2023 AMA Meeting Overview

Alec Bose:

Hello and welcome to this advocacy edition of the CAPCast. Last month, June 2023, physicians across the nation gathered in Chicago for the annual American Medical Association meeting. Many issues were discussed in the AMA House of Delegates including many issues that were relevant to the CAP and pathologists. We sat down with Dr. Joe Sanfrancesco to recap what happened at the meeting.

So thank you Dr. Sanfrancesco for joining us. We really appreciate you being here on a podcast with us today.

Dr. Joe Sanfrancesco:

Oh, it's my pleasure. Thank you for having me.

Alec Bose:

So just to start out, can you discuss a little bit about the delegation that was led by CAP that was representing pathologists?

Dr. Joe Sanfrancesco:

Absolutely, yeah. It's a really fascinating phenomenon and I would recommend that anyone who has any interest, as an AMA member alone, you are allowed to attend the meeting. Participation obviously varies based on whether you're a delegate or an alternate, or you hold an officer's position, et cetera but it is open to all AMA members, particularly reference committees, and you kind of get to see when the show's back in town, it's a massive undertaking with really thousands of people, members, staff, guests, members of the media. So it's pretty overwhelming even after doing it now for seven or eight years myself, and there's many others that have done it for a lot longer. What you do find out is that when you get to the House of Medicine at the AMA, and particularly the House of Delegates, it's a huge, huge diverse group. And even within specialties, there are various different groups.

So for pathology, we're pretty straightforward. Our delegation is the College of American Pathologists, but we are members of the Pathology Section Council, and that encompasses really any of the pathology organizations that have representation to the AMA. So off the top of my head here, we have the CAP, the USCAP, the ASCP, the American Society of Cytopathology, the National Association of Medical Examiners, and the American Association of Dermatopathologists. And I think that was everybody, and I apologize if I'm forgetting anyone. And then we have some guests. We meet a few times as a large group, and then we stay in constant contact throughout and prior to the meeting.

We don't all necessarily vote as a block. That's not something we do, but we do discuss things openly and it's really great. You have a lot of different opinions and a lot of different perspectives, and that really informs the Pathology Section Council with some excellent scientific background and really subject matter experts, no matter whether it's a forensics topic or a blood bank topic or a surgical pathology topic or an advocacy topic, each of the various members of the council and the representatives that are there on behalf of their organizations really bring a unique perspective and allow pathology really to be heard at the American Medical Association.

Alec Bose:

Yeah, thank you so much. And I think that's important to communicate in terms of just the scale of this sort of meeting, how many people are involved and how important these decisions are that are made during this meeting. So kind of on that note, do you think you could discuss a little bit about one of the big policy discussions that was happening at the meeting was surrounding Medicare physician payment. What actions did the AMA decide to take in regards to this issue, 'cause I know there were some campaigns and targeted messaging that was decided on, if I'm not mistaken?

Dr. Joe Sanfrancesco:

No, no. It was really fascinating for me, having done it for a few years now, you see different meanings, different vibes, for lack of a better term. This was one where the Medicare-

Alec Bose:

Good term, good term.

Dr. Joe Sanfrancesco:

... yeah, issue was front and center. I mean, it was really, really, really and one of the main topics this meeting. I would say that when you have an organization as large as the AMA and you have representatives from medical students to senior physicians to any type of pocket of medicine really truly is represented there, it's really hard to get everyone to agree on one thing. And I'd have to say that in the seven or eight years that I've done this so far, this is probably the first time I've seen a real significant, almost unified approach to saying that this needs to be done better by the American Medical Association.

There were various resolutions, people that spoke on the floor, people that spoke at reference committees saying that "We hear that you, the AMA, are doing things, we're not seeing it." And it was the first time that I've really seen where the membership almost wanted to take matters into their own hands. I think that at the end of the day, we really got to a place where the board literally came onto the floor of the house and said, "We hear you. We are working on it. We're trying to do better." And they're trying to approach it from a multi-pronged approach, including lobbying, grassroots efforts, providing physicians with information they need to contact their representatives to ensure that this is fixed.

One thing that was really fascinating, and I'm fortunate enough to participate in some of the advocacy efforts of the CAP, which is from a pathology perspective, but does have some mirroring in other parts of medicine, there's never been a cost of living increase in Medicare reimbursements, which is shocking to me. And I believe one of the quotes that I remember is it's really the only part of the entire kind of governmental process where we have not seen that. And so you're seeing consistent cuts and decreases, but we're seeing no cost of living increase, which is irrespective of what is justified to be paid for or not. It's just what the government typically does.

