Dollars and Sense

James Rohack, President of the American Medical Association and advisor to President Obama, explains the need for a collaborative healthcare infrastructure.

“We are firmly committed to the current burden of those who don’t have health insurance in the US, whose access to healthcare is through emergency departments”
-James Rohack, President of the American Medical Association

Medical education standards have always been an interest for James Rohack – he joined the American Medical Association (AMA) during his student days in the late 1970s, and for almost forty years has involved himself in medical education teaching. “It was because of that involvement that since the early 1980s, I started to become involved within the AMA’s political structure of the House of Delegates, the Council on Medical Education, which sets standards nationally in the US for medical education,” he explains.

Aside from his work at the AMA, Rohack is a medical director for a nonprofit community-based health plan at Scott and White Clinic, an integrated delivery system in the central area of Texas. Due to its numerous size – 770 physicians and nine hospitals – he’s been able to observe those health plans that work, and those that don’t. “And so the opportunity to say, “How can we decrease unnecessary costs in healthcare to make private insurance more affordable for all Americans?” has been something that has been talked about within the AMA for the last 20 years because of this,” he adds.

Political profile
His path of progression eventually resulted in his gaining the position as AMA’s President this year, but he has never departed from his political agenda. In June of this year, Rohack met with President Obama at the White House, providing advice and entering discussion not only as a medical director, but also as a practicing clinician.

“Having a president that has signaled that this is a high priority for him has made it easier for the AMA to say, “Well, here’s all our policies that we’ve developed over 20 years to make this thing happen.” Being able to be in the White House to talk to him, not only about what doctors can do, but also the recognition that part of the unique American healthcare cost is defensive medicine and our signal to say, “We’ll try and work on best practice guidelines for high cost, high volume medical care conditions, but if we don’t get liability protection over not ordering a test that isn’t needed, then the reality is that the pressure will be to start ordering those tests even though they may not be indicated, just because of the fear of not having a defense in a courtroom in case you’re sued.”

The meeting in the White House, of which Rohack attended, resulted in Obama unveiling a target to cut $2 trillion on healthcare costs. Rohack explains the unnecessary costs that would be need to be abolished in order to reach that target: “The three major ones are administrative waste and that is one of the things that America has – we have over 1,500 different health insurance companies. All of them have their own unique forms and processes, and so physicians and hospitals spend a lot of staff time trying to get permission to do different things because of the multiple forms and the multiple processes. It’s estimated that somewhere between 10 and 16 percent of American healthcare is spent in administrative waste that we believe we can get rid of if we all agree on common platforms and forms.

“The second real cost is duplication of tests and that is because our electronic systems right now in America don’t talk to each other. At Scott and White Clinic we’ve had our own electronic medical record for 15 years – all 770 physicians are linked to each other and our nine hospitals have interactions with each other. But a patient that leaves our system to go somewhere else, literally we can’t talk in any efficient electronic way. One has to go back to a paper way, which is not very efficient nor cost effective. So interoperable medical records will be a second big step.

“Then the third step is one of the things that the AMA has been involved with for the last seven years and that is what we call our physician consortium on performance improvement, whereby we bring together the multiple specialty societies and state associations to come up with best practices to improve care for patients, and by which we can help reduce unnecessary tests.”

Administrative proposals
EMR is one of the biggest topics currently dominating healthcare reform discussion. All institutions, both private and public, understand the benefits of an electronic system, but whether a universalized system incorporating a uniform record format is possible remains to be seen. Rohack compares America’s current electronic interchange with the railroad infrastructure in the early 1880s.

“When our railroads were first developed, the width of the gauge of the railroad track that the cars were on were of different sizes, different width, depending upon the company that owned the railroad, and so it required the federal government to come up with a common width of the rail line so that cars from one company could go to another track of another company and seamlessly move. And that’s where we are in America.

“We need the federal government to come up with the interoperable standards so you can still have innovation and buy your electronic medical record from a different vendor, but the key is it has to be able to be interoperable with other systems, and that doesn’t exist right now, and that’s a very important role for the federal government to create those standards. When a physician decides to purchase an electronic medical record they’ll be able to talk to others, which doesn’t exist right now.

With healthcare coverage on the political agenda, preventative care is taking center stage. Rohack notes the effect of disease burden on the number of diabetics, those with heart disease, resulting in more patients requiring dialysis and placing pressure on the number of those needing surgery.

“We are very aware that our current payment system in the US pays for procedures and treatments, but doesn’t pay for prevention. So we need not only incentives to keep the patients healthy, but also time so that physicians can educate patients about wellness, which means that we have to structurally reform how our payment occurs in the United States. Right now we pay for doing a procedure, doing an operation at a much higher level than we do for a physician to counsel a patient about proper nutrition, proper physical activity, stopping tobacco use, risky use of alcohol and other things that are preventable of a higher cost to treat the disease,” he says.

