Jan. 12, 2017

Issue Spotlight

The top issues that will affect physicians in 2017

The year ahead in medicine, tumultuous as it promises to be, holds several key issues on which physicians should focus their attention. Health insurance coverage and access, prescription drug pricing, the new Medicare payment system and the opioids epidemic all require a strong physician voice present in the conversation.

Health insurance coverage and access
A new administration will enter the White House on Jan. 20 and the president-elect has expressed his intention to repeal and replace the Affordable Care Act (ACA), which could reduce insurance coverage that more than 20 million Americans gained under President Obama's signature legislation.

Acknowledging that the health system reform is an ongoing process, the AMA has expressed its willingness to work with the incoming administration and Congressional leaders on addressing the shortcomings of current law while maintaining the insurance enrollment gains of the ACA and expanding health insurance affordability and choice. Read more about the AMA's vision on health care reform.

Implementation of new Medicare pay system
The Centers for Medicare and Medicaid Services (CMS) released its final rule for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) in October, which repealed the flawed Sustainable Growth Rate (SGR) formula in 2015. Thanks to physician feedback, the new payment system—the Quality Payment Program (QPP)—should transition the health care system toward one that supports physician efforts to provide high-quality care.

The AMA will continue its work to make sure this implementation offers the best possibility for success for physician practices. To help your practice transition smoothly, the AMA has put together a collection of resources, such as the payment model evaluator, that are housed on its understanding Medicare payment reform webpage. Learn more about the numerous terms and acronyms associated with the QPP.

Reversing the opioid epidemic
The latest data from the Centers for Disease Control and Prevention provide a sobering reminder that more work remains to reverse the nation's opioid epidemic. From 2014 to 2015, opioid-related deaths increased from 28,647 to 33,091—with significant increases in death from heroin and illicit fentanyl. At the same time, physicians have been using prescription drug monitoring programs with greater frequency, prescribing opioids more judiciously, taking more education, and becoming trained to treat substance use disorders. And tens of thousands of lives have been saved through the opioid antidote naloxone—thanks in part to nearly every state now having improved naloxone-access laws. While physicians must continue their efforts, to truly turn the tide, greater access to treatment for substance use disorders and non-opioid and non-pharmacologic pain care must occur.

The AMA's Task Force to Reduce Opioid Abuse, a coalition of numerous state and medical specialty societies, will continue efforts to increase registration and use of PDMPs, enhance physician education, reduce stigma of chronic pain and substance-use disorder, enhance access to treatment, and expand access to naloxone through co-prescribing and standing orders.

Prescription drug pricing
Recent increases in prescription drug prices are of major concern to patients. These increases have created higher costs and price swings, making it difficult for some patients to afford much needed medications. The AMA's grassroots initiative,, was launched late last year with the purpose of collecting patient stories about how rising drug prices are affecting their lives. Achieving greater transparency in prescription drug costs and coverage will be significant issues in the coming year as the nation attempts to address these concerns. The AMA's grassroots network is asking the public to join the initiative to uncover the truth about prescription drug pricing.

EHR interoperability
Physicians enjoy treating patients. A recent qualitative study found that physicians spend nearly two hours on EHR and other clinical desk work for every hour of direct face-to-face time with patients. One of the major sources of professional dissatisfaction found in the study was poor EHR usability and interoperability. This is a battle physicians have been fighting since the introduction of EHRs and the fight isn't over. One key step was taken late last year when Carequality and CommonWell, representing more than 90 percent of the EHR marketplace in acute care settings and nearly 60 percent of the office-based EHR market, entered an agreement to advance nationwide interoperability.

This is a step in the right direction, but physicians have also taken matters into their own hands. It will be important in the coming year to continue progress toward interoperability and make sure that these tools, which hold so much promise, are not just another roadblock to the patient-physician relationship.

Regulatory relief
The regulatory burden placed on physicians is a major component of physician burnout. Physicians spend too much of their time on administrative tasks rather than providing care to patients. The evolving health care system needs easier enrollment, more rational program integrity rules and, overall, fewer reporting requirements.

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National Update

AMA CEO: Before repealing ACA, offer replacement details

The AMA welcomes legislative proposals that make insurance coverage "more affordable, provide greater choice and increase the number of those insured," AMA Executive Vice President and CEO James L. Madara, MD, said in a Jan. 3 letter to House and Senate leadership.

