‘This is not about gun control … this is about public health’

Dr. Andrew Gurman, a hand surgeon from Hollidaysburg, Pa., became the 171st president of the American Medical Association earlier this month.

He sat down with Modern Healthcare Managing Editor Gregg Blesch to discuss the major policy decisions made at the AMA’s recently concluded annual meeting. The following is an edited transcript.

Modern Healthcare: Shortly after the worst mass shooting by a single gunman in U.S. history in Orlando, the AMA delegates asked Congress to end the de facto ban on funding research on gun violence. Why?

Dr. Andrew Gurman: Gun violence and its effects are a public health issue. It is important for everybody to understand what we did not do. We did not call for anything to do with Second Amendment rights or with gun ownership.

We simply said that we need to study the effects of gun violence. Thirty-thousand people each year in this country die from gun violence. Thirty- to forty-thousand people each year in this country die from opioid overdose. During the AIDS epidemic, at its height, 40,000 people per year were dying of AIDS.

With opioids and AIDS, we studied them to look for ways to reduce deaths. Yet with gun violence, we refuse to study to look for any possible means to mitigate the loss of life and the suffering. This is not about gun control; this is not about Second Amendment rights; this is about public health.

MH: Can you foresee a time, based on the results of such research, that the AMA would call for more aggressive policies to limit the availability of guns and certain types of guns?

Gurman: I have no idea what the AMA is going to do in the future. This is a public health problem, and we don’t know what the answers are. We don’t know what the causes are. It is just crazy to say that we are not going to even do the basic science, do the studies, so that we can try to prevent the needless loss of life.

MH: Another issue the delegates addressed was the opioid crisis. Did physicians play a role in creating this crisis, and what should their role be in its solution?

Gurman: Physicians see our role as being leaders to help solve the problems of opioid overdoses and opioid addiction. There are too many people dying of opioids; there are too many people using opioids inappropriately. We, as a country, constitute 5% of the world’s population, yet we consume 90% plus of the world’s production of hydrocodone.

Based on studying these issues, we need to learn better ways to control pain and better ways to deal with the symptoms that don’t necessarily need to be treated with opioids. This is a complex problem. It requires the availability of, and the coverage for, alternative therapies including physical medicine, biofeedback, mindfulness, exercise and other therapies.

The AMA has formed a task force to address those issues. We are studying the problem and coming out with recommendations.

MH: Do physicians acknowledge that they have played a role in overprescribing over the years?

Gurman: There has been a role for physician prescribing of opioids. While more and more people are turning to heroin and that accounts for an increasing share of opioid overdoses, most opioid deaths come from pills that were prescribed. They weren’t necessarily prescribed for that patient for the purpose for which they have been taken.

It is a complex issue. But when you drill down on opioid deaths from overdose, you find that most of the pills that were taken were not necessarily to be taken in concert with other drugs, for example, benzodiazepines for the treatment of depression. But that’s not what patients are using them for. It is complex, but we are studying, and we are taking a lead in trying to propose solutions.

MH: Last year Congress passed the Medicare Access and CHIP Reauthorization Act,

“It is just crazy to say that we are not going to even do the basic science.”

which replaced the sustainable growth-rate formula with different valuebased reimbursement frameworks. Do you support the changes?

Gurman: Before MACRA, physicians were already subject to a program that had three different reporting requirements: meaningful use, valuebased modifier and PQRS, the Physician Quality Reporting System. Taken together, those were three separate reporting streams and had a potential 11% penalty under that system.

MACRA consolidated those three systems into one. It simplified, to some extent, not only the reporting, but the breadth of measures that needed to be reported. It has a maximum penalty that starts at 4%. So it’s not necessarily good, and it certainly needs to be tweaked, but it is better than what we had before.

What we have so far is a proposed rule, 962 pages with lots of complexity. The AMA is preparing a very detailed comment on all of the things that are in those 962 pages. When we get the final rule, the AMA will be preparing materials to help physicians respond to and, hopefully, thrive or at least continue under the new system.

MH: Given the burden of the reporting and performance metrics under MACRA, will it push more independent physicians and small practices into bigger groups and hospital employment?

Gurman: That remains to be seen. The AMA has, through its website, a program called Steps Forward, which is a series of practice improvement modules. There are 35 of them. They are free to all physicians. People can get CME credit for participating, and some of them are fairly complex or deal with fairly complicated issues, such as value-based purchasing.

They are primarily aimed at smaller practices. Large conglomerates don’t need these measures. They produce their materials inhouse where they have departments that can deal with them. As we get the final rule, we will be preparing more materials, probably under the Steps Forward program, for physicians to access and use to navigate their way through MACRA, whatever the final incarnation is.

MH: Do the very big insurance mergers that are pending before the U.S. Justice Department and state regulators pose a threat to physicians?

Gurman: We are very concerned about these proposed mergers. Right now there are five dominant or major insurers in the country, and we think it would be detrimental to patients and to physicians if that number dwindles to three.

We have data upon which we base these conclusions. There was a UnitedHealth Group-Sierra merger out West several years ago. There have been other mergers that we have studied, and when you look at what those markets looked like before and after the mergers, rates go up, networks get narrower, and services are limited. It may be good for corporate profits, but it is not good for patients, and it is not good for docs.

There is no reason to believe that these mergers would do anything different.