So that was something that we've never addressed that, and the AMA heard the membership on that and they're working on it. One thing that was interesting was some of the resolutions and some of the policy that was trying to be crafted directly from the membership, that was halted by the board and said, "Listen, we hear you, but we're really putting a lot of finances and a lot of effort into crafting our message with professionals, making sure marketing is optimal to really appeal to patients who really is probably the most important body of support we need." Because they can to go to their representatives and go to their congressmen and women and say, "We need you to really look at this and really reimburse our physicians appropriately so that they can provide us with the care that we need."

So I thought that all in all, we echoed a lot of what was going on, particularly as a CAP delegation, we had candidates from the president-elect to various board members come and meet with us. And listen, we're not a large delegation, but it was really impressive to say that, look, we understand that your voice matters and we're going to take time out of our busy schedule to meet with you so that when we are elected or if we are elected, we hear you. And I have to say that it was really, really cool from someone who's not been doing this too long to see that really that unification of the body had that much of an effect. But having said that, it was the largest amount of business I think we've ever had in an AMA meeting, and not all of it was at Medicare.

There were many, many other things. So it's really interesting that when you do get to the House of Medicine, what is important to one specialty, one delegation, one cohort, doesn't necessarily apply to everyone. And I'll give one kind of interesting story I heard. So typically candidates will go and interview with various constituencies at the AMA before their election. And one candidate who I won't say it was, a really excellent interviewee, was very cordial with us, and she said, "My number one issue is Medicare reimbursement," which from a CAP advocacy perspective, that's what you want to hear. Unfortunately, I think she had done a lot of interviews that day and she met with a delegation that was of pediatricians. And unfortunately for pediatricians, Medicare reimbursement really isn't ever going to be [inaudible].

Alec Bose:

Right, right. Of course. Yeah.

Dr. Joe Sanfrancesco:

And so when she said, "My number one, if I'm elected, my number one issue will be Medicare reimbursement." Well, as a pediatrician, that probably isn't what you want to hear. So it just goes to show you that even when there's a unified approach, and obviously I'm sure they were understanding of it in the House of Medicine, while that was important, but does go to show to know your audience and understand that the American Medical Association really does encompass representation from the entire House of Medicine, and that includes a diverse portfolio of priorities. And naming a number one priority was really tricky because again that doesn't necessarily reflect everyone. So for me, it was a lot of amateur politics that you get to see firsthand, but it's important when you have a democratic body in a parliamentary setting like the AMA.

Alec Bose:

Dr. Sanfrancesco, you said so many great things, even just sort of hearing about the different priorities as pathologists, that's probably something that's very important. But as you noted, for pediatricians, Medicare, by the nature of the program, is not going to be very motivating.

Dr. Joe Sanfrancesco:

But it also goes to show you, interestingly, if the candidate would've said CHIP or Medicaid, probably, but it's a long meeting and there's a lot of information to get through. But even then you do learn as we interact with other delegations. And I have to give our section council and our leadership of the section council supported by CAP staff a lot of credit because one of the first things you learn is that there's some constituencies that really talk a lot, and there's some that when they speak, people listen. And I have to give credit to the Pathology Section Council and all of its various members that I feel that when pathology speaks, people listen. But we're very judicious in what we speak about and we make sure that we're as concise as possible, which is something you learn very quickly at the AMA is very appreciated.

Alec Bose:

And it's just fascinating to hear just how large this meeting is and how many interests are represented there. There was a specific sort of, I guess it was a testimony, it was a resolution that came from Dr. Forsberg and Dr. Sullivan regarding blood... I think it was blood donations. Can you talk a little bit about those specific recommendations as well as... And there was also a blood transfusion testimony as well, I believe. Can you talk a little bit about that, if that's possible?

Dr. Joe Sanfrancesco:

Yeah, I think it's a great example of really what our section and particularly the CAP tries our best to do with these meetings. And I give the staff a lot of credit as always. There's so much business to get through, and basically for the listeners, the way it typically works is the House of Delegates divides the submitted resolutions. So if you're a member, a member of a delegation, a coalition of various different caucuses, you can author a resolution. It's a very open and democratic process on a topic that you either feel there is non-existing AMA policy or the existing AMA policy may not be what you believe is the most representative or accurate to your thoughts or to let's say, science, changes in legislation, et cetera. So you compose it, you submit it, and then they're put into various waste baskets, medical education, legislation, constitutional bylaws, et cetera.

