As an otolaryngologist, plastic surgeon and longtime member of the American Medical Association, Bruce Scott, MD, knows the ins and outs of the biggest issues affecting physicians' practice.
By midday on June 14, Dr. Scott had performed several surgeries, caught up with a colleague who had decided to retire early amid Medicare reimbursement challenges, and spoke with the media about his priorities as president of the AMA.
"I live the issues every day that I'm going to be fighting for over the next year, in which the AMA has been fighting for and actually making some progress on, over the last few years," he said. "But there's still a lot of work to be done."
Days into his one-year term as president of the nation's largest professional association of physicians, Becker's caught up with Dr. Scott to discuss where things stand with Medicare and prior authorization reform, the AMA's stance on scope of practice expansions for advanced practice providers, and getting more physicians to practice in rural areas.
Editor's note: Responses have been lightly edited for length and clarity.
Question: You took over as president of the AMA several days ago, but you've worked with the group's House of Delegates and Board of Trustees for many years. What has kept you so engaged with the AMA for so long?
Dr. Bruce Scott: When I came to my very first AMA meeting back when I was a medical student, I saw physicians from every state, every system, every specialty and interest groups, all coming together in the best interest of the profession and our patients. I saw the power that physicians could have when they were unified and came together in a democratic process. Frankly, I was hooked. I've been back to 72 consecutive meetings. Thirty-six years later, and I'm still involved.
Over that course of time, I had the opportunity to serve as a young physician on the Board of Trustees back from 1998 to 2002. Then I served in the House of Delegates, the policymaking body of the AMA. After a number of years there, I was elected in 2015 to become the vice speaker, and then the speaker in 2019 of the House of Delegates. This is an interesting transition for me to go from being the person who helped create policy and guide that policy creation, to now being the person who is the lead spokesperson as president of the AMA.
I think what's kept me involved is that I believe the AMA can and does make a difference. And I think one of the key things that we need to do is unite physicians over issues that physicians agree upon and then impact physicians' practice every day. I am to this date an actively practicing physician. I actually did several surgeries this morning, after returning from all of my AMA duties. So I live the issues every day that I'm going to be fighting for over the next year in which the AMA has been fighting for and actually making some progress on over the last few years. But there's still a lot of work to be done. I believe, though, when there are challenges, there are opportunities, and I'm really looking forward to leading the AMA for this next year.
Q: In January, CMS finalized a rule to streamline the prior authorization process. Several states also recently passed prior auths legislation. What's next? — What other prior authorization reforms do you hope to make happen during your term as president?
Dr. Scott: That's a very timely question because just yesterday, we reintroduced federal legislation to extend some of the prior authorization transparency rules, and some of the other rules that had recently been adopted by CMS through federal legislation to Medicare Advantage. Included in our legislation is the concept of what we have called Gold Carding, which is basically that physicians who meet a certain threshold, whether that's 90%, or some other threshold of approval for their prior authorizations, do not have to go through prior authorization. They would in effect get a bypass — that is included in that policy.
The changes that CMS made earlier this year are estimated to save physician practices $15 billion over the next 10 years. When I think about that, I think Hooray, that's a lot of money. By the same token, I think it's just the federal programs that are costing physicians $15 billion. What is the total price tag of this unnecessary practice that insurance companies do that basically results in delay and denying needed care for our patients? The biggest challenge is it's a waste of physicians' time and resources, but it harms patients. And data is very clear that patients' care is denied or delayed, and that there are adverse outcomes from that.
I can tell you stories from my own practice and stories that I hear from other physicians. I can tell you about my own mother who finally found a hypertensive medication that worked for her after several that have caused her side effects. Then when a new year comes, they want her to go back and do step therapy all over again. That doesn't make any sense. So we're working with state legislatures to try to get reforms there. We have seen some movement by some of the insurance companies that have lessened the burden of prior authorization, but it continues to be a significant problem. In fact, when we talk to physicians about the administrative burdens that are causing burnout for them, prior authorization consistently rises to the top.
Q: Scope of practice continues to be a contentious issue. The AMA argues that expanding advanced practice providers' scope of practice threatens patient safety, while supporters of practice expansions say it can improve access to healthcare, particularly in rural areas. How do you plan to navigate these ongoing debates — Is there a middle ground here?
