The ASCO Delegation to the American Medical Association Discusses Policy Priorities and Process

Aug 28, 2018

Disclaimer	The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.
Dr. Clifford A. Hudis	Welcome to this ASCO in Action podcast. This is ASCO's monthly podcast series where we explore policy and practice issues that impact oncologists, the entire cancer care delivery team, and most importantly, of course, the individuals we take care of, people with cancer. My name is Clifford Hudis, and I am the CEO of ASCO as well as the host of the ASCO in Action podcast series. For today's podcast, I am really pleased to have as my guests - and you heard that right, plural - Doctor Ed Balaban, one of ASCO's delegates to the American Medication Association House of Delegates and Doctor Kristina Novick, an alternate delegate to the AMA House of Delegates. Both Dr. Balaban and Dr. Novick recently represented ASCO at the AMA House of Delegates meeting where they advocated for cancer policy priorities. During our conversation today, we'll get an update on the AMA meeting, we'll hear more about some of the key issues that we discuss, and then we'll spend some time talking more broadly about ASCO's role at the AMA. Dr. Balaban and Dr. Novak, welcome, and thank you for joining me today. Now, let's start with a general overview of the AMA House of Delegates, what this governance body is and why, as a medical specialty society, ASCO should care about its activities. Dr. Balaban, you have served for many years as an ASCO delegate to the AMA House of Delegates, and I want to take this opportunity first to thank you for that service. But second, I want to ask you what exactly is the role of the House of Delegates? And how does it influence what the AMA actually does?
Dr. Edward Balaban	So Dr. Hudis, thank you very much for inviting both Dr. Novak and myself to speak for a moment about this because it is something that I don't think that the general membership really understands or appreciates. So the AMA House of Delegates, it's an amazing collection. It's also known as the House or the HOD, and it turns out to be the principal policy-making body of the AMA. It is in a democratic forum that represents views and interests of a number of member physicians and, in fact, represents close to 170 or so societies. We meet twice a year, and the whole idea of meeting is to eventually establish policy in medical, professional, and governance matters that have to do with the AMA business activities and principles of the AMA.
Dr. Clifford A. Hudis	And how many members are there? And exactly how are the members selected?
Dr. Edward Balaban	So the delegates right now-- and I say right now because it does change based on the number of AMA members within each representative society. But right now, the delegates number around 620, I believe. ASCO, right now, we have six delegates. Three of them are full delegates and three are alternate delegates.
Dr. Clifford A. Hudis	All right. So ASCO has three delegates who are appointed plus three alternate delegates. Is that right?
Dr. Edward Balaban	That's right. The full delegates are voting delegates. And we'll get into the details of that, I'm sure.
Dr. Clifford A. Hudis	So what actually happens? You have 620 delegates get together. I assume you're in a big ballroom at a hotel in Chicago. And what exactly goes on in that meeting room?
Dr. Edward Balaban	So, again, we meet twice a year. We meet shortly after the ASCO annual meeting in June and spend a fair amount of time in Chicago then. And then we meet once again in November at another site. The meeting itself, each time, lasts maybe three or four days but the preparation for the meeting goes on for months. And in fact, Dr. Novak and myself and the rest of the delegation are beginning to think about November's meeting now. So the way this goes-- the way it all happens is a bit complicated, but it's fairly straightforward nevertheless. We as representing ASCO and I guess medical oncology come to understand some of the more important issues that are facing practice, no matter what setting it might occur in. Those issues then lead to crafted resolutions that are presented eventually to the House of Delegates. We go over them based on ASCO policy as well as the interests that lie within the delegation itself and frankly what we hear from the different committees within ASCO. As we're putting together resolutions, the other societies-- and again, there are a number of societies, 170, 180 societies. They're putting together their resolutions, too. In addition to that, problems that had been discussed in the past at the AMA that have made their way to the board or various committees, those reports are being formed.