And then once they're in there, they get letters. And then once they're in individual buckets, it's published to the membership who are attending the meeting or specifically the delegations that are providing representatives to the meeting. So we go through, I say we, but really we try to, and then the staff does an excellent job of really combing through everything and we try to highlight, okay, these are possibly pathology-specific or for your individual delegation for the CAP, these are CAP-specific. So Resolution 344 from the previous meeting was called Upholding scientifically and medically valid practices for blood transfusions.

So right away our antenna goes up as pathologists, and we are so fortunate to have Dr. Jean Forsberg and Dr. Cliff Sullivan who are blood bankers and they're experts. They're subject matter experts on the topic. But just to show you how this works, so that resolution was written by the Texas delegation. Well, Dr. Susan Strate is a member of the CAP and one of the CAP delegates, but she's also very, very in tune with what's going on in the Texas Medical Association. So with Dr. Strate being available, she was kind of our go-between, between Texas and our subject matter experts coming from the Pathology Section Council to offer some opinion and testimony at reference committee, which is where everyone gets a chance to speak.

And then the reference committee itself, which is various members of the AMA at the meeting deliberate, think they hear what they hear from the group, try to put it into a report and then make a recommendation to the house to say "Yay or nay," or "We like this resolution, but we want to make some changes." So what was great was Dr. Sullivan and Forsberg identified that some of the wording needed some tweaking. So they went, at the reference committee, they gave their testimony, and they basically did their best to try to correct and encompass what Texas was trying to do. And they did that. And the great way of doing that is really to kind of get together before, make sure everyone's in support, if you can do that, and then present. And that way the reference committee hears loud and clear, this is a friendly suggestion from subject matter experts to make this a better resolution. And that's exactly what happened.

And this actually had to do about some issues we had seen over the past few years where persons who would be receiving blood through transfusion wanted to specifically say, I wanted non-vaccinated blood, meaning a person who had not been vaccinated. It's just not feasible. We had a blood shortage. We always are always struggling to maintain the blood supply and to have basically two separate blood supplies would be nearly impossible for blood bankers and for laboratories to accommodate. And Drs. Forsberg and Sullivan did an amazing job being succinct to the committee saying "The wording of this could have some unintended consequences. Let's fix this." It was fixed. It was passed without any issue. And now the AMA staff and their lobbying efforts can have a clear message to the legislators they're going to talk to exactly what the AMA wants. And that's just a testament to really, when things go well, how well they can go.

Alec Bose:

Yeah. And I think that's fascinating just sort of to hear just in terms of just that sort of effective level of communication happening on not necessarily a personal level, but very much a individual interest level and being able to sort of collaborate beforehand to be able to make sure that the people who are undertaking this effort know that this is a good faith effort. And I think that what you were talking about was very important in that regard. I know there were a few other issues that were discussed. Maybe just dip our toes into a few of those topics.

Dr. Joe Sanfrancesco:

Sure. I think it was actually Resolution 404, and this was an additional intervention to prevent HP associated infections and cancers. So again, the pathology antennas go up. Now I will be as diplomatic about this as possible. This was authored by the medical student section who are incredible advocates, incredibly invested, strong opinions on many things, and they really take advantage of the fact that they have representation in there and they work very hard, and for that, I give them complete credit. But I would just say, unlike the Texas situation, they didn't take the opportunity on the front end to reach out to subject matter experts and say, "Hey, could we have some advice? Does this look right? What do you think?" In that situation though, the reference committee format allows us to offer friendly suggestions to say, "We like this resolution, but we have some minor tweaks that we think will make it even stronger."

Trying to get with them beforehand was a little more challenging. So then you take the risk of going in front of the reference committee and you hope that your subject matter advice in support is received well. And this was a scenario where it would've been nicer to have a little bit more discussion beforehand, but I do think we got to where we were going. And once explained and explained incredibly well by our cytopathology colleagues on the floor of the reference committee, it really improved the resolution and the resolution, it was a large resolution about many important topics facing HPV. There was a discussion about testing, and it was confusing because it suggested about, we weren't clear was this home testing versus in-office testing. And in an effort to just clarify, we offered some points, some backstory about HPV testing. It was very well received by the reference committee. It was incorporated into the resolution, and that resolution passed as well.

