Healio exclusive: AMA president discusses burnout, opioid epidemic, health care reform

David Barbe
David O. Barbe

Earlier this year, AMA swore in family physician David O. Barbe, MD, as its 172nd president. Previously, he had served in various capacities on AMA’s board and its committees.

“I am excited and eager to lead the nation’s largest and most influential physician organization,” he said in a press release at the time of his inauguration.

Barbe, who has been practicing family medicine in rural southern Missouri for more than a quarter of a century, assumed the presidency at a time when health care reform is still very much in doubt, more than half of all physicians are experiencing physician burnout, and physicians spend nearly the same amount of time on tasks collectively referred to as ‘desktop medicine’ as they do with patients.

In this exclusive interview, Healio Family Medicine spoke with Barbe about how he plans to address some of these issues, as well as the opioid epidemic, uncontrolled hypertension and prediabetes. - by Janel Miller

Question: How will you address the issue of physician burnout?

Answer: That is one of my personal passions. I think the state of and the morale of physicians in this country right now is a tragedy. Burnout rates are higher than they have ever been and they continue to rise. A recent Mayo Clinic study showed that 54% of physicians experienced some degree of burnout. We know that when physicians are feeling burned out, they disengage, and that begins to diminish the quality of care and the amount of care they can give. It can lead to early retirement, which compounds the physician shortage problem we have in this country. We are addressing that by advocating for regulatory relief to improve the health care environment by removing technological and administrative burdens that take time and resources away from patient care. This includes improving the reporting systems in which physicians record quality metrics and patient use to make it more rational. AMA is also leading a necessary change in medicine that embraces physician well-being as an essential element in achieving national health goals.

We also want to take things down to the practice level and we have multiple practice tools and resources for physicians to be more efficient and better deal with their stresses like prior authorizations for treatments and medications. We also want to address physicians’ well-being and their resilience to face and deal with what the practice may bring. Some of these tools include the AMA’s Steps Forward program, which contains 40 or so modules that help physicians streamline their practice. We have also developed 21 principles for health plans and other payers to reduce the burden of prior authorizations and make this process more effective and efficient. On this last initiative, we are seeing some early successes. In fact, some health plans have decreased the number of prior authorizations and tests. We’re very proud of that.

These initiatives are designed to retain physicians already in practice, and help high school and college students who are considering a career in medicine see it as a great career, and not frustrating as some physicians currently see it.

Q: How is AMA addressing the physician shortage?

A: We support increasing the level of Graduate Medical Education or residency slots. That’s the bottleneck in our system right now. Medical schools have increased the number of graduates—many schools have increased their class size by 30% and we’ve seen new medical schools and osteopathic colleges open around the country, but what we have not seen is any significant increase in funding for residency slots. So the number of medical students and the rate of increase is far outpacing the rate of increase and the number of residency slots. So not only do we not get physicians out of the pipeline, we’re seeing an increasing number of students not find residency slots when they finish medical school. That’s a real tragedy as well.

Q: Can you please elaborate on the initiatives to help patients with prediabetes and uncontrolled hypertension ?

A: In [the United States], there are 84 million people — or one out of every three people — that have prediabetes. And what’s worse, 90% of them do not know it. Prediabetes itself can cause physical changes in the body, and of course, if left unaddressed, a high number of these cases will progress to full blown type 2 diabetes and all of its complications. Our collaboration with the CDC and American Diabetes Association, which is about a year old, utilizes the website doihaveprediabetes.org. Patients can take a 1-minute test, answer a few simple questions and assess their risk of having prediabetes. If they score high on that test, they need to work with their physician to begin reversing that trend. Prediabetes is very reversible. It’s not a forgone conclusion that everyone with prediabetes is going to progress to type 2 diabetes. It can be changed with some very simple, straightforward life-style changes and has had a very high rate of success.

On the hypertension side, we are working with the American Heart Association to launch Target BP. That is mainly designed to raise awareness of uncontrolled high BP and allow both patients and physicians to be more vigilant about checking BP properly and treating it progressively when elevated BPs are found. An estimated 80 million people in [the United States] have high BP, and about 30 million Americans state that they have a regular source of health care and that their BPs are uncontrolled. That’s low-hanging fruit, and we can help them avoid the complications of uncontrolled high BP, because these can increase the likelihood of high BP or stroke.