But policy makers ought to provide "reasonable detail" about their replacement plan before moving to alter coverage provided under the Affordable Care Act, Dr. Madara wrote. "Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform."

As policy makers consider systemic reforms designed to make insurance coverage more affordable and accessible, he added, "it is essential that gains in the number of Americans with health insurance coverage be maintained."

The letter to Capitol Hill leaders comes as Congress prepares to repeal portions of the ACA through the budget reconciliation process. The AMA supported passage of the ACA "because it was a significant improvement on the status quo at the time," Dr. Madara wrote, adding that "we continue to embrace the primary goal of that law—to make high quality, affordable health care coverage accessible to all Americans."

Yet, Dr. Madara added, President Obama's signature legislative achievement "is imperfect and there are a number of issues that need to be addressed." The AMA looks forward to engaging lawmakers on proposals that are consistent with the Association's vision for health care reform. That vision arises out of a comprehensive policy framework refined over two decades through the AMA House of Delegates, which is composed of representatives of more than 190 state and national specialty medical societies.

The AMA, Dr. Madara wrote, is ready to work with lawmakers to continue the "ongoing quest for improvement" that health system reform represents. Such work, he wrote, is intended to meet the goal of "ensuring that all Americans have access to high quality, affordable health coverage."

Congress considers budget resolution

The Senate passed the Fiscal Year 2017 Budget Resolution (S. Con. Res. 3) with plans to hold a vote by the end of the week. The House of Representatives is expected to take up and pass the measure shortly afterward, though House leadership is still working to secure the votes needed for passage. The Budget Resolution generally establishes Congressional spending levels for a given year or years, and also serves as a messaging tool for policy priorities. It cannot be used to make actual policy changes.

The resolution currently under consideration is for the 2017 Fiscal Year, which actually started on October 1, 2016. The primary purpose for adopting a budget at this late date is triggering the reconciliation process. Reconciliation provides for expedited procedures in the Senate that will allow for repeal of key portions of the Affordable Care Act (ACA) with only a simple majority.

If the resolution is adopted, House and Senate committees will work on legislation targeting critical spending and revenue provisions of the ACA. However, the path to ultimate consideration of the reconciliation bill and any possible legislation to provide new health coverage options is still uncertain.

House passes AMA-supported public health bills

The House of Representatives Jan. 9 passed four AMA-supported public health bills that would better coordinate care and clarify existing law. All of the bills previously passed the House by voice vote in the 114th Congress. The bills include:

CMS releases 2017 QPP quality measure benchmarks

If a physician or practice plans to participate in the 2017 Quality Payment Program (QPP), also known as the Merit-based Incentive Payment System (MIPS), with the goal of receiving a bonus in 2019, it is highly recommended that they review the recently released 2017 QPP measure benchmark information. The quality benchmark information does not apply to physicians who plan on minimal participation in 2017 only to avoid a 2019 penalty—submit one measure, one time in 2017.

The 2017 QPP benchmark information was released late last week and posted to the Centers for Medicare and Medicaid Services (CMS) QPP website. The benchmark calculations for the 2017 performance year use data submitted for the Physician Quality Reporting System (PQRS) in 2015 by QPP provider types who were eligible for MIPS but not newly enrolled that year, or by groups with at least one such clinician. When a clinician submits measures for the QPP Quality Performance Category, each measure is assessed against its benchmarks to determine how many points will be earned. A clinician can receive anywhere from three to 10 points for each measure, not including any bonus points.

Benchmarks are specific to the type of submission mechanism: EHRs, QCDRs/Registries, CAHPS and claims. For CG-CAHPS, the benchmarks are based on two sets of data: 2015 PQRS CAHPS and 2015 ACO CAHPS data. Submissions via the CMS Web Interface will use benchmarks from the Shared Savings Programs.

Each benchmark is presented in terms of deciles. Points will be awarded within each decile (see Table 1). Clinicians who receive a score in the first or second decile will receive three points. Clinicians who are in the third decile will receive somewhere between three and 3.9 points depending on their exact position in the decile, and clinicians in higher deciles will receive a corresponding number of points. For example, if a clinician submits data showing 83 percent on the measure, and the fifth decile begins at 72 percent and the sixth decile begins at 85 percent, then the clinician will receive between five and 5.9 points. For measures where a positive performance is seen in a lower score, the scores are reversed in the benchmark deciles.

