Medgadget Interviews Dr. J. James Rohack, President-elect of the AMA

Medgadget: Another question.. We've been looking at the recent news, and we've found that Rasmussen Reports, a polling firm, has released their latest poll about healthcare in this country, and here's what they found. More than two out of three Americans (68%) rate healthcare in this country as fair or poor, but near identical number give good grades, or excellent marks, to their health insurance coverage, and are very reluctant to change it. Here's what Rasmussen concludes:

"Dissatisfaction with the U.S. health care system makes the issue a perennial campaign favorite. The fact that voters are generally reluctant to give up their own insurance coverage makes the issue resistant to reform."

Do you think that healthcare system will be a difficult issue to reform, once we have a new administration in the White House?

Dr. Rohack: We clearly recognize that the biggest concern patients have in the United States is the ability to take away choice, and the ability to disrupt their relationship they've developed with their personal physician. The recognition that we do have a pluralistic way in the United States of delivering healthcare, as well as the importance of insurance to make sure that the high technology treatments and the high technology tools are available, makes it very clear that the AMA policy for covering the uninsured, is to build on the strengths of a insurance system that can allow innovation and choice, and at the same time recognize that we do have, as practicing doctors, because of the medical liability problems sometimes tests are ordered that are not necessarily needed. So our awareness that if we're going to control healthcare costs as physicians, just having a philosophy of reducing payments to doctors as the solution is not sustainable. We as physicians have to lead the effort, and the AMA has invested lots of dollars to create our physician consortium for performance improvement with input from the specialty societies, as well as states, to say "What are the measures that we ought to be doing? What are the ways that we better care for?" Ultimately, if we as physicians agree, then we can go to the trial bar, and say "Hey, if the physician follows this evidence based guideline, and the patient still has a bad outcome, the physician shouldn't be sued for that bad outcome". So I firmly believe that it is only through having an umbrella association, like the American Medial Association, that represents every physician in the nation, regardless of specialty, regardless of geography, regardless of where you are as a physician, that having a strong, vibrant AMA, by having physicians being members of that, will only improve our medical profession, not destroy it. Which regretfully, the more we are divided, the more others, that is the government and insurance companies, will destroy us.

Medgadget: You've already mentioned a couple of times this recent project "Voice for The Uninsured". We were looking at it, and you can tell us a little more about this project, and what its purpose is. And the reason I'm asking is because to us as physicians it seems that the AMA should be an organization that represents the needs and views of American doctors. And it seems to us that projects like "Voice for The Uninsured", though admirable, are distracting the AMA from, or even working against the AMA's responsibility to represent the views of physicians. Collectively in the last 20 years or so, we've seen the erosion of our economic freedoms, and it's not always clear the AMA, when it comes up with a project like this, it doesn't seem like the AMA is on our side necessarily. For example when you look at the lobbies in Washington, you have AARP, you have Walmart, and other firms, and unions that are on the side of patients. So why is it necessary for the AMA to come up with projects like "Voice for The Uninsured."?

Dr. Rohack: Well, the American Medical Association, by representing physicians, patients come to physicians to be healed. Physicians are the ones patients trust to do what's right for them. It is clear when we survey our AMA membership, that 90% of the doctors provided us the feedback that having uninsured patients show up in emergency rooms for primary care is fundamentally wrong, that having patients going bankrupt because they can't afford to get treatment for breast cancer is fundamentally wrong, and the way we can correct that is to make sure that every patient in America has access to healthcare. The way that this current tax subsidy works, is that the richest employed patient gets a tax subsidy from their employer. They pay no taxes on that. Whereas the poorer you are, or if you're self-employed, and try and purchase health insurance, you don't get any tax advantage at all. That is why our message to deal with this problem is to change the federal tax code, so that those who cannot afford health insurance will get tax subsidies through tax credits, to be able to purchase. And those that can afford healthcare will continue to be able to purchase, except they will now have both a tax liability as well as a tax deduction to be able to fundamentally afford the care they need.

Medgadget: Here's a question from one of our editors, Nick Genes. He's a resident of emergency medicine at Mount Sinai in New York. Many pundits and experts believe that the US government will improve access to primary care (one way or another) in the next 2-5 years. The Massachusetts experiment suggests there will not be enough primary care doctors to cover the increased demand. Already, primary care doctors are overworked and under compensated, with many leaving the field or choosing specialty training instead. How is the AMA planning to respond to this challenge?