Q: How will AMA address the opioid epidemic during your term?

A: The [Obama administration] declared war on the opioid crisis in October 2015. AMA was ‘Johnny on the Spot,’ with full participation in that national campaign. Since then, we have focused our efforts on several strategies through our work with the AMA Task Force to Reduce Opioid Abuse First is opioid education for both physicians and patients. We need both of these parties to understand the risks and dangers of opioids if not used properly. There’s also caution that needs to be used in prescribing them in the first place and then continuing [to prescribe them]. Education on the safe, effective evidence-based prescribing practices is important.

The second thing we’ve done is continued work on making the prescription drug monitoring programs, or PDMPs, more effective and useful to the physician and the patient. An effective PDMP would be one that has real-time or near real-time information about a patient’s narcotic prescriptions in it and is easily worked into the physician’s workflow. These PDMPs need to be easy for physicians to access and have timely and accurate information in it. Physicians recognize the value of this, but in many states, they are not user-friendly, or they don’t have timely information, so we’re trying to get better use and improved functionality of PDMPs.

We’re also trying to increase awareness of naloxone as an antidote to overdose patients. It has been shown that if naloxone is at the scene of an overdose, and whether it is administered by a family member or friend or emergency personnel, in many of these instances it can be lifesaving. So we’re working to expand the availability of naloxone. We also believe there needs to be better substance abuse treatment facilities and programs available, more medication assistance treatment programs and the use of buprenorphine more readily available for those who want to get off narcotics. Physicians recognize that they have a very important role to play in turning around this epidemic, and we are seeing pretty significant decreases in every state in the number of prescribed opioids, which is a good sign.

While [opioid abuse] remains a problem, the increased use of heroin is another problem, that is going to take a multi-faceted approach so that we can turn the tide of total opioid deaths around, which is really escalating.

Q: What does AMA have planned for curbing heroin use?

A: We need better mental health services, better substance abuse disorder programs, as well as public education awareness programs about the dangers of this.

Q: How does your background in family medicine uniquely position you to tackle these issues?

A: Being a family physician gives me a unique perspective. Part of it is because family medicine is a specialty that covers a lot of different conditions. It helps me identify with the range of issues that the various specialties, such as obstetricians, surgeons and so on face, because I’ve dealt with those things in my practice. I understand where physicians are coming from when they come to me and say the payment for this service is being cut, or I’m having trouble getting authorization for a test or procedure that I’ve been doing for years. It makes me passionate about trying to work with the insurance industry on the administrative and regulatory level and make the environment better because I’ve experienced it myself. In addition, my experience as a physician executive in my health system has helped me see many sides of the health care landscape that perhaps some family physicians have not been exposed to. These two things have prepared me well to address the broad range of issues that physicians face in this country and that the AMA is working to improve.

Q: Where do you see health care reform going in the future?

A: There are clearly things that need improving, but that is most likely to occur through a bipartisan discussion ... We are really encouraged by the gains in coverage that were made through the [Affordable Care Act]. Twenty million Americans gained coverage through the exchanges or Medicaid because of the Affordable Care Act. Many changes were made to the insurance market, such as no exclusions because of pre-existing conditions and removing caps on annual or lifetime payment limits, and those things need to be maintained. We have seen through this last round of Congressional debates in both the House and the Senate that a lot of people don’t want to see us go backwards in regards to these gains ... and that is encouraging.

At the same time, we need to work on, and will advocate for, issues like affordability and stability of the insurance market. We are not advocating for the status quo, because as I indicated earlier, there are things that need improving. But we don’t want nothing to happen, either.

The fact that Republicans have not been able to unilaterally pass a health care reform bill makes me hopeful that this conversation can turn bipartisan. While we were opposing the House and Senate bills, we were simultaneously calling for a bipartisan discussion because we feel it’s the best way to go forward with health care reform that will benefit our country.