Patient-facing encounter codes now available

The Centers for Medicare and Medicaid Services (CMS) last week released and posted to the Quality Payment Program (QPP) website the list of patient-facing encounter codes. The list is used to determine the non-patient facing status of clinicians eligible for the Merit-based Incentive Payment System (MIPS). Given the flexibility in program requirements for non-patient facing clinicians, the encounter codes are critical for CMS to identify MIPS-eligible clinicians.

A non-patient facing MIPS-eligible clinician is:

The list of patient-facing encounter codes are categorized into three overarching groups of codes—Evaluation and Management Codes, Surgical and Procedural Codes and Visit Codes. The use of these codes classifies MIPS-eligible clinicians as non-patient facing and patient-facing.

CMS takes steps to help physicians identify dual eligibles

As an AMA notice reminded physicians in July, balance billing of Medicare patients enrolled in the Qualified Medicare Beneficiary (QMB) program is prohibited. The QMB program is a Medicaid program that helps very low-income patients who are enrolled in both Medicare and Medicaid with their Medicare cost-sharing.

In response to physician concerns that it can be difficult to identify their QMB patients, the Centers for Medicare and Medicaid Services (CMS) Acting Administrator Andy Slavitt recently notified the AMA of new steps the agency is taking to inform physicians of patients' QMB status:

Additional information is available from the Medicare Learning Network.

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State Update

How physician surveys impact major issues

How many surveys have you been asked to take in the last year? Now, how many of those surveys seemed like they mattered? The Internet is flooded with surveys about anything and everything, but surveys directed toward physicians and focused on specific impact issues can actually make a difference. For the Colorado Medical Society, surveying physician members has brought a new element to advocacy efforts on major health care concerns.

Benjamin Kupersmit, president of Kupersmit Research, joined forces with the Colorado Medical Society in 2008 to conduct a survey about comprehensive health care reform. Seeing tremendous value in the survey's data, the parties continued their relationship and addressed many other issues such as network adequacy, physician-assisted suicide, Colorado's attempt at a single-payer system, known as Amendment 69, and the Aetna-Humana and Anthem-Cigna mergers.

"We've been able to use the surveys primarily to create a representative view of the voices not in the room when the board meets," Kupersmit said, "the voices of the physicians who are too busy to show up and engage in that in-person level."

"We always do some kind of a focus group with the people who are involved," he said. "And we will always open up these focus groups to whoever wants to participate." For example, when Amendment 69 was on the table in Colorado, they brought in both advocates and opponents to collect perspectives from both sides and create legitimate data that reflects the full opinion of the organization.

Surveys make a difference
The society sent a survey to physician members to find out how they felt about the two major insurer mergers last year. "This survey set out to specifically create evidence of monopsony power and abuse by commercial payers as being experienced by our physicians," Kupersmit said. The critical questions in this survey were directed toward the physicians who could cite specific challenges in contract negotiations and that were hindering their ability to contract, authorize and be paid for their work.

One of the questions asked was how the mergers would affect physicians' abilities to negotiate contracts with the insurers. And about 85 percent of the physician members said it would negatively affect their negotiations. This data was critical for the society in how it approached its opposition to the mergers.

"It was very impactful," Kupersmit said. "We asked our decision makers, 'Do you support or oppose the mergers?'" They found compelling evidence that the physicians on the ground were largely against them.

Kupersmit pointed out an important part of choosing which issues to take a stance on or approach solutions to after surveying physicians. You have to look at "the balance between [strong] and soft intensity of support or opposition," he said. "When 63 [percent] strongly oppose and 16 [percent] somewhat oppose, that ratio is so tilted that we see that there's passion, and in this case fear, frankly, if this merger was allowed to go through."

With Amendment 69, the Colorado Medical Society's survey found that 67 percent of physicians across the state were strongly against the amendment and only 9 percent were strongly in favor. "What we found from our physicians is that [they] have little or no appetite … for a huge effort to restructure," Kupersmit said. And the results of this survey enabled the society to take a position on the issue.

