-level priority system that accounted for surgery type and indication. Patients with delayed surgery were matched to those without delay using propensity scores derived from variables that accounted for details of admission and the hospital stay, patient characteristics, physiologic instability, and surgical urgency and risk.

RESULTS:

Of 15 160 patients, 2820 (18.6%) experienced a delay. The mortality rates were 4.9% (138/2820) for those with delay and 3.2% (391/12 340) for those without delay (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.30–1.93). Within the propensity-matched cohort, delay was significantly associated with mortality (OR 1.56, 95% CI 1.18–2.06), increased length of stay (incident rate ratio 1.07, 95% CI 1.01–1.11) and higher total costs (incident rate ratio 1.06, 95% CI 1.01–1.11).

INTERPRETATION:

Delayed operating room access for emergency surgery was associated with increased risk of inhospital mortality, longer length of stay and higher costs. System issues appeared to underlie most delays and must be addressed to improve the outcomes of emergency surgery.

[Articles] Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records

Adjustment for routine test results substantially reduced excess mortality associated with emergency admission at weekends and public holidays. Adjustment for patient-level factors not available in our study might further reduce the residual excess mortality, particularly as this clustered around midday at weekends. Hospital workload was not associated with mortality. Together, these findings suggest that the weekend effect arises from patient-level differences at admission rather than reduced hospital staffing or services.

Hospital resources 2015–16: Australian hospital statistics

In 2015–16, there were 701 public hospitals in Australia accounting for about two-thirds (61,000) of all hospital beds. There were 630 private hospitals with 33,100 hospital beds. Total recurrent expenditure on public hospital services was about $64 billion. About 57% of this was for admitted patient care, 18% for outpatient care, 10% for emergency care services, 2% for teaching, training and research and 13% for all other services.

[Comment] Paediatric head imaging decisions are not child’s play

Clinicians who care for paediatric patients with blunt head injury must reliably identify all patients harbouring serious injuries and avoid catastrophic misses that could lead to permanent disability and death.1–4 CT head imaging plays a key part in injury assessment, but is not suitable for most children because of cost, inconvenience, and risk of radiation-induced malignant transformation.1,2,5,6 Clinical decision tools, including the Pediatric Emergency Care Applied Research Network (PECARN),2 Canadian Assessment of Tomography for Childhood Head Injury (CATCH),4 and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE)3 rules, have been developed to guide and inform paediatric CT head imaging decisions; however, concerns about the validity of these instruments prompted Franz Babl and colleagues to do a multicentre validation study1 that assessed their external performance.

[Clinical Picture] AIDS-related primary CNS lymphoma

A 54-year-old man with a known history of HIV, hepatitis B, and hepatitis C, presented to the emergency department in June, 2014, with a 2-week history of worsening headaches, hallucinations, and confusion. He was disoriented in time and place, but on examination we found no neurological deficits. He was not taking antiretroviral therapy.

[Review] Caustic ingestion

Corrosive ingestion is a rare but potentially devastating event and, despite the availability of effective preventive public health strategies, injuries continue to occur. Most clinicians have limited personal experience and rely on guidelines; however, uncertainty persists about best clinical practice. Ingestions range from mild cases with no injury to severe cases with full thickness necrosis of the oesophagus and stomach. CT scan is superior to traditional endoscopy for stratification of patients to emergency resection or observation.