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AMA: Put Practicing Doctors on Exchange Boards

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Members of the American Medical Association (AMA) House of Delegates approved new health insurance exchange policies this weekend at a meeting in New Orleans.

The AMA, Chicago, has developed the policies to respond to the exchange provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA).

If PPACA takes effect as written and works as expected, it will create a new system of federal and state health coverage distribution exchanges starting in January 2014.

The exchanges are supposed to create a marketplace that individuals and small businesses can use to buy high-quality health coverage with new federal subsidies.

The U.S. Department of Health and Human Services has developed exchange guidelines that give states a great deal of flexibility in designing exchanges. A state can run part or all of its exchange program, turn part or all administration over to the federal government, and choose how strict it wants to be about which health insurers and plans can participate in the exchange program.

States also are supposed to create a new Navigator program that is supposed to help low-income people, small business owners, and others who might be confused by the exchanges figure out how to use the exchanges.

The AMA’s Council on Medical Service has developed one proposal relating to exchanges and one relating to the Navigators program.

The exchange policies build on policies that the AMA House of Delegates adopted in 2009.

PPACA itself sharply restricts the ability of insurance companies and people affiliated with insurers from helping to run the exchanges. It is also not clear whether health insurance brokers can get paid to participate in the Navigators program.

AMA officials argue in a summary of the exchange system policy documents that they believe it is “imperative for physicians, as strong advocates for our patients, to be included on exchange government structures.”

Physicians involved in exchange governance should recuse themselves when potential conflicts arise, AMA officials say.

Physicians should be actively involved in discussions about how the exchanges will be funded, the officials say.

Exchange programs also need to develop information systems that let physicians known what level of exchange coverage a patient as at the time the physician is seeing the patient, officials say.

“Access to real-time information will help ensure that physicians are paid for the services they provide to their patients,” officials say.

The AMA council “believes that it is critical for exchanges to serve as open marketplaces to maximize competition between health insurance issuers and patient choice of health plan,” officials say.

Some consumer groups and other groups have argued that exchanges should be “active purchasers” that are rigorous about screening, and possibly bargaining with, the insurers that participate in exchange programs.

The AMA believes an exchange should be an “open marketplace” that simply verifies whether health plans meet federal quality standards and does not impose additional value and cost goals, officials say.

In the exchange document, AMA Council of Service officials say Navigators should supply information but avoid taking on any activity that could be construed as clinical in nature, such as interpreting lab results or medical symptoms.


The AMA House of Delegates also voted to try to block the looming shift to the International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), from an earlier version of the condition coding standard, ICD-9.

The ICD-10 would increase the number of codes to about 69,000, from about 14,000 today.

“The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients’ care,” Dr. Peter Carmel, the AMA president, says in a statement about the shift. “At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions.”