The AMA also conducted a survey, in collaboration with the California Medical Association, which was implemented in several other states and captured physicians' opinions on the mergers. That data was sent to the U.S. Department of Justice (DOJ) and state attorneys general, led to meetings between the DOJ and practicing physicians and culminated in the opposition to the deals not only from several states, but also from the DOJ. The lesson: Physician voices have power.

Read more at AMA Wire®.

Gun violence: Use public health approach in the exam room

Counseling patients on proper firearm safety and storage comes with cultural, societal and political barriers. But when physicians focus on the well-being of their patients, risk factors and research, and use an empathetic and knowledge-driven approach, firearm safety can improve. It's not about politics. It's about keeping patients safe and healthy.

Marian Betz, MD, MPH, an emergency physician and associate professor of emergency medicine at the University of Colorado School of Medicine, has found herself "on the front lines" of firearm violence prevention through treating victims of violence in the ED.

"I'm often frustrated by what feel like really senseless acts of violence that we should be able to prevent, and people's lives shouldn't be ruined," Dr. Betz said to a crowd of physician advocates at the 2017 AMA State Legislative Strategy Conference in Amelia Island, Fla.

Dr. Betz and her colleague, Megan Ranney, MD, MPH, associate professor of emergency medicine at Warren Alpert Medical School of Brown University, provided physicians at the conference with real-world information on how to talk to patients about firearm safety and violence prevention.

"There are patients who truly fear that a physician documenting firearm access is the first step to firearm confiscation," Dr. Betz said. "So should doctors talk about guns? We would both say, 'Yes.'"

Physicians have a role to play. "Even things as simple as educating families on safe-storage methods and homes with safe storage, [and] identifying people at risk of suicide can have a real impact," Dr. Betz said.

Know the numbers
When physicians are talking about firearm safety and violence prevention with patients, they should know the facts of the matter. Firearm ownership and reason for ownership—whether it's hunting, protection or recreation—can affect how a physician approaches the issue.

"Thinking about your [patients'] and what matters to them and what the firearm culture [in your area] is will be important in how you craft interventions," Dr. Betz said. The average U.S. gun-related death rate is about 10 per 100,000 people, and the rate varies by state and region, she added.

There were 33,636 firearm deaths in 2013. Of those deaths, just 1.5 percent were "accidental," while 0.3 percent resulted from mass shootings. Thirty-four percent were homicides and legal interventions, and 63 percent were suicides. "I'm not trying to imply that suicide deaths are more important," Dr. Betz said. "[But] in the national conversation about gun violence, suicide is often left out."

Safe storage of firearms could significantly reduce the number of firearm deaths because these are theoretically preventable, Dr. Betz said.

"We know that of all people with suicidal thoughts and even attempts, only 10 percent actually die by suicide," she added. "We know when people attempt suicide with a gun, about 90 percent of them die … and that final decision is often impulsive."

The right questions to ask
"We talk about smoking. We talk about family history. We talk about diet. We talk about blood pressure management," said Brown's Dr. Ranney. All of which have risk factors that lead to those discussions. There are risk factors that indicate someone has an increased risk of experiencing a firearm-related injury and they can be addressed through interventions that could potentially stop a shooting from happening.

"Unfortunately, due to the lack of research our knowledge of what those risk factors are is still very broad," Dr. Ranney said. For example, citing the recent violence in Chicago over the holidays, Dr. Ranney said, it's known that interpersonal violence is contagious. "After there's one shooting there's more likely to be another," she said. Another recent JAMA Internal Medicine study found that "social contagion" accounted for 63.1 percent of 11,000-plus Chicago acts of gun violence analyzed between 2006 and 2014.

When speaking with patients and their families, physician counseling should be individualized and routine, Dr. Ranney said, "so that they're not feeling singled out … but, rather, that you're taking into account the reasons for owning a firearm" and how to keep them safe.

Examples of the right questions when patients are at risk:

Having the conversations in an individualized, empathetic, but orderly spirit actually does work, Dr. Ranney said. Research has found that families given brief counseling and a trigger lock by a pediatrician are significantly more likely to use them. Emergency department and trauma service interventions can lower the risk of future fights and weapon carriage. Families of suicidal teens may lock up their guns if counseled appropriately.

Read more at AMA Wire.

