CINDY SANDERS

Nancy H. Nielsen, MD, PhD, President of the American Medical Association

At the Interim Meeting of the American Medical Association House of Delegates, held in November in Orlando, the national association voted on the key issues that shape the legislative agenda of the nation's largest physician organization.

Among the top priorities for 2009 is a mix of resolutions to ensure access to care, improve the health of patients, and work toward a healthier living environment. Specifically, the House of Delegates passed resolutions to find innovative ways to bolster the number of primary care physicians in the country, promote practice in underserved areas, and enhance programs to prepare minority students for careers as physicians. There was also a call for a federal ban on trans-fats in restaurants and bakeries plus support of state legislation banning text messaging while driving. Finally, the group called for more research into the health effects of global climate change and called for the endorsement of "green" initiatives and waste management policies.

However, the top priorities all centered on access issues and eliminating barriers to care. Chief among the AMA's concerns is finding an equitable method for Medicare reimbursement. While there are divergent opinions on the shape and form of a new system, almost everyone involved agrees the current sustainable growth rate (SGR) formula is fatally flawed and must be replaced.

"It's necessary because the way physicians are paid right now is really not working," said American Medical Association President Nancy Nielsen, MD, PhD. "It's not working for physicians, not working for the government, and makes patients crazy ... so it's really not working for anyone."

Calling this the "summer of Medicare meltdown," Nielsen said the AMA was very grateful to Congress for stopping the planned cuts in July 2008 ... and actually providing a small increase. When the legislators acted, there was an 18-month window to achieve consensus on Medicare physician payment reform and preserve access to healthcare for seniors before the next round of cuts ... that time has now dwindled to just under a year. If stakeholders cannot come up with a better plan, physicians face a 21 percent cut in reimbursement in January 2010, which would effectively shut down many practices.

Possible permanent solutions include gainsharing, converting to a medical home model, enacting quality incentives, bundling payments for medical services or trying other new payment models.

"There are a number of proposals," she said. "We're studying all of them. We want to make sure we don't go from one bad system to another bad system."

As the nation prepares for the onslaught of baby boomers who will become eligible for Medicare over the next decade, it is increasingly important to keep primary care physicians in practice and attract a larger percentage of new physicians to the field. In face of growing need, however, is a shrinking pool of clinicians.

"There are a number of reasons why there's been a decrease in the number of primary care physicians – a big one is the reimbursement," Nielsen pointed out, adding the disparity in pay between specialists and primary care doctors has clearly impacted young physicians' choices when it comes to a career path.

She noted the average medical school debt load is now $140,000. Being able to pay that debt back is a key concern for new physicians. The AMA is looking at expanded scholarships and loan repayment plans for students who choose to practice primary care.

Just as lower reimbursements are a negative, so too are the high expectation levels for primary care providers who must find a way to balance preventive, chronic and acute care while keeping up on the latest information covering a host of clinical and practice issues.

As senior associate dean for medical education at the State University of New York, Nielsen, who is a primary care physician, is all too aware of the concerns students have about choosing the broad-based practice route. "Medical students look at what expectations are by both patients and payers, and they say, 'this is crazy. We can't do all this,'" she said.