Dr. Scott: The AMA and physicians in general believe in team-based care — physician-led team-based care. We believe that is the best way to get good quality care. I practice in Kentucky, so I have some experience in rural areas. I believe that patients deserve access to a physician regardless of their zip code, and I think the system needs to provide that access to care. The data coming out as we get further into the expansion of scope of practice for nurse practitioners and physician assistants shows that those extenders tend to practice in the same areas as physicians do. We've also found that they have gone more and more into specialized care as well. Twenty-four percent of nurse practitioners are actually practicing in primary care, even though in many cases, that's what their training was. There was a report from the House of Delegates meeting … that details the fact that it's a myth that nurse practitioners and physician assistants are going to fix the access problems. They tend to practice in the same areas of the country, and they're drawn to specialty care even though they typically have no additional training when they switch from one specialty to another specialty. Literally, a physician assistant on Friday can be a primary care physician assistant or nurse practitioner, and on Monday be working in an orthopedist office or a neurosurgery office or an endocrinologist office with no additional training.
At the same time, if a primary care physician wanted to become a neurosurgeon, that would require seven additional years of training. That's the sort of dichotomy that has been created. In addition, data is now showing that when nurse practitioners practice by themselves, they order unnecessary antibiotics, hospitalization rates are more often and extended lengths of times. There's a clear study that showed that nurse practitioners practicing in states where there were no physician requirements of supervision prescribe 20 times as many opioids as those same people when they're being supervised by physicians in states that require physician supervision. We have an opioid crisis in America, and we have a group of people who have less training for prescribing more opioids. That's a problem. I see it every day in my practice, where patients have gone to an urgent care center where there is no physician supervision, and they come to see me after having been on an antibiotic or antibiotic ear drop, and they have wax in their ears or they have a problem with their jaw joint. And they've had a CT scan or an MRI that they didn't need. So it's a waste of resources, and it's not providing good care. Now, I want to be very, very clear. I work with very qualified extenders, audiologists and speech pathologists, and I work with some nurse practitioners, who, under supervision of a physician, provide excellent care. I can't do the job of my audiologist, but they can't do the job of me as an otolaryngologist.
Q: What do you think it will take to get more physicians and advanced practice providers to practice in rural areas?
Dr. Scott: The access issues in rural areas and underserved areas is simply a magnification or amplification of the whole system problem. Medicare payment, when adjusted for inflation, has gone down 29% since 2001. In those years when there's been significant inflation, what Medicare has compensated physicians has gone down. One of the other problems with this is that, at least in my area, every private-payer contract that I had in Medicaid has all linked their reimbursement levels to Medicare. They know that it's a downward spiral. So they know that in 2024, their reimbursement to physicians will be less than it was in 2023. Unless something changes, that's going to continue. AMA is making significant inroads with Congress on the fact that we need a fix to the Medicare reimbursement system. Just in the last few days, MedPAC has put out a report that says they agreed. Medicare trustees are now going on record in the last month or so saying that they agree that there's going to be an access problem for our Medicare recipients — that the system currently is unsustainable. So, we're getting recognition of that. I don't know any industry that could tolerate a 30% cut over the course of these years.
Last year, when we all faced considerable inflation, we actually got a cut in what we were paid. I had an insurance company that controls 60% of the market in Louisville, Ky., offering me rates that were less than what they paid me in 2017. They are 60% of our market. We don't really have a choice. If we say no, our patients — many of which don't have out-of-network benefits — suffer. And if we say yes, we're not sure that our practice can financially survive. So physicians, including my practice, make difficult choices. Do you maybe hire less staff? Do you downsize? Do you not invest in the latest technology? Some practices have decided that the answer is to reduce the number or control the number of Medicare or Medicaid patients that they are able to see. Some physicians have dropped out of Medicare and Medicaid completely, and others have chosen to just close their doors and give up. I actually spoke to a doctor earlier this morning who is 62 years old, another otolaryngologist, who told me that he has decided that is going to be his last year — that he just can't survive anymore in the current market. He wanted to work until he was 67, but he just can't justify anymore the fact that his practice basically loses money every month. This is a specialist. Imagine what's happening to the pediatricians and the primary care doctors who tend to be lower compensated. I'm a practicing physician, but I see my colleagues struggling as well. That's one of the things that brings an urgency to me during my presidency that we need to fix this broken system. I became a doctor to take care of patients. That's getting tougher every day. The healthcare system should help doctors provide good care, not get in the way. Yet, it seems that every year we face increasing administrative burdens and shrinking reimbursement. As a result, we've all seen the numbers of physician burnout. One in five physicians hope to be able to retire or significantly slow down in the next two years. One in three physicians say they're going to reduce their hours. These numbers, combined with an already physician and nursing shortage, are nearing crisis level. We need the legislators to understand that there's a problem, and they need to fix it. And I'm going to push them that way.