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Judicial Update

Patient-psychiatrist confidentiality hampered in liability ruling

A decision of the Supreme Court of Washington requires a psychiatrist to do the impossible: predict imminent dangerousness in patients who have neither communicated recent threats, indicated intent to do harm, nor indicated a target for a potential threat. This extra duty placed on the shoulders of psychiatrists could have a major impact on patient-psychiatrist confidentiality.

Howard Ashby, MD, is a psychiatrist in Washington. In 2010, one of Dr. Ashby's out-patients, Jan Demeerleer, attacked his ex-girlfriend, Rebecca Schiering, killing her and her son Philip Schiering, and injuring another son, Brian Winkler. DeMeerleer then returned home and committed suicide.

The attack occurred in July. Yet DeMeerleer had last met with Dr. Ashby in April, almost four months earlier. Dr. Ashby's notes for this last meeting state that DeMeerleer had indicated only "suicidal ideation"—not a threat of harm against another person.

At stake in Volk v. DeMeerleer was whether or not Dr. Ashby, or any psychiatrist, should be held responsible for failing to notify third parties that a threat of violence was imminent—even though the patient had not expressed violent intentions toward that third party. A lower court decided the psychiatrist could not have identified the actual victims as targets because the patient had communicated no threats against them during his treatment.

An appeals court then examined the duty of a mental health professional to protect a third party, ultimately reversing the trial court and ruling that mental health professionals who treat voluntary outpatients may owe a duty to protect "all foreseeable victims, not only those reasonably identifiable victims who were actually threatened by the patient."

But the Supreme Court of Washington in December held that a psychiatrist may be liable for damages if his patient kills or injures a third party, even if the patient has not communicated to the psychiatrist homicidal or violent intentions and even if, as here, the psychiatrist only treated the patient in an office setting.

"Holding mental health professionals liable to third-party victims who were not reasonably identifiable as targets of actual threats places an impossible burden on mental health professionals and limits their ability to treat patients," the Litigation Center of the AMA and several other medical societies argued in an amicus brief.

Psychiatrists are dedicated to providing treatment for patients who pose a risk for violence, "but they cannot accurately predict whether and when any particular patient will have a violent outburst, much less the target of that violence, as here, no threat of harm was made and no victim was indicated," the brief said.

The brief further argued that the law should protect patient-physician confidentiality. Mental health professionals should owe a duty to third persons only when a patient has communicated an actual threat of physical violence against a reasonably identifiable victim.

Read more at AMA Wire.

Case threatens limit on interstate medical liability exposure

A Washington high-school football player collapsed on the field in the middle of a 2009 game and later died. The Idaho physician who treated him for a concussion the week before was named in a Washington lawsuit brought by the teenager's family. But the courts have therefore held this would be inconsistent with Washington jurisdictional law regarding medical liability cases and could affect physicians' ability to provide care to out-of-state patients.

When Drew Swank was 17, he suffered a concussion during a high-school football game in his home state of Washington. One week later, a physician in Idaho, as well as his coach, cleared him to play. In that next game, his performance was slow and uncoordinated, according to the lawsuit. And after taking a big hit, Swank collapsed and was taken to the hospital where he died a few days later.

At stake in Swank v. Valley Christian School is whether the state of Washington can assert "long-arm" jurisdiction over the Idaho physician who provided medical treatment to Swank, a Washington resident, who later died in Washington, allegedly as a result of the physician's negligence.

The Washington Court of Appeals affirmed dismissal of the Swanks' claim against the Idaho physician in May, and now the Swanks are seeking review of that decision in the Washington Supreme Court before the case returns to the trial court.

Jurisdiction issues
Though the boy's death is a tragedy, naming the Idaho physician in the lawsuit is inconsistent with Washington's "long-arm" statute. In Lewis v. Bours (1992), a unanimous decision held that "in the case of professional malpractice, a tort is not committed in Washington if the alleged act of malpractice was committed out of state even though the injuries may manifest themselves in Washington."

The Swanks are asking the court to create a result-oriented exception to Lewis that is analytically indefensible, runs counter to public policy and offends due process, the Litigation Center of the AMA and several other medical societies argue in an amicus brief. "The Swanks urge the court to allow Washington courts to exercise jurisdiction over a nonresident physician if the physician knew or should have known the patient would be traveling to Washington, and if Washington law gives the patient a claim based on the physician's provision of care and exercise of medical judgment."

