‘We’re putting a lot of re­sources into re­duc­ing the bur­dens of prac­tice’

Modern Healthcare - - Q & A -

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.

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