David Barbe
David O. Barbe

Earlier this year, AMA swore in family physician David O. Barbe, MD, as its 172nd president. Previously, he had served in various capacities on AMA’s board and its committees.

“I am excited and eager to lead the nation’s largest and most influential physician organization,” he said in a press release at the time of his inauguration.

Barbe, who has been practicing family medicine in rural southern Missouri for more than a quarter of a century, assumed the presidency at a time when health care reform is still very much in doubt, more than half of all physicians are experiencing physician burnout, and physicians spend nearly the same amount of time on tasks collectively referred to as ‘desktop medicine’ as they do with patients.

In this exclusive interview, Healio Family Medicine spoke with Barbe about how he plans to address some of these issues, as well as the opioid epidemic, uncontrolled hypertension and prediabetes. - by Janel Miller

Question: How will you address the issue of physician burnout?

Answer: That is one of my personal passions. I think the state of and the morale of physicians in this country right now is a tragedy. Burnout rates are higher than they have ever been and they continue to rise. A recent Mayo Clinic study showed that 54% of physicians experienced some degree of burnout. We know that when physicians are feeling burned out, they disengage, and that begins to diminish the quality of care and the amount of care they can give. It can lead to early retirement, which compounds the physician shortage problem we have in this country. We are addressing that by advocating for regulatory relief to improve the health care environment by removing technological and administrative burdens that take time and resources away from patient care. This includes improving the reporting systems in which physicians record quality metrics and patient use to make it more rational. AMA is also leading a necessary change in medicine that embraces physician well-being as an essential element in achieving national health goals.

We also want to take things down to the practice level and we have multiple practice tools and resources for physicians to be more efficient and better deal with their stresses like prior authorizations for treatments and medications. We also want to address physicians’ well-being and their resilience to face and deal with what the practice may bring. Some of these tools include the AMA’s Steps Forward program, which contains 40 or so modules that help physicians streamline their practice. We have also developed 21 principles for health plans and other payers to reduce the burden of prior authorizations and make this process more effective and efficient. On this last initiative, we are seeing some early successes. In fact, some health plans have decreased the number of prior authorizations and tests. We’re very proud of that.

PAGE BREAK

These initiatives are designed to retain physicians already in practice, and help high school and college students who are considering a career in medicine see it as a great career, and not frustrating as some physicians currently see it.

Q: How is AMA addressing the physician shortage?

A: We support increasing the level of Graduate Medical Education or residency slots. That’s the bottleneck in our system right now. Medical schools have increased the number of graduates—many schools have increased their class size by 30% and we’ve seen new medical schools and osteopathic colleges open around the country, but what we have not seen is any significant increase in funding for residency slots. So the number of medical students and the rate of increase is far outpacing the rate of increase and the number of residency slots. So not only do we not get physicians out of the pipeline, we’re seeing an increasing number of students not find residency slots when they finish medical school. That’s a real tragedy as well.

Q: Can you please elaborate on the initiatives to help patients with prediabetes and uncontrolled hypertension ?

A: In [the United States], there are 84 million people — or one out of every three people — that have prediabetes. And what’s worse, 90% of them do not know it. Prediabetes itself can cause physical changes in the body, and of course, if left unaddressed, a high number of these cases will progress to full blown type 2 diabetes and all of its complications. Our collaboration with the CDC and American Diabetes Association, which is about a year old, utilizes the website doihaveprediabetes.org. Patients can take a 1-minute test, answer a few simple questions and assess their risk of having prediabetes. If they score high on that test, they need to work with their physician to begin reversing that trend. Prediabetes is very reversible. It’s not a forgone conclusion that everyone with prediabetes is going to progress to type 2 diabetes. It can be changed with some very simple, straightforward life-style changes and has had a very high rate of success.

On the hypertension side, we are working with the American Heart Association to launch Target BP. That is mainly designed to raise awareness of uncontrolled high BP and allow both patients and physicians to be more vigilant about checking BP properly and treating it progressively when elevated BPs are found. An estimated 80 million people in [the United States] have high BP, and about 30 million Americans state that they have a regular source of health care and that their BPs are uncontrolled. That’s low-hanging fruit, and we can help them avoid the complications of uncontrolled high BP, because these can increase the likelihood of high BP or stroke.

