Oncology Value Reformer Seeks AMA Post

Barbara McAneny, MD

The practice of medicine has undergone innumerable changes since Barbara McAneny, MD, graduated from medical school 40 years ago. Diagnostics have improved, treatments have improved, and patients are living longer. But not all the changes have been positive. Regulations have proliferated, treatment costs have skyrocketed, and the control of medical decision making has largely shifted from doctors to hospital administrators and insurance companies.

Many doctors complain about such trends, but McAneny hopes she can help fix American healthcare’s shortcomings while also promoting its strengths, which is why she’s running for president of the American Medical Association (AMA).

McAneny has donated countless hours to various medical associations over the decades, honing her understanding of how they can get things done while working to limit public health hazards such as second-hand smoke. She has also succeeded in making her practice, New Mexico Cancer Center, demonstrate the feasibility of what many people believe to be the future of American healthcare: outcome-based compensation that improves patient health, reduces total healthcare costs, and provides fair compensation for physicians and nurses.

McAneny developed the Community Oncology Medical Home (COME HOME) practice model, implemented it at New Mexico Cancer Center, and helped to implement it at 6 other practices across the country. The program has generated several years’ worth of data indicating that the model improves outcomes and reduces total expenditures.

“Many physicians are skeptical about any transition to outcome-based payments. They worry that payers will pocket any savings from reduced hospitalizations while putting them on the hook for unexpected and unavoidably high costs. I understand that fear, but the pilot projects have shown such cost reductions and such health improvements that payers have a huge incentive to strike fair deals,” said McAneny, who is running against Stephen R. Permut, MD, JD, a family physician from Delaware.

The vote will be cast by the AMA’s House of Delegates during an annual meeting in Chicago, which will take place June 10 to 14. Permut is endorsed by groups such as the American Academy of Family Physicians and the American College of Physicians.

McAneny has strong support from ASCO and the American Society of Hematology.

“If compensation is fair, then outcome-based payment is great for physicians and patients alike,” McAneny said. “The current system forces medical practices to waste a huge amount of time and effort documenting services and requesting payment. It also pays nothing for many services that clearly help patients, things like telephone consultations or Barbara responding to patient e-mails. With outcome-based payments, practices don’t have to justify everything they do. The system automatically rewards physicians for providing any service that helps patient health and discourages them from providing any service that doesn’t. And that’s really what basically everyone should want.”

Analyses of trial programs funded after the ACA’s passage have concluded that most experiments using these basic ingredients simultaneously improve outcomes while reducing costs. One analysis of 7 oncology practices that adopted McAneny’s COME HOME blueprint reported a reduction of 10 ED visits and 3 hospitalizations per 1000 patients per quarter and a savings of $673 per patient per quarter.

Hospitals will likely fight the adoption of such programs for fear of reduced utilization of both ED and in-patient facilities, said McAneny, but she believes the AMA should still push to speed up the transition because it will be good for patients and physicians.

“Any substantial reform to an industry that represents a sixth of the nation’s entire economy will always be very difficult. Savings for 1 group of people represents lost livelihoods to another group of people,” McAneny said. “Outcome-based payment will almost become the norm at some point, though, because the nation simply doesn’t have the money to keep paying more for the same quality of care.”

McAneny also believes the AMA should do more to make use of another factor that could shift payment away from hospitals and toward physicians in private practice: site-of-service compensation differentials.

Hospitals in many markets have negotiated significantly higher payment rates for many types of diagnoses and treatments. This extra money, McAneny said, has allowed those hospitals to increase their lobbying power, upgrade their facilities in ways that independent physicians cannot afford, and pay physicians more than they can make in private practices that receive lower payments for the same work.

However, the discrepancy in payment rates is now so great that third-party payers have a strong incentive to encourage patients to use independent medical practices for any work that can safely be done outside of hospitals. Some payers have already begun to act upon this incentive, but McAneny believes the AMA can encourage the trend by working with the payers them- selves as well as legislators and regulators.

Even if hospitals responded by giving payers better deals, McAneny thinks that independent practices ultimately would have a cost advantage. Such practices may lack the economies of scale that major hospital chains enjoy, but they have lower fixed costs, less internal red tape, and none of the administrative bloat that comes with having hundreds of employees.

A shift away from hospital-based treatment would likely decrease the number of physician employees at America’s hospitals and increase the demand for partners at the nation’s independent practices—and McAneny believes such a transition would bene t both patients, whose treatment would be guided by their MDs rather than hospital MBAs, and physicians, who would regain lost autonomy. The shift could also lower total costs and benefit third-party payers and the taxpayers and policyholders who ultimately bear medical costs.

“Over the course of my career, hospitals have bought up a huge number of medical practices and transformed physicians into employees whose medical decisions must conform with corporate policy,” said McAneny, who was once told by a dominant payer and provider in Albuquerque to choose between accepting a buyout o er and being put out of business. “The increased market share has been good for hospitals, but it hasn’t been good for anyone else.”

McAneny was born in Kansas City and raised in southern Illinois. Her father was a physicist, her mother was a mathematician, and she was a math major as an undergraduate at the University of Minnesota. She did not become interested in medicine until her junior year of college, when she realized that she didn’t want to teach math, work as an actuary, or pursue any other career associated with her major. A friend suggested medical school, and McAneny took to the idea.

She decided to specialize in treating patients with cancer after working her way through rotations in various specialties during her third year of medical school, and she chose clinical practice over research during her years as a resident, when she often made up excuses to see patients rather than write papers. “My involvement with medical associations started when I was complaining to a colleague in a hospital cafeteria that a product like tobacco—1 that kills people when used as instructed—was entirely legal. A third doctor overhead me and asked whether I intended simply to complain or whether I intended to do something about it. I asked what a single doctor could possibly do. He said I could join him in the state medical society,” McAneny recalled.

“A few weeks later, I was on the society’s public health committee, working to ban smoking in public buildings 1 city at a time with clean indoor air acts. It took 10 years to get the entire state on board, but we did it, and that success taught me that physicians really can shape health-related issues when they band together and speak with 1 voice.” McAneny believes there are many areas where the AMA can use that power to improve healthcare for both physicians and their patients.

She said the AMA should push for reforms that allow physicians like her to spend more time with patients and less time filling out paperwork and jumping through bureaucratic hoops. She acknowledged the benefits of some regulations that have been implemented during her years in practice, but believes that the vast majority of them actually reduce the quality of care that patients receive.

She hopes President Donald Trump’s administration, which has spoken strongly and repeatedly about the need to reduce regulation in nearly all facets of American life, will work with the AMA to lower the regulatory burden that many physicians feel has transformed them from caregivers to form fillers. On other issues, such as the first Republican proposal for modifying the Affordable Care Act, McAneny believes the AMA is correct to oppose the Trump administration on grounds that the proposal would greatly reduce the number of Americans covered by health insurance.

“The AMA has typically worked for or against particular pieces of legislation or regulation rather than giving blanket support or resistance to individuals,” McAneny said, “and I think that’s wise.”