On June 9, 2015, Steven J. Stack, MD, FACEP, will make history as the first emergency physician to be named President of the American Medical Association (AMA). He will be sworn in for his one-year term as the 107th President of the AMA at the association’s annual meeting. Dr. Stack recently spoke with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, about the challenges of serving as the second-youngest AMA President. He also commented on efforts to repeal use of the Sustainable Growth Rate (SGR) formula to determine physician payments via bill H.R.2, which had just been passed in the U.S. House of Representatives at the time of this interview.

Here we present part one of the conversation. Part two appeared in the June issue.

Dr. Kevin Klauer: You’ve spent the last year as President-Elect of the AMA. How do feel about the year ahead?

Dr. Steven Stack: It’s obviously a great privilege and honor in any sense to be able to serve in that role. It’s also really cool to be able to be the first emergency physician to have ever had that position. This is something of a complete cycle for our specialty since our journey toward the formal political process of recognition began on the floor of the AMA House of Delegates. John Wiegenstein, MD, and others had to fight very, very hard in that venue to persuade a dismissive and unconvinced medical profession that there was a need and a value for the specialty that you and I clearly know there’s a value and a need for. It’s really neat to close that circle. Just for your information—because I know this more clearly than I did before—at the age of 43, I will be the youngest president of the AMA since 1854, and I will be the second youngest of the 170 presidents. The youngest was Dr. Charles Pope in 1854. He was 36 years old. So to paraphrase whoever singer that was—Vanilla Ice?—“can’t touch that,” but it will be pretty cool to be so young in over 160 years of that position.

KK: Absolutely, and you’ll be able to instruct us on many, many different areas of medicine and policy, so I will instruct you on hip-hop. That was MC Hammer, my friend.

SS: Ah, MC Hammer. I’m sorry. That’s right. That’s my foray into popular culture.

KK: As far as scheduling and different responsibilities go, how much different will it be for you after June 9?

SS: I’m in a position where, because of the work I’ve done on health information technology and what I’ve done with my interactions with certain facets of the federal government, my schedule right now is at a presidential pace. My life will look something like this: I will average between 50 and 55 clinical hours in the emergency department every month, and I will travel probably more than 180 days for the AMA this calendar year. I will have innumerable conference calls wedged and peppered during transition points in airports, hotel meeting rooms, office places, or at home. It will be a very, very brisk pace, and I will obviously try very, very hard to build little pockets of time to make sure I remain familiar with my wife and my daughter.

‘They’ll always patch it.’ Well, that’s a risky assumption when you see that Congress has played Russian roulette with the entire nation’s economy through the debt ceiling debates when they shut the government down. If…people just take it as a given that all these patches are going to happen, they have not paid attention to contemporary politics. —Steven J. Stack, MD, FACEP

KK: Will your position provide some unique opportunities for them travel-wise or being exposed to things that they might not have otherwise experienced?

SS: Generally, no—because these trips are so focused on the task or on work, they don’t come with me. Two other reasons: My daughter is appropriately busy for a fourth grader, with her soccer and martial arts schedules and horseback riding, which she loves to do. My wife is a practicing pediatric allergist. She has a full-time practice, and she is the owner of the practice. She and my daughter have very busy lives on their own and can’t just up and come with me on trips. The one exception for that: I will attend the World Medical Association, which meets twice a year. It’s like the United Nations for physicians, and I get to travel around the world and meet with my physician colleagues who represent the other nations of the world. It really is a true conclave of the top leadership of the profession of medicine across the globe. [My wife], Tracie, will go with me on some of those trips because it’s such a novel and once-in-a-lifetime experience.

KK: I’m glad that she’ll get to experience some of this with you. Let’s get into some policy issues. Regarding the recent developments with the Sustainable Growth Rate (SGR) repeal, what are your feelings about the current success, and do you think there are any devils in the details, anything in fine print, any concessions that may soften the potential benefit of this repeal for us?

In this April 16, 2015, President Barack signs the bill H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015 in the Rose Garden of the White House in Washington.
Image Credit: © Carolyn Kaster/AP/Corbis

SS: On March 26, the House had a historic day whereby, 392 to 37, they passed a bill that would repeal the SGR once and for all. That’s historic because we’ve never gotten this far for a complete repeal of the SGR, and it was a slam dunk. It was overwhelming that the House of Representatives said we’re going to do this. Last year, we did not succeed, but the policy from last year was also historic because it was the first time that both chambers of Congress—the House and the Senate—and both parties—the Democrats and Republicans—and all three committees of jurisdiction within—two in the House and one in the Senate—all voted up policy in support of repealing the SGR.