Dr. Rohack: We clearly recognize that the primary care profession of physicians is in a fundamental crisis mode. And while the AMA set fees, and cannot negotiate for fees, every opportunity we have we've tried to recognize ... that physicians are doing a lot work that they're not being compensated for, specifically in primary care with the coordination of fees. We've advocated right now within the CPT code book. There are care coordination fees. We each year, at least since I've been on the board since 2001, have communicated to CMS as well as the private payers, that those fees should be recognized and payed for. Unfortunately, they are not, and I think that's part of the problem, if the primary care physician was able to bill and get reimbursement for the hour and a half per day on average of the paperwork that they're providing for their patient care, it will make the financial pressures a lot better. I should also quickly mention ... the AMA has taken all the heat for its ad campaign to try to get the Senate, those that voted against cloture, to reverse their votes. The Senate did pass HR 6331 with a veto proof margin, which for those in California on average, will avoid a ten to twelve thousand dollar cut per year. So this is something the AMA does for the profession. Whether you're a member or not, you benefit from AMA advocacy. We continue to mention the importance of trained primary care, and I should also mention the AMA created the scope of practice partnership, because our concern is, that there are those who would rather have the nurse practitioner become the primary care physician. And we don't believe that's fundamentally fair for patients to try and say that a nurse practitioner is the same as a well trained physician who's undergone post graduate training in the practice of medicine.

Medgadget: Knowing what you know about the practice climate in 2008, would you have chosen to go to medical school?

Dr. Rohack: Oh, absolutely. I would still go to medical school. The rewards of being a physician far outstrip monetary awards. Yes, we have difficulties and hassles, but if you take a look at physicians since we started as a profession centuries ago, we've always had different problems. Sometimes those problems were dealing with the plagues, sometimes those problems were dealing with typhoid fever. Currently in the world we have still not solved malaria. Individuals are dying of malaria, they're dying of diseases that can be prevented. So that we certainly have a lot more that we can do. I think entering the medical profession in 2008 is going to be exciting, it's going to be invigorating from the ways that technology will allow us to better identify patients earlier, to be able to get them target treatments, so I would not discourage anyone from entering the medical field. I think it just highlights the importance of having a strong American Medical Association that can speak for the profession, the profession of medicine, rather than us going into our tribes of named specialties. Because it's when you go into tribes when you lose your power. That's why we're fundamentally re-changing and refocusing ourselves as an organization, reaching out again to our individual member physicians, to provide relevance to their daily practice, to remind them that a strong AMA means a strong profession.

Medgadget: And the last question is from Dr. Joshua Schwimmer, who's an editor at Medgadget and a practicing nephrologist in New York City. You already mentioned to me online activities such as member only activities, such as Member Connect surveys, and Joshua is asking if the AMA has any current or future initiatives other than that to connect with physicians online. It seems to him that there's a largely untapped potential for communicating with, educating, and organizing physicians. And whether the AMA has any plans to start a blog, a social network.. that's his question.

Dr. Rohack: To answer specifically, the answer is yes, we have plans. We don't have the adequate IT infrastructure online yet, but it is [being] built into our budget to incorporate that within the next year or two in a staged process. What we found is we took a look at our databases and our ability to connect to our members. The AMA had unfortunately had lots of different databases that didn't talk to each other. So you may have called the AMA ordering your CPT books, and you have also been a member through your county medical society and state medical society, and could have participated in another forum. Unfortunately our three databases didn't do a good job of talking to each other. One of the things, we hired over the last year or two, some outside content experts that are not necessarily from the medical field, but from the information technology world. And having younger physicians on our board of trustees, they're helpful to keep our feet to the fire saying "Ok, how do we need to communicate down the road?" Overall we are far better off than we were in the past, but we know we got more to do.

Medgadget: Thank you very much. My little suggestion would be also for the AMA to take a look into working with companies like Google to figure how it is better to sort through medical information on the internet. My personal experience is that patients, and some of my friends, when they go online to search for medical information there is a lot of confusion... Basically, when physicists talk to each other on the internet, they're usually physicists. When it comes to medicine, everybody is an expert. And as a result of this, I personally think, patients are suffering, and I think some kind of effort by an organization like AMA and companies like Google may one day help sort information on the internet, so patients are presented with better information. But that's for the future. We appreciate Dr. Rohack your willingness to talk to us.

Dr. Rohack: Thank you and clearly stay tuned, because we will be continuing to evolve our interactions with the electronic communication world in the next few years.

Medgadget: Thank you very much. We congratulate the AMA for HR 6331 and for your willingness to apologize to black doctors for past racism, and we wish you a great success when you assume the AMA presidency in 2009. Thank you very much.

Dr. Rohack: Thank you, Michael, and perhaps you will reconsider us at some point and join us, because we'd love to have you back as a member.

Medgadget: Thank you very much Dr. Rohack, I will join back with the AMA. Thank you.

Dr. Rohack: Thank you.