Aloha everyone. Good morning. Thank you for joining us. First session of the APA Annual Meeting. Very, very excited to have you here. I know there's some folks joining us virtually as well. It is my pleasure to introduce Dr. Jesse Ehrenfeld. He is the President of the American Medical Association. He's also the Senior Associate Dean, Tenure Professor of Anesthesiology, Director of Wisconsin's largest state public health philanthropy organization, the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin. Dr. Ehrenfeld believes in the power of digital health and information technology to improve patient outcomes and radically transform healthcare for the better. Dr. Ehrenfeld is a board certified both in anesthesiology and clinical informatics. Please give a round of applause for Dr. Ehrenfeld. Thank you, Jacques, for getting us kicked off this morning. Thank you all for joining me. It's really great to be here at the APA meeting. As Jacques mentioned, I'm Jesse Ehrenfeld, President of the AMA. I also work in beautiful Milwaukee, Wisconsin. I'm not a psychiatrist. I'm an anesthesiologist, but I have lots of friends who are psychiatrists, so hopefully that's okay. The lens that I look at all of the challenges that we face as a community of physicians is broad, right, given sort of my role at the AMA and also my work in Wisconsin. And I know that throughout today and the rest of the meeting, you're going to be hearing from experts. You're going to be hearing from your colleagues about what makes delivering healthcare today in our modern environment so challenging and how various issues impact the cost of care, the quality of outcomes, and the experience that our patients have each and every day, from AI to biotech to value-based care models. Healthcare is rapidly evolving, and it can be difficult for even experienced physicians who've been in it for decades to stay ahead with the pace of change without feeling overwhelmed. So in the time that I was given this morning, I wanted to cast kind of a wide net about what are the challenges that are impacting various specialties, not just psychiatrists, but surgeons, pediatricians, everyone, but in different ways. And I'll take a look at some of the advocacy priorities of the AMA to fix some of these systemic issues through changes in policy and the creation of programs and initiatives. And I'll focus specifically on the crisis of physician burnout and how it impacts patient care and what effective solutions look like. The pace of change that's happening right now is having an enormous impact on physician and the larger healthcare workforce, and is putting even greater pressure on the larger healthcare system, creating labor shortages that's contributing to greater system inefficiencies and jeopardizing the care that we are able, and in many cases, unable to provide to our patients. So as we're working together to try to lower costs, improve patient care, drive better outcomes, all important laudable essential goals in healthcare, we've also got to pause to recognize and reflect on how burnout among physicians and other healthcare professionals imperils each of those goals. We've got to recognize how all of these issues are interconnected, held in place by a broken, bloated, widely inefficient healthcare system that has just erected barrier after barrier after barrier in front of our patients and physicians who are trying to deliver the care that our patients need. So the good news is there are solutions out there, so I want to talk about some of them. To give you some learning objectives, what I want to do at the end of the session is make sure that we've gone through what are the driving health trends in America today and what do they mean for medicine in a changing America, highlight how the AMA is supporting physicians and patients, particularly in an era of deepening divisions and this background of rising professional burnout, and examine the role of the AMA and physician leaders to combat medical misinformation and protect public health. So this is my 96-page CV broken down on one slide. It is available for download on demand. Just please, for God's sakes, do not print it because somewhere a tree will cry, but I am president of the AMA. I'm faculty in beautiful Milwaukee, Wisconsin. I have adjunct appointments at the Uniformed Services University, the Military Medical School in Bethesda. I'm also adjunct faculty at Vanderbilt, where I worked for nine years before going to Wisconsin, and I do a lot of work in the sort of standard space with WHO, AMI, and other organizations. I served in the Navy for about a decade, and while I was attached to the Navy, I had the opportunity to do some strategy work for the Navy Surgeon General as well as the 20th U.S. Surgeon General. When you look at all of the AMA's work, you can think about it being bucketed into really three core areas. Getting rid of the things that interfere with our ability to take care of patients, removing the obstacles. The second is leading the charge to confront public health crises, the rising growth of chronic disease, the burden that that places on our patients and us for needs for management, as well as things like a pandemic with COVID. And then the third bucket is driving the future of medicine, reimagining medical education, making sure that people coming out of our training programs are actually prepared to work in the delivery system that continues to evolve so quickly, promoting innovation, digital health tools to drive the ability to tackle these large challenges in healthcare. So what's driving burnout amongst us and our colleagues? You know, if you look at the weight that everybody carries on their shoulders when they practice today, there continues to be this huge growing expansion of administrative bureaucracy and paperwork, increasing hostility towards us and other healthcare practitioners. Continued attacks on science and organized disinformation and misinformation campaigns that have eroded trust in the profession. We continue to see government overreach. It used to be just third party payers that would tell us what we can and can't do. And now we have legislators in many jurisdictions legislating what is and is not acceptable, taking away the autonomy of patients to make their own healthcare decisions supported by their clinical teams. A surging rise of chronic disease, economic pressure, and geopolitical uncertainty that adds to the stress and the complexities of the world that we operate in, in our patients' experience. Of course, trust in medical institutions, trust in science, trust in experts continues to erode. Americans do not trust the CDC the way they did five years ago. They do not trust the FDA the way they did five years ago. And the good news is patients still trust their physicians. We see this from things like the long-standing Gallup tracking poll data, but not as much as they used to. That trust continues to erode. And then of course, driving all of this burnout are questions about what does digital health mean? All these questions about AI and emerging technology and concerns around what that's going to do to the patient-physician relationship. So as we think about the future of the healthcare system, you've got to consider the healthcare needs of the nation in the coming decades. And there's some concerning trends that we all have to pay attention to. So by 2050, a fifth of the U.S. population will be over 65. We have an ever-growing burden of chronic disease, widening income inequalities, rising healthcare costs, a shrinking medical workforce proportionately, and of course, who knows what the future holds in terms of other things like another pandemic. So there are some really important questions that we have to ask. Is there going to be a continued drop in life expectancy? A continued rise in maternal morbidity and challenges around infant mortality? What will the trajectory be for deaths linked to firearms or drug overdoses? Really important questions to consider. And then conversations about physician shortages. They tend to focus on these sort of longer-term alarming projections, right? But I will tell you, the crisis is now. And you know, the AAMC, they project that a decade out, we're going to be 37,000 to 100-something thousand physicians short. It's a wide range. It's a big number, whatever it actually works out to be. And if that happens, it will be devastating for patients as they struggle to access the healthcare system. But that statistic belies the fact that for many, the shortage is here. You know that. You see that. I see that. The U.S. faces a severe shortage of psychiatrists, mental health professionals. One study that I really like from the Kaiser Family Foundation showed that our nation had barely a quarter of the mental health professionals that we need to deliver care. And in some states, the percent of mental health needs is substantially lower. AAMC reports that more than 150 million people live in federally designated areas without access to a mental health professional. 