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The AMA’s David Barbe, M.D.: Let’s Work Together to Optimize MD Outcomes Reporting

September 16, 2017
by Mark Hagland
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David Barbe, M.D., president of the AMA, speaks to the challenges and opportunities inherent in MD reporting requirements under MACRA

Absolutely: this whole issue of burnout and frustration with HIT—it is very real. Physicians are overwhelmed, they’re asked to collect data, they’re given tools that don’t do it, and our studies—the first one we did last fall that shows that physicians are doing twice as much time doing data entry and paperwork as in direct clinical time with patients. We just came out with a second study that says the same thing. That is very  demoralizing to physicians; we didn’t train to be data entry clerks, we trained to be clinicians; that’s very  demoralizing. And we’re essentially now doing some of the most menial tasks. It cuts across every specialty  and every setting, including among employed physicians in medical groups. And they may be in groups that aspire to be high-performing, but also

So, one of the issues that’s emerged recently has been a full-blown discussion about the increasing use of medical scribes. Research is beginning to show that there is tremendous variation in scribes’ effectiveness, and even in their accuracy. How do you see this? Are scribes a point of relief for practicing physicians, or are they a sub-optimal response to a deeper and broader problem in the U.S. healthcare system?

I think there is a role for scribes in some settings. Of course, the fact that scribes are even being considered is an admission of failure of health information technology to begin with. That said, given the fact that it’s going to take a while for the EHR to evolve to meet our needs, an interim step is the use of a scribe. And it’s like any other person on the healthcare team; their degree of usefulness is directly related to their training and collaboration with the rest of the team. And the higher-skilled they  can be, the more effective it will be. There’s nothing inherently inadequate about a well-trained individual doing the documentation, but the key is working closely  and well with the physician. We wrestle with this in my  system. We use scribes in the ED in our health system, as the vast majority of scribes are used. We wrestle with it in our primary care offices, and you either have to allow that to produce more throughput to make the business case for it, or you accept the extra cost in exchange for increased physician well-being. They each their advantages and drawbacks.

Do you think that CMS and HHS will be responsive to pleas on the part of organized medicine for broader relief from some of the EHR-related physician documentation burdens, overall?

The generic answer to that is yes. I think they’ve shown willingness to help physicians transition into MIPS, as we’ve alluded to. That’s a good sign. I think they are hearing us with regard to the number of measures and their relevance. I’m a family physician, and there are a lot of measures I can pick on that are relevant to my practice; that’s not quite true for many specialties—two issues related. One is, how many of these things can you take down to the individual physician level—you need adequate numbers. And the other issue relates to risk adjustment and how sick my patients are.

And it breaks my heart to hear doctors around the country say, ‘You know, I might have to stop seeing some of my complex patients, because they’re bringing down my scores.’ But in order to [avert physicians refraining from seeing those patients], we have to be able to identify and adjust for the complexity of individual patients and populations of patients, and we have to adjust the reimbursement system to match the resources available to treat the more complex patients.

And that brings us to the topic of the shift from volume to value in healthcare. What is your perspective on this very strong shift towards value that’s taking place on the policy and payment front right now, especially with regard to value-based care delivery and purchasing, accountable care organization development, population health management, and care management concepts?

The answer is, it is absolutely the right way to go, and the AMA fully endorses the concepts of population health, of value-based payment. I’m in Chicago now, attending ChangeMedEd, a conference that we’ve designed around, how do we better educate our medical students? The keynote speaker just a half-hour ago, was speaking about population health. He was one of the nation’s experts on population health. He was preaching to the choir, but makes the argument that it’s the only way we’ll accomplish the Triple Aim, improving the health of the country, improving the healthcare to the country, and improved or reduced cost. And population health is a big piece of the way we can move towards that. So yes, it’s the right goal. It is gaining considerably greater momentum over the last few years. And there are now journals devoted to this.

And, getting back to the AMA, we’ve developed through this ChangeMedEd consortium, a plan around three legs of medical training, with the third leg of health system sciences specifically around reporting of outcomes measures, population health, care management—that’s almost as important as the purely clinical, and these sciences will be important to medical schools and residencies, and to practice, as we make that shift.

So, in the past, there was a perception—perhaps unfair—that the AMA as an organization was primarily a resister to change. Can you address that perception, and speak to the organization’s focus in the present moment?

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