Question: As you mentioned, the AMA is leading a lot of advocacy work to reform Medicare physician payments.What specific reforms do you believe are needed to keep pace with the rising costs associated with practicing medicine?
Dr. Scott: There is legislation right now (H.R. 2474) that would tie the Medicare reimbursement rate to the annual inflation rate as determined by Medicare. This is not the consumer price index. It's actually inflation of the cost of providing care, calculated by Medicare. This last year, they said that went up 4%. But yet, we got a two-plus percent cut. So this isn't some radical idea. Every other component of healthcare — hospitals, long-term care facilities, hospice facilities — all get an automatic update based upon inflation. But physicians don't. So the first step that needs to happen — and we're pushing MedPAC to agree with us, and they partially agreed with this just in the last couple of days — is that it needs to be tied to the Medicare-adjusted inflation rate as a minimum, and then we need to work from there.
The other thing we need to do is we need to continue to look at the consolidation that is occurring in healthcare. We had recently the whole event of the cyberattack on Change Healthcare. I can tell you that my practice and many other practices like mine, had to draw down a line of credit and take out a loan because of the challenges that were faced by that cyber attack on a mega company that controls a huge portion of processing for physician billing. This is all a consolidation that occurred while the AMA for years has been saying, "Caution." These insurance companies are coming together and these monopolies are being formed. The vertical integration that's happening, this horizontal integration that's happening — This is putting private practice physicians out of business. It's also really making us teeter on the brink of failure. There are physician practices that have been forced to sell out because of the cyber attack. That's how on the brink so many physician practices were. I think that patients are better served when they have options regarding physicians in private practice, physicians who are employed by a physician group, and physicians who are perhaps employed or associated with a hospital system. A plurality of modes of practice is in the best interest of both patients and physicians.
Question: Over the past several years, the nation's behavioral health crisis and access issues have boiled to the top of many healthcare leaders' list of priorities. What does the AMA believe is needed to expand access and prevent patients in crisis from showing up to emergency departments?
Dr. Scott: The first thing we need to do in behavioral health and mental healthcare is we need to enforce the rules that were actually passed by the federal government over 10 years ago that were supposed to create parity between payment for mental health benefits and other health benefits. And yet, a study done just about a year ago showed that even though we're 10-plus years into this legislation, the parity of payment is actually worse than it was when the rules were passed. AMA at this recent meeting was really pushing for statutory rules that include fines for insurance companies who don't provide this care. As a result, a significant percentage of Americans who seek mental health care are left with large bills. As a result, many mental health professionals no longer take insurance because the payment is unacceptably low. So the first thing is for us to enforce the rules. We need to put more teeth into those rules that have already been adopted.
The second thing we need to do is we need to encourage more people to go into psychiatric specialties. One of the ways we can do that is with direct loans and by expanding residency programs. We have more individuals graduating from medical school than there are residency spots. One of the things we know, going back to your question about rural care, is that residents tend to go into practice within about 80 miles of where they do their residency. And yet, many of the rural areas don't have residency. We could expand residency programs, particularly in primary care and behavioral health care, into those rural areas. At the same time, we should work with loan forgiveness programs. Only about four to six percent of medical school applicants come from rural and underserved areas. So we need to do something to stimulate those talented individuals to decide to go into healthcare and hopefully become physicians. On the other end, we need to work to reduce the number of people who are leaving medicine because of all the things that we've spoken about.
While we're talking about mental health care, one of the other topics that needs to be addressed is mental health care for physicians. Physician suicide has actually risen to new levels since the pandemic and we can't afford to lose one more person to suicide. Part of the problem is that people are hesitant. Physicians are hesitant to seek mental health care, because of the stigma that has traditionally been associated with that. For physicians, that stigma is even greater because on application forms for licensure and for credentialing at hospitals, they're oftentimes asked, have you had any previous mental health challenges? AMA has been pushing and pushing successfully in many states and with many hospitals to change those questions to talk about current impairment rather than past impairment. We're also reaching out to create, with money from the Lorna Breen Act as well as other sources, to create opportunities for physicians to get the care that they need before they reach crisis level.