150 million Americans. That's nearly half of the nation. And trends are that that's going to get worse as the psychiatrist shortfall soars over the next decade to an expected 31,000 short. On top of that, outside of psychiatry, it's estimated that 83 million Americans in the U.S. currently live in an area where there is not sufficient access to primary care. And we know what happens when people don't have access to primary care. In large parts of Idaho and Mississippi, pregnant women can't find OBGYNs to care for them. Imagine being pregnant and not having anybody to do routine care. Something like 80% of U.S. counties are without an infectious disease specialist. 90% of U.S. counties don't have a pediatric ophthalmologist. In Florida, my own parents lost their long-term primary care physician because the practice couldn't take Medicare anymore. They just couldn't make the numbers work with the continued erosion of the physician fee schedule. So like many, they scrambled. Had to find a new practice, a new physician. They travel farther away. Things were lost in the transition. And so while our current physician shortage is currently limiting access to millions of people, it's going to get worse. So how do these trends influence what I try to do and the AMA is trying to do to influence policy at both the state and the federal level? Well, we have something that we call our recovery plan for America's physicians. We launched this in 2022, sort of towards the tail end of the worst part of the pandemic. And this is really a summation of the key federal advocacy priorities that we have. The first is reforming a deeply flawed Medicare payment system that hasn't seen a real inflation update in two decades, requires burdensome reporting of irrelevant metrics, and has yet to implement any of the dozens of innovative payment models designed by physicians to improve quality and reduce costs, but are literally sitting on a shelf at CMS collecting dust. The second is supporting team-based care and stopping this group of practice creep that we continue to see, recognizing that physicians bring unique skills and training and experience to bear in diagnosing and treating our patients. And patients count on that expertise and they expect that a physician will direct their care. And the AMA scored more than a hundred victories in states around the country last year in 2023, but there continue to be challenges ahead. Third is fixing prior authorization to remove the growing burdensome hurdles that health insurers and others create to deny needed care to our patients. Fourth is reducing physician burnout broadly and addressing stigma around mental health and accessing services when physicians need it. And fifth is supporting the creation of digital health tools, telehealth, while bringing to the table our physician values and our experience from the front lines about what works and what does not. So the QR code down there will take you to a link on our website where you can get a lot more detail on any of those priorities. And it's also pretty easy to find if you don't scan it now. So as physicians, we know that there are many issues like these that jeopardize patient care, but in different ways. And one issue that's been a major focus of AMA advocacy for several years and will continue to be this year and in the year ahead is sounding the alarm on the completely unsustainable Medicare payment system. So adjusted for inflation, Medicare reimbursement to physicians has dropped, dropped by 29% since my first year of medical school in 2001. And that's after the AMA was able to secure partial relief to further cuts this calendar year in 2024. To be clear, the decision by Congress to eliminate only half of this year's scheduled 3.7, sorry, 3.37% pay cut for Medicare is still woefully insufficient. We are extremely disappointed that half of the 2024 cuts have been allowed to continue despite urgent calls from physicians across every specialty about the impact that two decades of annual payment cuts is having on practice viability and patient access to care. When we lack the resources that we need to keep our practices open, people close their offices. They reduce their hours. They stop taking Medicare patients. They make do with antiquated technology or equipment or fewer support staff. All those things hurt our patients. Patients suffer, especially older Americans, those with limited mobility who may lose access to essential care, who may have to wait months to get an appointment or may have to travel much further away to see a physician that they don't know. So the need to stop the annual cycle of payment cuts and patches and enact permanent Medicare payment reform could not be more urgent. And because of Congress's failures to reverse this year's cuts, again, millions of seniors are going to find it more and more difficult to access high quality care and physicians are going to find it more and more difficult to continue to accept Medicare patients. So we continue to call on Congress to fix this broken system that's placing enormous financial pressure on practices and threatening the delivery system overall. The financial stability of our practices and the long-term viability of the entire health care system really is at stake. And while physicians faced Medicare reimbursement cuts in 2023, 2024, the payment schedule confirmed a Medicare economic index. That's what does inflation look like for practices of 4.6 percent. So it's costing, on average, practices 4.6 percent more to make payroll, pay for utilities, pay for supply costs, while our reimbursement rates continue to decline. And that Medicare economic index inflation rate is the highest it's ever been. We know that. We see that. We feel that. On top of last year's 3.8 percent inflation adjustment. So under the current model, we unfortunately are subject to, under Medicare, a six-year payment freeze that ends in 2026. But even when that six-year freeze that Congress enacted stops, the statutory update for most physicians is going to be limited to 0.25 percent indefinitely, again, far below even normal rates of inflation. So we continue to advocate for the aversion of future cuts to the physician fee schedule, as well as promote long-term sustainable reform. And thanks to our advocacy, Congress took the first step in 2023 towards meaningful Medicare reform. They introduced H.R. 2474, which is the Strengthening Medicare for Patients and Providers Act, a bill that will provide automatic annual payment updates to account for practice cost inflation, as reflected in the Medicare Economic Index. We have long supported tying annual payment updates to that economic index, because it would place us on equal ground as every other health care provider paid under Medicare. And a lot of federation groups have joined forces in seeking bipartisan co-sponsors for this legislation