May 18, 2019
Issue SpotlightEmployed physicians now exceed those who own their practices
Chances are now slightly more likely that a physician is employed by someone and not a physician who owns his or her practice.
In 2018, 47.4% of practicing physicians were employed, while 45.9% owned their practices, according to a new entry in the AMA Policy Research Perspectives (PRP) series. The PRP is based on data from the 2018 AMA Physician Practice Benchmark Survey, which included 3,500 physicians from 50 states and the District of Columbia who provide at least 20 hours of patient care weekly and do not work for the federal government. The new ownership figures are a milestone, marking the first time the number of employed physicians is greater than the number of those who own practices. But it does not mean physician-owned practices are going away.
The PRP, “Updated Data on Physician Practice Arrangements: For the First Time, Fewer Physicians are Owners Than Employees,” shows there are still a large number of physician practice owners. And it notes that this decline is the continuation of a trend that medicine has been monitoring for more than three decades.
In fact, the rate at which physician ownership is falling is slower today than it was in the late 1980s and early 1990s. The share of physicians who are owners fell by more than seven percentage points in the six years between 2012 and 2018, data from the Benchmark Surveys shows. Between 1988 and 1994, ownership fell 14.4 percentage points, from 72.1% in 1988 to 57.7% by 1994.
“Given that only now has the point been reached where the number of employed physicians exceeds the number of owner physicians, caution should be taken in assuming current trends will continue indefinitely,” says the PRP, written by Carol K. Kane, PhD, Director of Economic and Health Policy Research at the AMA.
In 2018, 10% of physicians were employed in practices that are entirely owned by other physicians, also called private practice. In total, and including the practice owners and the physician employees and independent contractors who work for them, more than half of physicians—54% in 2018—worked in practices that are entirely owned by physicians, according to the PRP. That number is down from 2012, when the share stood at 60.1%. But the numbers indicate the downward trend has been slowing because half of the shift occurred in just the first two years of that six-year period.
Read more here.
The AMA provided strong support for the final report and recommendations of the U.S. Department of Health and Human Services (HHS) Interagency Payment Management Best Practices Task Force, which were approved at its May 9-10 meeting. The recommendations call for reversing harmful policies such as arbitrary limits on prescribed pain medications and one-size-fits-all approaches, instead treating each patient as an individual. The task force also seeks more support for multidisciplinary, multimodal pain care, better and more equitable health insurance coverage of non-opioid medications and non-pharmacologic treatments for pain, and recognizes an urgent need to address stigma faced by patients with pain and/or substance use disorders.
AMA President-elect Patrice Harris, MD, MA, participated in a roundtable discussion with task force members about dissemination and implementation of its recommendations. Dr. Harris emphasized the need to identify systematic and sustainable solutions to pain care and the epidemic of opioid-related overdose deaths, so that as a nation we can stop lurching from crisis to crisis and achieve a state of perpetual readiness.
The AMA will work to widely disseminate the final report once it is available.
New, life-altering pharmaceutical discoveries are expected to be expensive. Dermatologist Jack Resneck Jr., MD, chair of the AMA Board of Trustees, understands that. In testimony to Congress, he highlighted the personal impact of prescription drug costs. These are prices that can rise dramatically even for drugs that have been on the market for years or even decades, such as etanercept or adalimumab (marketed as Enbrel and Humira, respectively).
“I currently have a patient unable to afford the Enbrel or Humira that would alleviate his psoriasis and painful psoriatic arthritis—the average wholesale prices for a year of these drugs, both out for more than 15 years—has quadrupled to around $80,000 per year, and his PPO copay is 40% until he reaches his deductible,” Dr. Resneck said in his testimony. “So, he stopped his treatment.”
The U.S. spends nearly $334 billion a year on prescription drugs, and that accounts for nearly 10% of the nation’s total health care bill. In addition to high dollar amounts, Dr. Resneck told members of Congress, the price patients must pay includes sleepless nights and living in pain because they cannot get the medications they need.
“Physicians see every day that costs are a major obstacle to our patients getting the right medication at the right time,” said Dr. Resneck during his testimony at a May 9 House Energy and Commerce Committee Health Subcommittee hearing on lowering prescription drug prices.
Prescription drug price increases can lead some patients to not be able to afford critical medicine, causing them to skip doses of their medications or split pills, or force them to abandon treatment altogether.
Read more here.
On May 8, HHS finalized an earlier proposal that would require prescription drug manufacturers to disclose the prices of those drugs in some direct-to-consumer advertisements. The final rule requires manufacturers to disclose the wholesale acquisition cost, essentially the list price, of their drugs in all television advertisements. The requirement applies to drugs where the monthly cost of a typical treatment regimen is over $35 and does not apply to print or internet advertisements.
The AMA strongly supports the new requirement, calling the move a meaningful step towards much-needed transparency in the prescription drug marketplace. The AMA continues to work with the administration and with Congress to ensure transparency throughout the drug supply chain and that policy changes result in meaningful impacts for patient out-of-pocket costs.