So it just goes to show the benefit of our council having so many subject matter experts on a variety of issues, forensics, always an issue where that may be coming out of someone or a delegation that doesn't know anything about forensics has unintended consequences. And we have people of our... Physicians in our delegation who are able to step up and say, "This is fine, but we're just giving you our perspective." And I say, more often than not, the reference committee appreciates that data and incorporates that in. So it's what we try to do. And I think that all in all, it's a great opportunity for pathology to be seen and to be heard and to also monitor what's going on. So if there's anything would adversely affect our specialty, we're there to step up and say, this is why we're concerned, and we have our opportunity to speak to that.

And to your point about the non-competes, that's a great example where there's not a definitive plan. AMA doesn't want to fall on one side or the other. There's always unintended consequences. So we're there just to listen and make sure that nothing gets done or said or passed that would have an effect negatively on our specialty. And that was something where we'll see what happens with it. But CAP has policy on it. The AMA now has some policy on it or not, depending if it gets referred for decision or study at the AMA, but we'll always keep our eyes open and our ears open and make sure that if anything does affect us, we're there to comment on it if necessary.

Alec Bose:

Dr. Sanfrancesco, thank you so much for this conversation. I personally know, if anybody listening is unclear, I am personally not a pathologist, so I am always learning things in these discussions and I'm very fascinated by these topics and just being able to understand how these sort of logistics and political things get done and in something that I don't think a lot of people who are outside of medicine, patients, things like that, don't actually think about that much.

Was there anything else that you wanted to sort of discuss? One thing, and this wasn't in my questioning, but I was sort of curious as I heard you discussing just the Medicare payment cuts and how much of a priority that is not just for pathologists, but many doctors and even, and there's also some people who are not necessarily as interested in that, but I think about the Medicare Economic Index and just sort of being able to tie certain things to that. Can you speak a little bit to that? I'm just a little bit curious about that.

Dr. Joe Sanfrancesco:

No, you know, it's always been an issue in medicine in the time that I've spent in it, before I got into it. You always joke about the HMOs in the '90s and stuff. This felt different to me. This felt like physicians were coming to their colleagues and their House of Medicine and saying, "We need help" because this is not just an issue of being compensated for the work that physicians do. This is about keeping the doors of offices and hospitals open for our patients. And unfortunately, I think of all the things that happened through COVID, the cost of medicine for those providing it, to keep the offices and the hospitals open, is at a breaking point. And this is a situation where we're not just talking about us, we're talking about our staff, those that allow us to take care of our patients, to keep the lights on, to keep the water...

I had never seen that before. I had seen, oh, we should. This was really concerning. And I think that's where we saw such a unified front saying, this is an issue of the compensation and the reimbursement is not even enough to allow us to practice and take care of our patients. And for me, that was a whoa moment. That was a not doctors complaining, the classic narrative that whoever a lobbyist, insurance, whoever may be trying to portray against us, this was us saying, "If we want to be able to take care of our patients, we need help." And that was really, really impressive to me. And I felt very proud that day to be a member of the American Medical Association. And the last thing I'll say, a kind of a plug, we're able to be there because our members of the CAP are members of the AMA.

The way the number of delegates are assigned for the House of Delegates at the AMA is based on your specialties' ratio of members that are American Medical Association members. We are fortunate at the CAP to have a strong constituency of our CAP membership that also hold AMA membership. And that is so crucial because that gives us a voice. And if we don't have that, like some specialties go through, you could actually lose your delegation entirely. Now, you can still attend as an AMA member, but you don't have a say and you sure don't have a vote. So I want to say thank you to all of the CAP members that maintain their AMA membership.

I know you have a lot of options when it comes to memberships, but that really allows the CAP a seat at the table, several seats at the table actually. And with those seats come votes and influence to advocate for pathology and to make sure that anything discussed at pathology at the meeting has our input. So I want to thank members and anyone that is not an AMA member, I would politely ask you to consider joining because every vote matters, and our votes are predicate on how many of our CAP members are AMA members.

Alec Bose:

Well, I think that promotion is as good as a note to leave it off as any. Thank you so much Dr. Sanfrancesco for joining us today. We really appreciate your time.

Dr. Joe Sanfrancesco:

Alec, it's been an absolute pleasure. Thank you.

Alec Bose:

That's all for this advocacy edition of the CAPCast. Thank you so much for listening. For more advocacy updates, be sure to follow our advocacy newsletter and follow us on Twitter @capdcadvocacy. Once again for CAP Advocacy Communications. I'm Alec Bose, and we'll see you next time.

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