PAGE BREAK

Q: How will AMA address the opioid epidemic during your term?

A: The [Obama administration] declared war on the opioid crisis in October 2015. AMA was ‘Johnny on the Spot,’ with full participation in that national campaign. Since then, we have focused our efforts on several strategies through our work with the AMA Task Force to Reduce Opioid Abuse First is opioid education for both physicians and patients. We need both of these parties to understand the risks and dangers of opioids if not used properly. There’s also caution that needs to be used in prescribing them in the first place and then continuing [to prescribe them]. Education on the safe, effective evidence-based prescribing practices is important.

The second thing we’ve done is continued work on making the prescription drug monitoring programs, or PDMPs, more effective and useful to the physician and the patient. An effective PDMP would be one that has real-time or near real-time information about a patient’s narcotic prescriptions in it and is easily worked into the physician’s workflow. These PDMPs need to be easy for physicians to access and have timely and accurate information in it. Physicians recognize the value of this, but in many states, they are not user-friendly, or they don’t have timely information, so we’re trying to get better use and improved functionality of PDMPs.

We’re also trying to increase awareness of naloxone as an antidote to overdose patients. It has been shown that if naloxone is at the scene of an overdose, and whether it is administered by a family member or friend or emergency personnel, in many of these instances it can be lifesaving. So we’re working to expand the availability of naloxone. We also believe there needs to be better substance abuse treatment facilities and programs available, more medication assistance treatment programs and the use of buprenorphine more readily available for those who want to get off narcotics. Physicians recognize that they have a very important role to play in turning around this epidemic, and we are seeing pretty significant decreases in every state in the number of prescribed opioids, which is a good sign.

While [opioid abuse] remains a problem, the increased use of heroin is another problem, that is going to take a multi-faceted approach so that we can turn the tide of total opioid deaths around, which is really escalating.

PAGE BREAK

Q: What does AMA have planned for curbing heroin use?

A: We need better mental health services, better substance abuse disorder programs, as well as public education awareness programs about the dangers of this.

Q: How does your background in family medicine uniquely position you to tackle these issues?

A: Being a family physician gives me a unique perspective. Part of it is because family medicine is a specialty that covers a lot of different conditions. It helps me identify with the range of issues that the various specialties, such as obstetricians, surgeons and so on face, because I’ve dealt with those things in my practice. I understand where physicians are coming from when they come to me and say the payment for this service is being cut, or I’m having trouble getting authorization for a test or procedure that I’ve been doing for years. It makes me passionate about trying to work with the insurance industry on the administrative and regulatory level and make the environment better because I’ve experienced it myself. In addition, my experience as a physician executive in my health system has helped me see many sides of the health care landscape that perhaps some family physicians have not been exposed to. These two things have prepared me well to address the broad range of issues that physicians face in this country and that the AMA is working to improve.

Q: Where do you see health care reform going in the future?

A: There are clearly things that need improving, but that is most likely to occur through a bipartisan discussion ... We are really encouraged by the gains in coverage that were made through the [Affordable Care Act]. Twenty million Americans gained coverage through the exchanges or Medicaid because of the Affordable Care Act. Many changes were made to the insurance market, such as no exclusions because of pre-existing conditions and removing caps on annual or lifetime payment limits, and those things need to be maintained. We have seen through this last round of Congressional debates in both the House and the Senate that a lot of people don’t want to see us go backwards in regards to these gains ... and that is encouraging.

PAGE BREAK

At the same time, we need to work on, and will advocate for, issues like affordability and stability of the insurance market. We are not advocating for the status quo, because as I indicated earlier, there are things that need improving. But we don’t want nothing to happen, either.

The fact that Republicans have not been able to unilaterally pass a health care reform bill makes me hopeful that this conversation can turn bipartisan. While we were opposing the House and Senate bills, we were simultaneously calling for a bipartisan discussion because we feel it’s the best way to go forward with health care reform that will benefit our country.