and to educate Congress on why it is needed. And we certainly appreciate APA's participation in that. So we know that there is a lot of support for this issue. A bipartisan group of nearly 200 members of Congress have co-signed a letter urging leaders to expedite and pass this legislation. But we've got to keep the pressure on. We have our Physician Grassroots Network and our Patient Advocacy Network, and we would urge all of you to use the QR code to contact your member of Congress and tell them that it's important to pass this legislation. We created the Fix Medicare Now as a one-stop shop for everything that you might need to know in detail about the flawed payment system. And we continue to update that website with new content so that as you're out there trying to do advocacy, you can share your stories. And for the last two years, we have worked very hard, office by office, member by member, staff person by staff person, to educate Congress about the need for meaningful Medicare payment reform. And data demonstrating that payment gap between the rising costs and what we actually receive through the fee schedule has been particularly persuasive, leading to light bulbs going off and recognition of the problem. Now, I will say, in spite of all of those challenges and the upward hill that we have to climb, every now and then we get a big win. And a recent huge legislative victory for physicians was to make changes, substantive changes, in the onerous prior authorization process. And this really, in my mind, demonstrates the power of collective advocacy. So we got a really, really important victory for physicians through CMS in the final rule in 2024. And let me tell you what it does. It requires any government-regulated health plan to reduce time frames for prior authorization decisions and to publicly report out those metrics, which is going to reduce care delays and improve transparency. These plans will also be required to offer electronic prior authorization, something that directly integrates to our electronic health records. We can finally get rid of the fax machine, which will significantly reduce the burden that all of us face. And we expect, and this is a CMS estimate, not ours, CMS estimates that this is going to save practices $15 billion in administrative costs over the next 10 years. And these changes build on a new regulatory requirement that went into effect in January that ensures the validity of prior authorization clinical criteria and protections for continuity of care in the Medicare Advantage plans. We also secured the reintroduction of some legislative language that mirrors the Improving Seniors Timely Access to Care Act last year to expand on these reforms that would cover every plan, not just those that are regulated by CMS. We're also trying to get through the Getting Over Lengthly Delays in Cares as Required by Doctors, catchy title, Gold Card Act, which would exempt qualifying practices and physicians from Medicare Advantage prior authorization requirements. So as we continue to provide societies with legislative language that they can use at the state level, talking points, data, other resources, we would encourage everybody to join us through our grassroots network to try to continue the momentum that is there. The good news is when I'm on Capitol Hill or talking with a legislator at the state level, everybody has had a bad experience with needed care for themselves or a loved one being denied by a third party payer. And there is a broad recognition that we need reform, which is why we're starting to see momentum. 17 states now have adopted large comprehensive prior authorization reform laws, much of it based on model legislation that we have brought forward. And we expect that there will be more and more this year. So meaningful progress on a really important, difficult issue. Now, the AMA has also championed the use of telehealth and remote patient care long before COVID. We won an important victory with the passage of legislation that extends pandemic-related telehealth flexibilities through 2024, ensuring that patients can continue to receive remote care regardless of where they live. And we're continuing to work with Congress and HHS to make those changes permanent. They're not permanent. If we don't get those changes enacted, they will go away at the end of the calendar year. But CMS has proposed maintaining the waiver of geographic and originating site restrictions through the end of this year. And that waiver, which began during COVID, allows Medicare beneficiaries to connect with a physician anywhere in the US from home. And that creates flexibility. We know that's important for patient access. And CMS has also proposed extending payment for audio-only telehealth services, which we know is important for patients who don't have access to broadband or video capabilities. And we applauded the recent Drug Enforcement Administration's decision to extend flexibility in prescribing of controlled substances based on a telehealth patient visit through the end of this calendar year. We're also continuing to work with state medical boards as they are doing their work to license physicians and protect the public. We want to make sure that health care professionals are licensed in the state where the patient is located, recognizing that some exceptions, of course, are warranted. But it's important from an oversight standpoint. So to advance physician adoption of telehealth, the AMA co-founded something called the Telehealth Initiative. This was done in collaboration with the Physicians Foundation and state societies in Florida, Texas, and Massachusetts to help practices redesign their workflows to successfully integrate telehealth into the delivery of care services. At the same time, we've created a number of free online resources for physicians to understand how they can actually do that integration. One of the most notable helpful ones that we get a lot of positive feedback on is our Digital Health Implementation Playbook. It offers comprehensive step-by-step guides to how can you implement digital health solutions, specifically telemedicine, in your practice, driven by insights that we have garnered from physicians all across the country. We also have something called our Telehealth Immersion Program. It's our newest offering to guide practices to optimize telehealth at their organizations and builds on our telehealth initiative. OK. Let me turn to burnout. A key element of our recovery plan is addressing physician burnout. And alleviating burnout and holding on to physicians who are in practice today is such an important part of the larger conversation about workforce shortages. And we have adopted a multi-part strategy to attack the drivers of burnout at the root level. What do the latest survey results on burnout show? So burnout among physicians reached a peak in 2022 during the pandemic at 63%. Two in three physicians across every specialty reporting symptoms of burnout. And this was after years of decline. Things were getting better and then got a whole lot worse. For psychiatrists, according to the APA data, your own data, the burnout rate today is two out of five. Two out of five. So as I highlighted before, the key drivers are, again, the way that we get tortured by third party payers, excessive paperwork, EHRs that don't work very well, staffing and workforce shortages, economic concerns, the stigma around seeking mental health for yourself, and an increasingly bureaucratic system where we have a loss of agency and feel powerless to do things that we know are needed for our patients. So in 2016, the AMA passed a resolution through our House of Delegates to expand our version of the triple aim to the quadruple aim, which had been the industry standard since 2007. Took us a little while to catch up. And the quadruple aim, as you know, has this added important fourth goal of improving the work-life balance of physicians and other