‘We’re putting a lot of resources into reducing the burdens of practice’
Last week, the American Medical Association inaugurated its 172nd president. Dr. David
Barbe, a family medicine physician from rural Missouri, became the lead voice for the nation’s largest doctors’ organization. Barbe stopped by Modern Healthcare the day after his inauguration to talk about some of the most pressing issues facing physicians during his year-long presidency, including the ongoing opioid epidemic and how the proposed cuts to Medicaid might affect doctors and their patients. Modern Healthcare reporters Steven Ross Johnson and Maria Castellucci spoke with Barbe. The following is an edited transcript.
Modern Healthcare: Let’s start by having you give us the AMA’s top priorities this year.
Dr. David Barbe: Top of our list clearly, because this is on top of everyone’s list, is what’s going to happen with Congress and the administration’s efforts to modify and revise the Affordable Care Act.
The AMA has developed healthcare policy over more than a decade, and we believe that our policy is the best platform for us for advocacy. It covers Medicaid. It addresses how to cover the uninsured. And rather than put together a package, if you will, a comprehensive package, we believe that advocating for our principles and our policies is the more effective way for us to go.
MH: Why do you feel it was important for the AMA to state its opposition against the proposed caps on Medicaid?
Barbe: Our historical policy has been really fairly clear that we believe the safety-net programs are very important. We are opposed to anything that would weaken them and that we favor expansion of Medicaid as one way to cover more individuals in this country. It’s hard for me to understand how anyone could look at our policy and misunderstand that, but in these times when almost anything could be misconstrued, we wanted to be crystal clear that we are opposed to caps on Medicaid funding. We believe they simply don’t allow for unexpected contingencies within a population of a given state, changes in the healthcare landscape, changes in tests, treatments that might be on the horizon. There’s no flexibility there if you’re capped.
MH: Another contentious issue was whether to remove a waiver for the opioid addiction drug buprenorphine. What is the AMA doing to address the opioid epidemic and why are physicians butting heads about this?
Barbe: Buprenorphine is used to help people deal with the cravings for opioids and is used as part of a more comprehensive treatment program to reduce addiction. Part of the problem is that it’s very tightly regulated. You have to get certified to prescribe it, and then you’re only allowed to prescribe for a certain number of patients.
We believe that physicians, if they choose, should be able to prescribe to more patients. That would take some statutory changes. The other controversy was around not having to be registered to be a medicationassisted treatment program. If we really want to open up buprenorphine to more people, let’s take away some of those restrictions.
You may have heard that part of the legal-technical issue here is a law that was passed nearly 100 years ago now that says you cannot use, you cannot
“We wanted to be crystal clear that we are opposed to caps on Medicaid funding.”
“The majority of growth in residency spots over the past decade has been through private funding by hospitals. That’s not the best policy.”
prescribe narcotics to someone who’s addicted to narcotics. So, that’s what technically requires a waiver, and we think that is overly burdensome.
Those were some of the points of contention. How can you get more physicians, and is the training requirement really necessary, and if so, how much? And then there’s the issue of getting around this old and probably archaic law that restricts the use of things like methadone or buprenorphine to treat narcotic addiction.
And two of our five principles in addressing the opioid epidemic relate to reducing the stigma around both substance use disorder, which is the current term of what we’re talking about, as well as mental health in general, and secondarily, improving the number of services available for both of those, general mental health services as well as addiction or substance use disorder treatment, so they’re hand in glove. It’s not one or the other. We need both.
We need to destigmatize these in society and among physicians, and we need to expand the treatment resources that are available to those with substance use disorder and mental health issues that frequently go hand in hand.
MH: Where do you see ways for the AMA to address the burnout that plagues a lot of physicians?
Barbe: We have devoted a lot of resources over the past few years on what things will work best to improve the joy of practicing medicine again. Much of this we believe is the external pressures that physicians are under— paperwork burdens, prior authorizations, those hassles, and the frustration of the electronic health record in many cases.
We did a study last fall that shows that physicians spend twice as much time on data entry, clerical time, computer work, as we do on direct patient care and decision-making. That’s upside down. Nobody wants that. Patients don’t want that and doctors don’t want that, and that is a very direct cause of much of physician burnout. We want to practice medicine. We want to be with our patients and help them navigate their healthcare. So we’re putting a lot of resources into reducing the burdens of practice, to improving the practice environment itself.
The other part of this though is very much the individual part. It is physician health and wellbeing and resiliency. And we have brought individuals on to our staff who are helping us develop tools and resources for physicians to help that side of things. How do you strike a good work/ life balance, and how do you tailor that for me as a family physician, or how do you do that for a surgeon, or how do you do that for a 32-yearold female physician with two children? Those are each different scenarios, and so it’s not one-size-fitsall, but there is a balance that we need to achieve, and physicians have often not observed that as well because of our desire to be with our patients so much of the time.
So, those things are changing, and they will, in aggregate, help begin to reduce the issue of burnout and improve the joy of practice of medicine, and that’s good not just for the doctor, but that’s good for the patient. We give better patient care when we’re professionally satisfied with our practices.
MH: The physician shortage is a big concern for the industry. How did the AMA explain to the administration, which proposed policies that could affect foreign students from coming into the country to practice medicine, the important role that foreign medical graduates play in abating the overall physician workforce?
Barbe: In many cases the numbers speak for themselves. We mention the number of physicians. We can give them statistics about how many residents in training could be impacted by this. And then, secondarily, we talk about the importance of residents to our health system and how much care they give and that they often practice in inner cities, they often serve vulnerable populations, and without them we would have a very difficult time meeting the needs of some of those populations.
We also talk to them as part and parcel in this about the desperate need for more graduate medical education. Almost every study that has been done recently is projecting a severe physician workforce shortage across nearly all specialties. We have increased the number of medical students who are trained in this country significantly over the past decade. We have many international medical graduates that want to come and train in this country, many of whom will stay to practice in this country. Our bottleneck is in the number of residency positions to train those medical student graduates. That program is primarily funded by Medicare, and the number of Medicarefunded spots for residency training has been capped since 1997, so there have been very few additional Medicare-funded spots.
The majority of growth in residency spots over the past decade has been through private funding by hospitals. That’s not the best policy. That’s not the right way to ensure an adequate physician workforce for this country, irrespective if they’re U.S. grads or international medical graduates. That’s our pinch point in that pipeline.
We’re advocating for more positions; we’re advocating for more funding. We recognize the federal budget constraints, and we are advocating for a broader base of funding.
Our whole country benefits. Health plans benefit. We should broaden the base of funding for GME. Even a 10% or 15% increase in the number of spots would make a significant difference over time in the projected physician shortage.