Family physician David Barbe, MD is president of the American Medical Association. After 15 years in independent practice, he merged his practice with the 650-physician Mercy health system in Springfield, MO, where he is now VP of regional operations.
Tell me about yourself and the organization.
It’s really an exciting time to be president of the AMA with all that is going on in healthcare. The AMA is the largest and oldest national physician organization. We have over 220,000 members including students and residents – practicing physicians from all over the country in every specialty. It’s a way that we can bring the voice of physicians together so that we can, in fact, speak with one voice and articulate those issues that are most important for physicians and our patients.
You spent a good part of your early career as an independent physician before moving to hospital employment. How have you seen technology improve medicine? And on the flip side, how have you seen it take away from the art of medicine?
Once upon a time, when I first entered practice 34 years ago, everything was paper – prescriptions were paper and the chart was paper. Some physicians made pretty good paper charts and others didn’t. The EHR came into being really barely more than 10 years ago. I think most people think it’s been with us forever, but widespread adoption of the EHR is only about 10 years old. There were EHRs before that, but very few physicians in the country were using them. I think most of us looked at the EHR with great hope and anticipation. We understood the potential and the promise of the EHR, but for many physicians, and I would say even most physicians, the EHR has become a very significant source of frustration. It is the first or the second thing that physicians list when they talk about dissatisfaction with the way their practices are going and what stresses them.
While the EHR does continue to show promise, we are a long way from being in the perfect world with our EHRs. The AMA issued a white paper a couple of years ago. The authoring task force brought in practicing physicians from all over the country to talk about what it would take to make the EHR better. We came up with things that range from doing a better job of supporting team-based care to doing a better job of promoting care coordination. Reducing workload in terms of providing more effective decision support at the time of care, data liquidity, and interoperability continue to be a big problem. If a patient sees another physician and they’re on a different EHR than I am, that information just doesn’t transfer back and forth smoothly. We have a lot of opportunity for improvement.
The AMA believes that getting a practicing physician’s voice into that development and refinement process is critical. We work really hard with the vendors to try to encourage them to talk to practicing physicians to take to heart what we’re telling them about what does not work for us, and design that into the next update and next generation of the EHR.
Speaking of physician frustrations with EHRs, how do you plan on helping the AMA work to reduce physician burnout?
Most of the studies on this show that burnout comes from external factors. It’s things like the stresses of the EHR, workload and productivity, uncertainty regarding payment methods, the challenges of documenting and reporting the various quality metrics and Meaningful Use metrics that we are being asked now to report on. All of those things interfere with the doctor-patient relationship at some level. We did a study just last year that shows physicians spend twice as much time during their work day on the EHR and what I’ll call paperwork-related activities as they spend with their patients. The AMA has devoted a lot of resources to this. Physicians consider themselves evidence-based. The AMA has taken a lot of effort to gather information about what would really help.
We write that down into three big categories. One is, how do we change the external environment? How do we then give physicians tools to better cope with what we have to deal with? There’s still going to be that part of us that has to strive for more satisfaction, a better work-life balance, and adapting better to those external stressors. AMA has put together a suite of products called Steps Forward that contains 40 modules ranging from how to be more efficient at reauthorizing prescriptions to how to conduct a better meeting within your group practice, and everything in between. We have a lot of information in there about how to prepare your practice for quality reporting that has come down the pike under MACRA. It’s a broad suite of products.
We also want to change the practice environment. We want to reduce the burden, for instance, of prior authorizations. The AMA has put together a white paper with 21 recommendations of how the paperwork burden and a pre-authorization burden can be reduced and yet not compromise some of the things, if you will, that the insurance companies feel like they need to accomplish with their prior authorization forms. We have been successful. We’re seeing insurance companies discontinue requirements for prior authorizations in different markets. That will have a very meaningful improvement in a physician’s life. We found that it takes an average physician, or his or her staff, 16 hours a week to do prior authorizations. That’s two full work days for someone to do prior authorizations that add very little, if any, value to the care we give. In fact, they often delay care. Ninety percent of physicians said that care has been delayed due to the time it takes to process and get approval on a prior authorization.