health care practitioners. And the AMA, since that time, has recognized the significant role that burnout plays and recognized the critical importance of supporting clinician well-being as a part of overall strategy to strengthen the health care delivery system. And everybody here knows that the stressors that impact all of us have grown since we made that step in 2016, creating even more urgency to fix the underlying problems that are leading to burnouts and more and more people choosing to cut back their hours or leave the profession entirely. This is a quote from an in-depth article in The Atlantic. If anybody wants a reference, I'm happy to send it to you, from 2021, that perfectly sums up the current state of our health care workforce. And the author wrote, health care workers aren't quitting because they can't handle their jobs. They're quitting because they can't handle being unable to do their jobs. And even before COVID-19, many struggled to bridge that gap between the noble ideals of their profession and the realities of its business. And the pandemic simply pushed them past the limits of that compromise. So these are the challenges. I think none are new or surprising to you. What do solutions look like? Well, to start, the most significant drivers of physician and workforce burnout point to systemic problems in health. And this is a system problem. It's not a problem with the individual physician. It's not a problem with us. The problem is the organizations and the structures that we are working and living in. And so it demands system-level solutions. And that's what the AMA is focused on. We're focused on the US health care system and these organizational drivers, not individual practitioner issues. So the AMA has made alleviating physician burnout a cornerstone of our strategic work for more than a decade, trying to work at the systemic level to fix the common drivers of burnout. We know that solutions have got to go beyond administrative simplification to establishing support systems that empower physicians to address their own mental health needs without fearing a negative impact on their careers. And following the passage of the Dr. Lorna Breen Health Care Heroes Provider Act in 2022, a bill which we strongly supported, we continue to push for legislative, regulatory, and other reforms that can direct more funding and more resources to support the mental health needs of physicians. We're working with state societies and at the national level to, piece by piece, reform, identify, and get rid of stigmatizing outdated language on medical licensing board, health system credentialing, and other applications, as well as employment and credentialing applications. And I have lost track of the number of state medical boards and licensing secretaries that I have met with personally to point these important needs out to. And the good news is that many have followed through with their commitments and their promises to make this easier and better for everybody. In partnership with the Lorna Breen Health Care Heroes Foundation and state societies, we are making progress on getting rid of these questions that ask about past diagnoses and replace them with questions that only ask about relevant current impairment. For too long, too many of our colleagues have been reluctant to seek help for their own mental health needs over fears that they'll lose their license or they'll be out of a job. And we know that that has happened. And those fears are well-founded. Four in 10 physicians, in a survey that Medscape did last year, four in 10 said that they did not seek help because they worried about their medical board or their employer finding out. These are physicians who recognized that they needed help. And we know that seeking help early is critical to prevent crisis later on. So more than a dozen health systems this past year alone changed their credentialing applications. And we also had 10 state medical boards that either got their changes done or they have that work in progress. And we've also had some legislative victories in several states to create confidential physician wellness programs so that physicians who need coaching, counseling, other services to address burnout or stress or a similar situation have a confidential place to go. And I will tell you, Wisconsin is one of the last three states, sadly, where I live that does not have a confidential physician health program. But I've got a commitment from the health secretary, the licensing secretary, the insurance commissioner, that we're going to bring one online. We're really, really excited to do that. And we're going to make sure that the other two states have one too. So in 2019, we also created something called our Joy in Medicine Health System Recognition Program to not only recognize practices and health systems and hospitals and medical groups for exemplary work in supporting well-being. That recognition is important. When people are digging in and finding ways to make things better for us and our colleagues, we want to celebrate that. But we also want to provide a roadmap for others to follow to implement the things that work to reduce burnout. So last year, we recognized 72 medical groups and health systems as a part of this program, helping spread best practices, lessons learned to more and more groups and institutions and centers and hospitals who want to make these changes. We also created something that we call our Organizational Biopsy. It's a tool to help organizations perform their own self-evaluation to measure the well-being of groups in four core areas, organizational culture, the leadership, the teamwork, the trust, practice efficiency that looks at team structures, team stability, workflows, self-care, levels of post-traumatic stress, post-traumatic growth, work-life balance, and retention and work intentions. Another resource that we've launched is our AMA Steps Forward series. It's a collection of very engaging, well-put-together interactive toolkits that give actionable how-to guides to improving practice. And one of those toolkits is focused on establishing a chief wellness officer. Many organizations are creating a new C-level executive position responsible for organizational strategy and guiding system-wide efforts to improve professional fulfillment and reduce burnout. Establishing a chief wellness officer position paves the way for a lot of organizations to improve not only the care team well-being, but also the patient experience and health outcomes and retention of key personnel, as well as better financial position. We know that physician burnout can lead to inefficiencies that ultimately drive up costs at the macro and the local level. Physician burnout is not just bad for the individual. It's expensive to organizations. It contributes to the direct costs of recruitment and replacement when people leave or reduce their hours. And for an organization, the cost of physician burnout can range from half a million dollars to a million dollars per doctor. And that is because of the challenges of having to pay for recruitment costs and sign-on bonuses and lost billing and onboarding and all the things that groups have to go through when they have to replace physicians. And of course, the cost of burnout can include indirect costs, medical errors, higher malpractice risk, reduced patient satisfaction, damage to the organization's reputation, loss of patient loyalty. So to determine the projected cost of physician burnout related to turnover in our AMA Steps Forward toolkit, we have a calculator that organizations can use to justify the costs of investing in these critical programs. And these calculators are really helpful. We've heard this from many groups and practices in health care systems as they're trying to calculate the return on investment for interventions that might improve physician well-being. Now, while a recovery plan doesn't specifically talk about workforce shortages, we