Dr. Edward Balaban	And so there is a gathering of all those resolutions and all of those board reports that become available perhaps a month, six weeks, maybe eight weeks prior to the beginning of the meeting itself. Each one of those resolutions and board reports that are then reviewed in our case by ASCO and a staff. And oh, by the way, I should say right off the top that ASCO staff is superb, and nothing happens without their help. But we review each resolution that's pertinent to the world of medical oncology. We develop our own resolutions as best as we can. We start to share them with other societies that we feel might be interested. And then eventually, those are all submitted to the AMA and then we gather. The first day in Chicago or wherever we meet is usually sort of the time to start to politicking. And it really is in the truest sense that. We review those resolutions. We review our thoughts. Others meet us in hallways and meeting rooms and committee spaces that want us to participate and/or get our thoughts on different problems. Those resolutions then make their way to a panel where we testify for them. Either Cristina or myself or one of the delegation stands up and says, "This is what we have our concerns with from ASCO. We would like the AMA House of Delegates to think about this." Those resolutions are then thought through by a committee that is an aside committee. It's made up of maybe five or six people. And again, this occurs the day before the actual House itself meets in that big ballroom that you just mentioned.
Dr. Edward Balaban	That committee then decides, "Well, that resolution that Dr. Balaban just presented, that is already AMA policy," or, "That does hold some water," or, "We need to think about is whether we want to go forward with that or not." The following day, that is when we met in that big ballroom, a whole bunch of us. And it's all the voting delegates, the 600 and so, alternate delegates. There's usually a number of international organizations there. Press is there. Observers from around the country are there. And each one of these resolutions that need to be talked about are then brought forth. The debate sometimes can be very quick but sometimes, it could be fairly contentious and confrontational sometimes but fortunately, that's not always the case. It's done in a very structured, Parliamentarian way. And then at the end of all that, there is a vote that the AMA House of Delegates either accepts or rejects the particular resolution that, in our case, ASCO has presented or reaffirms it into data and/or policy that the AMA already has or wants to re-look at it and send it down the road to be looked at, again, at the board level or at some committee level to come back.
Dr. Edward Balaban	It all sounds terribly complicated. The business of the House of Delegates can spread over two or three days. It is always an amazing process with so many folks with so many different ideas. And you would think that at the end of all that that there has to be great chaos, but year after year, meeting after meeting, I'm always impressed how we walk away from there with a consensus. And it may not be exactly like you wanted but it makes sense at the end of all that meeting. So it is a complicated process. It's a difficult one to explain. It's a bit of a learning curve to be part of it but once you see it happen, you understand that something good has taken place.
Dr. Clifford A. Hudis	Well, that's great. We're going to come back a little bit maybe and talk about execution or implementation, what all of this leads to. But maybe first, I want to ask Dr. Novick-- first of all, I want to say thank you for joining us again today. Your role in all of this is as an ASCO alternate delegate. So tell us, what exactly does that mean?
Dr. Kristina Novick	Well, thank you very much, as well, for having me today. So I think as Dr. Balaban has explained is that ASCO's allocated three delegate positions and three alternate delegate positions. And together, we make up what we call the ASCO Delegation to the AMA. Being an alternate delegate allows me to participate in the House of Delegates and support ASCO's activities. We work together as a group often several months before the meeting to try to create a list of priorities that we can then formulate into resolutions. During that time, we're often working with other specialty societies that have similar priorities. We try to gain their support for our objectives. And likewise, they reach out to us to gain support for their objectives. We then create this list of resolutions that we submit for the meeting. And often, we end up reviewing probably over 100 to 200 resolutions just for each meeting. With the help of ASCO staff, we review these resolutions and we come up with position statements for the resolutions, especially when some of them are related to ASCO's priorities and policies. So as an alternate delegate, really, what I get is pride in being part of the medical oncology community and being an ASCO member. We're a small but mighty delegation. We only make up 0.5% of the delegates but we find that we have friends not only in the cancer caucus but also within other organizations that have similar priorities. And then we have the respect of the House representing our patients who are vulnerable in terms of their cancer diagnoses.
Dr. Clifford A. Hudis	So maybe you could expand a little bit and talk about what some of the policy priorities that we actually worked on to advance in the June meeting. Are there any specific ones that come to mind that you think our listeners should be aware of? I mean, I guess, for example, PBMs or 340B or opioids. Are any of those issues that you could illuminate for us?