The bipartisan Conrad State 30 and Physician Access Reauthorization Act, S. 948, has been introduced in the Senate to reauthorize and improve a program that provides access to care in underserved communities. The AMA helped draft this legislation and voiced its support in a letter to sponsors of the bill.
Currently, resident physicians from other countries working in the U.S. on J-1 visas are required to return to their home country after their residency has ended for two years before they can apply for another visa or green card. The Conrad 30 program allows these physicians to remain in the U.S. without having to return home if they agree to practice in an underserved area for three years. Since 1994, the Conrad 30 waiver program has enabled more than 15,000 non-U.S. physicians to provide care in medically-underserved communities.
The Conrad State 30 and Physician Access Reauthorization Act would:
• Reauthorize the J-1 visa waiver program for an additional three years, protecting patient access to care in medically underserved area
• Make improvements to the program by requiring more transparency in employment contract terms
• Create additional waivers per states
• Protect spouses and children of physicians in the program
The legislation would also address the current physician green card backlog exacerbated by the statutory per-country cap for employment-based green cards. Physicians who practice in underserved areas for five years would be eligible to receive priority access within the green card system.
On May 8, the White House released principles and a fact sheet on developing solutions to “surprise billing,” which affects patients who receive unanticipated and sometimes large balance bills from out-of-network physicians in circumstances where they had no opportunity to choose who would be involved in their care.
The AMA supports the need for federal legislation to protect patients in these situations but has several concerns with some of the approaches that have been suggested, including some of the principles outlined by the White House. The AMA is working with specialty societies to raise awareness about insurers’ contributions to the problem as well as the challenges of proposals that would tie out-of-network billing to Medicare or contracted rates, bundling hospital and provider payments into a single bill, and other issues. The activity now moves to Capitol Hill, where it is anticipated that bipartisan legislation will be introduced in the next several weeks. The AMA will continue to actively engage both the administration and Congress.
In May 2018 the AMA and the American Heart Association (AHA) urged the Centers for Medicare & Medicaid Services (CMS) to expand the covered indications for ambulatory blood pressure monitoring (ABPM) coverage for Medicare beneficiaries to include the diagnosis of hypertension. As a result of this advocacy, CMS proposed a coverage expansion related to ABPM for confirming a diagnosis of hypertension. On May 9, 2019, the AMA and AHA jointly submitted comments on what CMS has proposed, which expands the covered indications for ABPM to include masked hypertension. The AMA and AHA encourage Medicare’s ABPM coverage policy to be consistent with recent changes to the thresholds used for diagnosing hypertension.
Target: BP™ is a national collaboration between AHA and AMA to reduce the number of Americans who have heart attacks and strokes by urging physician practices, health systems and patients to prioritize blood pressure control.
The 2017 American Heart Association/American College of Cardiology Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults states that office based blood pressure measurements lack the precision and reproducibility needed to make an accurate diagnosis of hypertension, and thus, out-of-office blood pressure measurements are recommended to confirm a diagnosis of hypertension. This is consistent with the 2015 U.S. Preventive Services Task Force recommendation for obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
A final decision is expected July 2019.
The Medicare Access and CHIP Reauthorization Act (MACRA) remains a work in progress, but there are several specific steps Congress can take with MACRA and its Quality Payment Program (QPP) that will help physicians succeed and advance patient care.
“The QPP is a complex program that remains challenging for CMS to implement and difficult for physicians to understand,” AMA President Barbara L. McAneny, MD, told the U.S. Senate Finance Committee at a May 8 hearing. “However, the AMA is confident that if Congress, CMS and the medical community continue to work together to improve the program, we can ensure physicians have the opportunity to be successful and provide high value care to patients.” To improve MACRA programs, Dr. McAneny prescribed three priorities: continue support for small and rural practices, extend the bonus period for physicians investing in advanced alternative payment models (APM), and replace the scheduled payment freeze with annual updates. Dr. McAneny also outlined six suggested technical adjustments.
“We believe the goal of the program should be to help physicians succeed, not to cause physicians to fail, and we believe these technical changes, along with other changes, will allow CMS to increase the program requirements gradually and transition to a more meaningful program over time,” Dr. McAneny said.
She added that, despite all the changes that need to be made, the QPP remains an improvement over the sustainable growth rate (SGR) payment formula that it replaced.
Read more here.
Two new reports produced by the AMA and Manatt Health highlight the life-saving strategies that are being used to combat the opioid epidemic in North Carolina and Mississippi, in addition to noting areas where improvements could be made. The reports, which are based on data, include a review of policies and discussions with key policymakers and point to policies that have helped patients with opioid use disorder.
In North Carolina, the state Medicaid program and leading commercial payers have improved treatment opportunities for patients by making medication-assisted treatment (MAT) more available, promoting access to comprehensive pain care and expanding access to the overdose-reversing drug naloxone, while promoting harm reduction services. Similarly, Mississippi has expanded naloxone access and engaged the community with StandUp Mississippi, a program designed to help reduce stigma and promote overdose prevention across multiple state and federal agencies. Mississippi also started a program at the University of Mississippi Medical Center focused on increasing access to opioid alternatives.