have other AMA advocacy that is working to address it. There are three bipartisan bills in Congress that we strongly support that would expand residency training options, provide greater loan support, and create smoother pathways for foreign-trained physicians who already compromise a quarter of our nation's physician workforce. This is particularly important to address in medically underserved areas of the country. So for example, the AMA supports the Conrad 30 and the Physician Access Reauthorization Act bills, both now on Congress, which would make necessary improvements to the J-1 visa waiver program to address physician shortages, especially in rural and underserved areas, but also to promote a more diversified workforce. The Conrad 30 bill also provides important worker protections to prevent physicians from being mistreated. We also support the Health Care Workforce Resilience Act, which would recapture 15,000 unused employment-based physician immigrant visas. There's also the Retirement Parity for Student Loans Act, which would allow retirement plans to make voluntary matching contributions to physicians while they are in residency. And there's the Physician Shortage GME CapFlex Act, which would finally expand residency training programs in psychiatry and primary care. AMA supports, obviously, expanded roles for international medical graduates, and we support advancements in digital technology that may also provide a role in solving the workforce shortage. So we are about to enter what I like to call the silly season, elections. And in this election year, there are all kinds of external forces on medicine, creating new layers of stress, some of it fueled by misinformation online. And whether deliberately spread disinformation meant to sow distrust, confusion for patients, or whether it's misinformation that is accidentally recycled and reported online, both of those actions undermine trust, trust in science, medical institutions, and ultimately us as physicians. And in some extreme cases, medical misinformation has resulted in physical attacks and threatening behavior directed towards physicians and other health care workers. I think it's important to point out that medical misinformation isn't new. The AMA made a name for itself in the 19th century, in the 1800s, by pushing back against the harm being done by junk science and quack remedies. And one way to begin rebuilding trust in science and medicine is to effectively counter those voices who spread disproven, blatantly false information online. And we're engaged on this issue on a whole bunch of different fronts as we continue to see bills pop up in states that are underpinned by medical misinformation. So for example, during the pandemic, we saw several bills at the state level seeking to prevent licensing boards from taking disciplinary action against physicians for prescribing ivermectin for COVID-19, hydroxychloroquine, or for expressing their professional opinions. And recent state bans on gender-affirming care often disregard the evidence and treatment guidelines from professional societies for gender dysphoria. And along the same lines, the rash of recent abortion bans, often based on a mischaracterization of fetal developments. Abortion ban exceptions, such as that to save the life or preserve the health of the mother, also don't always reflect the reality of medicine. And as a result, all of these new laws have created confusion, and in many cases, are delaying care for our patients. So we continue to call out these efforts and to push back through our state and federal advocacy, as well as our work in the courts. Our House of Delegates has adopted a comprehensive strategy to address misinformation. And it calls for us to do a number of things, making sure that credible, evidence-based medical and public health information is accessible. And so we're engaged with publishers, research institutions, the media, to develop best practices around paywalls, preprints, to make sure that we can improve access to evidence-based credible information and analysis. Addressing disinformation by health professionals on social media platforms, addressing how monetization of disinformation is driving a lot of the fuel of this, educating health professionals around, how do you recognize information that is not credible, educating the public about how can they understand the source of a piece of information that they are seeing online. And we're obviously working at a policy level to try to figure out how do we stop the spread of disinformation and ensure accountability at the platform level online and at the place of origin. And the media obviously has a role in all of this. And we're in deep conversations with all of the social media companies and streaming services about how they can remain vigilant to help their readers and their viewers and their listeners more easily separate out fact from fiction and reduce misinformation. And we believe all of this can be done while upholding the principles of the First Amendment that obviously we all hold so dear. OK. Like everything else today, whoa, oh, jeez, OK. I thought I was about to get the hook, but we still have time. Like everything else today, technology plays an important role in the conversation about physician and health care worker burnout. And I'm not talking about robot doctors or nurses powered by AI, but I'm talking about a number of practice inefficiencies that we have suffered through with things like the rollout of electronic health record. On the flip side, the practice efficiencies that could be achieved through the creation of smartly designed digital tools created with the insights of physicians. So we have created a number of platforms to connect physicians with technology innovators to give entrepreneurs real world insights into clinical practice. And we recently released our Principles for AI Development, Deployment, and Use last fall. It is a lengthy document. There's a link to it with a QR code. I won't go through all of it in detail. But a couple of really, really important things. Foundationally, they encourage a comprehensive, all-of-government approach to AI governance for issues around transparency, design, development, deployment. We need to make sure that we have enough detail to understand what these systems are doing as they continue to grow in scope, and in scale, and in number. And health care AI, and I could spend an hour just talking about AI, because I also have an informatics background. Health care AI requires a risk-based approach where the level of scrutiny, and validation, and oversight should be proportionate to the overall potential for harm or the consequences that the AI system may introduce. So at this moment, from a technological and regulatory standpoint, where I think AI can really excel, isn't it unburdening all of us, detethering us from our computers and restoring the patient-physician relationship? So to be clear, when we talk about AI, I think it's really important to actually not call it artificial intelligence, but to call it augmented intelligence, to emphasize that human beings must always be at the center of patient care. And in no specialty is that more critical than psychiatry. It's our view that clinical decisions influenced by AI must be made with specified human intervention points in the decision-making process. And as the potential for harm goes up, the point in time where a physician is able to utilize their clinical judgment to interpret, or act, or intervene on a recommendation, that ought to occur earlier in the care plan. So some of you may know my good friend, Dr. Abraham Verghese. He's a well-known professor, author out at Stanford. He's the best-selling author of Cutting for Stone, which gives a really important perspective on how to think about AI in health care. And he said, and I really like this, that the way to think here is not about technology versus the human, but to ask, how do they