Dr. Kristina Novick	We had a number of resolutions that we submitted this year. The ones that really do come to mind are, first of all, the pharmacy benefit managers resolution. We found that there was a lot of interest, not only from our organization and the experience that we've had within oncology with pharmacy benefit managers but also other specialties have also expressed frustration as to what has occurred with their involvement over time. In particular, ASCO's resolution asked for data gathering on the impact of the pharmacy benefit managers, on clawbacks in direct and indirect remuneration fees. The House of Delegates agreed with us on this and also wanted to gather data on the top 25 medical pre-certification requests with exploration as to what percentage of those ultimately were approved after physician appeal. I thought this resolution was really important because we know that pharmacy benefit managers, they end up controlling the drug benefits for over 210 million Americans, many of which are Medicare Part D participants as well. In addition, there were other resolutions that were focused on pharmacy benefit managers such as the state of Michigan was concerned about the regulation of compounded medications by pharmacy benefit managers and requested that the FTC and FDA get involved with increased regulation. And the board of trustees as well further outlined AMA's efforts to combat restrictions that were created on prescription and dispensing of opioid analgesics by pharmacy benefit managers and requested that we oppose their control of dose or duration limits on our prescription and on dispensing.
Dr. Kristina Novick	In addition, we also looked at the 340B program. I think that there's going to be a lot of interest in this as we try to further control drug costs. The 340B program, for those that aren't familiar with it, was a program that was actually created decades ago in an effort to try to increase the affordability of supporting patients who are underinsured or uninsured and have their access to medications that often can be quite expensive which is something that our patients in oncology experience quite often. Over time, the program's been used especially by large hospital systems as a way to try to increase the reimbursement that they receive for medications that they dispense to their patients. And we had questions as an ASCO delegation as to whether this was really going to the benefit of the population that it was originally intended for. So our resolution asked for increased transparency and oversight of the program. We believe that you need to use those savings in order to help the patients that are underinsured and most need that support. Ultimately, the AMA supported this but they also wanted to investigate our request that we no longer use the disproportionate share hospital adjustment to determine the eligibility. So we'll hear back from them in the fall of 2018 as to what the conclusions are of that report.
Dr. Clifford A. Hudis	So I think it sounds like these resolutions and some others that we were promoting were received favorably. I hinted though with this question a moment ago, with them passed, can you tell our listeners exactly what this means? How does the passage of one of these resolutions actually lead to a practical change in our environment? What happens next to make this part of our new reality?
Dr. Kristina Novick	So resolutions typically are either new policy or directives that take action. Essentially, new policy can be used to support further action by the AMA as issues arise within the legislature, within courts, within allocation of resources by the AMA which is a very large organization. They can also be used to help coordinate efforts by other organizations. The directives that take action are more specific, and the AMA will report back as to what actions they have done and also what they've achieved in response to those directives. So essentially, the House of Delegates, because it meets twice a year, directs these directives and the activities of the AMA. And in between the meetings themselves, the board of trustees acts as the body that will make the recommendations as to what the AMA needs to do to achieve the directives if there's any question in that regard. So what will happen from here is the board of trustees will be reviewing the resolutions that have been passed and then create the list of priorities and objectives to pursue over the next year. And the AMA has a tremendous amount of advocacy that it's able to do. But I think the most important thing that it can do is help coordinate these efforts across states, societies, across specialty societies which is something that we wouldn't be able to do just on our own.
Dr. Clifford A. Hudis	So the real boots on the ground as it were amounts to advocacy at the state and national level, talking to legislators, talking to regulators, talking for that matter I guess to other stakeholders in the healthcare ecosystem and trying to influence practical rules and regulation and policy. Is that a fair summation when it's all said and done?
Dr. Kristina Novick	I think that's a great way to summarize. Essentially, if you go meet with a legislator, it's very easy for them to dismiss you although we do have a lot of clout, I think, coming from the oncology perspective. But still, it's easier to divide us up into different specialties and say, "Well, psychiatrists want this and dermatologists want that." But when it turns out that we all share common objectives, we can approach them and say, "The medical community, this is what we want. This is what is best for our patients." It's a lot stronger, I think when it comes from that perspective.