In order to fix the current Medicare physician payment system, Rohack describes the current physician payment system as “counterproductive to trying to do what we want to do.” He envisions a system that incentives individuals to spend time on an outpatient care program to prevent costly patient hospitalization, rather than the current system, which he believes to penalize physicians for such treatments. The more patients that can be transferred into an outpatient program, the greater the cost cuts are likely to be.

“Punishing physicians for outpatient treatments ought to be completely abolished and a move should be made toward a payment methodology that’s based on the cost of delivering healthcare, based on inflation, which is the same method that others that participate in the Medicare program – like hospitals and nursing homes – are paid on that Medicare economic index,” he explains.

Troubled times
The year 2009 has not been the easiest one for Rohack to begin his presidential tenure. The election of Obama and his focus on healthcare reform has highlighted its dire need for repair, and all of this in light of the current economic recession. Worst of all has been the recent World Health Organization declared pandemic of the H1NI swine flu virus. The AMA has played a role of educating the country of the outbreak, linking with the national federal government’s educational groups through the Centers for Disease Control.

“We’re involved with the National Influenza Summit, looking at how we remind patients of steps to prevent the spread of communicable diseases, of which influenza happens to be one. Proper hand hygiene is key – making sure that there is an immunization available for those who are at highest risk of influenza and that they get that in a timely fashion. Also, being able to make sure that we have the latest updated materials for physicians to use in their office through our website, which we’ve ramped up so that we do also have a patient portal for patients that want to get additional information on particular health-related conditions, and that they’re able to access that in a timely way,” he explains.

Added to this is the increasing issue of hospital-acquired infections (HAIs), a huge concern for the general American public. Rohack again notes the partnerships the AMA has with other groups in the US – the Joint Commission, the Institute for Healthcare Improvement and so on – as a way of looking at how to help decrease HAIs. He acknowledges Ignatius Semmelweis and his discovery almost 160 years ago that proper hand hygiene is an extremely important simply step, but a key one in trying to prevent spread of communicable diseases.

“Part of the barriers that we had, for example, is that we knew that alcohol-based hand-washing material was very effective, but our federal organization, due to safety concerns, prohibited alcohol to be within certain areas within the hospital, so we had to work to try and remove those regulatory barriers that prevented a very simple way for hand hygiene to occur and to be placed in the emergency departments, in hospital rooms and other places. Again, our federal government system having one agency that doesn’t talk to the others and, as a result, becomes more burdensome in our ability to provide efficient, effective, high-quality care,” explains Rohack.

Future
Rohack predicts that Obama’s push to fix a fragmented and desperate system has in no way come at an easy time and certain to be no mean feat. He describes America as pending on the brink of crisis point, due to the demographics of a baby boomer generation. “In three short years, they start hitting the Medicare population. When they start hitting the Medicare rolls in 2012 with four million individuals and continues at that pace for almost the next 20 years, it’s going to stress the American system as it currently exists,” says Rohack.

“So we are firmly committed to the current burden of those who don’t have health insurance in the US, whose access to healthcare is through emergency departments, these individuals live sicker and die younger and, as a result, aren’t as productive in the workforce as they could be. America’s economic health is related to the health of its citizens and having this health reform so that we can have a health system with interoperable medical records, high value in the healthcare dollar, that is improved quality, and reducing unnecessary costs is an achievable vision for the United States and one that we believe is within our reach as long as everyone is focused on that same commitment and goal.”

“Our current payment system in the US pays for procedures and treatments, but doesn’t pay for prevention”
-James Rohack, President of the American Medical Association

James Rohack became the 164th President of the American Medical Association in June 2009. He is also Senior Staff Cardiologist at Scott & White Clinic in Temple, Texas.

Obama’s address at the AMA annual meeting, June 2009
Today, we are spending over $2 trillion a year on healthcare – almost 50 percent more per person than the next most costly nation. And yet, for all this spending, more of our citizens are uninsured; the quality of our care is often lower; and we aren't any healthier. In fact, citizens in some countries that spend less than we do are actually living longer than we do.

When it comes to the cost of our healthcare, then, the status quo is unsustainable. Reform is not a luxury, but a necessity. I know there has been much discussion about what reform would cost, and rightly so. This is a test of whether we – Democrats and Republicans alike – are serious about holding the line on new spending and restoring fiscal discipline.

Building a healthcare system that promotes prevention rather than just managing diseases will require all of us to do our part. It will take doctors telling us what risk factors we should avoid and what preventive measures we should pursue.

I want to commend the AMA, in particular, for offering to do your part to curb costs and achieve reform.

Electronic partnership
June 2009 saw a collaboration established between the AMA and Microsoft to enhance patient-physician communication. The software giant has launched HealthVault, a platform in which patients and physicians can exchange health information, and which will also provide physicians with access to a single sourced location of practice-related products and resources.

“The use of electronic medical records, and health information technology overall, holds great promise for improving patient care and increasing practice efficiency,” said James Rohack, AMA President.

“The addition of Microsoft’s HealthVault on our AMA portal will enable patients using HealthVault to share more comprehensive health information with their physicians. Having ready access to patient information can help physicians make treatment decisions and reduce the time spent gathering this information resulting in more face-to-face time with patients.”