Team-Based Care, Principles for Employed Physicians Take Top Spots at AMA Interim Meeting

The roles of independent and salaried physicians in the nation's health care system were primary topics for delegates at this year's AMA House of Delegates interim meeting in Honolulu, Nov. 10-13. Delegates discussed how physicians of either type can successfully employ team-based care.

For example, AMA delegates adopted new policy (2-page PDF; About PDFs) designating physicians as leaders of the health care team and using a definition of team-based care nearly identical to the one used by the AAFP. The resolution, which is based on an AMA report on team-based care, also recognizes that physicians in small and solo independent practices can form and lead health care teams -- language that was added at the behest of the AAFP delegation, said AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash.

"We asked for, and the reference committee provided, some clarifying language in this report that says the health care team could be a solo physician working in a practice -- working with a nurse or a medical assistant to provide health care," said Stream in an interview with AAFP News Now.

The resolution itself encourages "independent physician practices and small group practices to consider opportunities to form health care teams, such as through independent practice associations, virtual networks or other networks of independent providers."

Stream, who served as part of the 19-member AAFP delegation to the AMA meeting, noted that the AMA's definition of team-based care and its emphasis on physician-led health care teams is "very much in line with the AAFP's vision of team care and the patient-centered medical home."

The definition also closely resembles the definition used in the AAFP's Primary Care for the 21st Century document, which makes an evidence-based argument for physician-led health care teams to improve quality and cost efficiency in the U.S. health care system, said Stream.

The AMA resolution calls for adopting principles to help guide physician leaders of the health care team, including incorporating a focus on patient and family-centered care; clarifying the team's mission, vision and values; and engaging with other team members in delivering patient care.

Another topic of interest at the AMA meeting was principles for physician employment. A report (pp. 13-29 of 33-page PDF; About PDFs) issued by the AMA Board of Trustees looked at the growing trend toward physician employment in the medical profession.

"Physicians are increasingly entering into employment and other contractual relationships with hospitals, group practices and other health care organizations and delivery systems," says the AMA report.

The report goes on to say, "The American Hospital Association estimates that physician employment by hospitals has increased by 32 percent over the last ten years. This trend toward employment is expected to continue, as indicated by a recent Merritt Hawkins survey that found that 32 percent of final-year residents preferred hospital employment over any other practice option."

The report argues that, although contractual relationships can benefit both physicians and patients, "employed physicians face a unique set of challenges as they seek to protect their professional, ethical and financial interests while maintaining the inviolability of the patient-physician relationship."

In response, AMA delegates adopted principles for physician employment in six key areas:

A physician has a primary responsibility to his or her patients, says the principle related to conflicts of interest. However, employed physicians also need to be loyal to their employer. "This divided loyalty can create conflicts of interest, such as financial incentives to over- or under-treat patients, which employed physicians should strive to recognize and address."

The principles also note that "employed physicians should be free to exercise their personal and professional judgment in voting, speaking and advocating on any matter regarding patient care interests, the profession, health care in the community and the independent exercise of medical judgment. Employed physicians should not be deemed in breach of their employment agreements, nor retaliated against by their employers for asserting these interests."

One area of debate that particularly attracted the attention of the AAFP delegation at the AMA meeting was a report from the Council on Medical Service (pp. 30-44 of 81-page PDF; About PDFs) that recommended changing Medicare from a defined benefit program to a defined contribution program in which beneficiaries would use Medicare funds to purchase Medicare coverage from competing health care plans.

During reference committee testimony on Nov. 13, Stream testified against turning Medicare into what he described as a voucher program, saying it would result in "unintended consequences." With a voucher program, Medicare beneficiaries likely would choose high-deductible plans that skirt wellness and prevention, hallmarks of primary care and family medicine, Stream said.

AMA delegates adopted a final report that calls for maintaining the traditional Medicare program while also allowing beneficiaries to use defined contributions to purchase Medicare coverage from private health plans. Stream described the outcome as "reasonable."