come together where the sum can be greater than the parts for an equitable, inclusive, human and humane care in the practice of medicine? Whatever the future of the delivery system looks like, patients need to know that there is a human being on the other side helping guide their course of care. So as I get near the end of my prepared remarks, I want to take a few minutes to talk about the challenges of substance abuse, the opioid crisis, and what's happening. As America faces a profound shortage of psychiatrists, mental health professionals, addiction specialists, we're also simultaneously grappling with a true drug overdose epidemic that has climbed to record levels. The drug overdose epidemic is now killing more than 100,000 Americans every year, 100,000 lives lost, which is why we are trying to get rid of barriers to evidence-based treatment for substance use disorders and for patients with pain, as well as increasing access to harm reduction strategies. Every state, every state has reported an increase in opioid-related mortality at the state level or in individual cities. But unfortunately, as you know, there remain significant challenges in accessing evidence-based care for those with mental illness or a substance use disorder. And the data continue to point to a need to remove inequities for treatment in historically marginalized communities. While drug overdose deaths for all racial and ethnic groups are on the rise, the rate among black men in the US more than tripled from 2015 to 2020 and continues to climb today. So what's the AMA doing? We have a lot of policy on this. We have a roadmap to how do we slow down and hopefully one day reverse these trends. We've got to urge more physicians to prescribe medications to their black and brown patients with an opioid use disorder. That is not happening. We need to get rid of barriers to access to these medications for pregnant people. The high incidence of stigma faced by pregnant people with a substance use disorder is limiting access to treatment and increasing mortality risk. AMA, ACOG, ASAM, the US Substance Abuse Mental Health Services Administration, SAMHSA, all of us support treatment with methadone or buprenorphine for pregnant people with an opioid use disorder, but they're not getting it. In increasing access to primary prevention harm reduction services, we strongly urge states and individual communities to identify and support primary prevention initiatives that have demonstrated success in preventing drug use. We released our latest opioid overdose epidemic report at the end of last year. You can find it on our website or at the QR code. It'll take you right there. And it does show some encouraging signs with regards to at least opioid prescribing. Opioid prescribing has dropped 13 years in a row and overall decline of nearly 50% since 2012. Meanwhile, registration use of prescription drug monitoring programs, the PDMPs, continues to increase. There were 1.3 billion queries in 2022. Treatment capacity is also increasing. More physicians now than ever certified to provide buprenorphine to treat opioid use disorder and prescriptions for both buprenorphine and naloxone are increasing alongside it. All welcome news, all encouraging signs that in this long, long, long fight to reduce the opioid crisis, we're making some progress. But it's also kind of hard to celebrate that progress when we know that the death rate is going up and particularly alarming because of drugs that are now laced with fentanyl and other synthetic substances. So the battleground on drug overdose has shifted and, if nothing else, intensified. We have a substance use and pain care task force. And our advocacy helps lead to the FDA's approval of the first over-the-counter naloxone product. And we continue to urge all naloxone manufacturers to submit OTC applications as well as provide responsible pricing for OTC naloxone. And we continue to push pharmacies and retailers to not hide it, but to put it out in accessible locations so they don't have to ask somebody, where is it? We've done that with condoms. It's time to do that with naloxone. And we've supported the administration's National Control Drug Strategy, its focus on harm reduction, encouraging the administration to continue to remove barriers to access to medications for opioid use disorder as well as harm reduction services. So our substance use and pain care task force has a comprehensive strategy. And it focuses on, how do we get better data? How do we get better individualized pain care? How do we get a comprehensive public health and harm reduction strategy deployed at scale across the nation? And obviously, a lot of this is totally dependent on multi-sector collaboration. So following the CDC's issuance of new opioid prescribing guidelines in 2022, we have urged states, the health plans, pharmacy chains, and others to remove policies based on the old 2016 guidelines, which was misapplied and often harmed patients with pain. And after the X waiver requirement was eliminated for buprenorphine prescribing for opioid use disorder treatment, we urged state and federal officials to make sure that they had adequate networks of physicians who were accepting new patients and offering this service for patients with an opioid use disorder. And when the DEA extended the law for prescribing controlled substances via telehealth, we worked with states to ensure that there weren't conflicts between the federal flexibilities and what the states were allowing. Last fall, I had the opportunity to represent you, physicians in the AMA, providing testimony to the DEA about prescribing controlled substances via telemedicine. And in my testimony, I made a couple of key points to help the DEA better understand this issue and the stakes for patients with an opioid use disorder or a substance use disorder. First, we saw during the pandemic that telehealth induction with buprenorphine for an opioid use disorder was extremely helpful, helpful for maintaining continuity of care, helpful for preventing relapse. Second, that telemedicine prescriptions allow people to get timely therapy without delay, especially for patients with chronic conditions, people with cancer, people in hospice, people in remote areas, people in underserved areas, lots of groups of patients. Third, that we don't support sham practices that have no assessment, no evaluation, or other markers of legitimate practice of care. And finally, in cases where an in-person evaluation would result in a care delay that could lead to patient harm, we urge that telemedicine prescribing of Schedule II medications be permitted. So where do we go from here? Well, there's a lot that we still need to do. We've got to remove barriers to evidence-based care for patients with a substance use disorder, barriers to medications. We've got to take steps to protect families, making sure that we don't separate families because of opioid use disorder or substance use disorder. We continue to support the implementation of the CDC's new pain guidelines. And we're applying a lot of pressure to state insurance commissioners, attorney generals, the U.S. Department of Labor to increase efforts to review health insurer policies to make sure that they comply with the Mental Health Parity and Addiction Equity Act. And I am pleased to tell you that last week I'm on the road a lot, last week I had something unusual happen. I was summoned to the Department of Labor, which is a very unglorious cement building, probably designed in the 60s in Washington, for a tri-agency conversation. Department of Labor, Health and Human Service, and the U.S. Treasury. What do all three of those agencies have in common? Well, it turns out that they all have different overlapping jurisdiction and regulatory authority over the Mental Health Parity and Addiction Equity Act. And there's a draft rule coming out that's looking pretty good, and it finally, after, what is it, 15 and a half years, is