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Emergency departments without ED doctors and policies discouraging hospice use of antipsychotic drugs would be history if resolutions discussed at the American Medical Association House of Delegates interim meeting achieve their intended results.

Delegates discussed these and many other issues during a meeting Saturday at National Harbor, Maryland, of the AMA Reference Committee on Legislation.

ED Care

Heatedly debated was whether hospital facilities should be prohibited from having bright red signs advertising "Emergency" care despite having no physician on duty, much less one trained in emergency medicine.

The proposed resolution would direct the AMA to develop state model legislation requiring all facilities that claim to provide emergency care have "real-time, on-site presence of a physician, and on-site supervision of non-physician practitioners."

"There are entities that advertise provision of emergency services with no emergency medicine-trained physician or even a physician on-site," argued Theodore Jones, MD, alternate delegate from the Michigan State Medical Society, which introduced the proposal.

Woody Jenkins, MD, speaking for the Oklahoma delegation, objected, saying the policy would make rural hospitals -- especially critical access hospitals -- "vulnerable to financial closure."

"We know that the mortality rate increases in the surrounding area when a rural hospital closes," he said.

Cindy Smith, MD, a delegate from Minnesota who spoke for the Rural Health Caucus, favored referring the matter for study. "As written, it would devastate rural emergency services and cost people their lives," because hospitals have neither the personnel or the money to comply, she said. "Frankly, when 'Farmer John' gets his arms ripped off in a power take-off, the distance and time to service are far more important than board certification of who provides us with services."

Hugh Taylor, MD, speaking for the American Academy of Family Physicians, said most areas of the country at least have family medicine doctors with ED experience, even if they're not board-certified. And for some facilities, there could be waivers.

No to AI?

Don Cinotti, MD, speaking for the Section Council on Ophthalmology, supported a resolution that would have doctors tell patients not to use artificial intelligence for medical advice.

"If you ask [an AI bot]: 'I have glaucoma; I have cataracts or eye disease, who should I see?' the answer comes back: see an optometrist."

Erin Shriver, MD, speaking for the American Society of Ophthalmic Plastic and Reconstructive Surgery, said some AI tools inaccurately advise that ophthalmic laser procedures are low-risk, and suggest that optometrists perform laser surgery on the retina, which she said is not allowed in any state.

Medicare Advantage

One of the more animated discussions involved a resolution that would mobilize doctors to fight fast-moving privatization of Medicare through Medicare Advantage (MA) plans, which speakers criticized as not really providing an "advantage" over fee-for-service.

Daniel Choi, MD, a spine surgeon from Garden City Park, New York who spoke on behalf of the Private Practice Physicians section, was especially upset about MA plans, which now enroll more than half of Medicare's 66 million beneficiaries.

"It's a game ... Every single surgery is a prior auth[orization] denial resulting in a peer-to-peer call" and another denial. "And that patient's surgery gets delayed 3 to 6 months," he noted. Choi said most of his MA patients tell him they are surprised. They say, "I thought this was the better plan. That's what my insurance agent told me."

The resolution directs the AMA to educate patients about threats to the Medicare system from such plans, and address an estimated $23 billion in overpayments MA plans will receive in 2023 alone from Medicare funds due to plans' allegedly upcoding risk scores -- an estimate of the patient's level of health or sickness -- to garner higher reimbursement. The proposal asks the AMA to urge the Justice Department to prosecute those found complicit in fraud. The resolution wants MA plans to be renamed "Alternative Private Health Plans," since many argue they are not an advantage over fee-for-service.

Dirk Baumann, MD, speaking on behalf of the California delegation, opposed the measure. Not only are MA plans affordable, he said, they incentivize improved quality outcomes, and increasingly, there are no other options.

"In the San Francisco Bay Area where I practice, care is largely provided by large healthcare systems, and PCPs [primary care physicians] within these systems do not provide care to traditional Medicare patients, making it very difficult for patients with traditional Medicare plans to find care," he said.

Some physicians objected to the resolution's clause that would urge prosecution of "those found complicit in fraudulent activity," such as upcoding. Ray Page, DO, of the Association for Clinical Oncology, said that clause could lead to "unintended consequences, where you can be potentially criminalizing physicians... [who] may be ignorant to some of the things going on in the corporate healthcare system."

Other Issues

Two resolutions dealt with enabling patients to have easier access to psychotropic medications in long term care and hospice settings; such facilities are currently reluctant to use them because of state laws that may criminalize providers for prescribing them.

Stacie Wenk, DO, an alternate delegate from Indiana and one of the authors of the resolution, said the issue is most important in hospice, where she sees "patients on a daily basis harming themselves because they are agitated; 65% to 80% of patients at the end of life develop agitation."

Antipsychotics, she said, "allow patients to relax, to have comfort. It allows them to be safe; they are not falling out of bed. They are not breaking their hips."

Delegates also tackled the impact from a 2018 Supreme Court ruling that, in effect, resulted in the elimination of a 72-year standard requiring administrative law judges (ALJs) who decide Medicare and Medicaid coverage appeals to have at least 7 years' experience in relevant areas of law and to have passed an examination.

It prompted former President Donald Trump to issue an executive order that relaxed those standards. ALJs now need only have a law license and to have been appointed to a federal agency "by the temporary, politically appointed agency head," the resolution said. That change has resulted in a politicization of the ALJ service.

Tosha Wetterneck, MD, of the Wisconsin Medical Society, who spoke as an individual, said she routinely attends ALJ hearings on whether patients' denied claims should be overturned. "It's important to have a judge who knows what they're doing in these cases, so that the Medicare patient actually gets what they deserve out of these hearings," she said.

Additional topics garnering attention included physicians' opposition to policies that prohibit hospitalized patients with opioid use disorder from accessing post-acute care beds, which leads to longer and unnecessary acute care stays. AMA delegates also expressed support for more "age-friendliness" in smartphone apps and patient portals -- for example, apps and portals could use larger font sizes that would encourage seniors to try them.

All the issues will be assessed for a vote by the full House in the coming days.

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