The AMA also seems to focusing its resources on the opioid epidemic and educating physicians about best prescribing practices. What role do you see technology playing in stemming this tide?
We believe that the PDMP – a good, well-functioning PDMP – is critical to helping physicians help their patients through this very difficult issue of opioid misuse and what it often leads to, which is substance abuse. The good PDMPs, and I’ll define what I mean by that, they have clearly shown that they reduce prescribing. We see evidence of this in fewer overdoses and fewer deaths as opioid prescribing goes down.
Good PDMPs are products that have real-time information. If I see a patient on a given day and PDMP data is a month old, then I don’t know if they went to two other doctors over the course of that past month. It needs to be in near real-time. It needs to be easy to access as part of the physician’s natural workflow. If you have to get out of your EHR, log in to a PDMP, and go through several security steps – and all that takes five minutes to get there – that physician is just not going to use that. That is not an efficient use of their time even though when they get there, the information may be good. It needs to be a natural part of the workflow, easily incorporated and accessed through their EHR, and contain timely information. If you make it easy, physicians want this information. They know how important it is. We need to continue to work toward making each of these as easy as possible to use. That is a huge step.
In terms of other technologies, there are some that are developing out there that will help patients more closely regulate their own use. If I prescribe a bottle of 100 pills to a patient, I don’t know if they take them in one week or two weeks, or if it really lasted the whole month that it was intended to. There are dispensing systems out there in which the medication is dispensed out on a daily basis so that it makes it less possible for a patient to misuse the medication that they’re given. Things like that are also on the rise. I expect that some innovative physician developers will come up with other easy to use, effective apps that would help patients and physicians do a better job at monitoring and tracking medication use.
Let’s back up to PDMPs for just a second. Are there any states that you’ve heard of that are using them in really effective ways?
In terms of good examples, there is some sharing of information between state PDMPs, but quite honestly, these things often end up getting hung up in state legislatures. That slows down our ability to be nimble and to make rapid cycle improvements in PDMP effectiveness. That also requires state-to-state collaboration, the sharing of information across state lines. In my home state of Missouri, we have two large metropolitan areas that are right on the state line – St. Louis on the east and Kansas City on the west. If you live in Illinois and you come to Missouri to see a doctor, the doctor can’t access the Illinois PDMP; same thing on the other side of the state. Again, opening these up, making the information available across state lines, certainly in regional areas, would really be a giant step forward.
What are your thoughts on the black eye Missouri has created for itself in terms of standing up a statewide PDMP?
The fact that we haven’t been able to get a PDMP approved has been a real sore spot for physicians in the state. Again, sometimes the problem rests with the state legislature. That has been the case in Missouri. It demonstrates, however, how determined physicians and other governmental agencies are at getting this information into the hands of prescribers. You may be aware that in St. Louis, St. Louis County has actually developed a PDMP that they are willing to share with other counties around the state. That is really gaining traction as a workaround to a statewide PDMP. I think it will actually not only help us in this intermediate term, but will actually move the discussion at the state level forward in a more effective way.
Speaking of state legislation, how are you seeing the political climate in Washington affect AMA members? Are they heartened that HHS Secretary Tom Price, MD comes from a physician background? Happy that the ACA is still in place?
We always think it is important that a physician leads agencies like HHS and even CMS. We would prefer to see physicians in all of those roles, especially physicians that have had practice experience. Someone who has been in the trenches and understands what it’s like to work in an EHR, what the burden and the hassle of prior authorizations is like. A physician that has that background is in a better position to understand and address those problems. We hope the current administration will address regulatory relief, making it easier to practice medicine, taking less time away from our patients, and giving us more time for the highest and best use of a physician’s training. We do believe that the current administration is more interested in that. We have begun to see movement in that.
We also know that the Republican Congress seems to be a little more favorable toward regulatory relief. It was just a couple of weeks ago that I met with Chairman Brady of the House Ways and Means Committee to discuss regulatory relief and how could they change things to make it easier for physicians to do their job. I am cautiously optimistic that we are going to see improvement.