going to provide enforcement opportunities to make sure that the dream of mental health parity is a reality. And we're not gonna stop until that happens. So, despite all these challenges, everybody that I know who goes in the profession continues to show up. And they continue to show up, and that is why I am so optimistic about the future of medicine, because I know that organizations like the APA and the AMA and so many others continue to fight for us. I'm buoyed by what the AMA has accomplished, by what I've seen this year as president, by how we continue to fight. You know, we continue to shoulder enormous challenges, but despite all those pressures, we continue to show up, we do the work, we provide compassionate care, we make a difference, and we change lives. And with that, I just wanna say thank you for the opportunity to be here today at your meeting. Thank you for what you do for our patients, for the profession, for our communities. I know I've covered a lot of ground, and as long as Jacques doesn't give me the hook quite yet, I'm happy to answer any questions from the audience, or I suppose we're getting some online as well. Thank you. All right, we'll take some Q&A from the audience and alternate with the online folks. Please. Hi, I'm Brad Offenberger from Cincinnati, Ohio. One thing that we're seeing a lot in Cincinnati are private equity companies buying up a whole range of health organizations. Is that a problem the AMA is seeing? And what ideas are they implementing? Yes. In fact, I put out an op-ed this week. As some of you know, there's a little bit of heat applied to UnitedHealth. Now, UnitedHealth is not private equity backed, right? They're publicly traded. But the unifying theme of the challenge is around consolidation, market pressure, loss of agency by physicians who no longer are driving the delivery system. That, to us, is unacceptable. And when we have loss of competition in marketplace because of consolidation, we know what happens. And there are obviously horrific stories of a growing number of specialties having real challenges, where suddenly, first it was Derm. And PE companies came in, and they bought everything up, squeezed out every last penny that they could, realized they couldn't make any more money, and then they turned over the practices, who then had to rebuild themselves. We're seeing that happen in a lot of places. It's a concerning trend for us. We're not pro or con private equity. It's a tool. It's a vehicle. It's part of the capital markets. But how it's applied, how oversight occurs at a regulatory level is obviously important. And at the end of the day, practices ought to be driven by physicians. Some of you know that one of the very irritating things that was tucked into the Affordable Care Act, and the AMA was a big proponent of the Affordable Care Act, the Affordable Care Act would not have passed without the AMA's support. It has improved coverage and access for millions of Americans. It is not perfect. It needs to be iterated. But one unfortunate provision that was sort of tucked in was a ban on physician-owned hospitals. Well, physician-owned hospitals, there's not a huge number of them. No new ones have been brought online because of the ban and the moratorium on new ones. But it limits competition. It is a structure. The AMA is not pro or against ownership structures, but we ought to have those choices. And so certainly, the aberrancies that the private equity capital markets are creating across practices is deeply concerning to us. Yes, please. I wasn't sure if you were going to alternate with the online people, but we'll take the live folks first. Thanks. David Young, Nashville, Tennessee. First of all, thank you for starting off this conference with one of the most important topics that I think is going to be presented this whole week. So I had a question about whether you might have a comment on whether physicians are really getting enough time with patients, because that just seems like something that I'm sure you and many other colleagues have just heard patients complain about, that physicians often feel rushed. And you cited some data about a physician shortage, both now and projected. And I'm kind of wondering if those shortage data assume that physicians are going to keep spending the same standard amounts of time with patients as they're doing now, because it's widely accepted in mental health that we need more time with patients than in a lot of other specialties. Yeah, that's a great question. And the AMA has worked with a number of centers to do some time motion studies. And the data point I'm going to give you is not specialty specific. It's broad. I'm pretty sure that it was from primary care. But it was for every hour that physicians spend face-to-face with a patient, they spend two hours doing EHR and administrative work. That's got to change, right? That's not why we went into medicine. That is a driver of dissatisfaction. We know that there are workflow changes, practice re-engineering strategies that can help. But what that does, obviously, is put more and more pressure as reimbursements going down. Well, let's just see one more patient. Let's reduce the number of minutes in the slots. And those things are sort of this unfortunate cycle of challenges that then just make things worse for us and for our patients. So ultimately, I talked a lot about the workforce. I talked a lot about pipeline expansion. We need to do those things. We need to expand GME. I was in Nashville last week on Monday for America's newest medical school, Belmont. Opened up the Thomas Frist School of Medicine, if I got that right, which is great. And so there'll be another 50 medical students graduating in a year. And it's wonderful. But that does not solve the problem at scale. When we have so few folks in the pipeline, we've got to think about how do we re-engineer the delivery system broadly across specialties to make sure that we have the capacity to deliver care. And that's going to require some challenging thinking about what does that re-engineering look like. I think that digital health will play a significant role in that. But it's not the end all be all. Thank you. All right, we'll take an online question. What steps are being taken by the AMA to help thousands of physicians waiting for a long green card backlog? This would really help tremendously in the age of physician and psychiatrist shortage. Sorry, thousands of physicians who are waiting for green cards. Oh, yes. So I spent a lot of time on Capitol Hill. And it's hard to get Congress to do even the things that they agree on that they know they need to do. It's just the reality. Nobody thinks it makes sense to give physicians a 3% pay cut in this inflationary environment through the physician fee schedule. No office I ever went to said, yeah, that's a good idea. No, we don't need to fix that. But it's still hard for them to act. And then there's immigration reform. God help us. With the J-1 visa waivers and Conrad State 30 and the Reauthorization Act, there's bipartisan support. But unfortunately, particularly as we get into election season, I have little hope that we're going to see much movement. And unfortunately, that impacts, as the online questioner asked, thousands and thousands of physicians who are in a difficult spot on these visas trying to get through the green card process. Thank you. Please. Salim Al-Sabah. I'm a psychiatrist here in New York. Thank you for your very enlightening presentation. It's an ongoing issue with us psychiatrists in terms of reimbursement and the time we spend. And I think a big part of burnout is feeling compensated and rewarded for the work that we do. A lot of the questions touch base on the time that we put into seeing patients and stuff. But going back to the reimbursement, how venture capital firms are coming in. And in some ways, I think they're providing benefit to psychiatrists. I don't know if you've heard