Medicine prepares for battle.

Battle lines were drawn on the initial day of the 1989 Annual Meeting of the House of Delegates of the American Medical Association, even before the House had settled down to reference committee hearings and to its own deliberations on the issues that face the medical profession. Louis Sullivan, MD, Secretary of Health and Human Services, addressed the House and spoke for the Bush Administration in endorsing changes in the Medicare program. These changes include a national fee scale for physicians, but only one that is coupled with volume controls, such as expenditure targets (ETs). Dr. Sullivan described the development of a geographic practice cost index that should provide some inherent equity. He endorsed the use of the resource-based relative value schedule (RBRVS), but only for identifying and decreasing payment for "overpriced procedures."

Shortly after Dr. Sullivan's speech, James Sammons, MD, Executive Vice President of the AMA, took the podium to announce the AMA's campaign against ETs. Under ETs, the government would establish goals for payments for physicians' services under Medicare Part B and subsequent payment screens would be adjusted downward if the goals are exceeded. Dr. Sammons likened this approach to rationing. He cited the failures of the Canadian system and expressed concern over the primacy given to cost savings over provision of care.

Other actions and reactions by the House of Delegates to varied proposals for changing the health care system included receiving the AMA's study of the Canadian health care system. The study report expressed the belief that the Canadian system is not a good model for the United States. The Board of Trustees announced a major initiative involving initial annual expenditures of some two and a half million dollars to maintain the superiority of the U. S. health care system and to inform the public of the advantages of that system. Elements of the AMA proposal are expansion of the Medicaid program, development of a program for coverage of the underinsured, and reform of Medicare. In a separate report on covering the uninsured, the Board adopted a proposal that endorsed the concept of mandating the provision of health insurance by employers. This approach would initially involve larger employers and would be expanded in the coming yearsto smaller companies. There would be a program of tax credits to decrease the stress on employers. The House again endorsed the concept of the resource-based relative value scale (RBRVS) for physician services, but as a portion of the indemnity payment schedule rather than as a freestanding system. The House opposed the use of data from RBRVS to create a "hit list" of overpriced procedures, overpriced physicians, or overpriced specialties.

AIDS

The House reacted to new understanding of the nature of the disease, advances in therapy, and the changing nature of the epidemic and referred a number of complex resolutions dealing with the subject to the Board. Of 11 resolutions offered to the House, 10 were referred to the Board for inclusion in a comprehensive report that is due at the AMA's Interim Meeting in December 1989 in Honolulu. The one resolution that was passed supported increased funding by state and federal governments of state and local health department efforts to plan and provide. testing, education, and counseling on AIDS. Resolutions referred to the board represented more controversial aspects of the AIDS epidemic, particularly in the testing area.

Resident Work Hours

The House, urged on by the Resident Physician's Section, reflected the impatience of that group with the failure of the medical education establishment to create rigid guidelines to prevent excessive work hours and resident fatigue. Some Residency Review Committees of the Accreditation Council for Graduate Medical Education (ACGME) have adopted precise guidelines similar to those imposed in the State of New York, while others believe that such rigidity would interfere with the educational process and with patient care. Some specialties feel that such specificity is unnecessary. Although the AMA's Council on Medical Education opted for a policy of letting the Residency Review Committees work the issue out on a specialty-specific basis, the House referred to the Board a resolution urging the Board to work toward a change in the General Requirements for Accredited Residencies of the ACGME to require that residents have on-call duty no more than once every third night and work a maximum of 80 hours a week, both averaged over 4 weeks. The resolution passed by only nine votes in the House and was opposed by the reference committee in which it was debated.

Tobacco

The House continued strong efforts to achieve a smokefree U.S. society. It advocated that all U.S. hospitals ban tobacco use by Jan. 1, 1999; urged physicians to prohibit smoking and use of tobacco products in their offices; and suggested that such policies be implemented legislatively, educationally, and as a condition of accreditation of health care institutions. The House further called on the AMA to stimulate the education of physicians and medical students in how to work with patients to enable smokers to give up the habit.