Dr. Clifford A. Hudis	That's great. So before you go and I turn back to Dr. Balaban, I'm just curious as to what your perspective is on the fact that we have this very exciting, new milestone for the oncology community at the last AMA meeting and that was that Dr. Barbara McAneny was sworn in as the president of AMA. She's the first oncologist to serve in that role. What do you think that role means for ASCO and the oncology community?
Dr. Kristina Novick	We are very excited about Dr. McAneny taking over as president of the AMA. She certainly brings not only a medical oncologist perspective to the leadership of the AMA but she also brings the perspective of a physician who is taking care of underserved populations, who is a patient advocate before all else. And I think we're all going to benefit from that leadership that she's shown over the years in that regard. She's also been very good at being a role model in terms of how to practice medicine in a sustainable fashion which is something that we need. So I am incredibly excited about her leadership and her accomplishments of rising to this position within the organization. A lot of leaders within the AMA will come from large delegations. And as I said, we're not a large delegation. We're a specialty society that has three delegates spots, three alternate delegate spots. But the fact, I think, that we have now also as our advocate the president of the AMA, I think that there's going to be a lot of potential opportunities for medical oncology to get additional help from the AMA on our key issues and to be more involved as well. So I think it was very exciting to see her take that position.
Dr. Clifford A. Hudis	So Dr. Balaban, I know you've known Dr. McAneny for many, many years. And I was really touched and I thought it was a thought-provoking comment during her inauguration where, if I remember correctly, she made a plea to move away from the term providers. And I think it was a plea to focus really on physicians. I don't know if I'm misremembering that, but it struck me that it was an important semantic distinction. Knowing her, knowing her passion, knowing her years of service to the community, to ASCO, to her patients, what's your perspective on how she'll be different as an AMA president?
Dr. Edward Balaban	Like you mentioned, she's been involved with the AMA in every facet of the AMA, oh, my gosh, for years. And as Cristina mentioned, this is almost precedent-setting. Neither she nor I can remember a specialty society having a successful campaign for presidency. Barb did say exactly that. She moved away from the idea of provider because to her-- and I shouldn't speak for her but she has shared enough with me and with the AMA. Provider's sort of a tone of a definition that's part of the system. And when I say the system, I mean as it currently is in the medical community. Well, the one thing that she has proposed is that she would like to fix this system. And she'd like to readjust it, reset it, rethink it, re-personalize it that we are just not providers. We are the physicians. We are the people that drive it. We are the people that make those decisions that will make it flounder or be successful. So she has tried to reroute this, and she can do it because she does relate. As Dr. Novak said, she can communicate so well, whether it's the Navajo Indians in New Mexico or with the CEOs in Chicago. She has traveled all those different areas.
Dr. Edward Balaban	And she does not mince ideas or words. She'll say very effectively what needs to be done. And Barb and I, as with most people on the planet, we'll go back and forth on a number of things. But I could tell you that we're all very pleased to be, in a sense, on her coattails. But let me just add to that that when it comes to oncology patients, I have come to learn at the AMA that our patients and our problems tend to be first and foremost almost Barb will say a canary in a coal mine. Maybe it's with the expensive and difficult drugs that we use and the difficult diseases that we face and the multitude of problems that we do run into with each and every one of our patients, whether it's physically or economically or socially or whatever, we tend to run the tip of the iceberg. And so other societies, other world within AMA will come to see what oncology thinks. And Barbara represents a huge spokesman in that area.
Dr. Clifford A. Hudis	Well, that's really great. And I think that we're all excited by this turn of events and the unique opportunities that the year ahead will bring, and also I think the lingering impact in the years that follow we'll be able to have on the AMA. So with that, I want to again thank both Dr. Balaban and Dr. Novak for joining me today for this ASCO in Action podcast. For the listeners, I'd like to remind you that you can always learn more about ASCO's work with the AMA, and you can continue to follow ASCO in Action for news and updates. You can visit ASCO Connection to read great recaps of the meetings that are usually written by Dr. Balaban himself. And you can find them online at connection.asco.org searching for Balaban, and that's B-A-L-A-B-A-N. So until next time, thank you all for listening to this ASCO in Action podcast.