The president of the American Medical Association (AMA), Jesse M. Ehrenfeld, MD, MPH, sat with Medscape editors for a wide-ranging conversation about his term in office.
In an opening statement, Ehrenfeld, a practicing anesthesiologist in Wisconsin, said his outreach efforts to the members of the association have revealed "a system in crisis" — marked by overburdened physicians, technological flaws, and a failing reimbursement scheme that has been particularly onerous on "small private practices which are the backbone of our health system, particularly in rural America and in underserved communities."
This interview has been edited for length and clarity.
What are some of the major challenges currently facing the healthcare system?
In my recent discussions with healthcare professionals across the country, I've consistently heard about our system being in crisis. The Change Healthcare cyberattack and the resulting mess, along with reimbursement challenges, have exacerbated an already failing Medicare payment system. Small and private practices, especially in rural and underserved areas, are under significant stress. After adjustment for inflation, the payment rate to physicians through Medicare has decreased by 29% since my first year of medical school in 2001. This creates substantial financial strain, especially for small practices.
How are these financial strains affecting physicians?
The pause in payments, particularly from entities like UnitedHealthCare, has lasted for months. Coupled with burnout driven by the demand for services and prior authorizations, it's no surprise that many physicians are considering leaving practice or cutting back their hours. Additionally, with nearly half of practicing physicians in the US being 55 or older, and an aging population, the future delivery of services is at risk.
How is the aging physician workforce altering the delivery of healthcare?
We face significant challenges with an aging workforce. Moreover, creating pathways for international medical graduates to practice in the US remains difficult, despite our reliance on them. Approximately 25% of practicing physicians in the US were trained abroad.
Can you discuss the financial burden of medical education on new physicians?
Medical school graduates are entering residency with an average debt of $250,000. This debt often drives them to choose higher-paying specialties over primary care or practicing in rural areas, further exacerbating the shortage of primary care providers in underserved communities.
What are the AMA's key priorities for addressing these issues?
Our priorities include bolstering the physician workforce, fixing the broken Medicare payment system, and creating sustainable models to ensure access. We are focused on telehealth, digital tools, prior authorization reform, and reducing physician burnout as part of these efforts.
How receptive is Congress to the AMA's concerns?
Congress is aware that the Medicare payment system is irrational and unsustainable. However, the challenge lies in the political polarization and dysfunction that hinder the implementation of sensible solutions. Even with bipartisan support for some measures, such as the Conrad 30 J1 visa waivers for international medical graduates, progress is slow owing to broader immigration debates.
How does the AMA approach its support for elected officials with differing views on healthcare policies? For example, the AMA has donated money to politicians who oppose reproductive rights for women and who are outspoken in their desire to repeal the Affordable Care Act (ACA), which the association has strongly supported.
We work with elected officials who support rational healthcare
policies, even if we disagree on other issues. Although the idea of repealing the ACA has been a topic of debate, we believe in iterating and improving it rather than repealing it entirely, because it has significantly increased access to health plans and coverage for millions of Americans.
How does the AMA handle the increasing influence of politically oriented fringe groups in healthcare?
We focus on promoting credible organizations and policies based on the science of medicine and public health. Although fringe groups may try to confuse the public and policymakers, we aim to elevate our policy and scientific positions to ensure informed decision-making.
What is the AMA's stance on private equity in healthcare?
The AMA does not take a pro or con stance on private equity. It can drive innovation but also poses risks for consolidation and reduced physician leadership. We advocate for choice, flexibility, and competition in practice modalities. We are in discussions with agencies such as the Federal Trade Commission to scrutinize practices that might inflate costs for consumers.
Roughly two thirds of Americans living in rural areas do not have adequate access to a primary care physician, and access to specialists also is limited. How is the AMA addressing the crisis in rural healthcare?
Rural healthcare is facing significant challenges with hospital closures and decreased access to care. Innovative solutions include developing primary care–focused medical school campuses in rural areas and establishing programs to train Native American physicians. These efforts aim to ensure that students from underserved communities return to serve those areas.
How does the AMA view the role of nurse practitioners and physician assistants in healthcare?
Nurse practitioners, physician assistants, and other healthcare professionals are crucial to addressing workforce shortages. We believe in interprofessional teams delivering better care, with physicians leading these teams. Siloing care does not benefit patients, and we advocate for collaborative practice models.
How is the AMA responding to challenges to expanding and preserving diversity and inclusion in medical education?
The AMA is committed to diversity, equity, and inclusion because diverse care teams improve patient outcomes. We support pathways into practice for underrepresented groups and believe this work should be embedded in all aspects of healthcare delivery.
Is the AMA developing its own artificial intelligence tools for healthcare?
Although the AMA is not developing its own large language models, we are engaged in innovation through our company Health2047. We are piloting precision education tools for physicians to enhance clinical decision-making and improve patient care.
What are you most proud of accomplishing in the past year, and what do you feel still needs work?
I'm proud of the first reduction in opioid deaths in years, but there's still much work to be done. We are optimistic about new rules that will enforce mental health parity and improve access to critical services, but we have a long way to go to fully address the opioid crisis.