This exception would run counter to the Lewis decision. The Swanks' argument "would offend due process by making personal jurisdiction depend not on the nonresident physician's acts, but rather on the unilateral acts of patients," the brief says.

Read more at AMA Wire.

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Other News

Attest to meaningful use by Feb. 28

Physicians have until Feb. 28 to attest to meaningful use for the 2016 program year. Physicians have been required to attest to meaningful use every year to avoid a payment adjustment in future years. For all returning participants, the reporting period will be a minimum of any continuous 90-day period between Jan. 1 and Dec. 31, 2016.

To attest, eligible professionals should submit their data through the Centers for Medicare & Medicaid Services' (CMS) Registration and Attestation System. To speed the attestation process, the AMA recommends that physicians attest during off-peak hours, such as evenings and weekends, and that they take time now to ensure that their information is up to date before beginning to enter 2016 data. CMS has provided a "What You Need to Know for 2016" tip sheet for eligible professionals.

CMS releases more information on ICD-10 update and its impact on PQRS

The AMA several months ago was made aware of the yearly ICD-10-CM coding update potentially affecting successful 2016 Physician Quality Reporting System (PQRS) reporting and Value Modifier calculations.

Due to the delayed transition to ICD-10, there was an unusually large yearly coding update in October, 2016, that affected some quality measure specifications. As earlier reported, the Centers for Medicare and Medicaid Services (CMS) responded to AMA advocacy and announced that it will not apply the 2018 PQRS penalty, as applicable, to any eligible professional (EP) or group practice that failed to satisfactorily report from Oct. 1 to Dec. 31, 2016, because of the Oct. 1, 2016, ICD-10 update. The Value Modifier program will also consider eligible professionals as successful if they meet PQRS reporting requirements.

CMS has released FAQs outlining the scope of the issue. The majority of the ICD-10 coding changes that impacted 2016 PQRS measures were related to diabetes, pregnancy, cardiovascular, oncology, mental health and eye disease diagnoses. The impacted PQRS measures may be different depending on the reporting mechanism. However, CMS still expects EPs and group practices to report and submit quality measures for 2016 PQRS regardless of whether they believe they are affected by the coding update.

CMS will determine after the data is submitted whether the EP or group practice was impacted by the ICD-10-CM code update. The affected practices will be removed from the PQRS penalty prior to the release of the 2016 feedback reports.

CMS also has released revised and updated its 2017 electronic quality measure (eCQM) specifications. The original release of the 2017 eCQM specifications last year did not include the October, 2016, ICD-10-CM update. For physicians planning to report eCQMs in 2017 to satisfy the Quality Payment Program (QPP), the AMA encourages physicians to contact their vendor to ensure they have incorporated the latest eCQMs into their electronic health record.

Nominations open for 2017 Belle Chenault Award for Political Participation

Named in honor of former AMA Auxiliary member of the AMPAC Board of Directors, Belle Chenault, the award was established in 1990 and is awarded every two years by the AMPAC Board of Directors to the AMPAC/AMA Alliance member who has made significant personal contributions of time and talent in assisting friends of medicine in their quest for elective office at the federal and state level.

The nominees must be AMPAC and AMA Alliance members for both years of a two-year election cycle. The deadline to submit nominations is Jan. 30. Read the full criteria for the 2017 Belle Chenault Award including how to submit a nomination.

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Upcoming Events

Feb. 17 – 19, 2017:
Whether you want to run for public office or campaign for a candidate who supports issues that are important to medicine, AMPAC, the AMA's bipartisan political action committee, offers the hands-on training you need. The Candidate Workshop is designed to help you make the leap from the exam room to the campaign trail and give you the skills and strategic approach you will need to make a run for public office. Please note participants are responsible for their registration fee, hotel accommodations at the Hyatt Regency Washington on Capitol Hill and travel to and from Washington, D.C. Faculty, materials and all meals during the meeting are covered by the AMA. Learn more or apply today.

Feb. 27 – March 1, 2017:
The 2016 National Advocacy Conference will take place in Washington, D.C. Participants in this year's conference will gain important insights from industry experts, political insiders and members of Congress. Conference participants will leave more well-informed and empowered to advocate for patients, the medical profession and the future of health care. Learn more and register today.

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