The other big area, of course, is health system reform and where we stand with regard to potential changes in the ACA. The AMA believes that significant gains were made under it, including Medicaid expansion, and insurance exchanges and subsidies to help patients with low and moderate incomes purchase insurance were very beneficial. We saw 20 million people get insurance that did not have it prior to the ACA. That is a good thing.
We also believe that there are some areas in which the ACA is falling short or not working. Affordability is one of those. Even with the subsidies, there are some low-income individuals that have difficulty affording coverage. The other thing is the high deductibles in some of those plans. If you’re low income, even if you’ve been able to afford the premium, you still may not really have access to care because of the high deductible.
The stabilization of the insurance markets also needs urgent attention. You may know that over a third of the counties in this country have only one offering in the insurance exchange. That’s really no choice at all if you value patient choice, which the AMA does. One insurance company is not choice. There are many counties that now have no offerings in the exchange. If we were to have this conversation six months ago, 97 out of 114 counties in Missouri had only one offering on the exchange. I’m sad to say that a couple of months ago, an insurance company pulled out of the Kansas City area and has left 24 Missouri counties now with no insurance offering. This action is by the insurance company. I’m not defending them. They have simply not found the insurance exchanges to be profitable. They have been losing money in many areas of the country.
In order to get the insurance companies back in, the AMA would like to see the cost sharing reduction program stabilized and effectively reinstituted so that insurance companies can offset some of the premium cost to low-income individuals. We’d also like to see a reinsurance-type program such that if insurance company losses are excessive, there is a reinsurance to limit their losses. It’s through those types of programs that we can entice some of the insurance companies back into these markets where there’s no offering in the exchanges. We believe that competition will actually help bring down premium prices, and certainly improve choice and availability for patients.
What health technology has you most excited in terms of its ability to help improve access and outcomes?
The AMA is very interested in what I’ll generically call telehealth. It’s often referred to as telemedicine, but I think it is much broader than that. It improves the ability to link physicians and patients in ways that we’ve not been able to do before. We now have the technology available to link up, let’s say, a specialist in an urban area or an academic center with patients in a more rural area. For me, in Missouri, that really makes a difference. In my day job as a physician executive with my health system, I oversee five small hospitals and 75 physician practices – some of which are 100 miles away from urban or tertiary care centers. We are already employing technologies like e-hospitalist where we have a hospitalist or an intensivist in an urban area that can provide backup and assistance to both nurses and physicians in a smaller rural hospital. It allows us to sometimes keep patients in a rural hospital that would otherwise have to have been transferred, sometimes hours away to a tertiary care center. Things like that really make a difference in patient care.
We believe that we’ve just scratched the surface. To that end, the AMA is involved in many activities to help accelerate the development of and adoption of new technologies – all the way from simple limited scope technologies like apps on a mobile device all the way up to how we make the EHR better. As I said earlier, we really want to insert the voice and the experience of the practicing physician into this development process earlier. To that end, for instance, the AMA participates in innovation center in Chicago called Matter, where we have the opportunity for practicing physicians to come in and meet with innovators and discuss their ideas. We have a mock exam room in which we can actually try to see how these innovations would play out in a real-world practice. We believe doing that will help make the final products more usable.
What frustrates physicians as much as anything is that these new technologies may be developed in a vacuum with regard to practicing physician input. They’re developed and rolled out to doctors with the promise of being the next best thing. But I look at it and say, “What practicing physician ever thought this would work for them?" In many cases, in spite of best efforts, they just haven’t engaged with practicing physicians. We really think that there’s a lot of opportunity out there for new technology and physicians are eager to adapt. We’re ready to do things that will help patient care. It’s just that much of technology at this point has been as much of a curse as a blessing.
Do you have any final thoughts?
I think it is important for physicians to be involved and engaged. We talked about physician burnout. When physicians get burned out, they tend to disengage. This is the wrong time for that. We need every physician to be in there, to be active in their groups, to be active in their hospitals if they have a hospital part of their practice. To be active in physician organizations like their county and state medical societies. That’s how we change difficult practice environments – through physician involvement and engagement. The AMA wants to help that happen. I encourage physicians to stay connected and engaged, and to not withdraw. That’s how we’re going to make things better.
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