about Headway, for example, a platform where they're providing better reimbursement to psychiatrists seeing insurance patients, for example. There's just this trend that I'm seeing of big hospital systems, VCs collecting all of this money, and then the physicians and the psychiatrists not collecting part of that. Is there any kind of initiative on your end to pressure these systems and greater organizations to maybe pay physicians more, hospital systems and stuff? And then my second question is a small technical question on billing code 99214, where I saw recently, I noticed, if I'm not mistaken, they increased the time required for a 99214 code from like 25 minutes to like 30 minutes. Are you familiar with that? And can you comment on that? I am absolutely not. But we have a whole unit that does CPT coding and whatnot. And if you give me a card, I'm happy to have somebody follow up, and they will get you a technically correct answer. That's not something that I can speak to. On the larger question about some of these platforms and the reimbursement and whatnot, so a lot of the pain is around the third-party payer shenanigans of underpaying all of you. I mean, that's what it is. So the statistic is patients have to go out of network nine times more often for behavioral health services as opposed to medical surgical. How is that parity? It is not. And so the federal government is well aware of this. And I am very optimistic that through rulemaking, they are going to put the squeeze on third-party payers through rulemaking with enforcement, civil monetary penalties for not fixing that. Now, why are all of you out of network? Because the reimbursement is so bad. So the only way to get people into network, obviously, is to start to fix some of this. So I think that hopefully some of the outsized influence and power that the third-party payers have is going to erode. Given what's happening with one of the larger third-party payers right now and how they're under scrutiny in Congress, I think it's a wonderful time to try to sort of pull back some of the power that unfortunately has been garnered by that massive consolidation on the payer side. Thank you. Yeah. Thank you. You're going to go online first, or? Since you're there, why don't we go front mic. Thank you. Elise Perlmutter, general and child psychiatrist here in New York City. Thank you, certainly, for this really wonderful overview. My question is really dedicated to my constituents who are small, bigger, and even some of the adults who require psychostimulants for attention deficit hyperactivity disorder or variants. And the challenge these days of providing good care for these patients can really suck the joy right out of medicine, out of being a psychiatrist. And I'm wondering if the AMA is involved in the exploration of the reasons for this terrible backlog, or if it's only FDA. You're talking about the drug shortage? Yes. Yeah. So yes, we are deeply engaged with FDA on that. And I will share something outside of the room with you that is probably not fit for public consumption, which is pretty good for being recorded. But it's multifactorial. We know that, unfortunately, the financial incentives, particularly for generics, have gotten out of whack. There are regulatory things that the FDA has done that has not made it easy for manufacturers to continue continuity. And there was a report that the FDA put out on the root causes of drug shortages. We took that up with some internal work to try to put pressure to look for policy solutions. But we know that this hurts. It hits lots of specialties. There's a little board in our OR pharmacy. I'm an anesthesiologist. And it's, what are we short today? And you walk in, and it's like, wait, we have no calcium chloride? We're out of saline? How is this possible? And chemotherapy agents, I have oncologists calling me saying that I can't get chemotherapy for my pain. How is this possible? I've got a cancer patient who's not. So we hear it. We feel it. It's awful. It's multifactorial. There are lots of things driving it. And we do have a few strategies on the policy side that are trying to make it better. And I can chat with you offline. Thank you. All right, an online question for you, Jesse. In your opinion, are there specific states that seems to be most amenable for physician practices? And are there states that are least amenable for physician states? Yeah, that's a loaded question. I will tell you, I have two physician colleagues who are dear to me, who chose to move their families, leave their communities, change their practices, because of state restrictive laws that they just felt like they could no longer do what was in their patient's best interest. And I think a lot of people have mixed feelings about that decision. That's a hard decision, because the community is still there. And the community still needs health care. But I also understand why an OB-GYN would leave a state where they no longer can provide the full scope of reproductive health care that they feel like they need to. Why an internist who specializes in gender medicine would leave a state where they can no longer take care of transgender kids. I understand those hard decisions. And so certainly, as I think about my life, and I talk with my husband, you see our two beautiful boys up there, there are certain parts of the country where I know it would be more challenging for us as a family unit to live and thrive. That's just the reality, for lots of reasons. And so I think, obviously, there's a lot of decision that goes into the environment, and the practice, and policy, and reimbursement that leads people to make those choices. But I would say that I love living in Milwaukee. And if anybody wants to come to Wisconsin, I'll give you my card afterwards. All right. What is your message to early career physicians and residents? The person asked that I work for a large organization in New York City. And it seems like the psychiatric and medical complexity of patients have drastically increased in recent years. I mean, yeah. So I sometimes have a little window into the psychiatric comorbidities of my patients as an anesthesiologist. But to be very honest, not usually a whole lot, because I meet them day of. They go to sleep, and then out the door. But what I do see is the corollary, which is none of my patients are healthy. ASA, physical status, class one. Everybody's got comorbidities. Everybody's on 5, 15 medications that I now have to look up, because the generic names change, and they're new, and all of the associated things. And that burden of comorbidity and chronic disease makes all of our work more complicated. And that's just the reality of practicing medicine today. I was talking to a friend of mine who's a senior, well-known, nationally recognized cardiologist. And he's like, yeah, in the 50s and 60s, when somebody had a heart attack, we put them in bed rest. That's not what we do now. Thank God, right? We have all sorts of wonderful medications, and tools, and interventions, and imaging, and all the things. But that's a lot of work. And we just haven't scaled the delivery system or reformed how we actually organize our systems of care to accommodate that. So for folks who are at the start of their career, is that you stay engaged with the APA. Consider joining forces with your state society, AMA, others, because if we don't come together to advocate for what our patients really need, then we will have more of the same. And we will end up with a divergence of a two-tier system, where if you happen to be able to write a check, you get what you need. And if you can't, God help you. Well, on that very delightful and optimistic note, please join me in giving Dr. Ehrenfeld a round of applause.

Jesse Ehrenfeld

American Medical Association

digital health

physician burnout

Medicare payment reform

telehealth

drug shortages

healthcare inefficiencies

misinformation

AI in healthcare

patient care