At that time, the AMA was able to get over 600 physician organizations to join in a sign-on letter supporting that policy. That’s the whole profession of medicine. I’ve never seen a sign-on letter in our profession with that many signatories. This year, we got a sign-on letter with over 700 physician organizations. There apparently were more societies who have come out of the woodwork and signed. When we have over 700 physician organizations signed on to a letter supporting the policy, if you are on the outside of that group, you are clearly the outlier because everybody has joined in supporting that this is the best opportunity we have within the political process to finally eliminate the SGR and achieve meaningful reform.

When you ask about the policy itself, the SGR every year or every six months or every three months, depending on the 17 different patches of varying durations, was like a guillotine over the head of the profession. If these cuts, 20 or 30 percent, were ever to happen, it would be devastating. It would be crippling, and it would be entirely unsustainable. To their own detriment, there are a number of folks, physicians included, who have become inured to this and say, “Oh, it’s no big deal. They’ll always patch it.” Well, that’s a risky assumption when you see that Congress has played Russian roulette with the entire nation’s economy through the debt-ceiling debates when they shut the government down. If we’re willing to go that far with the entire nation’s economy and people just take it as a given that all these patches are going to happen, they have not paid attention to contemporary politics.

The only way the federal government doesn’t already have $150 billion more as part of its debt is we pretend we haven’t spent [it] already, because the only way we haven’t spent it is if they let a 25 percent cut into play and they take it back from us by not paying us. —Steven J. Stack, MD, FACEP

All of these other changes that have to happen in payment and delivery reform for new ways to pay physicians, new ways to measure quality, and new ways to adopt technology always get bungled up in this SGR mess. It makes it harder to address those other policies because you have this much more enormous issue that affects everybody. If we pave this over and get rid of this deficit, now physicians at least will have the stability or predictability of knowing, “I don’t have that threat every year.” They’ll have to deal with all of the other regulatory burdens that the government is forcing on us, but they won’t have that burden and the uncertainty of a massive disruption in their revenue stream. Hopefully, we can focus on those other programs and make those better, and physicians and their practices will be able to better invest in the future knowing that there is some stability going forward. By any measure you look at it, the proposed policy that the U.S. House of Representatives passed is directionally better, and in some ways substantially so, than where we currently are; however, I have to qualify that and say we haven’t actually won it. There’s always more work to be done, and when this hopefully finally comes to a close by the time you publish this, hopefully we’ll be in a better position with this gone to focus on the other never-ending parade of issues we have to deal with.

KK: If I understand correctly, there’s about a $200 billion price tag on the SGR repeal. How are they paying for it? Is it all in incentives and payment reforms from physicians, or is there some other mechanism?

SS: Well, no. The “price tag” is an artifact of the way of the political process more than the reality. The only way this has not already been part of the federal debt is that we pretend we haven’t spent the money because whatever the price tag is estimated over a 10-year period, which is how the Congressional Budget Office (CBO) does it, whether it’s $150 billion, $140, or $200, you have to remember there are other things included when they quote the total price because there’s not just Medicare. There are extenders for various other payment programs, programs like the Children’s Health Insurance Program (CHIP), Tricare, and other things that are tagalongs to the SGR. What the true cost of the SGR is apart from all of these other things almost doesn’t matter. The only way the federal government doesn’t already have $150 billion more as part of its debt is we pretend we haven’t spent that $150 billion already because the only way we haven’t spent it is if they let a 25 percent cut into play and they take it back from us by not paying us. It’s actually spent money. It’s a debt, and it’s just not recognized on the books. It’s the kind of stuff that probably Enron did, and we all know what happened to Enron. It is funny accounting, and to say that it’s going to add to the debt is a fallacious premise in the first place because it’s already part of the debt. We just pretend it doesn’t exist in the first place. All the politicians say, “We’d never let a cut like that happen with docs because we know it would destroy the health system.” Even the CBO, when it shows projections, has to follow the assumption that the laws of the land will be executed, but it even creates a second series of charts that show, given that the history is they never follow the law of the land, what we really predict to happen. Because we don’t follow the law, there’s more than enough evidence that shows that this is already part of the debt.

As far as how are we going to pay for it, they have a number of different ways where they partially offset it and some where they don’t offset. There’s a new quality paradigm in the bill called MIPS, Merit-Based Incentive Payment System. They are rolling up existing quality programs and integrating them into a more coherent penalty and incentive program. There are still things we’d like to have changed, but politics is a compromise when possible, not about me always getting what I want. We’ll work on that over time, but it really is taking things like Meaningful Use, Physician Quality Reporting System, and Value Based Modifier and rolling them up into a more integrated program.

KK: That makes perfect sense and is probably the best explanation I have heard about whether this is actually incurring additional debt. Like you said, it’s money already spent. I am glad we’re down the road, and I suspect from your comments that maybe things aren’t exactly perfect but any way to get the SGR repealed would be of great value to us, despite the fact that there may be small details we’d want to tweak later.