To read the reports in full and learn more about what the AMA is doing to combat the opioid epidemic, visit www.end-opioid-epidemic.org.
Leading national and New England-based medical associations joined together to applaud a federal appeals court ruling that a Maine jail must provide a woman with MAT for her substance use disorder while she serves a 40-day sentence. The ruling from the U.S. Court of Appeals in Boston upheld an earlier ruling from the federal district court in Maine. Over a dozen leading medical associations asked to file an amicus brief in support of the lawsuit.
The appeals court affirmed the lower court ruling without the need for oral argument or further briefing. Medical experts and addiction specialists from those associations hailed the appeals court decision, calling it an incredibly important step in the fight to end the opioid crisis that will reduce pain and suffering and save lives. Citing this momentum, they called on corrections facilities around the nation to begin providing necessary care to people in their custody who have substance use disorders.
Read more here.
National and state physicians are congratulating the Iowa Legislature and Gov. Kim Reynolds for their roles in passing a law that will remove common barriers that keep patients from accessing MAT.
Gov. Reynolds signed the bill, which removes prior authorization under Medicaid fee-for-service and managed care administration for at least one form of MAT: methadone, buprenorphine, naloxone, buprenorphine-naloxone combination products and naltrexone.
“Medication assisted treatment saves lives, and, removing the barriers and delays that prevent and slow access to care for patients in need is a critical step in the fight against the opioid epidemic,” said AMA President-elect Patrice A. Harris, MD, who chairs the AMA Opioid Task Force. “We strongly commend Gov. Reynolds and the Iowa Legislature for their leadership and dedication to confront this challenge. This legislation will increase access to care and save lives; states that have yet to take this step should follow Iowa’s lead.”
“The Iowa Medical Society (IMS) worked hard to get this bill enacted because medical evidence clearly demonstrates how MAT improves recovery, reduces health care costs and most important—saves lives,” said IMS President Marygrace Elson, MD. “No patient should have to face a delay or denial of evidence-based care for opioid use disorder—this bill helps remove those barriers for our most vulnerable patients.”
Iowa joins a growing number of states this year that have increased access to MAT. Other states include Arkansas, Colorado, New York, Virginia and the District of Columbia. Bills are pending in other states, including Louisiana and Vermont.
Learn more about what the AMA is doing to help end the opioid epidemic at www.end-opioid-epidemic.org.
It has been brought to the attention of the AMA by the International Society of Hair Restoration Surgery that some hair restoration companies have been advising physicians that hair restoration procedures, including surgical excisions, can be delegated to non-physician health care providers in their office. This is contrary to AMA policy. The AMA clearly defines surgery to include the incision or destruction of tissues, as well as the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes and needles. Surgical procedures can only be performed by a licensed physician who meets appropriate professional standards and cannot be delegated to other health care professionals.Back to Top
May 22: A physician will share her practice’s journey through the phases of transformation and how both the struggles and the triumphs have prepared the practice team for operating and succeeding in an APM. Register now for the webinar at 1:00 p.m. Eastern time.
May 22: Augmented intelligence (AI) in health care is complex and changes in this space are rapidly evolving. This discussion is one of the initial steps in the AMA’s effort towards educating physicians about the changes AI systems and methods will likely bring to clinical practice and how physicians can leverage these changes to support their practice. The discussion will be hosted by the AMA’s Physician Innovation Network on May 22 at 8 a.m. Eastern time. Join the discussion.
May 29: A million family caregivers provide complex care. These family caregivers need more support and instruction from health care professionals according to “Home Alone Revisited: Family Caregivers Providing Complex Care.” Susan C. Reinhard, RN, PhD, FAAN, senior vice president and director, AARP, will share findings from the report and how to access resources and tools for the family caregiver including how-to family caregiving instructional videos, resource guides and evidence-based articles. Register here.
June 8-12: The 2019 Annual Meeting of the AMA House of Delegates (HOD) will be held at the Hyatt Regency Chicago in Chicago. Officials and members will gather in Chicago for the AMA Annual Meeting to elect officers and address policy.
Visit the Annual Meeting overview page to stay current on meeting information, and the Sections Annual Meeting overview page to stay current on important dates, meeting agendas, sessions and more.
Open to AMA members, their spouses, medical students, residents and state medical association staff who want to become more involved in campaigning process, the 2019 AMPAC Campaign School will be held Sept. 26-29 at the AMA offices in Washington, D.C. The Campaign School is designed to provide participants with the skills and strategic approach they need to run a successful political campaign.
During the two-and-a-half day in-person portion of the program, under the direction of AMA political experts, participants will be broken into campaign staff teams to run a simulated congressional campaign using what they have learned during group sessions on strategy, vote targeting, social media, advertising and more. Faculty, materials and all meals during the meeting are covered by the AMA. Participants are responsible for the registration fee and hotel accommodations at the Hyatt Regency Washington on Capitol Hill.
The deadline to register is June 21. For more information or to apply visit: www.ampaconline.org/apply or contact firstname.lastname@example.org.