No one can predict what the future of the nation's healthcare system will look like, but there are certain needs that are "musts" to prioritize, no matter how healthcare shifts over the next century. That's how the American Medical Association's CEO sets the organization's objectives.
James Madara, MD, executive vice president and CEO of the AMA, overcomes uncertainty by focusing on what he calls "pre-competitive needs."
"That is, needs that have to be filled no matter what the health system looks like in 2050," Dr. Madara told Becker's.
In order to make any advancements in healthcare, improving the nation's chronic disease burden; eliminating obstacles that get in the way of physicians' direct time with patients; and training the workforce for the 21st century must all be prioritized.
"It doesn't matter what the shape of the health system is in five years, 10 years, 15 years" if the healthcare industry can't address its most pressing needs first, Dr. Madara said.
Ahead of the AMA's 175th anniversary on May 7, Becker's spoke to Dr. Madara about highlights of the organization's history, how healthcare can retain physicians and more.
Editor's note: Responses were lightly edited for clarity and length.
Question: As you look back on the organization's 175-year history, what are you most proud of?
Dr. James Madara: I would start out by saying the need for the AMA 175 years ago started out with a couple of fatal flaws in American medicine. First, there were no standards for medical education, and second, there was basically nothing in terms of agreed upon clinical ethics. So the AMA's first two products were the first standards for medical education in the U.S. and the first code of clinical medical ethics for the country. Then through the history of the organization, [it] played a major role in the anti-tobacco messaging, anti-smoking area, the advocacy for seatbelts in all cars, the advocacy for access to healthcare, and therefore support of the Affordable Care Act. When the AIDS epidemic started, [I'm proud of] the work that was done to prevent discrimination against those with HIV and AIDS. Those were all major things.
Then in the pandemic, the lobbying for fiscal support for practices, the hard work that was done for improving access to PPE. And then really proud of the science evidence-based positions that were taken during the pandemic. With the medical education standards in 1847, we sidestepped quackery. We fought quackery. There was a lot of quackery going on during the pandemic around hydroxychloroquine, ivermectin — these things that were just frank misinformation.
Q: You've led the AMA for 11 years. What's been the biggest challenge for you as a leader during this time?
JM: First of all, the breadth of physicians in the United States — parallel that with the breadth of societal opinions. We get 190 medical societies (all state societies, all specialty societies) together twice a year to construct the policy of the AMA. A big challenge was, in that framework, how do you have a long-term strategic plan? And the answer came from looking in that policy portfolio for meta-signals where there are 30, 40, 50 policies around the same thing. And around those kinds of things, you're going to [develop] a long-term strategic plan. So that was one challenge.
Another challenge during the pandemic was working across with the American Nurses Association, the American Hospital Association and the AMA on many projects, like personal protective equipment being available, mask availability. Coordination across those associations was both challenging and rewarding.
Q: What's the most significant way the field of medicine has changed over the course of the COVID-19 pandemic?
JM: I would say two things. One is telemedicine and telehealth. Entrepreneurs hope if they have a big discovery or a new venture that they get a 10X response, and if you look at the use of telemedicine from January 2020 to May [2020], it wasn't a 10X, it wasn't a 30X. It was more like 100X. So the field moved forward about 10 years in one quarter. That was due to both the forcing function of the pandemic and the relaxation of administrative requirements. Prior to the pandemic, telemedicine was geographically constricted. If it was a rural area, it might be allowed. Urban area? Not so much. Federal relaxation of those restrictions — which we hope will be made permanent — allowed for telemedicine to really mature.
The other thing that was really remarkable about the pandemic was we knew that there were health disparities among these communities that had not been invested in for a long time. And the pandemic shone a light on the stark difference in the outcomes and morbidity and mortality between those communities that were limited by social determinants of health and how an advanced, rich society like ours could have these important pockets of people just not getting the access to care and the vaccinations that they needed.
Q: The Great Resignation hit hospitals and health systems hard. What does healthcare need more of to attract and retain people to the industry?
JM: We started this pandemic with an estimated future workforce deficiency of physicians. We now know after the pandemic from a study published by Mayo Clinic Proceedings that one in five physicians say they plan to leave the profession within the next couple of years. So that shortage will be, if anything, amplified. There is an effort in medical schools and DO schools to increase admissions. A lot of folks still are interested in medicine, really talented folks. There have been some expansions of slots for internship and residencies, but that's been relatively limited.
What we have stepped back and realized from our own work is that physicians are most satisfied by having face time with patients. We know they're dissatisfied by things that get in the way of that face time with patients. We know from our studies pre-pandemic that for every hour of face time with patients, they spend roughly two hours doing administrative work. So here is a highly trained, highly educated, expensive workforce, where two-thirds of it is being used for administrative purposes. So one of the three arcs in our strategic framework is focused on getting rid of the obstacles to physicians that get in the way of time with their patients.
Q: Data reports suggest healthcare organizations are falling short on meaningful health equity progress, despite it being named as a value or pillar in many organizations. What is the AMA doing to ensure health equity remains an actionable priority?
JM: Health equity is really important. In our strategic framework, we have three arcs. We also have three accelerators going across all three arcs, and one of those accelerators is health equity, because one of our arcs is limiting and addressing chronic disease. Without health equity, we're not going to be successful in doing that. Another arc is removing obstacles so physicians can interact with patients more fully. Without health equity, that is limited. So all of what we're trying to do in educating the workforce for the 21st century — which is the third arc — if we aren't attentive to health equity, that doesn't work either. So we have a glass ceiling limitation of health equity because of the inequities we have in our strategic framework.
We created a Center for Health Equity in 2018-19. That's one of the accelerators, but all our business units now have health equity goals. We've created a judicial health equity fellowship in collaboration with others. We have joined the West Side United effort. We've invested in companies: for example, a Medicare Advantage company called Zing that is targeted toward communities that have been disinvested in for years. So [health equity] is part and parcel of what we do, and we have goals and metrics for progress in all these areas. We need to be, I think as a nation, embarrassed by the lack of health equity and the inequities that we have in a society as rich as ours.
Q: Let's look ahead to the next decade. Can you point to any specific goals the AMA hopes to accomplish by 2032?
JM: Let me put this in a framework of looking at 2050, mid-century. Not only am I uncertain what the health system's going look like in five to 10 years, I'm very uncertain what it's going to look like in 2050. So what do you do in a situation like that? What we've done is look for what I would call pre-competitive needs, and that is needs that have to be filled no matter what the health system is in 2050.
And they take us back to our strategic framework and our arcs. If we don't remove those obstacles for patient care, if we don't train for the 21st century rather than the 20th century — if we don't do those things, and we don't deal with a chronic disease burden … If we don't make progress on those areas, we're going to be really, really behind the eight-ball on trying to get done what our aspirations dictate.